Making sense of mental health problems
Making sense of mental health problems

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Making sense of mental health problems

1.1 An assessment of Mandy’s situation

In this section you will focus on the case study of Mandy and carry out your own initial assessment of Mandy before finding out more about how different mental health practitioners might assess her. Read the case study summary below and then answer the questions that follow.

Case study: Mandy

Figure 2 ‘Mandy’

Mandy is a 25-year-old woman who lives alone in a small privately rented flat.

Mandy’s birth mother had problems with drug addiction and led a rather chaotic lifestyle, which meant that her contact with support services was intermittent. She never revealed who Mandy’s father was and had started to live with another man some months after Mandy’s birth. After social services were called in to investigate suspected physical abuse within her mother’s home, Mandy was taken into care at the age of two. She was fostered by a couple in a nearby town who went on to adopt her. The couple wished for Mandy to do well but rarely displayed warmth or love either towards her or towards each other.

Mandy found it difficult to settle at school, but at the age of 15 she began to take a keen interest in art. This new interest motivated her to work harder, and she left school with A Levels in art, English and geography. She went on to study art and design at a university located in a city more than 100 miles away from her family home, and maintained only minimal contact with her adopted parents. She enjoyed the course and the student lifestyle, throwing herself into the social scene associated with the Art Department and its students.

Mandy was in a relationship with a fellow male student while at university. After graduating they stayed in the same city and moved in together, but neither of them was able to find a job that used their degrees; thus they regularly grew despondent and rowed frequently over money. Mandy worked as a waitress for a few months but found it too stressful and tiring, so she went to work in a department store instead. Her boyfriend decided to move to another city in the hope of finding better work there; the distance drove them apart and they eventually split up.

Meanwhile Mandy tried to distract herself by using her spare time to create abstract paintings and by socialising with some other graduates from her course who had also stayed on in the city. But she couldn’t help comparing herself to the other graduates, who all seemed to be much more successful in their careers than she was. Over the next few years her contact with these other people gradually declined and she spent most of her free time in her flat, either painting or watching television. She often found that she was consumed with a deep sense of dissatisfaction with how her life had turned out and wondered at times if this was all life had to offer. 

In the past year Mandy has started to hear a voice commenting on what she is doing. At first she thought it was someone outside the flat talking through the door, but each time she opened the door, there was nobody there. Sometimes the comments are negative, at other times, they merely describe what she is doing at that moment. She recently found out that her ex-boyfriend is getting married and has since been feeling particularly depressed. The voice has become increasingly distracting of late. During a recent shift at work, when she encountered a difficult customer who accused her of short-changing him, she found herself unable to stop herself from shouting at him the things which the voice had uttered. She woke up the next morning with a bad cold, which she used as an excuse to take time off work. She has not been to work for the past two weeks, only leaving the flat briefly to run small errands. She has not told anybody about hearing the voice and has told her work manager that she was down with ‘the flu’. She is vaguely aware that she feels out of sorts but hopes it will pass.

Activity 1 Your assessment of Mandy

Timing: Allow about 45 minutes

Imagine that Mandy has asked you to help her make sense of her problems (and decipher the possible solutions) by writing these down on a piece of paper, so that she can take these notes with her when/if she goes to see her general practitioner (GP).

To do this, try to write a few paragraphs in response to each of the questions below as if you are preparing notes for Mandy. At this stage use your own judgement and experiences, recording your initial thoughts, without worrying about there being a ‘right answer’ to the questions posed.

Once you have recorded your initial ideas, you could look at the Comment section which enlists some brief points that you might like to consider. Having read these you could add any ideas that seem relevant to your notes.

  • a.What is the main problem, or are the main problems, affecting Mandy?
  • b.What are the likely causes of these problems?
  • c.What support (if any) does Mandy already have in place?
  • d.What services (if any) could Mandy be referred to for further assessment and care?
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These comments are not intended as a ‘model answer’ but might help you to think of alternative answers to the questions posed.

  • a.The main problem Mandy is facing seems to be that she hears voices and finds this disturbing. This in turn is limiting her ability to lead the life she wants.
  • b.Depending on your viewpoint you could have identified one or more different factors that may have caused Mandy to hear voices. Below are some possible questions that could also be used in a real-life situation (some of which might be difficult to discuss with Mandy), but you may have come up with different questions and ideas.
    • Did she inherit a genetic predisposition to experience hearing voices (auditory hallucinations) from one or both of her biological parents?
    • Did she experience abuse as a young child that has left a legacy of ongoing trauma?
    • Did the experience of being taken from her birth mother contribute to her later problems?
    • Is the previous lack of emotional warmth from her adoptive parents a factor in her having difficulties now?
    • Did she experiment with recreational drugs as a student, and did this trigger unusual (i.e. psychotic) experiences?
    • Is she experiencing stress or dissatisfaction in her current life that is causing her to have these problems?
    • Moving outside of conventional explanations, is Mandy sensitive to messages from ‘spirits’ or other forms of disembodied beings that most people are unable to communicate with? This might be something that, for instance, followers of Shamanism could consider to be a possibility.
  • c.It is not clear what support Mandy has in place. She does not have much contact with the couple who raised her (i.e. her adopted parents) and she has reduced the time spent with friends in favour of more solitary activities.
  • d.What suggestions did you come up with for sources of help for Mandy? Did these reflect what you saw as the cause of her problems? For instance if you saw her as being influenced by previous events in life, did you think she needed counselling to deal with these? If you thought she had some sort of brain disorder, did you think that she needed medication? Or did you think she had social problems that needed a more informal approach? 

Having made your own initial assessment of Mandy’s situation, you will now hear a group of mental health practitioners talking about how they would approach the task of assessing her need for support and treatment. In subsequent activities later in this course, you will have the opportunity to learn about their approaches in more depth.

