15 The service user experience
Introduction
The following case studies describe three different experiences of accessing mental health services. The questions that follow each section aim to prompt you to apply your reading, experience and discussion to a clinical situation. You may already have this knowledge or you may need to do some additional research. The activity boxes in case studies 1 and 2 will direct you to sources of information which will help you to learn or reflect upon how you might respond to a situation or manage the clinical scenario. However, in case study 3 you are encouraged to use your own research skills to seek out the information required.
Case study 1: young male experiencing his first psychotic episode
This case study will focus on a young male who experiences a psychotic episode for the first time. When reading this case study, you should consider the following key areas of learning and think about how you would apply them to your own clinical practice, including how they help you to achieve your practice competencies to become a registered nurse:
9.15 a.m. Monday
A phone call from the GP to the crisis intervention and home treatment team:
GP:
Hi, I need an urgent assessment of one of my patients, Christopher Ellis. His mother has been in and out of the surgery for the last 4 days saying that he is acting oddly and won't leave his room. He hasn't eaten for the past week and, as far as his mum knows, he hasn't even been to the toilet. It all came to a head last night when his dad banged his door down and they ended up in a physical fight. Can you get out to him today?
CPN:
1. What additional information would you and your mentor need from the GP in order to inform your approach to the initial visit?
2. How would you and your mentor approach your initial visit taking into consideration how Christopher and his family may be feeling?
3. What would be the priorities for the first visit?
4. What might you discuss or clarify with your mentor before the visit in relation to your role and learning?
You may want to refer to the sections on assessment (Ch. 8) and forming therapeutic relationships (Ch. 7) to help you with these questions. The students' top tips in Chapter 4 may also help you to think about what role you could have in this scenario and how you might approach this with your mentor to achieve your learning goals.
11.30 a.m. Monday
You arrive at Christopher's home with your mentor. Christopher's mum opens the door. She has obviously been crying and does not look like she has slept. Your mentor introduces you both and you enter the house.
5. What factors should you consider in terms of your personal safety when visiting someone in their own home for the first time?
6. How might you greet Christopher's mum once you have been introduced?
The section on practicalities in Chapter 5 will help you with this one. There should also be a policy relating to this in your practice area which you should read before going out on home visits, even if you are with your mentor. You could also look at the communication section in Chapter 6 to help you consider how you might enhance your approachability when meeting Christopher's mum.
Your mentor explains to Christopher's mum that her GP has referred Christopher to the service and that you are both here to find out more about what has been going on in order to agree on the best way forward. His mum immediately appears relieved, bursts into tears and thanks your mentor for agreeing to help. You offer her a tissue from your bag which she takes and she smiles at you. Your mentor begins the assessment process.
7. What questions might your mentor ask to initiate the assessment process?
8. What style of questioning might be appropriate at this stage?
Chapter 8 on assessment will give you some ideas about how to work through this scenario. You may also have observed your mentor or other professionals in practice and learnt from their approach.
You learn from Christopher's mum that he has been smoking cannabis on and off for the past 4 years. She tells you that although she doesn't agree with it, it doesn't seem to do him any harm and she appreciates that most of his friends are also doing it. Over the past month he seemed to be smoking more and she had a hard time getting him out of bed in the morning to go to his job in the local call centre. He had been late so many times that he got the sack and hasn't made any effort to look for something else.
His Dad has been getting more and more frustrated with him and they have been arguing all the time. This led to Christopher retreating to his room and the smell of cannabis was constantly coming from his door. Last week Christopher's mum convinced him to let her in to his room to change the sheets. She was shocked because all his electrical gadgets had been taken to pieces and were scattered all over the floor. Christopher told her that they were all malfunctioning because of aliens attempting to communicate with him through his TV, iPod and computer. She initially thought he was joking, but when she returned from home the next day he had also taken the microwave in the kitchen to pieces and made a start on the downstairs TV. His Dad was furious and that was when they went to see Dr Ascot at the GP surgery. She described things as going from bad to worse since then:
Christopher has locked himself in his room and hasn't had a scrap to eat. He keeps telling me that the food is contaminated! God knows where he is going to the toilet because he hasn't been out of there in days. Last night his Dad got to the end of his tether and banged the door down. Christopher went crazy, shouting about the aliens and that they were coming for him. He pushed his Dad out of the door and hasn't been out again since. I'm so worried about what he might do to himself in there.
