The Flip Side of Seriousness

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Obum Mokeme. The Flip Side of Seriousness

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1. IT’S A BABY!

THE PRESENTING SCENARIO ON ADMISSION: Danny was admitted in a manic state. On admission, he presented with an elated mood, grandiose ideation, and a degree of disinhibition. He was also easily distracted and interfering. He was well known to mental health services, having previously had several admissions into hospital with similar presentations. He had been doing well but had recently become highly excitable and unmanageable at home. His behaviour had become so disturbed and threatening that his pregnant girlfriend feared for her safety. There was a high risk that he might become physically violent towards her as he believed that her pregnancy was the cause of his current problems. BACKGROUND TO THE PRESENTING PROBLEMS: Danny has worked as a clerk at various places but he found it increasingly difficult to hold down a job for more than a couple of months. His behaviour was such that he was quite difficult to be with. He was too highly strung and quarrelsome. He was easily provoked, argumentative and disruptive at home. At work, he was often in trouble for frequently being absent from work and for the poor performance of his duties. He was unable to concentrate on one issue at a time for a considerable period of time. He tended to jump from one topic to another without successfully completing any one task or story before taking on another. His last employer tried to help him by sending him to a number of courses to help improve his performance at work but he came back without completing any of the courses he was sent to. In his view, the tutors did not like him. The fact, however, was that he was unable to cope with constructive activities or to concentrate on one task long enough to bring it to a conclusion. After a couple of months, he stopped showing up at work altogether. At home, he still behaved like a teenager. He still expected his parents to continue to provide for him even though he was now a fully grown man. When he left his last job, he stayed at home most of the day and went out in the evenings. He applied for unemployment benefits and was overjoyed when he received the first instalment of his benefits. He kept the payments he received for his personal use as pocket money and refused to make any contribution towards his upkeep or that of the family home. He also refused to contribute to the physical maintenance of his home, such as helping out with cooking, gardening or any other house work. He frequently flared up when his parents asked him to pay for anything or to perform any chore at home. In order not to provoke him into an uncontrollable rage, his parents did not insist that he should make some contribution towards his keep. He spent his benefits to himself without any consideration for the sacrifices made by his parents. Gradually, he became involved in more altercations both at home and with his friends when he went out in the evenings. His parents began to find it too difficult to manage him at home and they suggested that he should make an application for his own separate accommodation. In response to this suggestion, he smashed up nearly everything in the house. His parents realized that his reaction to their suggestion was not normal behaviour and that something was wrong with him. They called the police to help prevent further damage to their home. When the police arrived, Danny tried to run out of the house but was stopped by two police officers. He was partially restrained, cuffed and escorted into the police van. When they arrived at the police station, he was assessed by the Force Medical Examiner (FME) commonly known as the police doctor. The police doctor identified symptoms of a hypo-manic state. He was deemed to be mentally unstable and was referred to the A&E department of the local hospital for further assessment. After a second assessment by the mental health professionals there, it was decided that he would benefit from a short admission into hospital for a full assessment and a review of his current treatment. Danny was eventually transferred to one of the acute mental health wards at the local mental health hospital. After a short period of observation on the ward, he was diagnosed to be suffering from a mood disorder known as a hypo-manic state. He remained in hospital for a few weeks during which time, his parents were seen in ward rounds nearly every week. In the ward rounds during the course of his various admissions, his parents provided useful information about the onset of Danny’s illness, his family history, his childhood milestones, the level of his education and his performance at work. At the end of all the investigations into the causes of Danny’s illness, the opinion of the ward team was that his major stressor was an extremely low stress threshold due to poor impulse control. In conjunction with the medication that had been prescribed for him, they identified further activities which they hoped would help Danny to remain well post discharge. The activities included breaking up his week into three blocks to help improve his educational level; day centre attendance for recreational activities and life skills acquisition to prepare him for independent living. The ward psychologist felt that in addition to this treatment plan that had been prescribed for him that Danny might also benefit from a psychological input to help him to gain more insight into his behaviour and to help him better manage his impulses and his stress levels. He was discharged back to his family after a two months stay in hospital. That was about six years ago. At ward rounds during his current admission, it became clear that the triggering factor was that Danny became extremely upset that his girl-friend was expecting a baby. He felt that she should have taken precautions to prevent her from becoming pregnant. In order to enable him to gain some insight into his situation, he was asked what he thought would happen if both he and his girl-friend were not taking any measures to prevent her from getting pregnant. In response to this question, Danny insisted that she should have ensured that she would not get pregnant. After several attempts at explanations about whose responsibility it was to prevent a pregnancy were offered to him, he reluctantly admitted that he could have reminded her to take precautions. That was the extent to which he realized that the pregnancy was as much his fault as it was hers. It was then that it dawned on him that they were both equally responsible for the pregnancy. He conceded that it was also his fault but he went on to add that she should have informed him that she wanted to have a baby as he was not yet ready to be a father. His last statement caused quite an uproar of laughter in the conference room. He was told that