Practitioner: Mark Sloman, a social worker in a community mental health team
Field: Mental health
Client: Derek*, 61, lives alone.
Case history: Derek has not left his house for more than 40 years. After the death of his brother, who lived with him and was his main carer, the family GP became concerned that Derek now lives alone may be unable to care for himself.
Dilemma: Following up the doctor’s initial concerns, the social worker assesses Derek. However, Derek is adamant that he does not wish to receive outside support.
Risk Factor: Derek is a vulnerable man who lives alone. He receives some support from his sister but the social worker is unsure whether this is enough and would like to arrange external services for him.
Outcome: The social worker takes into account Derek’s wishes, his functioning and the family support. After careful consideration he decides to abide by the client’s wishes and does not arrange additional support.
* Not his real name
Social workers never know what to expect when they meet a client for the first time. In this case, the referral from a GP to social worker Mark Sloman had scant information because the referrer himself had never met the client, writes Mark Drinkwater.
The doctor feared that Derek would be unable to cope alone after the death of his brother, his main carer, who had been a patient at his surgery. He had concerns that Derek might be agoraphobic because he was said to never leave the house.
Sloman, an approved mental health practitioner (AMHP), called at Derek’s home several times but received no reply. He left a note on each occasion which prompted a relative to respond. “Eventually I got a call from his sister who lives nearby,” says Sloman. “I explained my concerns and she arranged for a time for me to meet Derek.”
During the house visit, he assessed Derek’s mental state by getting him to talk about his memories of the world outside. “He told me that he had attended mainstream education, but had never had a job after leaving school and never left the house,” Sloman says.
He tried various approaches to establish why Derek never left the house. “I asked him questions about why he didn’t leave the house, using open and closed questions,” says Sloman. “He said, ‘I can’t see the point. I don’t see the point of going out’. He said that hadn’t been out of the house since 1966.”
Derek was given some short mental tests to assess his mental capacity for making informed decisions. When asked how he managed day-to-day, Derek said that each day was roughly the same. “He had fixed patterns,” says Sloman. “He got up at eight each morning and watched TV. And he had a bath on a Tuesday.
“I did suspect that he was on the autistic spectrum, but he was not anxious in any way. He was not suffering from any other form of mental health problems. He was not depressed and was not psychotic. I did not think it appropriate to use the Mental Health Act because he was not a risk to himself or to others.”
From discussion with Derek and his sister, Sloman established that Derek was totally reliant on his sibling. She went shopping for him and sorted out his paperwork and bills. Neither Derek nor his sister saw why there was any need to consider outside support.
Sloman found no evidence to substantiate the doctor’s initial fears that Derek had agoraphobia. In his assessment he found Derek to be in appropriate accommodation, with adequate support from his family and not showing any signs of distress.
Sloman was convinced that Derek would benefit from support services, but Derek steadfastly refused to consider any form of help. “He had [mental] capacity to make decisions and chose not to engage with us. He made it very clear that he didn’t want further involvement from us and didn’t want me to come back,” he says.
Back at his office, Sloman shared his findings with colleagues, who concurred with the decision-making. He then contacted Derek, his sister and the GP once more to explain that the case was now closed. “We are limited with what we can do with a case like this,” Sloman says. “There is a need to respect an individual’s self-determination. I left it open for him to get back in contact if he changed his mind.”
Weighing up the risks
Arguments for taking risk
● Mental capacity
Derek has shown that he has the mental capacity to make decisions about his own social care needs. The assessment also established that he has no mental health problems.
● Person-centred approach
The social worker would be respecting Derek’s views and wishes. This person-centred approach is guided by social work values that support service users’ rights to control their lives.
● Support from family
There is significant support being provided by his sister. Families are often resourceful and resilient. To undermine this could create an unnecessary dependence on support services .
Arguments for taking the risk
● Vulnerable person
Derek is a vulnerable person and the risks have increased since his brother died. Providing additional support could safeguard him from danger or harm.
● Possibility of autism
There may be more to this case than is apparent. Schools in the 1960s would have been unlikely to have known about the autistic spectrum and it may be that Derek has undiagnosed autism.
● Overly dependent
Derek is only just managing, and his welfare is wholly dependent on his sister. If that support breaks down his welfare may be at risk.
It is extremely difficult for social care workers to assess risks and needs when the client is reluctant to participate. Service user engagement is key to everything we do in social care. Because Derek’s brother has recently died, this engagement is more complicated.
The risks have undoubtedly increased. Consideration should be given to a longer-term engagement plan. There is a balance between being able to show that you have tried a number of ways to engage Derek and being seen as harassing him.
Voluntary sector workers often successfully engage service users where statutory services struggle and this possibility should be explored.
The team was right to ascertain his mental capacity to choose to decline help and stay at home. This assessment is key for the team to decide whether or not to continue to work with him, although should not be the only consideration.
It would appear that the decision not to use the Mental Health Act was the correct one, although this should be reviewed if the client’s situation deteriorates. It is also important that Derek and his sister are easily able to gain help should the need arise in the future.
Lance Carver, service manager, Herefordshire
This article is published in the 22 April issue of Community Care magazine under the heading “I decided to do nothing”