9. How might you initially respond to Christopher's mum?
10. What are your impressions of what is going on for Christopher?
11. Thinking about the Stress Vulnerability Model, what might be the factors which are increasing Christopher's stress and vulnerability at this time?
It seems like Christopher's mum is highly distressed by the situation and would benefit initially from reassurance and support. Additional reading, such as Gamble and Brennan (2000) and Chapter 10 on working with people who experience voices and unusual beliefs, might help you understand what might be going on for Christopher and inform your decision around your course of action.
You and your mentor discuss your next steps and decide to try and talk to Christopher. You agree that two people may be intimidating so your mentor initially approaches him and you stay with his mum to provide comfort and reassurance. Your mentor returns after 15 minutes and tells you that Christopher hasn't responded to her at all although she can hear him pacing in his bedroom.
The document Keys to Engagement (1998) published by the Sainsbury Centre for Mental Health and Chapter 7 on forming therapeutic relationships might offer you some ideas on approaches to working with Christopher. You could discuss with your peers what risks are present in this scenario. Chapter 12 will also help you to identify the risks and possible ways of working with them in a way that is therapeutic.
You suggest to your mentor that you could try writing a note to Christopher telling him who you are and that you would like to speak with him about his worries and fears. You could say that you might be able to help and that you will come back this afternoon to see if he would like to speak with you. Your mentor agrees that this is a good option as Christopher may be suspicious of her motives and finding it difficult to trust her. His mum agrees with the plan and takes your contact details in case anything happens in the meantime.
3.30 p.m. Monday
You and your mentor return to the house. Christopher's mum tells you that she has heard him continually talking in his room. Your mentor approaches his room again and he opens the door slightly. He is sitting on the floor and your mentor also sits down on the other side of the door. She introduces herself and they talk for some time. Christopher tells her in detail about his fears for his safety as the aliens will be coming for him at 6.30 that evening. He tells her that he would rather die than let them take him because they have told him what they will do to his brain. He is highly distressed, scared and speaking very quickly. Your mentor talks with him about going into hospital as a place of safety to get help with the thoughts and beliefs that he has. Christopher becomes angry with this and accuses your mentor of being part of the plot to get him out of his room. He slams and locks the door.
15. What are your concerns about Christopher's level of risk in light of gathering his perspective?
16. What action do you think your mentor will need to take as a result of his response?
It may be helpful to talk with a few mental health practitioners and find out how they would respond to this scenario. We often find that different practitioners view levels of risk differently and therefore would respond differently. It can be helpful to consider what influences the practitioners' responses and discuss the subjective nature of assessing risk.
You and your mentor agree that you will need to initiate a Mental Health Act assessment in order to ensure that Christopher and his family are not placed at further risk. You discuss this with Christopher's mum and inform her of the process that will be followed.
17. What would be the purpose and rationale for a Mental Health Act assessment in this scenario?
18. What would be your mentor's role and responsibilities in organising and carrying out the Mental Health Act assessment?
19. How might the Mental Health Act assessment be carried out in a way that is least distressing for Christopher?
20. What could be the possible outcomes of the Mental Health Act assessment?
Look at the practitioners' guides to mental health law referenced in Chapter 3. Once you have read some of this material, examine with your peers how you think this might apply to Christopher's situation using the questions above to prompt your discussions.