couples routinely discussed such things but that the reality was that the baby was almost here. His girlfriend was in the eight month of the pregnancy. When Danny was advised to either abstain or take other forms of precaution in future, he asked what that meant. After a lengthy explanation was given, he retorted angrily that it would have been easier if the doctors did not use fancy words. He said that he could simply have been told not to sleep with his girlfriend. He then added that he would not abstain because he was not a priest. That was followed by another episode of mirth. After a short interlude, he agreed that in future, he knew what to do as he was not ready to have more babies. That was about six years ago. It was during his first admission to this ward that Danny met other young patients. He found out that most other patients had their own flats and lived independently with the help of care co-ordinators. He learnt that some of them only visited their families at weekends and festivals and that they also attended recreational activities or classes as part of educational programmes which were organised for them by their care co-ordinators. He joined ward based activities and realised that he was actually good at some of them. He enjoyed such games as table tennis, snooker and quizzes. He was surprised when other patients were visited by their girl-friends because his parents were his only visitors. He began to look forward to going home and perhaps finding a girl-friend too. Before he was discharged, he was allocated a care co-ordinator for his after care. The name of his care co-ordinator was Simon. A few months after he was discharged from the hospital, Simon helped Danny to secure his own accommodation. His benefits were also reviewed to reflect his current needs. In order to prevent a relapse, Simon also visited Danny forth nightly to ensure that he was compliant with his treatment regime. Danny was encouraged to visit Simon at work every other week. This way, he had weekly contact with Simon. During this interlude, Danny met Moira at the day centre and they become friends. Eventually, Moira became Danny’s girl-friend. As Danny was doing quite well under Simon’s close supervision, both Simon and Danny reached an agreement to reduce the weekly contact to monthly visits. In essence, Simon visited Danny once monthly while Danny visited him once a month. However, the plan fell apart when the contact between Danny and Simon was extended by Simon going away on holiday. While Simon was away, Danny suffered a relapse and was re-admitted into hospital. That second admission sort of confirmed that there was an enduring mental health problem which required revaluation and closer supervision than his current treatment plan and Simon’s monthly visits. As time went on, Danny eventually had more admissions. The triggering factors varied; ranging from an altercation with his parents, to a fight in the pub, or disagreements over trivial matters with Moira. Each incident began as a trivial issue but quickly escalated into a major incident often requiring the intervention of law enforcement agents. The trigger for his current admission was an elevated stress level which started when he found out that his girl-friend had become pregnant without his consent. He felt that he was not ready for fatherhood and should have been consulted over the matter beforehand. TREATMENT PLAN:

RELAPSE PREVENTION:

2. THE DISFUNCTIONAL FAMILY!

THE PRESENTING SCENARIO ON ADMISSION: Ann was admitted into an acute mental health ward. She had been sent to the hospital by the occupational health doctor at work. Her boss had observed a steady deterioration in her work. She was also not her usual ‘perky’ self. After a brief evaluation by the doctors at the local Accident & Emergency Department, she was referred to the ward for a full evaluation and treatment. BACKGROUND TO THE PROBLEMS PRESENTED: Ann has an older brother, one older sister and another younger sister. They all lived with their mother in a three bedroom council flat. Their mother brought them up as a single mother. The children were still quite young when their father abandoned his family. He went to work one day and did not return. Nobody had seen or heard from him ever since. His wife had exhausted her searches before she went to the police station to report him as a missing person. She had already been to see all his relatives as well as hers but nobody had seen or heard from him. The police reported that there was no trace of the husband and father and that the case has been closed. After several months of going to beg for money, food and toiletries from various family members, she was advised to go to the council offices for help. At first, she was too ashamed to approach the council for help. But relatives started turning her away when she came round again and again to ask for help. Some refused to see her while others told the children to say that they were not at home. The situation became increasingly difficult. She tried to ration the food and the snacks that she was able to find in order to stretch what little they had. But children do not understand such reasoning especially if they were used to a different standard of living before. Eventually, she had to swallow her pride and go to seek help from the council. She was directed to the social services department which dealt with issuance of benefits. After the usual information gathering; investigations; and confirmation that her case was genuine, funds were allocated to her and to her children. Things improved for the family. The first two children were neither in education nor were they interested in learning new skills to help them get into the job market. They had already been missing school as there was no money for transport to and from school. Now that they had some help from social services, the two older children still refused to return to school in spite of their mother’s efforts. The school took their mother to task about her failure to get her children to attend school but there was not much that she could do besides prompting them to return to school. Gradually, they dropped out from education one after the other as they reached the age of sixteen. The two oldest children, George and Susan both left school without any qualification. George appeared to be Susan’s role model. Whatever he did, she copied. They both also refused to attend the free skills acquisition classes run by the council. Ann was the third child. She seemed to be the sensible one. She asked her mother if she could be transferred to a school nearer their home so that she could walk to school as she would not need transport fares. Her mother was both surprised and delighted by Ann’s suggestion that she had both Ann and Robin, the youngest, transferred to the nearest primary school. Both children went on to complete secondary school education at a secondary school near their home. Ann