Coalition of the caring

Declan Henry became social worker to a middle-aged man with bipolar affective disorder as the client’s life fell apart. But an alliance with the man’s advocate proved crucial to recovery, writes Graham Hopkins

Case Notes

Practitioners: Declan Henry, social worker, community mental health team and Rev Malcolm Gerdes-Hansen, mentor and advocate.

Field: Mental health.

Location: Rochester, Kent.

Client: Ian Parker, 58, has had a diagnosis of bipolar affective disorder (previously called “manic depression”) for 40 years, although for the first 20 he was incorrectly diagnosed with schizophrenia. He was divorced in 1999 and has two daughters in their twenties.

Case History: Parker has a history of hospital admissions, which have mostly been due to elated highs – “mania” – with few relating to depression. He had been well for more than five years and was living successfully in the community in supported accommodation. In April 2006, Declan Henry was appointed as social worker to Parker. “Ian appeared well – was likeable and intellectually interesting,” he says. However, by June it was apparent that something had started to go wrong. Unbeknown to others, Parker had started adjusting his medication, which led to behaviour that ultimately was to have him evicted from his placement, estranged from his family and admitted to hospital.

Dilemma: Hospital staff look to discharge patients they consider to be well. However, those who knew him felt Parker wasn’t well enough.

Risk Factor: With no satisfactory placement available, Parker’s discharge would have been bad for his recovery.

Outcome: Parker’s discharge was delayed until alternative accommodation was found. He is now recovering, re-engaging with the community and rebuilding his family relationships.

Courtesy of recent high-profile celebrity sufferers – including Stephen Fry, Frank Bruno and Robbie Williams – bipolar affective disorder is media-friendly. But are we any the wiser about it?

It is a mood disorder. The sufferer has marked mood swings which are beyond those that most people experience. These extremes include the lows of depression as well as elated highs, known as mania. It is thought to affect about one in 100 people at some point in their lives.

Some may have just one or two episodes, but for others, such as Ian Parker, it is more long term – in his case 40 years. Until early summer 2006 he had been well for about five years. But then things began to fall apart.

“Being a new social worker for Ian, I had never seen him unwell but it was evident that all was not as it should have been,” says community mental health team worker Declan Henry. “It was clear that he was a vulnerable person, as he had been defrauded by a female acquaintance to whom he had lent £1,500.”

Parker’s daughters contacted Henry the following week when they found their father showing signs of mania. An urgent outpatient’s appointment was arranged for him to see his psychiatrist. It was unclear why he had suddenly become unwell.

Later it was established that Parker had stopped taking a prescribed mood stabiliser because, he says, they made him put on weight. However, his advocate, Rev Malcolm Gerdes-Hansen, sees it differently: “Ian, in his depressive state, reads literal not actual – so he decided that the medication was the most significant thing in his weight gain when, in truth, it was his inactivity because of a hip problem.”

However, despite an increase in antipsychotic medication and support from the home treatment team, Parker continued to deteriorate. “It was a turbulent time,” recalls Henry. “Ian started to display sexually inappropriate behaviour which alienated his daughters – and later this caused him to be evicted from his supported lodgings.”

With nowhere else to go, Parker was advised to accept voluntary admission to hospital, to which he agreed. He says: “I would normally fight tooth and nail against it, but there was no other option.”

After three weeks and believing him to be well, hospital staff wanted to move Parker, who had also contracted MRSA, back into the community.

Gerdes-Hansen says: “It felt like there were tremendous pressures on us to get Ian out. As an outsider of the NHS and care system I was surprised at the haste of the discharge. Ward staff, to me, saw Ian’s bipolar disorder as if it were measles: once the spots had gone he was cured. But it’s not like that – it affects people individually.”

It also badly affected Henry: “For the first time in my 14 years as a social worker I was doing something I was not happy with. I was having to ring around relatives and church friends of Ian in the hope of finding him a bed until suitable permanent accommodation could be found.”