8.30 p.m. Monday
Christopher is admitted to hospital on Section 2 of the Mental Health Act for assessment. On arrival at the ward he is taken to a side room and given a drink. A nurse sits with him until he is settled. He is given some medication to help him sleep and will be seen by the doctor in the morning. Christopher remains scared and requires a great deal of reassurance from staff about his safety.
21. What type of medication may be helpful for Christopher in light of his distress and difficulty sleeping?
Chapter 9 looks at supporting people to make choices about their treatment and will help you to identify the type of medication that Christopher might benefit from. You may also want to look this medication up in the British National Formulary (Royal Pharmaceutical Society 2010) to give you more information on the dose and possible side effects.
Case study 2: a 57-year-old female who has had long-term contact with mental health services
This case study will focus on the experiences of a 57-year-old female who has been in contact with mental health services for many years. When reading this case study, you should consider the following key areas of learning and think about how you would apply them to your clinical practice:
• Recovery and social inclusion.
• Values-based practice and self-awareness.
• The therapeutic relationship.
• Challenging negative attitudes in teams.
• Working with people who are diagnosed with personality disorder.
Setting the scene
You are on placement at a residential rehabilitation unit in the voluntary sector. The unit offers support to people who have been in contact with mental health services for many years and aims to facilitate the move to independent living. You arrive at the unit for the first day and you are greeted by your mentor who introduces you to a number of the service users who are residents on the unit. She encourages you to spend the first week getting to know the residents and the routines of the unit. She advises you to avoid reading the residents' medical notes before you have had a chance to meet them and to spend as much time as possible engaging with them.
1. What might be the rationale for a service which aims to support people with long-term mental health problems to move into their own accommodation?
2. Why might your mentor encourage you not to read the residents' medical notes before you have met them?
Chapter 1 describes the history of mental health services and the changes that have occurred over time to ensure that mental health care is delivered in the least restrictive environment. Reading this chapter will help to inform your answer to question 1.
Chapters 6 and 7 both identify the importance of being aware of prejudices and the importance of displaying a non-judgemental attitude towards others. These chapters will help you to think about how reading a service user's notes before meeting them might influence your opinion of them and your ability to demonstrate these key qualities which facilitate the building of a therapeutic relationship.
Week 1
You initially spend a great deal of time with 57-year-old Mary who is preparing to move out over the next month. You begin general chit chat and start to get to know her. She tells you that she is looking forward to having her own place as it is 16 years since she has lived alone. You immediately like Mary and find it easy to talk to her. You plan to go shopping together for the things that she needs for her new home and help her to complete forms for reassessment of her benefits. You notice that Mary is often breathless when walking short distances and is significantly overweight. You attempt to initiate a conversation with Mary about this but she changes the subject to a TV programme she has watched.
3. What approaches are being used here to facilitate engagement with Mary?
4. Why might Mary be reluctant to discuss her physical health with you and what is your role in promoting physical health?
5. What might be the therapeutic benefits of the relationship that you are building with Mary?
Chapter 7 and further reading such as Callaghan et al (2009) will help you to think about what is going on within the interaction between you and Mary. You will also find the information in Chapter 6 on health promotion helpful to understand Mary's reluctance to discuss her physical health.
You attend handover for the first time and feed back to the team on your activities with Mary. You are surprised when a couple of the team members begin to laugh. You ask them what they are laughing at.
– Ah, don't worry about it love, we were just laughing because she always takes advantage of the students. She's a manipulative one that one, and you need to watch her. She'll have you doing everything for her before you know it. You do know about her history, don't you?
– No, my mentor advised me to get to know the residents before I read their notes.
– Well, about 30 years ago she set fire to her house with herself and her kids in it. Ended up at one of those high-secure hospitals. Never been allowed to see her kids since. She'll be on one of those Home Office sections for the rest of her life I reckon.
6. What is your response to this information?
7. How might it influence how you work with Mary from now on?
8. How do you feel about the team member's attitude towards Mary?
The section on values-based practice in Chapter 3 might help you to reflect on how you feel towards the team's response. You may also want to discuss this with your student colleagues and identify how you might respond to them if you were placed in this situation in practice.