Activity 2 Mental health team discussion about Mandy

Timing: Allow about 20 minutes

Now watch the video of a psychiatrist, a clinical psychologist and a social worker discussing their approaches to the case study of Mandy.

You will examine each practitioner’s approach in subsequent activities in this course. At this stage just make a few brief notes about the similarities and differences in their approaches that emerge from the discussion.

Download this video clip.Video player: Video 1 Group discussion
Skip transcript: Video 1 Group discussion

Transcript: Video 1 Group discussion

In terms of Mandy and the challenges that she’s facing, what stands out in terms of the issues that Mandy has at the moment?
The main thing I suppose that stands out for me is the fact that she’s experiencing these voices, so those voices are characteristic of, oh, I would say, a psychotic illness, for example schizophrenia. However, obviously, there’s lots of other difficulties that she has in her background, which you’d be wanting to take into consideration both in terms of her diagnosis but also in terms of how you might help her.
I’d be interested to find out a little bit more about her background. I think in terms of psychological formulation, I’d be wanting to assess whether there is anything in her past that maybe has been of a traumatic nature that might have made her more vulnerable to succumbing to these experiences which she’s having in terms of hearing these voices and why they’ve come up now.
Obviously, we want to find out about her past. But we also want to find out a bit more about what’s happened in the present. So usually, we might go back the last two weeks or what was the last significant event for Mandy? So it might have been losing her job. What happened in that getting a bit of an idea of her networks. Does she go out? Did she used to go out?
Has she got a circle of friends? Does she see family? So those kind of things a bit more, so you get an idea of what type of lifestyle she has. Does she drink? Does she party?
She’s a young person. What are the things that she likes to do? Has she got any plans for the future? That’s a good indication of where someone's mind is at in terms of are they making plans for the future or do they feel everything’s hopeless?
One of the cornerstones of our work is that we work in a multidisciplinary way. It’s quite usual for us to do joint assessments. So from a psychiatric point of view, it’s very helpful to have another perspective from a different angle.
So I would be interested in looking at it in a particular way, for example thinking about diagnosis and thinking about treatment, especially in a more medical perspective. But I would be drawing very much upon the experience of my non-medical colleagues, who bring something very valuable as well.
I guess I’d want to know, from Mandy’s perspective, what it is that she thinks is the problem at the moment, because it may be that what we think is the problem, which may be that she’s hearing voices and that she’s begun to isolate herself further, that may not be the primary problem for her. For her, it might be that she’s feeling very low in mood. She might be at risk of harming herself, for example. And that might not be something that we’ve been told about. So we might want to do a full assessment to explore that further.
From the social work perspective, I wouldn’t be focusing as much on the diagnosis but on the effects of the symptoms itself. So her being socially isolated, withdrawing, those are the things we’d be focusing on and minimising risk to her, so trying to prevent self-neglect, measuring the risk, those are the things that we would be doing in the first instance.
Pending on your theoretical perspective in terms of psychological theory, we would be looking at constructing a psychological formulation, thinking about whether there are any early experiences that have predisposed her to hearing voices. So I’d want to know whether as a child she’s learnt particular ways of coping with stress or distress and whether as a grown-up these patterns of coping have become maladaptive. I’d want to know about her family history, whether there’s anybody else in the family that’s had similar experiences. I’d want to know whether there are any current triggers that maybe have caused these difficulties.
And I’d probably hypothesise that perhaps she’d had similar experiences in the past that she hadn’t told people about. So there may be lots of things that could then contribute to a formulation and a plan of action really.
And we didn’t mention stimulants. You know, that be a question, it might be uncomfortable, but to ask her, has she taken drugs, alcohol? Those kinds of things can have an impact from a younger age.
What standardised tools or assessments might people use to help in terms of assessing Mandy?
We have a core assessment that we would use. So meeting her for the first time, we’ve completed core assessments that would go through background history, medical history, previous mental health history, social networks.
Substances, education.
Financial. So very holistic assessment, which should really pick out a lot of information.
Because I use hardly any, I think.
Yeah, it’s hard, isn’t it? Yeah. I mean, it’s hard because when you’ve been a clinician for a while, you don’t really remember the kind of standard, a structured tool that you’d use, necessarily. But in terms of psychology, we would be thinking about using an early intervention service specifically designed for Mandy if this is her first presentation with experiences of voices. We might use, yeah, there are various standardised measures of psychosis. But certainly at the beginning of her entry to a community mental health team, it would be much more of a generic assessment – finding out everything about her past and particularly focusing on current stressors, because it seems like that’s maybe what’s causing her to deteriorate at the moment that combined. Finding out her boyfriend is getting married, not having work, I would think that we would be focusing on the current stressors.
End transcript: Video 1 Group discussion
Video 1 Group discussion
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Some features to consider when pondering over the similarities and differences in the practitioners' approaches could be:

  • How did the language that was used in the group discussion differ according to the professional background of the practitioner (e.g. who used terms like ‘diagnosis’ and ‘psychotic illness’ and who used phrases like ‘traumatic nature’ or ‘social networks’)?
  • What aspects of Mandy did each practitioner seem interested in assessing further (e.g. which of the practitioners seemed most focused on Mandy’s distant past [or early life experiences] and why did they think this was important information)?
  • The practitioners mentioned the value of mental health practitioners working together to support someone like Mandy. Why are varying perspectives thought to be useful?
  • Mental health practitioners will be similar in that they would all say they want to assist someone like Mandy – what did the practitioners say that made you think they would want to help Mandy?

Having made your own informal assessment of Mandy’s situation and having had an introduction to three different practitioner perspectives, you will find out more in the next three sections about how the different practitioners perceive the problems Mandy faces. 


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