VOL: 97, ISSUE: 39, PAGE NO: 36
John Sims, MSc MEd RN RMN, Community Psychiatric Nurse (Alcohol), Community Mental Health Team, Pwllheli, Gwynedd, Andrew Lancelot, BSc (Hons) RMN, Community Psychiatric Nurse, Community Treatment Service, Pwllheli, Gwynedd
John Sims, MSc, MEd, RGN, RMN, is community psychiatric nurse, alcohol service, Dwyfor Community Mental Health Team, PwllheliWhen people with a history of substance abuse are referred to mental health services, they bring with them a whole raft of problems and challenges.
When people with a history of substance abuse are referred to mental health services, they bring with them a whole raft of problems and challenges.
Mary was suffering from alcohol misuse and psychological distress following the death of her son, Michael, who was killed in a road accident in Germany. Although she had support from her husband, Anthony, and her 19-year-old daughter, Celia, she found it difficult to cope in the period after Michael's death.
She was referred to our multidisciplinary community mental health team by her family doctor, whom she had visited a number of times and who was being plagued by constant telephone calls from Mary when she was drunk. Her family life had broken down and she was lurching from one crisis to another.
The link between psychological distress following bereavement and alcohol misuse has often been noted (Caetano and Weisner, 1995). Australian and Canadian studies (Swift and Copeland, 1996; Ross and Shirley, 1997) have confirmed that alcohol misuse with associated psychiatric co-morbidity is common in women. In fact, the degree of chronicity of the alcohol misuse component appears higher in women than in men (Caetano and Weisner, 1995).
Mary scored highly on the severity of alcohol dependence questionnaire (Stockwell et al, 1983) and presented with high levels of distress under the general health questionnaire (Goldberg and Williams, 1988). She also scored highly on the Health of the Nation outcome questionnaire (Wing et al, 1998).
She was admitted to the acute psychiatric facility and also made unplanned visits to the community psychiatric support bed unit on an ad hoc basis. However, these interventions appeared to achieve little except to generate further chaos.
Anthony and Celia turned to the private sector for answers they believed 'mainstream psychiatry' was unable to provide. Mary entered a private health facility, causing further distress to her husband and daughter as they had little money to pay for such treatment.
Eventually she was discharged from this unit, but her difficulties continued. Her self-destructive pattern of behaviour culminated in a conviction for driving a vehicle while three times over the alcohol limit. She was given a three-year driving ban and a large fine, and it was at this point that she was referred to our community alcohol team.
The team decided that the driving ban was evidence that she was not improving despite previous interventions. Her admissions to the acute psychiatric facility had been inappropriate and clearly had not resulted in any constructive outcomes. She was continuing to demonstrate 'hysterical' communication, both verbally and non-verbally, with her family as well as with professionals in contact with her.
The family dynamics were not functioning either. All the focus was on Mary, to the extent that Mary became everyone's problem, leaving her feeling even more isolated. She was also expected to fit the care model, rather than the model being made to fit the needs of her and her family.
The clinical interventions to which she had been subjected appeared to be prescriptive and conditional, and were therefore not effective. As a number of studies into substance misuse and psychiatric co-morbidity have suggested, a more flexible approach can yield better outcomes (Manley et al, 1998; Holland, 1998), so we felt the model of care needed to be changed.
A new model of care
The focus was shifted to the family rather than just the client. Early acknowledgement was made that it was not just Mary who had been bereaved; Anthony had lost a son and Celia had lost a brother. This helped to bring the family together as a unit. Consultations were arranged to take place in the family home, and the caseload was shared between a member of the intensive intervention team working alongside the mental health team to provide out-of-hours support. Family therapy in the form of bereavement counselling began.
The family was now seen as a unit, by appointment, under a more structured approach. The poor interpersonal relations were given priority, with communication exercises set as homework between sessions. All family members appeared to see value in this way of working and cooperated well.
Other areas addressed by clinical interventions included:
- Verbalisation of loss;
- Legacy of guilt issues;
- Acknowledgement of each family member's equal vulnerability;
- Recognition of changes in family dynamics;
- Post-bereavement sexuality;
- General education on the bereavement process.
As we began to implement the new model of clinical intervention, we saw evidence of positive changes. There were visible improvements in their quality of life for all members of the family, who appeared to value the process of bereavement counselling and support. At last they felt listened to.
Mary stopped drinking, and the inappropriate out-of-hours requests to her GP stopped within two weeks. Weekly appointments with the family gradually became less frequent.
Mary's erratic behaviour had exhausted the patience of some people within her community, but there are signs that she is winning back some goodwill and the return of her driving licence in the near future should aid her social reintegration.
There is always a danger that clients with a substance misuse problem associated with mental distress may not have their needs met. Services are often geared to respond to clients with either a mental health problem or a substance misuse problem, but rarely both (Steel, 1997). Services must become more flexible and cater for the individual needs of clients (Swift and Copeland, 1996).
In this case, changing the model of care to a more flexible one based on tackling the client's needs within a family context proved successful. By looking at Mary's problems from a wider perspective, we were able to achieve a positive outcome that suggests other people with similar problems could benefit from being treated in this way.
- All names have been changed