You decide to write a reflective piece for your portfolio to consider how this information has impacted on you. You discuss this with your mentor who encourages you to think critically about the way other team members respond to Mary in order to understand their perspective and identify how you may challenge it in the future. Your mentor supports you to continue in your work with Mary and you discuss what you have learnt about the values and skills which underpin the building of therapeutic relationships. She also reminds you that you will only have a limited time to work with Mary and asks you to think about how you will manage that towards the end of your placement.
9. Why might other team members be responding to Mary in this way?
10. How might you challenge these attitudes:
11. What are the values and skills that underpin the building of therapeutic relationships that your mentor is referring to?
12. How might you prepare for ending the therapeutic relationship?
Draw upon your previous reading on forming therapeutic relationships and discussion with your mentor to consider the ways you might prepare for ending therapeutic relationships.
Week 6
Mary has moved into her new home and you are continuing to visit her as part of her care plan to facilitate her transition. You notice that she appears anxious and is continually asking you for reassurance about day-to-day things that she would normally take in her stride. When you leave, she continually calls the unit and asks to speak with you for long periods of time. If you make attempts to end the phone call, she tells you that she isn't coping and can only feel calm when she is speaking to you.
13. Why might Mary be finding the transition to independent living anxiety provoking?
14. What concerns might you have about how Mary is responding to you and the requests she is making on your time?
This one is difficult and would need to take into account Mary's specific needs and the approach the team adopts to supporting people to move on. Discuss with your mentor how this situation would be managed in your current placement area. Chat with your student colleages to find out if their placements would respond differently.
Week 7
You visit Mary at home as planned and feel increasingly concerned about how she is coping. Her home is messy and she has out-of-date food in her cupboards and fridge. You remind Mary that you will be leaving the placement in 3 weeks and she becomes very distressed. She tells you that you are the only person who she can trust and that she doesn't feel she can cope without your support. You try to reassure Mary but this doesn't seem to work. You return to the unit and immediately seek support from one of the nurses.
– I'm really concerned about Mary. She seems to be becoming more and more dependent on me no matter how hard I try to reassure her that she is doing really well on her own.
– It takes a lot for Mary to trust someone and she will be upset that you are leaving. This is her way of telling you how much you mean to her. People with personality disorder often behave in this way because of past relationships.
– It feels like she is forcing me to push her away because I just can't meet her demands.
– Perhaps you could spend your last few weeks looking at her coping skills so that she knows she has other options other than support from you? We could do some more joint visits as well to remind her that there is support available from the whole team.
16. Why might Mary be expressing her distress in this way?
17. How might you approach working with Mary to enhance her coping skills?
18. How might other members of the multidisciplinary team help support Mary to cope in her new home?
Chapter 11 will assist you to consider how you might support Mary to cope with her anxiety and develop a sense of personal control to help reduce her dependence on you.
End of placement
You reflect with your mentor on how you have worked with Mary and what you have learnt to inform your future practice. You spend your final visit with Mary at the local café which serves her favourite cheesecake. You thank Mary for the time you have spent with her and wish her the best for the future. You feel confident that she will be well supported by the team and that her care plan has been reviewed in light of her new goals for the future.
Case study 3: experience of a young female student nurse who has been referred to mental health services
This case study will focus on the experiences of a young female student nurse who has been referred to a mental health nurse working in a primary care setting by her GP. When reading this case study, you should consider the following key areas of learning and think about how you would apply them to your clinical practice:
• Risk assessment and management.
• Recovery and social inclusion.
