In this practice study work carried out with Joyce will be discussed and critically analysed. Joyce is a 35 year old White British woman. According to reports Joyce’s mother experienced a normal labour, and Joyce met most of her major developmental milestones on time. However, around the age of six years her parents (Mr and Mrs White) raised concerns that Joyce’s language development was delayed in comparison with her siblings and peers. Due to underachievement in primary school, Joyce was assessed by a psychologist who attributed her difficulties to an emotional causation as opposed to cognitive. At the age of fifteen years Joyce was given a diagnosis of dyslexia which meant that Joyce had difficulties learning to read, write and spell. At the age of fifteen Joyce left school with one general certificate of secondary education in drama and joined college and undertook some vocational courses. She found it extremely demanding and she was reassessed again by an educational psychologist who suggested Joyce did not have dyslexia but instead a global delay in intellectual functioning. This meant that Joyce could only understand basic language in school (PCF1).
According to a psychiatrist’s report Joyce has a diagnosis of both paranoid schizophrenia (a subtype of schizophrenia in which the patient has delusions that a person is plotting against them) and emotionally unstable personality disorder. This is a condition characterized by rapid mood shifts, impulsivity, hostility and chaotic social relationships (Allan, 2014). The onset of Joyce’s hallucinations appears to have occurred following her father’s death. It may be that Joyce’s relationship with her father provided a stabilizing function, the death requiring her to draw upon internal sources that were not adequately developed. According to Joyce the voices say horrible things to her, at times she has attributed the voices to her siblings and they appear to reflect a real conflict that she can sometimes experience with her siblings and again a persistent repetition of making negative comparisons of herself with others. Psychotic symptoms in individuals with personality disorder are often trauma and stress related (Goodman, 2013). This highlights the importance of contextualizing the patient’s symptoms, investigating the historical trauma as well as the daily stressors that may trigger symptom presentation (Barrow et al, 2010).
Joyce moved to Community Housing and Therapy CHT in March 2014 following an assessment carried out by a clinical psychologist. It was felt that Joyce would benefit from having the opportunity for intensive support directed at helping her to begin to take responsibility for herself and her environment. This is in a context with others that are negotiating the same challenges and where she is able to develop a sense of belonging, and feel part of a community. Joyce has reportedly benefited from a structured approach providing clear guidelines regarding expected behaviours, daily activity structure and support and encouragement to engage in activities of daily living. The project provides a psychologically informed, planned environment for individuals with severe and enduring mental health diagnosis. Research indicates that structured therapeutic environments with psychotherapeutically trained staff are an effective treatment for individuals with complex mental health and practical needs (Walker, 2014).
CHT provides services for people with mental ill-health from the ages of eighteen years to sixty five years of age. CHT is a registered charity that runs therapeutic communities which help people who are experiencing severe mental ill health gain a foothold in the world. This is met by focusing on their relationship with others within the community setting and placing particular emphasis on individuals and the deeper meanings which lay behind current symptoms and ways they find to express themselves. CHT runs a daily and weekly program, involving one to one therapy sessions and community groups where residents gather together to talk over issues affecting them and how to work together as a community. The Mental Health Act 1983, 2007 and The Mental Capacity Act 2005 framework guides CHT. CHT believes that all sufferers of mental ill health, regardless of their financial circumstances, should have access to psychotherapy and not just be treated with medication (Walker, 2014).
I was allocated the case to work with Joyce to review her goals and support her to be more independent by possibly helping her to secure a job, her preference was British heart foundation charity shop. In addition, support her to build relationship with other residents and explore some coping mechanism to help her deal with anger and low mood. It is essential to work collaboratively with the service users and those around them to enable them to rebuild their low self esteem and on this case Joyce (Karban, 2011). According to National Health Service (NHS) and Community Care Act 1990, CHT has responsibility to put in place set arrangements for the care and treatment in the community of people with mental health problems. (Goodman, 2013) Therefore, the agency had the responsibility as set out under Mental Health Act 1983 and 2007 to promote good health, manage behaviour, maintain records and ensure that policies and procedures in working with adults were followed (PCF8). At first, when I was allocated this task it appeared to be quite complex appeared challenging. The work entailed working with someone with very changeable mood, delusional and irritability I did not feel confident to tackle the issues However, I am aware that this can be cultivated through practice and good supervision (Wonnacott, 2012). I was prepared for the challenge as this was going to involve working with the psychiatrist through regular reviews governed by the care programme approach (CPA) (Allan,2014). This can have great impact on people suffering from mental health disorders as both the medical model and a therapeutic approach are used to analyse their progress (Walker, 2014).
