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Particular factors |
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Mental state |
Psychosis |
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Past history |
Previous deliberate self-harm |
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Social and demographic |
Living alone |
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Current episode |
Acute relapse |
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Ward and staff |
Staff hostility to patient |
61. Everyone has their own path through life. That things happen and have consequences usually makes sense and is accepted. Coming into contact with mental health services means that a professionally directed opinion and focus is super-imposed on that personal understanding.
62. For the professional, the process of making someone a patient or client is divided conveniently into assessment - service provision - continuing care/follow-up - discharge/end of service. This makes the tasks and skills more explicit.
63. For those in contact with a service, the rules tend to be made by the worker or the professional. People have difficulty in confronting a system in which they feel unequal and in which they feel their personal experience counts for nothing. Being in contact with the care system understandably makes people anxious, often insecure and uncertain and rarely shows them at their best. In the patient's 'journey' through the care system, it is likely that there will be changes in mental state, insight, and willingness to be fully compliant with actions designed to be helpful. Thus the risk perceived by others or experienced by that person is likely to fluctuate.
64. The danger of the 'patient's journey' concept is that the journey is only fully visible in retrospect. In its course a variety of things can happen which cause deviations. The person making the journey will also come across all manner of workers from different agencies, different departments within those agencies and different disciplines. Some will have one, often brief, contact others may travel on the journey quite some way. Yet all should blend their impressions or knowledge into a coherent whole and it would help if the person's experience made sense too.
65. Generally, the more obvious and severe the personal disturbance, the wider the ripples flowing to families or carers, wider social groups, the general public, other service users, and to health, social care and voluntary workers. This process of outward spread crucially depends on:
66. All too often assumptions, stigma, shame or simply embarrassment hinder effective communication and make subsequent developments surprising and perhaps catastrophic to those who might have been expecting to be forewarned. Some individuals who are quite unwell inwardly do not show much outward evidence of their illness. Episodes of disturbed behaviour occur unpredictably and organisations need to allow for this in their plans and practices.
Vignette
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Andrew completed his university education but cut himself off from his former life and returned to his parent's home and sought work. Andrews' father became disturbed about his behaviour the following summer. He arranged for a GP and psychiatrist to visit Andrew at the home against Andrew's wishes. Andrew competently responded to their questions and they did not identify a need for care. Over the next 18 months, Andrew's parents were convinced of a steady deterioration in his condition. They attempted many times to get Andrew to see his GP. From the GP's perspective, it was important that Andrew should visit him, but Andrew did not recognise that there was anything wrong so would not. Following a trip away from home, Andrew became convinced that he had a physical problem and agreed to visit the GP. The parents briefed Andrew's GP on their concerns before the visit but the GP did not identify a mental health problem. Under his duty to maintain patient confidentiality, he had no option but to refuse to discuss Andrew's condition with his parents. A few months later, the parents were extremely worried by Andrew's behaviour one afternoon. It was not possible to obtain a visit by his GP. Within 3 hours, Andrew suddenly attacked a very young relative and nearly succeeded in killing him. Only the presence of relatives, able with great difficulty to restrain Andrew until the police arrived, prevented a tragedy. Andrew is now a detained patient and, when he has recovered, has to live with the knowledge of the tragedy that his illness nearly produced. This episode illustrates the difficulties - not every untoward episode can be averted. |
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Stages of care/treatment
(The underlying assumption in this "process" is that there will be changes in mental state, insight and concordance with treatment throughout the person's contact with services.) Source of risk people
Source of risk historical
Source of risk practice
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