left school with seven GCSC’s. She did so well that her teachers encouraged her to go on to study for Advanced levels in preparation for university but she declined to do so. She was in favour of finding a job so that she could help her family. Meanwhile, while she was still at secondary school, Ann worked at the local shops during weekends and school holidays. She also earned a small wage during work experiences which were organized by the school. She was able to contribute to family expenses out of the meagre wages that she earned. The difference that her contributions made to her family’s upkeep influenced her decision to get a job to help her family rather than going into further education. Although she passed her examinations with flying colours, she preferred to look for a job so she would be able to help her mother. Even though they now had some financial help from the council, it only met the basic needs and left nothing for emergencies or small luxuries like new clothes, shoes and family celebrations. Most of her clothes were handed down from her mother or her older sister while she did the same for her younger sister, Robin. Her brother George was not employable as he had no qualifications and he did not want to do any unskilled job, which he considered to below his status. He grumbled that nobody would employ him but at the same time, he refused to take up an unskilled job. He stayed at home all day and went out with his friends in the evening. George applied for unemployment benefits. When it was approved, he kept the money for his personal use. He spent it on cigarettes, clothes and drinks when he went out with his friends. Susan copied everything that George did. She too applied for unemployment benefits which like George she spent on herself. She was worse than George because she loved to stay in bed till late and then dress up in Ann’s best clothes while Ann was out working. She spent the money that she was paid as benefits on makeup at the salon. She had her hair and her nails done every week. She complained about everything but she would not lift a finger to help because she did not want to ruin her nicely manicured finger nails. They all sat at home while Ann went out to work. After work, she stopped at the shops to get some ingredients for dinner on her way home. When she came home, she cooked for the family. Ann hardly had friends as she was too busy at work and at home to create time to spend with friends. George also made a point of breaking up any friendships which Ann got into, especially if the friend in question was a man. He would become verbally aggressive towards any man that showed an interest in Ann and would go further into physically attacking them if verbal abuse was not enough to drive them away. After a while, Ann asked why nobody else was helping with the housework except their mother. Her question was met with a resounding silence. The situation remained unchanged week after week, month after month as the years rolled by. As they grew older, the months turned into years, but there was no change in the situation. The only visible difference was that they had grown into adults but they were all still living at home with their mother. Their mother did everything that needed doing while Ann was at work. She has been doing so since they were children, but she has continued doing so even as they grew into young adults. When her neighbour and friend asked her why she worked so hard while her children sat at home doing nothing, she responded that she felt that life has been quite tough on them since their father left. Her friend warned her that she was slowly working herself into an early grave which will turn her children into orphans. Her friend advised her to get the children to start helping a little at a time until they would able to take on more of the house hold chores, but she would not be talked out of habits she formed several years ago. She continued to over-compensate for their father’s absence even now that they were all adults. George was now a fully grown man, living at home with his mother and his three sisters. He had no job, no home of his own and no wife. He often stated that he would inherit the flat when their mother passed away and the others would have been married or moved away. Susan was not interested in anything. She turned up her nose at the idea of getting married or getting a job. She was gradually growing into an old maid, but she seemed quite oblivious of her situation. Their mother was growing older and less able to help Ann with the house work. Ann found it harder and harder to cope with both her job as well as doing all the house work at home. Robin, the youngest of the four has now completed secondary education. She was seeking admission into a school of nursing. Ann was delighted with her younger sister’s quest for further education. She encouraged Robin but at the same time was aware of how Robin’s interest would impact on her life. She was the only one who helped when Ann asked her to do one thing or the other. As time went by, the situation at the family’s home began to take its toll on Ann. Her health suffered under the weight of her work and her private life. She seemed to be working twenty-four hours a day, busy both at the bank where she worked, as well as at home. She seemed not to have a work-life balance. She was always so tired, she had no appetite, and she could not sleep well through what was left of the night, that she gradually began to be absent from work. Her boss noticed a gradual deterioration in the quality of her work. Her health appeared to be on a downward slope too. She began to take time off work on grounds of illness. Her manager referred her to the occupational health department. When she attended the appointment with occupational health, the doctor identified some symptoms of depression and sent her to a hospital for further assessment. The symptoms were confirmed at the hospital and she was eventually admitted into hospital for treatment. Her family were up in arms and demanded that she should be discharged immediately. Her brother, George was the loudest in demanding that she should be “released immediately” as there was nobody to do the shopping, the cooking and the housework. His behaviour was reported to the consultant. He was first seen by one of the junior ward doctors who thought that it would help to plan Ann’s care if the consultant interviewed George directly. The junior doctor invited George to a ward round to discuss his sister’s care. George was delighted at the chance to meet with the ward team as he believed that he could convince them to ‘release’ his sister from the hospital. At the ward round George was asked why he demanded that Ann should be ‘released’ from the hospital. He responded that there was nothing wrong with Ann and that there was nobody to look after the rest of the family while Ann was kept in hospital. He was asked what he did for a