I went through Joyce’s file as it is good practice to learn about the individual, their family and past history to get a clear and concise picture prior to intervention. I went up to Joyce’s flat to introduce myself and explained what my role entailed. Joyce also introduced herself, told me more about her family and some difficulties that she faces on a daily basis. We agreed on a mutual convenient date and time to have a meeting to conduct a review of her needs. I conducted a thorough risk assessment as stipulated by The Health and Safety Act 1974 to manage the risk of lone working as most of the time Joyce preferred us to go for a walk or to the local Italian cafeteria for a coffee. This was to ensure that I kept myself safe (Brayne and Carr, 2010).
Assessments are a continuous process that entails gathering information, analysing the information using professional knowledge and experience and judgements to make a decision in order to safeguard vulnerable adults and promote their welfare (Hughes and Owen, 2006). Therefore, I sought consent from Joyce to contact the agencies that she was working in partnership with i.e. hospital, social services and general practitioner (PCF5). However, I was aware that The Data Protection Act and The Mental Health Act 2007 allowed for information to be shared in regards to Joyce’s mental health wellbeing and professionals needed to be updated regularly on all incidents in the project involving Joyce.
I resolved to use a person centred approach as this acknowledges, skills and potentials in service users (Sharry, 2004). It was vital for me to listen to Joyce’s personal story and understand her cultural background and appreciate its strengths and benefits. It was important for me to work in collaboration with Joyce, therefore I also used the exchange model of assessment. The model assumes that service users are experts in their issues and that professionals have the knowledge in problem solving (White and Harris, 2013).
I was very apprehensive about my first meeting with Joyce and really questioned myself about becoming a social worker (PCF6). Prior to the meeting I acquainted myself with the agency lone working assessment policy and procedure as Joyce had chosen for us to have our meeting in the cafeteria. I informed my supervisor where I was going, the address and how long I was likely to be. I ensured that I had visited the cafeteria prior to our meeting to familiarise myself with the neighbourhood and to be aware of emergency exits in case of an emergency. I also ensured my phone was fully charged and it had programmed speed dial. On the day of our first meeting I knocked on Joyce’s door and introduced myself again and reminded her of our meeting and sought Joyce informal consent on whether to go ahead with the meeting and if she was happy with the arrangements. I explained that according to the agencies confidentiality policy and The Data Protection Act 1998, information would be shared on a need to know basis (Brayne and Carr, 2010). I also stated that if Joyce felt that the information was not relevant she had the right to say so (PCF4).
