The Practice Panel: Social workers and a service user offer advice on a case involving the alcoholism and mental health of a mother
Diane* has been drinking excessively since her divorce six months ago. Just before the separation, she lost her job as a secretary at a building firm, because her drinking at work was making her unreliable. Diane lives alone and her parents are now looking after her child (from a previous relationship). She receives jobseekers allowance, most of which she spends on alcohol.
Once very active, Diane is now lethargic, depressed and drinking to excess. Her morale is low and she lacks the confidence to return to work. She has neglected her own health and that of her child and has never sought help for drinking. She appears depressed and there are concerns that her physical and mental health is deteriorating. After falling behind on her mortgage payments, Diane’s house is about to be repossessed. She feels as though her world has fallen apart and has expressed thoughts of committing suicide. Her parents remain supportive, but are at a loss about what to do.
*Name has been changed
The user view by Kay Sheldon, mental health service user and Mental Health Act Commission member
Whether Diane has the inner strength to improve her situation needs to be established quickly. Sometimes people reach a stage where there is no hope left and decisions have to be made for them. The fact that Diane has not been able to find the motivation to look after her child signals to me that she needs someone to take the initiative.
Someone from her GP practice, community mental health team or a local voluntary organisation should attempt to approach Diane to offer help. In the first instance, this could be assistance with finances and accommodation to try to build a relationship.
Diane’s health is getting worse and her life may be endangered. But the use of the Mental Health Act to help Diane should be considered only as a last resort and as a short-term solution. If Diane starts to feel better, she may have more resilience to tackle her problems and direct the mental health services herself.
Various options could be offered, such as psychological input, alcohol counselling, assistance to find employment and accommodation. Alternatives such as a retreat or complementary therapies may be preferable.
The social worker view by Mark Sloman, social worker, community mental health team, Somerset
Community mental health teams often come across this scenario. The first task is to carry out a comprehensive assessment of Diane’s health and social care needs. I would do this in collaboration with a colleague from a different professional background, a community psychiatrc nurse or occupational therapist for example.
I would want to explore with Diane the origins of her drinking and not just focus on it being “the problem” it could be a symptom of a deeper underlying psychological trauma. Supporting her to attend the local Citizens Advice Bureau could be an important first step to see what could be done to try and save her home. With Diane’s permission I would want to speak to her parents, obtain a family perspective and consider their role and needs as carers. A formal carer’s assessment would also be good practice.
I would organise a medical assessment with a psychiatrist. This could include a blood test which would be useful to eliminate any physiological causes of the lethargy and low mood (problematic thyroid functioning, for example, can have a major impact on mental health). It would also assess the impact that her alcohol consumption is having on her liver function and general health. It would be a chance to consider if anti-depressant medication might help.
Investing time and energy in building a relationship with Diane is essential. Developing a focused recovery-based plan with good quality user-led psycho-social interventions will be key.
Lance Carver, service manager, mental health services, Cardiff
Diane appears to have developed a co-existing mental health and alcohol problem. The situation appears to be deteriorating and could spiral out of control. She will need an intervention in order to halt this decline.
There is always a risk that specialist services will struggle to respond when the issues cover more than one service area many mental health treatments will be unsuccessful if someone is drinking heavily. If someone has an underlying mental health issue then a dependence on alcohol can be difficult to break. The Department of Health has issued guidance for dual diagnosis cases recommending that mental health services should take the lead (see panel below left).
The key to most complex cases lies with the service user and so engaging her is vital. Reinstating her parenting role may be a key motivator. However, the needs of the child would be paramount.
Her GP should be able to provide medication or refer her for appropriate therapy for her low mood. It is essential to involve primary care as Diane’s problems are not purely related to mental health issues and alcohol misuse.
Tackling problems such as increasing her activity levels and getting back to work may be the best way to achieve a lasting recovery, but concentrating initially on small, achievable goals may help build Diane’s self-esteem.
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Published in the 22 January 2009 edition of Community Care under the heading Divorce was the Cue for Mental Health Decline