living “Why are you asking what I do for a living? This is not about me, I am not the patient! I have only come to get my sister out of this hospital,” he answered angrily. Continuing with the assessment, the doctor said, “George, the point here is, that what you do for a living might be having an impact on your sister’s health.” “I don’t see what that has to do with my sister being here,” George retorted. “I am unemployed,” he added reluctantly. The doctor asked George where he lived “Is this the Spanish inquisition?” George thundered as he stood up to leave “Please sit down Sir,” said the doctor calmly. “You may not understand why these questions are being asked now, but by the end of our conversation, it will become clearer to you. Please answer the questions so that we can formulate your sister’s treatment plan.” “Alright,” George said. “We all live at home with our mother.” “How many are you and what sort of accommodation do you live in?” George stated that there are four of them and that their mother and they lived in a three bedroom flat “How many of you work?” “Ann is the only person who goes out to work,” he replied “Who does the shopping, the cooking and the housework?” the doctor went on “Ann does the shopping on her way home from work.” “Who does the cooking?” “Our mother helps but she has to wait for Ann to come home from work because she brings the shopping home with her after she closes from work.” “Does Ann help with the cooking too?” “Yes, she does the cooking with our mother,” George replied “It comes across as if Ann works, does the groceries shopping after work, comes home to cook and does the rest of the house work? What do the rest of you do?” “I already told you that I am unemployed. My sister Susan is also unemployed and Robin is now in college. So it is Ann that has a job and pays for things at home. Our mother also helps to pay the bills with some of the benefits that she receives.” He was asked again. “Please correct me if I am wrong,” the doctor said. “So Ann works, buys the food, comes home to cook for you all, and clears up afterwards. Is that why you are demanding for her ‘release’ from hospital?” “No, that’s not why,” George answered. “We just want her to come home.” “Alright,” said the Consultant. “The ward team will review the information that you have given to us in the light of Ann’s needs. It will help us to formulate a treatment plan for her. We shall let you know the outcome in due course. Thank you all for coming to the ward round.” George shouted, “Is that it! Are you not going to ‘release’ her today?” “No,” answered the consultant. “She needs to remain with us for a few days more. As he was not the patient, it would be rather out of place to suggest to George that he should look for a job and also try to help with some of the house-hold chores. George stormed out of the room grunting some obscenities under his breath. He was followed by his mother and his sister, Susan. After the family’s exit, the consultant said, “This case presents a microcosm of the wider society. George seems to believe that he has a right to the things that Ann does to help her family. Ann on the other hand believes that she is helping her mother with the burden of looking after the family, but she is in fact denying herself a normal life while at the same time allowing the rest to abuse her generosity. If each of them contributed a little bit, instead of putting pressure upon one person, things might work out better for all of them.” It had become quite clear to the ward team that pressure from the family was the principle cause of Ann’s illness. Although she was not on any psychoactive medication, she had improved significantly during the two weeks that she had been on the ward. While on the ward, she was simply encouraged to eat well at meal times, to participate in ward based activities and to try to sleep well during the night. She remained on the ward for a further week to allow the ward team time to plan her care in readiness for her discharge meeting the following week. Meanwhile, George came to the ward almost every day to find out when Ann would be “released” from the ward. TREATMENT PLAN:

RELAPSE PREVENTION: The following to be consider. The following ideas were suggested in humour. But in actual fact, they seem to be what Ann needed to do in order to break away from the strangle hold which her family had over her life

3. BACK FROM THE FRINGE

THE PRESENTING SCENARIO ON ADMISSION: Mark was escorted to the ward by John, his fiancée Abbey’s brother. On admission, he was emaciated and dishevelled in his physical appearance. His clothes were crumpled and slightly dirty. In fact, he was unkempt. He spoke eloquently but in a low tone of voice which was hardly audible. The contents of his speech were appropriate but he made little or no eye contact when he spoke. His mood appeared to be low, and he was on the verge of tears while he was being interviewed. The admissions nurse felt that he was mildly depressed and asked the ward junior doctor to see Mark for further assessment and to prescribe medication for his treatment. BACKGROUND TO THE PRESENTING PROBLEMS: Mark has been in a relationship with Abigail (Abbey) for slightly over three years. After two years, they had a lavish engagement party and were expected to be married within the next year. However, Mark would not commit to a serious relationship but was quite content with the situation as it was. Abbey on the other hand wanted to move the relationship to the next level, as she was, according to her, not getting any younger. After several refusals to decide about their future, Abbey had given Mark an ultimatum to give her an answer regarding the question of their future together or to call the relationship off. Abbey’s siblings and friends were now all married or had children with their partners. She said that she was also tired of being the only single woman among her friends; tired of attending their weddings, christening of their children; and tired of spending substantial amounts of money on presents for her friends on these ceremonies. She constantly moaned that she was not getting any younger and that she would love to settle down to have children like her other siblings and her friends. Moreover, her mother had been hinting on her single status whenever they met. Mark, on the other hand saw no reason to make any changes to their current life style. He thought that he was quite a catch. Whenever Abbey brought up the question of marriage, he told her that she should count herself lucky that they were an “item”. He played up whenever things were not done exactly the way he wanted them. He behaved as if he had a right to this life style. Abbey went out to work to pay most of the bills, she did all the housework, and met most of his other needs. His excuse was that as an only child of his parents, he was pampered and did not have to do any housework. He added that his mother did