Setting the scene
Anna has been seeing her GP, for the past 6 months, who has diagnosed her with mild anxiety and depression. He has prescribed sertraline which she takes when her mood is low but not on a daily basis as prescribed. Anna is a student nurse and has been finding it increasingly difficult to go to her placement and attend lectures. She has spoken to her personal tutor, about the difficulties she is having, who is supporting her to continue but has raised concerns about her ability to manage the stress and demands of the course. Anna is very concerned that she will be thrown off the course and that peers, mentors and tutors will perceive her as incapable or unsafe. She is therefore reluctant to tell her mentors and peers about her mental health problem which is leading to people perceiving her as unsociable and not interested in her studies.
1. How might anxiety and depression be impacting on Anna's ability to engage in her nurse education?
2. What is sertraline and how might Anna's way of taking it be influencing its efficacy?
3. What do you think about how Anna is managing the situation in terms of disclosing her problems to peers and mentors?
4. How would you feel if you were in a similar situation and how might you manage it?
Anna's mood continues to deteriorate. She stops attending lectures and communicating with her personal tutor. She spends her days at home and is beginning to feel scared to leave the house. She feels guilty and believes she is a failure but is unable to take any action to help herself. She begins to have thoughts of ending her life due to the hopelessness she feels with her situation. She finds her sadness is relieved when she digs her nails into her arms. This helps her expel her anger with herself. Her boyfriend, who is beginning to feel frustrated and impatient, forces her to go back to her GP. She tells her GP about the thoughts she is having. In response, he refers her to a mental health nurse who is working in primary care for assessment.
5. What are your views regarding risk in relation to Anna's current mood, thoughts and behaviour?
6. From a cognitive behavioural therapy perspective, how would you describe the way Anna currently copes with her problems?
7. How might the mental health nurse approach the assessment process?
8. What might be the mental health nurse's possible course of action following the assessment?
Anna attends the assessment and discusses in depth how her thoughts and feelings are impacting on her behaviour. She is able to identify her negative thinking patterns and recognise how she is managing her mood and anxiety in an unhelpful way which is leading to further deterioration in her mental health. They talk about her suicidal thoughts and Anna is able to see that this is a response to her feeling that she has no other way out. She is reassured by the mental health nurse's plan to see her weekly for the next 6 weeks to focus on how she can make changes and alter her current way of thinking.
Anna receives an e-mail from herpersonal tutor asking her to get in touch and expressing concerns about her poor attendance and lack of communication. Anna deletes the e-mail and decides that the tutor will think she is not able to continue and therefore there is no point in discussing her recent appointment and plans with him. She also thinks that others will agree that nurses should not have mental health problems and, therefore, the Nursing and Midwifery Council (NMC) would not allow her to register.
12. How is the way Anna responds to this e-mail linked to her negative thinking style and unhelpful behavioural response?
13. How accurate do you think Anna's perception is of attitudes to mental health problems within nursing as a profession?
14. How might the mental health nurse and Anna's personal tutor work with Anna to support her to continue with her course?
15. What role might education and employment play in Anna's recovery from her mental health problem?
Anna discusses the e-mail from her personal tutor with the mental health nurse. They identify that responding to this should be a priority for the first stage of change, with her overall goal being to return to university and complete her nurse education. Anna goes home and writes the e-mail, explaining her circumstances and the help she is receiving. She arranges to meet with her tutor to discuss her options and gain accurate information which may challenge the assumptions she is making about how the NMC will respond to her problems. Anna and her tutor agree that she would benefit from a short break from the course due to the amount she has missed but with a view to returning in a few months. Anna agrees to communicate frequently with her personal tutor and share with him the work she has been doing on relapse prevention so that he can support her during times of stress. Anna is aware that this has been documented in her file and, at times, she does feel concerned about people seeing it and judging her.
Callaghan P., Playle J., Cooper L. Mental health nursing skills. Oxford: Oxford University Press; 2009.
Gamble C., Brennan G. Working with serious mental illness: a manual for clinical practice. Edinburgh: Baillière Tindall; 2000.
Royal Pharmaceutical Society. British national formulary 61. London: Pharmaceutical Press; 2010.
Sainsbury Centre for Mental Health. Keys to engagement. London: SCMH; 1998.