I worked in partnership with Joyce in identifying her goals and agreed on a strategy. One of Joyce’s goal was to secure a part time job. I could hypothesise Joyce was likely to fail the interview process due to her learning difficulties if she attended without staff support. This most likely would have resulted in an incident at the charity shop as Joyce finds it difficult to accept no for answer. According to Allan (2014) service users are the experts and a user led and user focussed approach must be adopted in helping the individual overcome the challenges. In this case I respected Joyce choice by offering her the support to attend the interview. This was likely to have a negative impact on her mental health wellbeing and cause hallucinations i.e. Joyce hears voices commanding her to do negative things like breaking plates and cup. My priority was to conduct a holistic assessment on finding employment. I arranged a meeting with Joyce and followed the exchange model which sees the service users as experts. This enabled me to work with Joyce in anti-oppressive and anti-discriminatory way by letting her to come up with ideas on how to achieve her goals (PCF3). I drew up an agreed plan with Joyce for her to contact the charity shop and as a volunteer once a week and booked an appointment for both Joyce and I to attend together. This was to allow us to explore on what Joyce role would entail at the shop and what were the expectation. I also discussed with Joyce and sought her informal consent for us to work on basic maths course at home at least twice a week (PCF9). This was to assist Joyce in basic maths as her volunteer role was going to involve money. I suggested to Joyce about enrolling on anger management course, this was to help Joyce overcome her frustrations and look into other coping mechanism instead of breaking things. This was also intended on reducing Joyce incidents in the house (PCF7). I was aware Joyce had capacity to make decisions under The Mental Capacity Act 2005 and she declined my offer. I respected Joyce decision and self determination to make choices which had negative impact in her life. I proposed and put in place for a review progress with Joyce to check on how she was fairing on a weekly basis. This was to allow quick intervention in case Joyce did not adhere to the agreed plans (Trotter, 2006).
I consulted Joyce and sought her consent on my proposal that she needed to work with a psychologist to talk about her past to overcome the difficulties she encountered. This was to help Joyce with the input of a psychologist to look for other coping mechanism (Heanue and Lawton, 2012). I made a referral to a psychologist and stated the reasons on why Joyce case was urgent to allow early intervention. I followed the progress of the referral taking telephone calls (PCF8). We agreed with Joyce on the possibility of attending recovery college which helps people with mental health disorder overcome challenges that they face on a daily basis (Walker, 2014). Joyce agreed to contact the recovery college and I provided her with the telephone number. I agreed to attend the first few sessions together with Joyce for support and also to learn the process of recovery. I was aware it was not obligatory for Joyce to attend these classes and it was her right to make unwise decisions. It was my duty to respect Joyce choice and self-determination (Weinstein, 2009).
I recommended to Joyce to start attending local day centre for social interactions where she was going to meet other service users with similar diagnosis and have a chance to talk about her experience on mental health disorder. The day centre promotes equality of opportunity by providing services that cater for all in order to eliminate discrimination as stipulated in the Equality Act 2010 (DfE, 2013) (PCF2). I sought Joyce informal consent and she agreed for us to draw a plan on this. The plan was for Joyce to telephone the day centre and book a day to look around the centre and what they offer. I provided Joyce with the telephone number to make contact and we checked on the eligibility criteria together and Joyce was eligible as she lived in her own home in a flat. Due to Joyce changeable mood she kept on accepting the support but changing her mind. I can argue that this is due to Joyce mental health disorder and it may appear like she has given up on herself but support staff will keep offering the support, prompting and encouraging Joyce to visit the day centre as this may be a new beginning for her when she meets other people who are facing similar difficulties on a daily basis (Allan, 2014).
It was important for me to maintain eye contact as an indication of openness and honesty as I felt it was vital to adopt a friendly attitude in order to build rapport with Joyce, therefore I sat directly opposite Joyce (Terpak, 2008). Joyce conversed with me and stated that people judge her because of her mental health illness, she thinks they are jealous of her as she has got a lovely and caring family, but that because of her illness she should be locked up in hospital. I was aware from research according to Shah (2007) people with mental health disorders are marginalised and socially excluded in our society. There is a need for the government to create more awareness about mental health disorders as statistics shows one person out of five will experience a mental health disorder in their life time (Goodman, 2013).
Joyce stated that her family were originally from Ireland though they never lived there. Joyce was born in Surrey and lived in Australia for about three years when she was a teenager. It was there that Joyce met her ex-boyfriend however, the relationship broke down and the ex boyfriend migrated to South Africa. Joyce stated she found it difficult to cope as she really loved the boyfriend, it was at this time that she resorted to using illegal drugs i.e. cannabis. Cannabis is also known as marijuana which contains over four hundred chemicals and is addictive (Allan, 2014). Some of the possible side effects include suicidal thoughts mood swings and disruption to normal learning activities (Ibid). This demonstrated that Joyce had suffered the loss of a partner and a lifestyle that she had created. Our lives are shaped by loss, change and transition no matter the extent or magnitude, individuals experience events that challenge how they view themselves and others (Worst, 1986).