most of the housework while his father only helped occasionally. He said that he was raised to believe that housework should be done by women just as his mother did practically everything within the house. To Mark, things couldn’t be better between Abbey and him. He had everything that he wanted or needed and he did not see why he should allow himself to be tied down by marital responsibilities. Abbey had come to the end of her tether. She felt that she had used up all her persuasive powers; this included the “water works”, but Mark’s position on the question of marriage could not be swayed. Instead of relenting on his position, he complained that Abbey had become the “nagging champion of the century”. He began to stay out till quite late almost every night so as to avoid the constant rows which had become a regular feature of their relationship. Sometimes, he stayed out all night. When he returned, he behaved as if nothing was wrong or as if it was normal for him to spend the night elsewhere and to stroll in whenever it suited him. Things grew worse at weekends. He disappeared after work and reappeared on Monday morning for a change of clothes. He provided no explanation for his absences or for the changes in his behaviour but he still expected Abbey to look after him as if he was her husband. After a while, Abbey decided to call off the engagement. She confided in a friend who agreed to sublet a room in her apartment to Abbey. When Mark returned from one of his “away nights”, Abbey was not at home. Mark thought that Abbey had just gone out, perhaps to the shops. He waited for a few hours but there was still no sign of Abbey so Mark went around the flat looking for food or to find something to drink. The fridge was empty! He looked in the cupboards but there was no food or any utensils left in them. He ran into the bedroom to check the wardrobes and to his horror, all Abbey’s clothes and shoes were not there too. It dawned on him that Abbey had left him; that she had moved out! Mark collapsed into the armchair next to where he had been standing. After the situation fully sank in, Mark rang Abbey’s mother to ask if Abbey was there but her mother replied that she had not seen Abbey for a few days. Mark rang Abbey’s siblings but none of them knew where she was. He then began to ring Abbey’s friends one after another until he ran out of people to ring about Abbey’s whereabouts. Some of Abbey’s friends hung up when they realized it was Mark that was on the telephone. He suddenly realized that nobody wanted to speak to him about Abbey. As he could not cook, he started to eat out at restaurants. The apartment became dirty and untidy. He was also not able to pay all the bills which accumulated rapidly after Abbey had left. At work, colleagues began to comment on his unkempt and dishevelled appearance. His clothes looked dirty or crumpled as he could not wash or iron them. His performance at work also began to deteriorate. Some of the women with whom he used to spend the ‘away night’ with also lost interest in him because he no longer looked smart and well kempt. He began to spend more time at home, perhaps in the hope that Abbey would return. She didn’t. The bills piled up so much so that he had to reduce his expenses at restaurants to make ends meet. He was running out of money halfway through the month. He was now desperately searching for Abbey. He went to the places that they used to visit together, but Abbey had cut off going to such places. He felt that he had to find her before things got out of hand. But nobody would help him to locate where Abbey lived as they had all warned him about his behaviour towards Abbey but he would not listen to them. The rent was not being paid regularly as it had been when Abbey lived there. After several months of non-payment of the rent, the landlord gave him a quit notice. At the same time, the situation at work became worse. His line manager called him into his office for an impromptu appraisal. There was still little or no improvement in Mark’s performance. It would be Mark’s last appraisal as, his manager had met with him on several other occasions even when these appraisals were not due. He appeared unable or unwilling to make amends. Mark was sent for various training programmes aimed at helping to improve his performance at work, but his work remained below the standard expected of him. He was suspended from work for three months to help him review his interest in the job and to reconsider his prospects in that area of work. He returned after the suspension in a worse state than he was before the suspension. His work colleagues and his friends stepped in to help him, while his line manager placed him on light duties and further training programmes. Nothing seemed to work so he was suspended for six months. He was advised to look into other areas of work. After he had been suspended from work on two occasions in rapid succession, Mark was fired. All efforts to help him had failed. Other various attempts by his friends and his colleagues to help him to improve his work performance or to cover up for him were also unsuccessful. He showed no interest or no appreciation for the help he was given. Sometimes, he behaved as if they were imposing themselves and their opinions on him. Most colleagues at work concluded that he lacked the will to make the changes that were suggested to him. After he was given a quit notice from the apartment, he tried to move in with friends but some said that they had no spare room in their homes to accommodate him. Others just refused to hear him out. They all knew how his life had gotten to the state that it was now. He could not go home to his parents because he knew that returning home would be the cause of serious arguments and rows between his parents. Mark was an only child. While he was growing up, his mother mollycoddled him to such an extent that he was not allowed into the kitchen;. he was not allowed to do any chores at home. She did his laundry, his ironing, and she served his meals as if he lived in a hotel. His father tried so hard to get him involved in on-going family activities such as gardening, taking care of the house or doing his own laundry, but to no avail. He eventually gave up and he was relieved when Mark went to university. But the damage had already been done. He was unable and unwilling to look after his own needs. He transferred this dependency to Abbey when they moved in together after he graduated from university. He accepted that moving back to his parents was not an option at this point of his life, so he decided not to contact his mother. Now, Mark had no home, no job, no friends and he had no idea where to find Abbey. His physical appearance deteriorated until it became socially unacceptable. His behaviour gradually grew erratic and sometimes bizarre. Word about the changes in Mark’s life reached Abbey through her friends. She sent her brother who was a medical