We welcomed the Early Intervention in Psychosis (EIP) service when it was set up and some of our workers moved on to take posts in the team. It was uncomfortable however when they became the new exiting team with lots of attention from management while we got our budget cut. So more recently, I was not very supportive when they started referring their service users to our team. Why, I asked, would we offer more of the same, when this had not worked? Three years of intensive outreach interventions had not delivered outcomes and now they were asking for more of this!
I am not just being awkward, this is a reasonable question. With cuts to our resources what should we do when people do not turn up to appointments? A young man, Ashleigh, had engaged well with EIP, at times. But then he failed to take treatment and he was difficult to trace in the community. The EIP workers managed to get him to the local Housing Department a couple of times but he did not stay in the temporary bed and breakfast accommodation he was offered. Ashleigh is a ‘sofa surfer,’ staying with various friends for a few days then moving on. He also stays with his mother, but when he comes back late after drinking alcohol or smoking cannabis with his friends she does not let him in. He explains that he often sleeps in the garden shed. When you can find him, Ashleigh presents as friendly and motivated. He promises to settle down and to find work, but when arrangements are made to attend appointments or organise activities, he cannot be found.
Ashleigh’s friends are aware that he has mental health problems, but they do not treat this with any seriousness. It seems that it is great fun to wind Ashleigh up and get him into trouble. He now has a criminal record for minor offences, criminal damage, affray, breach of the peace etc. Across his time with EIP, he was often admitted to our acute psychiatric hospital, responding to voices, feeling paranoid and entertaining ideas about persecution. Last year he absconded on a number of occasions and was then discharged in his absence. He recently appealed against his detention under Section 2 and I travelled to the local PICU to present the Social Circumstances Report. Ashleigh had the support of a solicitor and a mental health advocate. He successfully minimised all concerns about his non-engagement and non-compliance with treatment. He said he would take treatment this time and explained that he just wanted to get a job and get on with his life.
The hearing was going well for Ashleigh. He was again presenting as capable and able to take control of his life. However the doctor stuck with the evidence and described symptoms such as a fear of being watched or followed. Ashleigh was described as making threats against someone he met in the street. He thought this man was recording his actions and when this was mentioned at the hearing Ashleigh started to show signs of anxiety. He challenged the doctor repeatedly; asking why was he so unsupportive? The panel agreed to take a break and I listened to the mental health advocate talk with Ashleigh about the need to emphasis recovery philosophy, rather then pushing the ‘medical model.’ Then, back in the hearing Ashleigh lost his self composure. He told the doctor he would get him struck off, accusing him of being involved in a vendetta against him. Ashleigh was sent back to the ward and the Section was upheld. However, a week later Ashleigh was made informal and transferred back to our local acute ward. The next day he climbed over the roof and has not been seen since.
Our team has taken the referral but Ashleigh’s new care co-ordinator has not met him, despite every effort to make contact. I we spoke with colleagues in EIP who believe Ashleigh is developing an entrenched mental health problem, causing problems with his concentration and his ability to remember things or organise his affairs. In contrast, it seems that he thinks there is nothing wrong with him. If he does feel anxious he believes that a can of beer or some cannabis are better solutions than taking anti-psychotic medication. But our colleagues in the Recovery Team would have to discharge Ashleigh due to his failure to attend appointments. In Assertive Outreach we are concerned by his ‘life-style choices.’ We do not see these as separate from an underlying psychotic illness. We will keep trying to engage him in the hope that we can prevent further admissions, manage risks to the public and avoid a more damaging breakdown in Ashleigh’s mental health.