Joyce informed me that she was financially constrained as she was in receipt of welfare benefits. Joyce stated that her mother was her appointee and because of her limited and basic knowledge of money, she was only entitled to ten pounds a day. Joyce found it difficult to cope as she loves to spend her money on cigarettes, visiting different cafeterias for coffee and shopping in the charity shops but the money was not enough. Joyce stated that this makes her angry and makes her break cups, plates including personal and community belongings. Joyce is not able to replace these things and most of the time she has to wait for money from her mother to replace them. This at times takes a long time, during which the community are left without cups. This has created conflict and misunderstandings in the community as other residents feel that Joyce has been allowed to break things as no action has been taken against her. Therefore, the residents feel that Joyce’s behaviour will not stop until the staff team intervene and put in place clear boundaries of how to work with Joyce. During staff meeting we discussed Joyce most recent incidents and I suggested that Joyce needed to be given a warning letter and be made to pay for all the damages she had caused. The manager issued her with the warning letter and a meeting was booked to review Joyce placement with her social worker. I suggested to Joyce for us to work together on a budget plan for her allowance of ten pounds to ensure she does not run out of money before the end of the day. I created a blank finance contract and Joyce came up with the ideas of spending five pounds a day on cigarettes and five pounds on coffee. This does not work always as Joyce at times prefers to spend ten pounds on coffee only. This usually leaves her without money for cigarettes and mostly lead to incidents. I am aware Joyce has capacity to make decision which at times may have negative impact on her behaviour and I must respect her choices.
There seemed to be no clarity on what is expected of agencies and other professionals on Joyce case. For several weeks now Joyce has been breaking plates, cups and other households’ belongings which belongs to the community. Joyce was involved in two incidents whereby she threw a kettle and a remote control to the staff. I completed the incident report and the manager forwarded them to Joyce psychiatrist. As a team member I felt that Joyce’s health was deteriorating and needed psychiatrist intervention for assessment as soon as possible as this was also the first time for Joyce to throw things at staff. The psychiatrist did not respond to the emails and this could be mostly likely due to high caseloads, which was likely to lead to being overworked and overstressed, this practice was likely to leave vulnerable adults at risk (Grobman, 2012). The agency was in a dilemma they had to balance safeguarding a vulnerable adult or issuing Joyce with an eviction letter. The agency funding comes from the local authority and there is fear of loss of contract if they evict the service users as they may be seen as not offering the right support or coping with the service user’s needs. According to Bank (2012) professionals should communicate with each other, engage and make complete interpretations of the service user. Safeguarding Vulnerable Adults requires agencies to ensure that in order to achieve positive outcomes for vulnerable adults their staff need to share information (Hughes and Owen 2006).
Joyce stated that when she moved to the project she did not leave the house for one year as she was too scared to go out. Joyce also informed me that she found it difficult to make new friends for fear of being discriminated against due to her learning difficulties and mental health problem. Due to social prejudice, stigmatised individuals experience negative outcomes. Therefore, I attempted to build an alliance without reformulating Joyce’s perspective (Paris, 2002). In addition, I knew from research Joyce was likely to need help in coping with the loss of self respect (Council, 1999). I was aware that Joyce was likely to be teased due to her previous incidents in the project of breaking cups and plates.
After completing the assessment, I went through the information recorded and gave Joyce a chance to add or rectify the record to ensure an accurate account had been made (PCF2). This was because social work activity is often focussed towards filtering and prioritising requests for a service whereby needs are either met or partially met (Beckett, 2010). Joyce engaged very well and was receptive to advice given. I observed her having good interactions with some of the residents in the community.
Empowerment is an ongoing process with shifting goals, this does not happen in a step by step process (White and Harris, 2001). I provided a platform for Joyce and enabled her to define her own needs, she had a say in planning and decision making. In doing so I equipped her to take power by acquiring confidence and self-esteem (Ibid, 2001).