doctor to visit Mark and to confirm the stories that she had been told were true. Her brother searched far and wide before he eventually found Mark sitting in a corner at the restaurant where Abbey said he would be. He returned to Abbey and confirmed that the stories were true. Abbey pleaded with her brother, John to help Mark and to escort him to see a doctor if that was necessary. John took time off work to help Mark. Mark had lost much of his body weight as he had not been eating regularly, perhaps because he did not have enough money or that he could possibly have lost his appetite. His mood had also plummeted. It was clear that Mark had become depressed and he needed help. Mark was greatly relieved to see John. Abbey had previously told John that he would find Mark at a restaurant where they both used to eat in the past. When John arrived at the restaurant, he went straight to a waiter who was standing at the reception to help him place an urgent order for lunch. He said that although he was on his lunch break, that he was in a hurry as he needed to get back to work urgently. He raised his voice and spoke loudly, probably for Mark’s benefit. On seeing John, Mark quickly rose up on his feet and walked towards John. John asked Mark if he had already had lunch. He replied that he hadn’t. John placed an order for a second plate of food for Mark. After lunch, both men left the restaurant together. Mark was grateful for John’s visit. It had been a long time since Mark had seen a friendly face. He eagerly accompanied John to John’s office at the local hospital. Mark was not aware of the reason for a visit to John’s place of work. Anyway, once they were inside the office, John’s colleague discreetly carried out a quick assessment of Mark’s mental state. After the brief assessment, he came to the conclusion that Mark was suffering from a mild but acute depressive episode. Later, he told John that due to Mark’s physical appearance, that a full assessment at the A&E Department might be useful to fully identify Mark’s health needs. He suggested that Mark would probably need a short admission into a mental health facility for treatment. He nodded at John, and took his leave. Pretending not to know Mark’s situation, John asked him where he lived and he offered him a ride home in his car. At this point, Mark began to weep. He begged John to mediate between him and Abbey. He stated that he now knew that he had made a terrible mistake in the way that he had treated Abbey. He begged John to tell him where to find Abbey. John feigned ignorance about his sister’s whereabouts. He said that he might be able to find out where Abbey was from their mother. John asked him what had happened between him and Abbey. When he ended his story, John turned to look him squarely in the face. He told Mark that he was concerned about his health because he seemed to have lost a lot of weight. He suggested that it would help if Mark agreed to accompany him him to the nearest hospital to see another doctor because doctors do not treat family members or close friends and associates. John told Mark that his clothes looked a bit dishevelled which was out of character for Mark. Mark used to dress smartly; he took pride in his physical appearance but he seemed not to care much about that now. He had studied economics at university and had graduated with honours. Mark did not believe that he could have mental health problems and he was reluctant to go to the local hospital. He said that he had always been in good health and that he had not ever been admitted to a hospital before. John pressed on until Mark relented and agreed to go to the hospital but on one condition: that his mother must not know about his present situation as it would break her heart. When they arrived at the hospital, the doctor who was on duty that afternoon was John’s friend at university. When it was Mark’s turn to be seen, the doctor was greatly concerned about Mark’s physical condition than what he was about the state of his mental health. After a prolonged examination, he informed them that Mark would benefit from a short admission into a hospital ward. Mark disputed the doctor’s findings and asked John to take him back to where he used to live with Abbey. John tried to persuade him to follow the doctor’s advice but again, Mark asked John to drop him off at the top of the street where he used to live with Abbey. He was too embarrassed to admit to John that he was homeless. In reality, he had been hiding in the toilet at the restaurant just before the staff shut the doors and closed for the night. He came out to sleep on one of the chairs in the back of the restaurant until morning broke, he then sneaked back into the toilet for a wash while the staff were busy setting up the restaurant for the day’s business. Somehow, nobody noticed that he practically lived in the restaurant, eating there, changing where he sat every so often so that he would not attract the attention of the staff as well as those of the restaurant’s other regular clients. He went out for walks, or read free newspapers to keep busy. Sometimes, he went for a ride on the local buses for sight-seeing before returning for his evening meal at the restaurant. John too, did not want to embarrass Mark by telling him that he knew that he was homeless. He dropped him off where Mark had asked him to. Before dropping him off, John pleaded with Mark to consider the possibility of a short admission in order to have his health issues properly assessed and addressed. He vouched to ensure that Mark’s hospital stay would not be unduly long. He also promised to track Abbey down and to bring her to see Mark as soon as he had found out where Abbey lived. Before they left the hospital, the doctor had informed John that Mark was suffering from raised blood pressure and palpitations which he felt were the result of overwhelming and prolonged states of anxiety. In his discussion with Mark, John concentrated on Mark’s physical health. Any mention of mental illness would have thrown a spanner in the works and Mark would have definitely refused to go to the hospital voluntarily. In the end, Mark agreed to accompany John to the hospital to discuss the possibility of a short hospital admission. Mark’s agreement was on the grounds that John would go with him. When John finally succeeded to lure Mark to the hospital, it was quite a daunting experience for Mark. After a brief ‘interview’ with the admissions doctor, Mark was escorted to a bedroom and was offered a set of pyjamas, towels and toiletries. He spent the weekend in hospital, mostly in his bedroom. He was grateful for a clean bed and a bedroom. He was given a hair cut by a volunteer who came to the ward to shave or to give the patients hair-cuts. After breakfast on Saturday morning, Mark was assisted to use the washing machine on the ward to wash his clothes. A nursing assistant assisted him to iron them later. By Monday morning, he