A nurse who never gives up

Clinical nurse specialist Dorcas Gwata is the winner of the Mental Health category of this year’s Nursing Standard Nurse Awards. She specialises in work with young people involved in gangs who are at high risk of violence, sexual exploitation, self-harming and substance abuse. Her empathy and persuasive style means she can engage young people who would otherwise reject help.

Picture credit: Nathan Clarke

‘A lot of my patients do not take their ritalin and have poor literacy skills,’ says clinical nurse specialist Dorcas Gwata. ‘Anxiety is a major problem. These young people carry knives and incidents can often spiral into anxiety as they expect reprisals after stabbings. And their high levels of substance misuse can escalate into untreated psychosis.’

The London mental health nurse holds a unique role in the Westminster Integrated Gangs Unit (IGU). She won the Mental Health category of the 2015 Nursing Standard Nurse Awards in recognition of her innovative engagement with difficult to reach young people, and her culturally sensitive approach to families and communities affected by gang culture.

Ms Gwata is a member of the Central and North West London (CNWL) NHS Foundation Trust’s Westminster child and adolescent mental health service team, which aims to improve the health of socially stigmatised, deprived young people associated with gangs. The team works with social services, the police and community protection.

Ms Gwata was brought in to the team following a Home Office report in 2011, which showed significant unmet mental health needs in young people involved in gangs.

Some have developmental problems such as learning disabilities as well as health needs, substance misuse and behavioural problems. ‘Young people often end up in gangs because they are rejected from their homes and the gangs provide a perceived sense of family and protection,’ says Ms Gwata.

Teenage girls are at particular risk – 20% in Westminster are involved in gangs. They are in danger of sexual exploitation and subsequently of self-harming or substance misuse.

Ms Gwata receives referrals from five key workers who identify young people with basic mental health needs, as well as those who might be having difficult relationships with their peers. She has built links with youth offending teams and probation services, and does in-reach work in prisons before inmates are released. She also liaises with workers from Red Thread, a youth violence intervention project.

I never use the word gang in my work – it is about peer relationships

Getting young people with chaotic lifestyles to engage with services is one of Ms Gwata’s biggest challenges. She has to call on her 18 years’ nursing experience, including in emergency and trauma, as well as her skills in child and adolescent mental health.

Hard-won experience outside the UK has also proved invaluable in her current role. ‘I developed my innovative thinking and practices from working in developing countries where they have minimal resources,’ she explains.

She says she often uses clients’ physical health needs as a ‘way in’ to a mental health assessment. A key strategy has been strengthening pathways with emergency units and other hospital and community services.

‘Except for the most severe cases, the young people use A&E very minimally,’ she says. ‘And if someone is stabbed, nurses there can find it extremely difficult to manage these complex cases.

‘It can be difficult to gain access to the young person if gang members are present, but we have a pathway if they are discharged. They will not go to an outpatient clinic, but I can provide follow up.’

Ms Gwata has to be highly flexible. She meets clients on the streets, in cafes, at their homes and at youth clubs. ‘A lot of the time I just jump on my bike and cycle around Westminster. Some clients don’t wake up until 2pm so most assessments are after 4 or 5pm.

‘I regularly get stood up, but I look at context and what it means – what is going on with that young person, their behaviour and lifestyle. It takes a lot of perseverance. When a young person is not engaging, we have to look at alternatives. We might intervene when they are at school, or if they are in custody without their gang I visit and see if we can have a chat.’

Timing can be crucial. ‘There can be a dip before a breakthrough. There is a high level of violence around the transition time from adolescence to adulthood, aged about 15 to 17.’

How Aisha was helped to build a better life

Aisha is a 15-year-old British/Iranian girl who had been associating with gang members. Videos of her performing oral sex were on social media.

After she was admitted to St Mary’s Hospital in Paddington, following an overdose and attempted self-stabbing, Ms Gwata saw Aisha for an urgent assessment for self-harm risk. Aisha disclosed that she had been misusing cannabis, cocaine and alcohol.

Child protection concerns were reported to social services and a child protection plan implemented, including intervention for sexual exploitation.

Ms Gwata worked with Aisha’s mother on reducing risks of self-harming and overdose at home. This meant storing medication safely, having no razors around, keeping sharp knives away – and monitoring the child’s behaviour regularly. She also advised the mother to have a very low threshold for calling an ambulance.

