Stage 3 - Deciding what to do
- 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
- 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.
- What kinds of ethical and other practice dilemmas exist for practitioners
at this stage, working with this family?
- 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
- What should the response be to Stan's anger and possible aggression?
Research Focused Questions
- What kind of factors bring about depression?
- How does depression affect people?
- How can depression be treated or prevented?
- How does crisis work tackle the situation where a person has
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
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.
- There should be rational systems both for allocating resources
and for sharing the emotional and intellectual demands of therapy.
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
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
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
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.