was neatly dressed and looked so well that other patients wondered why he was on the ward. When he was seen by a nurse in a one one therapeutic session, Mark also said that he felt much better than he did a few days ago. His blood pressure reading had normalized and his anxiety level had almost disappeared too. He was seen for a full assessment by the ward team. His speech was coherent and eloquent. It was appropriate in both its form as well as its contents. John and Abbey were also in attendance. Mark was overjoyed to see Abbey. After a thorough review of the information given by John, Abbey and Mark, and in the light of his physical appearance and physiological changes, the consultant said to Mark “Judging by your looks, you are too well to be on the ward. You don’t look like one of our patients. Your behaviour and your speech pattern suggests that you are well educated. I was informed that you are a graduate; which university did you attend? and what did you study?” Acknowledging the compliments, Mark said, “Thank you Sir. I went to Leeds and studied economics.” “I was informed that you were in a bad way when you arrived here last Friday. How are you feeling now?” “I am feeling much better now, Sir,” Mark replied “The good news is, Young man, is that you were not mentally ill,” said the Consultant. “The changes and the difficulties that you experienced were the natural responses to the multiple losses that you suffered. The losses are as follows: one – the loss of your principle provider and carer; two – the loss of your home; and. three – the loss of your job.” “In my professional opinion, you do not need a bed on a mental health ward, because your situation can be put right quite easily at home. What you have to do is to grow up and to accept your responsibilities as an adult male. A bed in this ward costs the British tax payer three hundred and fifty pounds per night. That is higher than the cost of a bed in one of the top hotels like the Hilton for example. Hospital beds are for the use of seriously ill patients who need treatment. My professional advice to you is to go home with your fiancée and play an active role in your relationship. Be the man in your relationship with Abbey.” He turned to Abbey. “Thank you for coming to my ward rounds,” he said. “The information that you provided has been extremely useful in the formulation of Mark’s treatment plan. You seem to be in the best position to help him to recover fully and to return to how he was before this interlude in your relationship. I can tell you that he has no mental illness at the present time as you intervened through your brother John, just in time.” In response to his remarks, Abbey thanked the Consultant for his kind remarks. She added that she will do her best to help Mark. Turning to John, the consultant said, “Young doctor, thank you for the part that you played in this saga. Your intervention has helped to mitigate any further decline in Mark’s situation.” “Thank you, Sir,” John responded. Mark was then promptly discharged as he was not deemed to have mental health issues to a degree that warranted treatment or a stay in a hospital bed. He was slightly embarrassed to be on the ward as a patient but he had realized that the short hospital stay had done him good. He was referred back to his doctor for advice and if the doctor deemed it necessary, for treatment. John had brought Abbey with him to the ward rounds and in so doing, he has reunited her with Mark. Mark looked so pleased that he could hardly control his excitement. John moved slightly away from the two, in order to give them some space to talk. Mark’s behaviour prior to this short admission was described as “acopic” – poor coping mechanism skills for independent living. TREATMENT PLAN: Due to the significant improvement in both Mark’s physical appearance as well as his mental state, the ward team decided that he was not mentally ill to a degree that called for medication or any other form of treatment. Moreover, his blood pressure had subsided as his anxiety levels reduced. These changes in his physical health status proved that the diagnosis of the A&E doctor were correct. RELAPSE PREVENTION:

4. THE GOOD SAMARITANS

THE PRESENTING SCENARIO ON ADMISSION: Stella was escorted to the ward by a nurse from the Accident and Emergency (A&E) department and a social worker from the Children’s and Adolescent Mental Health Unit. Her age was given as seventeen but she was so thin for her age that she could have passed for a thirteen year old. She seemed to be looking around her fearfully. She was clearly scared. She needed a lot of reassurance before she could engage meaningfully with the admissions nurse. In her handover details, the A&E nurse who escorted her to the ward had said that she was brought in by two police officers who responded to the head teacher’s 999 call from the secondary school. She added that Stella had been rescued from an abusive relationship with the foster parents who have been using her like a slave “Our doctors’ assessment at A&E indicated high levels of anxiety, low mood and fearfulness. He felt that she needs a fuller assessment by specialists like yourselves and that is the reason for her transfer to you” BACKGROUND TO THE PRESENTING PROBLEMS: Stella was a seventeen year old girl. She arrived in the United Kingdom as an unaccompanied minor five years ago at the age of twelve. Her parents had sold every valuable thing that they possessed to buy an air ticket to send her away from their war torn country. They had hoped that it would give her a chance of a better life. On arrival in the United Kingdom, Stella was placed with a family who had two children of their own. She seemed to have settled down well within the family. She was registered at a nearby school that their two daughters also attended. She appeared to be happy and she seemed to get on well with the couple’s two daughters. After about a year after her arrival however, her behaviour began to deteriorate. She became withdrawn, less communicative and she appeared to be fearful most of the time. A teacher at the school had noticed the changes in the once boisterous and happy teenager. The teacher had also been informed by Amina, a student in her class, that Stella was unhappy at her foster home. Amina’s teacher went to see Stella’s class teacher to discuss her observations as well as what Amina told her about Stella with Stella’s teacher. The two teachers agreed that something seemed to have gone wrong in Stella’s life. They decided to take the matter to the head teacher. After listening to the two teachers, the head teacher advised them that a visit to Stella’s foster home should be arranged. When the two teachers eventually visited Stella’s home, the foster parents were overly delighted about the visit from the two teachers. Their false happiness at seeing the teachers belied their anxiety as it is not usual for teachers to visit a student’s home if