Aisha has been referred to sexual health services and the family has been helped to move to housing in a new area.

Language is also important. ‘I never use the word gang in my work – it is about peer relationships,’ says Ms Gwata.

The skill is in making every brief contact count.

So what does she say to a 15-year-old drug dealer in ten minutes? Ms Gwata says she talks about the risk factors associated with drug dealing and how it affects the young person’s sense of safety, physical health and family.

‘We might discuss ways of reducing criminal activity, building healthier peer relationships, and social enterprise projects for them to earn legitimate money and life structure. I would also discuss appropriate sexual behaviours around young women.’

If a young person refuses to accept her intervention, she will try to appeal to their parents. A non-judgemental attitude is crucial. ‘I have had 80% acceptance from parents. It is very important that I’m not there to “take their kids away”.

‘There is a huge conflict between young people’s values and their parents’ values, which tend to be conservative,’ says Ms Gwata. ‘Parents find it hard to understand the concept of their children having sex before marriage and there is real stigma around that. Much of my work is about repairing family relationships.’

To help vulnerable young women, Ms Gwata developed links with a sexual health clinic at St Mary’s Hospital in Paddington. ‘There are high levels of chlamydia among girls involved in gangs,’ she says. ‘And we look at the mental health impact of sexual exploitation, which can escalate quickly into self-harm. Of course these interventions occur alongside appropriate safeguarding and child protection measures.’

There are safety planning measures for girls at risk of sexual exploitation and kidnapping, and a mental health plan to help reduce self-blame and self-harm.

As many as 80% of the young people Ms Gwata works with come from a minority ethnic background.

‘If we didn’t pay attention to culture and the impact this has on the families, we would be missing a huge chunk of potential positive interventions,’ she says. Her work involves complex cultural clinical issues such as female genital mutilation and safeguarding for African children.

Dorcas Gwata is ready to meet her young clients in any environment

Picture credit: Nathan Clarke

Ms Gwata has been a mental health adviser for AFRUCA (Africans United against Child Abuse), providing mental health interventions to those affected by accusations of witchcraft and by human trafficking.

Even with all her experience, her current role is challenging. She admits that clinical evaluation can be tricky.

‘The short attention span for young people with learning disabilities and their high-level substance misuse means we have not been able to implement standardised questionnaires and measures, which would have been useful,’ she says.

Ms Gwata knows that her services are not reaching all the young people who need help. ‘We can only help those who become known to the police or social services,’ she says. ‘Others may be at risk of exploitation and engaged in high-risk behaviour but are not yet proved to be committing crimes.’

Persuasive style

Her colleagues and partners testify that she has made real improvements to her clients’ health and to their lives.

IGU acting inspector Al Cowen says: ‘Dorcas has worked with numerous gang members, many of whom have been subjected to highly traumatic experiences. She offers invaluable advice and guidance during our daily meetings, and it is helpful to be able to refer clients to her direct. She is an integral part of our team.’

How engaging three generations paid off

John is a 15-year-old British/Congolese boy who was at the top of the police risk matrix. He has a young mother and was responsible for a one-year crime spree following his father’s absence from the country and his involvement with a new set of peers.

John’s family were struggling with his behaviour and relationships were breaking down.

Ms Gwata worked with both John and the family to change the cycle of his behaviour, using a culturally sensitive approach. This recognised and appreciated the impact that John’s actions were having on the family’s relationship with the community. The grandmother was the matriarch in the family and rebuilding John’s relationship with her was the key to addressing his behaviour.

Ms Gwata also worked with John’s parents on their parenting skills and helped them set boundaries for their son. With John, she helped him to learn to respond to his mood and life events in a less antisocial and more self-regulated manner.

Her clinical supervisor, CNWL consultant child and adolescent psychiatrist Tami Kramer, says Ms Gwata’s way with young people has secured her success in a difficult field.

‘Dorcas is able to engage young people who are not primarily looking for help and are often initially dismissive of their need for professional intervention,’ says Dr Kramer. ‘Her warm, enthusiastic and persuasive style enables these often inarticulate youngsters to share and reflect on their general and mental health needs and the links with their behaviour.

‘She never gives up on giving young people the chance to find positive solutions to their life dilemmas.’

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