Practice panel: advice on a case involving poor mental health and fire starting

The parents of a man with mental health problems fail to involve services in his care but eventually a crisis occurs

Case Study:
The names of all service users have been changed

Situation: Martin Richards, 29, lives at home with his mother Liz, 53, and father Bert, 57. Always a loner, he was a fairly bright child but as he got older he was often excluded from school for aggressive behaviour. From the age of 19 he began to hear voices. He now spends all his time in his bedroom, where the walls are filled with crammed hieroglyphic-like drawings in blue biro: Martin says these are messages from aliens. His parents have never really asked for help, preferring to keep things within the family.

Problem: Martin had recently taken up smoking in his bedroom. There had been two or three incidences when small fires had started but Bert had been alerted by the smoke alarm and had put the fires out. Despite their protestations Martin continued to smoke. One night a serious fire took hold – Martin had taken the batteries out of all the smoke alarms. Bert was out – it was his night out at the pub, and Liz escaped into the garden. Martin refused to leave the building. Police and fire officers persuaded him to come into the garden but he started to speak unintelligibly. Considering him to be unwell, and despite Liz’s pleas to let her sort things out with him, the police officers escorted Martin to the nearest psychiatric hospital under section 136 of the Mental Health Act 1983 which makes provision for a place of safety for “mentally disordered persons found in public places”.

Practice panel Milton Keynes mental health team

Panel responses
David Glover-Wright
Although section 136 of the Mental Health Act 1983 allows for people to be removed from a place to which the public have access, it is doubtful whether this applies to the Richards’ garden. It is also unclear why Martin needed to be removed from his home given his mother’s pleas to the contrary.

That said, Martin has unwittingly created a situation where rigid boundaries and expectations prevail, resulting in crisis when his internal world collides with the outside world. His parents have helped him to maintain this fragile equilibrium and now seem powerless to intervene.

Perhaps the parents should be more proactive in addressing their son’s mental health needs. Intervention at an earlier stage might have prevented the establishment of rigid patterns and conventions. Support from a community mental health service and the provision of medication might have helped him control his symptoms and live a more productive life.

His parents have done him no favours now his life is laid bare before the statutory services. The parents might argue he has every right to express himself as he chooses. However, his behaviour is generating significant risks which can’t be ignored by the statutory services.

Martin’s best option might be an admission to hospital where treatment could be provided to help him understand the impact of his behaviour on others. His understanding of the world is probably very important and he’ll want to return home as soon as he can. A long stay might be avoided if the crisis resolution team (CRT) is involved in the assessment and determines “home treatment” is viable despite the risk factors. This will only to be successful if Martin is prepared to accept this kind of input. His parents are crucial in smoothing his path through the mental health services and will need significant support if they are to introduce positive change in his life.

The current family system seems predictable and inflexible with Martin ensuring nothing changes through his obdurate behavioural patterns. CRT could focus on supporting the parents, helping them to impress on him the need to comply with certain rules if he is to remain at home. Failing this, an admission to hospital might be the only way to break the rigid patterns of behaviour in the family.

Jane Ross
Martin has had mental health problems for more than 10 years. It seems there might have been signs of mental health difficulties in his early years. This could have been picked up by his school. Times have changed in that now there should be comprehensive support services for children and young people.

In Milton Keynes, for example, parents can make direct referrals to a “tier two” service for assessment. If these require further intervention, he could be referred on to a “tier three” service for longer term input. Contemporary practice works on the premise that signs or indicators of serious mental health problems should be picked up at the earliest possible stage to promote good mental health. Many areas now have specialist intervention services to detect and address early signs of psychosis in young people.

His parents’ experience with the school was not positive given Martin’s exclusion for his behaviour and this might have caused an “us against them” mentality. Martin’s parents have also colluded with his illness, preferring to keep him away from services, in the belief they are acting in his best interests. It is crucial to establish a professional rapport with his family and enable them to recognise his illness and its problems.

The risks seem to be escalating in his situation. The parents need a carers’ assessment and need to be linked in to carers support schemes. In Milton Keynes, we have a carers’ support officer working within our community based teams who can work alongside carers while professionals address the mental health needs. Martin’s parents would have the opportunity to access carers’ support groups and share their concerns and experiences. This is often a crucial requirement in the recovery process.

Other carers are often better at providing insight and knowledge in to accessing services and explaining their rationale.

Martin’s parents are an important factor in his life and need to be included at every stage along the way. It is essential that the professionals involved in the subsequent Mental Health Act assessment make every effort to validate the parents’ role and help them understand his circumstances.

User view
The first priority should be to find out Martin’s view of the situation. Efforts should be made to find out what he would like from mental health services and to discuss with him what might be on offer. There should be support from an advocate on hand to facilitate Martin’s views being both heard and heeded, writes Kay Sheldon.

Formal admission to hospital under the Mental Health Act 1983 should be avoided if at all possible. The negative impact of having a sectioning on your record cannot be overstated. It is easy to see how Martin might be viewed as meeting the criteria for detention as a danger to himself and others, having just caused a serious fire, but this should not be seen as an automatic reason to section him.

Concerted attempts should be made to engage with Martin and his parents. Fear and vulnerability, together with an unsympathetic approach from the professionals assessing Martin, could cause a hostile reaction and so make detention a more likely outcome.

If the process does result in Martin being detained in hospital, it will be important for both Martin and his parents to be provided with a full explanation and also told their rights. At some point, a debrief with them might help them understand what happened and how detention could be prevented in future.

Martin’s parents do not trust the mental health services. There may be a real fear that Martin will be taken away and locked up as many people are not aware of how mental health services can be provided. It would be time well-spent to build up a rapport with Martin and his parents. The rapport should be one of respect, openness and also a genuine desire to help without taking away self-determination.

Alternatives to hospital admission should be offered to improve Martin’s well-being and quality of life. The starting point should be defined by Martin. There are various options that could be discussed with Martin in time, including independent living. Immediately, the risk of fires in the house should be discussed with Martin and his parents to devise a strategy to prevent a recurrence.

Martin appears to have spent most of his twenties existing rather than living. At some point, the services should help Martin define what his needs, hopes and aspirations are and how they can best be met. The sensitivity and responsiveness of the mental health professionals will be crucial to setting the tone for subsequent contacts with the services and could have a big impact on Martin’s life. It is worth getting right.

Kay Sheldon is a mental health service user