Henry and Gerdes-Hansen worked closely together with the housing association in finding Ian somewhere to live – and eventually chose his present bungalow.

Through an enduring power of attorney, Parker appointed Gerdes-Hansen to manage his affairs. “Had Ian been discharged earlier I believe he would have been out on the streets or in a hostel before his new accommodation was ready – which would have been severely detrimental to his future well-being.”

The importance of Gerdes-Hansen’s persuasive skills and standing in the community was not lost on Henry. “It was great working with Malcolm – for whom I had tremendous affinity and respect. He attended meetings and really made a difference.”

Parker agrees: “Malcolm has been my advocate, administrator, accountant, priest and, above all, my friend.” Gerdes-Hansen is now mediating between Parker and his daughters in rebuilding the family relationships.

“Ian paid a terrible price for his behaviour,” adds Henry. “He enjoyed the mania and it made him feel great. But it wasn’t so great for his family – they went through agony. But there have been a lot of blessings – he’s in a comfortable house, doing well, is mentally stable and has lots of hopes and aspirations for the future.”

Parker adds: “Bipolar is disruptive and dangerous. I can now say that I am content with everything in my life and the way it is going.”

Arguments for risk

● Finding Parker somewhere suitable to live was a priority – and it was largely thanks to the efforts of Henry and Gerdes-Hansen that Parker was offered a one-bedroom bungalow – something which, if he chooses, can be his for life. Parker says: “My current accommodation is far superior to that I had before – by far more conducive to my independence.”

● There is a good support network now in place. Central to this has been Henry and Gerdes-Hansen, who says: “Declan and I have been a sounding board for each other for ideas and we have been able to lay down plans which aid Ian’s rehabilitation.”

● Henry has helped organise a carer to come in for an hour a day.

● Parker is now re-engaging with the community – as well as church, he attends a day service and Henry has appointed a community support worker to assist with socialisation and leisure activities.

Arguments against risk

● Although recognising the need to make beds available, the hospital’s desire to discharge Parker before he was perhaps ready is symptomatic of the mental health system – too often it is based on quantity rather than quality.

● Parker was asked by hospital staff if he was well and he said he was. Gerdes-Hansen says: ”It was an act that staff couldn’t – or didn’t want to – see through. Ian is incredibly skilful in giving the answer that he thinks others want to hear.” Parker adds: “I would feel in a good frame of mind and put on a façade. I’ve been practising this for 40 years – and it works.”

● Another concern is Parker’s potential isolation. His new home is in an area away from his previous social contacts. Further, staff turnover in mental health social work is high and Henry may soon be moving on and Gerdes-Hansen is moving away from the area next year.

Independent comment

Ian Parker’s case demonstrates several missed opportunities – both historical and current, writes Eric Davis.

The first is the historical confusion of schizophrenia with bipolar disorder. The importance of working with key thoughts and feelings from a psychological perspective must have been under-explored. Also, prescription of medication would not have been optimally targeted to help manage the marked emotional swings typically associated with bipolar disorder, and less so with schizophrenia.

Also Ian could have benefited from working with an “early warning signs” system which would help identify the onset of greater psychological vulnerability. For example, signs such as attributing weight gain solely to medication administration (a cognitive/thinking error), inappropriate sexual behaviour, and the lending of a lot of money (behavioural disturbances) could have been spotted earlier.

These difficulties are compounded by systemic failures. The lack of hospital beds creates pressure for rapid discharge before care can be completed. This is a false economy because quicker re-admission to hospital is made more likely.

On the plus side, Henry and Malcolm Gerdes-Hansen formed a helpful coalition to progress Ian’s care. Gerdes-Hansen’s role as advocate was particularly helpful. Further work should examine the role of the two daughters, who may wish to receive more information about bipolar disorder and may feel that they can contribute to future EWS planning for their father.

Dr Eric Davis is a consultant clinical psychologist for the Gloucestershire Partnership NHS Trust and co-editor of Changing Outcomes in Psychosis (Blackwell, 2007)