Scenario: I suspect the person I am supporting is not taking their medication

The scenario

You are a case worker with an organisation that provides services to people living with a disability who require support to participate in their community.  The person you are working with, John, has been diagnosed with schizophrenia. He has experienced severe psychosocial disability that has impacted his quality of life.

You are assisting John to build his capacity to participate independently in a monthly model trains group, his favourite hobby. You have been working with John for two months and have got to know him quite well. He has been well during this time. His confidence is growing and it’s clear that he feels very comfortable with you. He is now tentatively interacting with others in the hobby group.

When you meet John at his home, he hesitates to let you in and is not dressed ready to go out. He appears anxious, continuously glancing at you nervously and looking away. When you enter the house, it looks unusually untidy. When you try to engage with John about today’s activity and ask if everything is alright you hear him say “Yes, yes, yes, yes ...” the rest you do not understand as he is talking very fast, his words are hard to understand and he isn’t listening when you try to interrupt. This is not like John at all.

You suspect John has not been taking his medication. You have talked to John previously about what you should do if he seems to be getting unwell, and he has said you should contact his mental health case worker.

Tips for responding in the moment

How you react is important:

• Remain calm and friendly as usual.
• Listen to gain an understanding of John’s current reality, showing interest e.g. look at him, nod your head.
• Speak quietly using short, simple sentences. When asking a question give John time to process the information and respond.
• Where possible ask questions to clarify what John is experiencing.
• Don’t state any judgments about what John says he is experiencing.

What you could say:

• State the specific behaviours you are observing that are concerning you e.g. “John you are talking very fast. I am having trouble understanding what you are saying” or “You seem to be anxious. How are you feeling?”
• Whether John responds or not, reassure him that you are there to help and support him and reassure him that he is safe.
• Ask John what will help him to feel safe and in control e.g. “What can I do to help?” or “What has helped when you have felt this way before?”
• Offer John choices of how you can help e.g. “Would you like to call someone to help?” or “Would you like me to call someone to help?”
• Ask John if he is happy for you to stay with him until help or a trusted support person arrives. If not, let him know you will be close by if he needs you.

What approach you could take:

• As far as possible, let John set the pace and style of the interaction. Given John’s thoughts may be confused and he may be frightened by his thoughts and feelings, he may not respond to your questions.
• If John says he doesn’t want you to call anyone, state your concern about his wellbeing. Remind him that he has given permission for you to speak to his mental health case worker when you are concerned that he is becoming unwell, and that you feel this is one of those times.

What de-escalation actions you could take if John becomes aggressive:

• Take any threats or warnings seriously.
• Do not respond in a hostile, disciplinary or challenging manner.
• Avoid raising your voice or talking fast.
• Stay calm and avoid nervous behaviour e.g. shuffling your feet, fidgeting, making abrupt movements.
• Do not restrict John’s movement e.g. if he wants to pace up and down the room.
• If you become concerned for the safety of John or yourself remove yourself from the situation, keeping John in sight if possible, and call the Mental Health Line on 1800 011 511.

Tips to help prepare for next time

• Contact your supervisor and provide the details of what occurred to obtain advice on future contact.
• Follow up with John’s mental health case worker before your next meeting with John to agree on the best approach for your future involvement.
• Always follow your organisation’s policies and procedures regarding your own and client safety.
• Look after yourself. Speak with your supervisor and ask for help if the situation has left you with feelings of unease. Many organisations will have an Employee Assistance Program where you can talk to someone confidentially.

Resources

Mental Health First Aid: Psychosis First Aid Guidelines
This guideline helps you identify signs that psychosis is developing, and includes how to approach the person, and how to deal with delusions and communication difficulties.
Type: Guidelines (PDF)
Length: 3 pages
Produced by: Mental Health First Aid

Schizophrenia Fact Sheet and Guide
This fact sheet explains schizophrenia, how to recognise it, and how it can be treated. The site also provides a guide to support people experiencing schizophrenia, their family, friends and carers.
Type: Fact sheet and guide
Estimated reading time: 10 minutes 
Produced by: SANE Australia