Chapter 6: Diversity issues within mental health care

Case Study: Paranoid schizophrenia

Aamina is a 22-year-old female.  She was born in Karachi in Pakistan, but she was brought over to Northern Ireland when she was two years old with her two older brothers by their parents. There were no reported problems in her childhood and she met all her developmental milestones.  However, her parents were noted to put a lot of pressure on their children to study and do well academically. Aamina did very well at school, and was 18, in her first year studying philosophy at The University of Cambridge, when she became unwell. She started to fall behind with her university work and lost interest in socialising, choosing to stay in her bedroom alone. Aamina became very private and isolative, and she would not allow anyone access to her room.  Her behaviour became irritable and defensive. Her Personal Tutor at the University contacted her parents with these concerns. However, they were very dismissive and refused to accept that anything was wrong. Therefore, Aamina received no formal mental health assessment.

Index Offence

On 30 January 2013, Aamina invited fellow student and friend Vorana back her room so they could study together. Later that evening, Aamina was found by the police wandering the street covered in blood shouting repeatedly: ‘Jakata is coming, Jakata is the highest order, and I have obeyed his orders.’

The police brought Aamina to the Cambridge Mental Health Unit under Section 136 of the Mental Health Act 1983 [as amended]. When the police went back to check Aamina’s room they found Vorana dead. She had been stabbed seven times.

Aamina was subsequently convicted of the manslaughter of Vorana on the grounds of diminished responsibility and diagnosed with Paranoid Schizophrenia. She was sent to a high secure hospital under section 37/41 of the Mental Health Act 1983 [as amended] where she remains an inpatient.

Past Psychiatric Care   

On admission Aamina was nursed in seclusion owing to her unpredictable and violent behaviour towards staff and fellow patients. Despite attempts to nurse Aamina on the ward, on each occasion she became violent and attacked staff or fellow patients.  She appeared to show no insight into her illness or index offence.

Current Presentation

Aamina has been in long-term seclusion for the past 18 months. Her family have recently requested to visit her every Thursday; this has not yet been facilitated. They have also asked if they can bring her homemade Halal food when they visit. She has also expressed a wish to practice her Muslim religion. Nursing staff insist on her wearing a ‘strong suit’1 while in seclusion, as Aamina has been known to self-harm. Aamina becomes very distressed being forced to wear this suit, as it does not cover all of her legs.

Question

What would you do any why to facilitate Aamina to practice her religion in this situation?

1 A ‘strong suit’ is a piece of clothing that cannot be ripped.  The patient wears this in lieu of their own clothing. It is used when there is a potential that individuals may use their clothing to ligature.

› Possible answer

  1. Ensure that a finger food Halal diet is ordered for Aamina, as she may not be allowed cutlery in seclusion. 
  2. Nurses should adhere to local policies in regards to food being brought into the hospital from visitors. The policy would need to be explained to Aamina and her family.  
  3. If Aamiina is too unwell to receive a visit from her family, staff should care plan access to a telephone thus allowing her to maintain contact with her family.   
  4. Ensure Aamina has access to an Imam.
  5. Obtain a bespoke ‘strong suit’ for Aamina that covers her legs, and constantly assess whether this is actually required. 
  6. Aamina must prey facing to Mecca. Therefore, the ward should obtain a qibla compas (or qiblah) that points in the direction of Mecca. This will enable staff to enter the seclusion room during a seclusion review and mark a stop on the seclusion room floor that points in the direction of Mecca thus orientating Aamina during her prayers. 
  7. Before performing certain rituals, most importantly before prayers, Muslims are expected to perform a form of purification, known as ablution or ‘wudu’ in Arabic. This involves washing the hands, face, arms and feet with water. Given that Aamina is in seclusion, she may not have access to running water. Therefore, to allow her to meet this ritual and to maintain her safety, staff need to provide her with fresh water in a disposable cardboard pulp kidney dish bowl before her prayers.