Working with man with a history of bipolar disorder and substance misuse who is accused of assault

Social workers and a service user offer advice on a case involving a man with mental health problems who uses drugs

CASE STUDY

THE SITUATION

G is a 30-year-old male with a long history of bipolar disorder and substance misuse – primarily cannabis and cocaine. His substance misuse is a major factor in his mental ill-health. When he has misused substances, G becomes aggressive and has assaulted members of his family. He has had numerous hospital admissions under the Mental Health Act 1983. He is on a compulsory treatment order in the community and is a client of an assertive outreach team.

THE PROBLEM

G was recently arrested for assaulting his two brothers and his mother. His mother had reported that he had stolen £150 from her two days previously and had called for the team to “do something about him”. A police surgeon assessed G at the police station and felt he was under the influence of substances.

When G was assessed by a social worker in the outreach team he blamed his brothers for provoking him and made no mention of assaulting his mother. He admitted to smoking a small amount of cannabis and asked to return to hospital.

As there were no independent witnesses, the police said it was down to the family to press charges but G’s mother refused to do so. She is Italian and said in her culture “they don’t do that sort of thing”, despite her earlier comment to the team.

The team felt that G needed to start taking responsibility for his actions. Since he had been offered support to self-refer to the local community substance misuse team many times, it was clear his motivation to change was limited. G’s mother was encouraged to consider that charging G could be used as a way to try to get him to change, but she was adamant in her refusal to consider anything but family honour.

G was transported back to hospital after his CTO was revoked by the responsible clinician. All team members feel frustrated at an opportunity lost, and the injustice at G’s seeming ability to commit criminal acts without suffering the consequences.

The social worker view

Mark Sloman, a social worker with a community mental health team in Somerset

This case illustrates the dilemmas often felt by professionals about how far someone with a known mental health problem could or should be responsible for their actions, especially in the context of criminal activity.

G’s case is complicated by his use of illicit drugs and their impact on his mental state. Of course, what we also know is that people with mental health problems are often wrongly accused of carrying out crimes such as assaults. Based on the information given, it would be easy to jump to false conclusions. Consideration and respect needs also to be given to his mother’s wishes to deal with this issue within the family unit.

It can be easy to criticise or dismiss people who don’t act in the way that one might imagine. Although the care team might feel that G’s mother’s decision not to make a formal complaint with the police is incorrect, that should not influence their supportive interventions or their commitment to continue to work with G.

Family-based interventions are often very useful in these situations, so trying to engage all family members in discussion about ways of managing future discord might help.

Professionals need to fundamentally ask themselves what they would have done if they had been in G’s mother’s situation.

Peter Corser, a social worker in a mental health team in the Midlands

This kind of client is very draining to deal with as a worker. It’s difficult not to think of yourself as a kind of fire fighter, dealing with the client’s chaotic life. I suspect that the cultural aspect of the picture is a red herring, which is something that we as social workers tend to be nervous about saying. I have yet to come across a family, of whatever cultural background, that is comfortable about using the sanction of calling the police when a family member is causing this kind of distress.

What are required here are clear boundaries about what the assertive outreach team can and cannot do.

I would suggest that this is done by attempting to make some kind of contracts with G and his family. The contract could use specific examples of G’s past behaviour to suggest what should happen in the future, and how this will ultimately help G. The difficulty with such approaches in cases like these is that it can be seen by service users and carers as an attempt by professionals to shift responsibility. This is where worker congruence is so important. G and his family need to understand what the contract is to try and end the cycle that he is in.

The user view

Anna C Young uses mental health services and is a wheelchair user and a disability activist

One element of this case is abundantly clear: G must be removed from his family situation. His outreach team may be too quick in blaming G entirely for the assaults. Certainly, he is responsible for his own behaviour, but the family dynamics at play cannot be dismissed.

G may have committed criminal offences in this case, but the evidence isn’t conclusive. The team must move away from lamenting this “lost chance” of securing criminal charges and look forward to other options. As he did ask to be returned to the hospital, it seems that he is not entirely opposed to treatment.

Perhaps G could be convinced to enter a treatment facility that concentrated on improving his mental condition first and foremost. How much of his drug misuse is a form of self-treatment?

Additionally, his family’s behaviour should be assessed as well. Perhaps if they were referred to counselling, a holistic alteration in their family life could take root.

The sooner G’s team concentrate on working with him to improve the quality of his life, the sooner they might have a breakthrough.

This article is published in the 10 September 2009 edition of Community Care under the headline “An opportunity lost to tackle aggression”