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Introduction Beginnings Making sense of the information Deciding what to do Reviewing the plan

Stage 3 - Deciding what to do

Case Information

  • Bernie has been physically screened. His symptoms do not have an organic cause. He has been given anti-psychotic medication previously by a psychiatrist in the CMHT. The medication enables Bernie to engage. He has not been given anti-depressant medication. The social worker has discussed this with him and he agrees instead to receive counselling about the death of his granny. Bernie is experiencing grief at the death of his granny. He is, as it were, 'stuck' in a state of shock at this loss.
  • Edna, meanwhile, is both carer for Bernie and a client in her own right. She is rediscovering through this death earlier losses which were traumatic for her, particularly the death of her father when she was 6. Surprisingly, perhaps, Edna has never had the opportunity to grieve for this loss. She has been left with undiluted fear. Her relationship with her mother was not secure enough to compensate for her father's death. Her current loss of her son, in effect, through his withdrawal, is experienced by Edna as another death. It re-awakens insecurities from her childhood. A further layer of childhood experiences is reawakened during counselling. It appears Edna's fear that Jim might attack her arouses childhood memories of her father hitting her siblings. She always wanted to distance herself from such behaviour.
  • The social worker asks Jim about Edna's fear of him attacking her. Jim says it's her imagination, not his problem. With more probing questioning, Jim admits to the social worker to occasional feelings of uncontrollable anger and wanting to hit somebody. At first, he insists it isn't a problem because he controls it. A couple of weeks later, Jim asks if anything can be done. The plan is extended to include a worker with Jim, who does some anger management counselling with him.
  • Edna takes an overdose of sleeping pills. It is not clear where she obtained these. They were in her medicine cabinet at home, it appears, from an old prescription. Bernie comes home, finds his mother and goes hysterical. He takes a handful of headache pills, rings the ambulance for his mother and shouts into the phone that he's killing himself.
  • Team members, including the psychiatrist, assess Edna's actions and consequences for her. There is discussion as to whether this was a serious suicide attempt.
  • One of the approved social workers in the CMHT with two doctors, one approved under Section 12, Mental Health Act 1983, carry out the assessment under the Mental Health Act 1983. The assessment suggests this suicide attempt was not planned or serious, but impulsive, a bid for attention.
  • The social worker discusses with colleagues in the Community Mental Health Team (CMHT) and they make the decision to refer Edna's circumstances to the Crisis Resolution Team who work alongside the CMHT and the in-patient psychiatric ward of Fenton hospital. Not all members of the CMHT are convinced this will be appropriate.
  • A similar assessment process is followed for Bernie. There is prolonged discussion and much uncertainty. Ultimately, the view is his attempt was not a serious suicide attempt. The CMHT decide Bernie is mentally disordered under the Act.
  • The social worker has access to other person-centred services in the voluntary sector, if these become necessary to support Bernie.

Key Questions

Values-based Questions

  • What kinds of ethical and other practice dilemmas exist for practitioners at this stage, working with this family?

Practice-driven Questions

  • Is Edna suffering from reactive depression?
  • Is Bernie suffering from mental disorder?
  • What should the social worker do to tackle Edna's problems?
  • Do Edna's problems constitute a crisis?
  • What is a crisis?
  • Is a crisis service necessary for Edna?
  • How should the social worker respond to the family's circumstances, now Edna's depression is out in the open?
  • Would cognitive behavioural therapy be a useful option in work with Edna?
  • What should the response be to Stan's anger and possible aggression?

Research Focused Questions

Knowledge Questions

  • What kind of factors bring about depression?
  • How does depression affect people?
  • How can depression be treated or prevented?

Skills Questions

  • How does crisis work tackle the situation where a person has attempted suicide?

Relevant Knowledge

Cognitive Behavioural Therapy is only one of many treatment options open to team members. Any approach should be scrutinised critically to ascertain its appropriateness in given circumstances. This should be carried out with reference to research on its effectiveness.

Research into what works in Cognitive Behavioural Therapy (CBT)

Durham, Swan and Fisher (2000) have carried out research into the relative effectiveness of CBT under different conditions of practice. They conclude that

  • Teamwork is an essential prerequisite for identifying and meeting people's needs (p. 435);
  • In considering the appropriateness of different CBT programmes, their intensity should increase with the complexity of people's circumstances (p. 437)
  • The context and system in which CBT is delivered needs as much emphasis as the competence and orientation of the practitioner. (p. 442)
  • There should be rational systems both for allocating resources and for sharing the emotional and intellectual demands of therapy. (p. 442)

Durham, Robert C., Swan, John S., and Fisher, Peter L. (2000) 'Complexity and Collaboration in Routine Practice of CBT: What Doesn't Work with Whom and How Might It Work Better?' Journal of Mental Health, 9, 4, pp. 429-44

Mental Disorder

If Bernie's behaviour is merely the result of drug taking it is not sufficient to be mental disorder. However, he is depressed, he took an overdose, which is sufficient to bring him within the definition.


Depression arises from many causes, some within the individual, others in the person's environment. Depression takes many forms. Symptoms and signs a person is depressed vary from obvious grief and sadness through irritability, to inactivity, a loss of emotion and complete apathy.

Brown and Harris (1978) studied the factors leading to women becoming depressed. He found a significant contribution was made by their social position, in predisposing them to being diagnosed with depression. Government policy has recognised the social pressures generating a higher incidence of diagnoses of mental health problems among women than among men (DoH, 2002).

Hammersley concluded that mild or moderate depression may be worsened through taking anti-depressants. Severe depression makes it impossible to counsel people or give them therapy. Also, the side effects of medication can make this difficult. Hammersley, M. 1995 Counselling People on Prescribed Drugs London Sage

Research into depression, contrasting the professional and the user perspectives:

Research by Rogers, May and Oliver (2001) shows how the GP perspective on mental health practice is shaped not just by the preferences of the person experiencing the mental health problems, but also by the context of budgeted resources, professional interactions with others in primary care and current medical knowledge and practice.
Rogers, Anne, May, Carl and Oliver, Dianne (2001) 'Experiencing Depression, Experiencing the Depressed: The Separate Worlds of Patients and Doctors', Journal of Mental Health 10, 3, pp. 317-33

Crisis intervention

A crisis is an upset in the status quo brought about by a stressful precipitating event, which disturbs the usual way an individual, or member of a group or family, acts.

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