things were going well. Their attempt to appear hospitable was over the top too. They prepared a lavish dinner for the teachers and they were too eager to please the visitors. The teachers interpreted their behaviour as a cover up for something. Stella’s class teacher explained the reason for their visit. She stated that certain changes have been observed in Stella’s behaviour and that the school was slightly concerned about these changes. She gave details of what the changes were, and then she asked for an explanation about the changes from the foster parents. The foster mother said that they had also noticed that Stella had lost a bit of weight but that she ate well at meal times with the rest of the family. She added that Stella was happy and played with her “sisters” in their spare time. She feigned ignorance of Stella’s fearfulness especially when the foster father was present. The foster father left the talking to his wife. He nodded in agreement with whatever she said but he avoided eye contact with Stella. The teachers thanked the foster parents for their kindness but they did not touch the food or the drinks that were offered to them. They said that they would send a copy of the report of their visit to the foster parents and they then left. After the home visit the two teachers reported their findings to the Head teacher. He immediately arranged an emergency case conference with social services to discuss Stella’s situation and to review the existing placement. They also thought that a contingency plan should be put in place as an interim alternative foster home for Stella, just in case it became necessary to move her for the immediate future. When the first meeting was set up for this purpose, the family did not attend. The foster mother made excuses that she was ill at the time and she could not attend. When a second case conference was arranged, the foster mother was encouraged to endeavour to attend as her contribution to the discussions as well as the planning for Stella’s future was crucial. It was clearly indicated that Stella would be removed from the care of the family if either of the foster parents failed to turn up at the second meeting. At the second case conference which subsequently took place, the head teacher and the two teachers who visited the foster family, represented the school. The local Social Services agency for the borough was represented by the social worker who was assigned to Stella’s case when she was placed with the foster family and the head of the social services for the local authority. Both of the foster parents were in attendance. The conference was chaired by the school’s Head teacher. He invited Stella’s social worker to tell the conference what her experience of monitoring this case had been since it was assigned to her. She spoke hesitantly, and when she ended her speech, the head teacher then called upon the class teacher to describe the events which had led to the home visit. Next, he invited the second teacher to describe what transpired during the home visit. As the chairman of the conference, he paraphrased what the various members in attendance had told the panel. From what every speaker had said, it became clear that the social service agency had been negligent in the case as the social worker failed to observe or to report the signs which had prompted the attention of the two teachers. From her own account of life within the foster family, there was no question that she did not know much about the welfare of the child who was assigned to her. When the foster mother was asked about the regularity and depth of the social worker’s visits and involvement, it became clear that her visits were not regular and her involvement, scanty. On the question of the quality of her visits, the foster mother reluctantly admitted that her visits were brief and occasional. Her class teacher was finally called upon to inform the panel what prompted her request for a home visit. She related how Stella was frequently caught falling asleep in class. Secondly, she had lost her boisterous behaviour and she only spoke when she was spoken to whereas she was previously often at the centre of whatever was going on among her group of friends. Her school work had showed significant deterioration and she seemed to have lost some weight. Moreover, she was no longer able to hand in her homework on time and when she eventually did, it was far below her previous standard. Her class teacher concluded that Amina’s teacher had received some rather disturbing information from Amina who was one of the students in her class, who also happened to be friendly with Stella. In order not to prolong the time spent on this matter, the Head teacher asked Amina’s class teacher to narrate the information she had passed on to Stella’s teacher. Amina’s teacher said that Amina’s mother had come to the school to see her daughter’s teacher regarding something that her daughter had told her which she found to be quite concerning. Amina’s mother said that she had caught her daughter stuffing two lunch boxes into her school bag. And that when she questioned Amina about it, that Amina subsequently admitted that the second lunch box was for her friend at school. She refused to say who her friend was until her mother threatened to punish her. Amina’s mother had told her that she would be “grounded” for a month unless she told the truth without any omissions. Amina knew that her mother was a no nonsense woman and she decided to tell her the truth. It was only then that Amina reluctantly informed her mother that her friend was not allowed to take food from her home for lunch at school. The teacher said that after the conversation with Amina’s mother, that she had interviewed Amina separately in order to obtain more information about what Amina’s mother had told her. It was then that Amina revealed that she had been bringing extra food to school for her friend, Stella. Amina’s class teacher then went to see Stella’s teacher about what she had been told. She concluded that it was how both teachers realized that something was seriously wrong at Stella’s foster home and they decided to bring the matter to the attention of the head teacher. The head teacher brought the meeting to an end. He said that the group would have to meet once more but that in the meanwhile, the school’s secretary would prepare a report of the day’s deliberations. He encouraged the head of social services to have a report done from the social services perspective. The two reports would be read at the next meeting and a plan for Stella’s future would also be drawn up. In the meantime, he would personally take charge over the provision of lunch for Stella until the case was resolved. He did not want to alert the Ahmed’s about the forthcoming investigation. At the next case conference, and in the letter from social services, Stella’s social worker, Debby included an explanation which she had not mentioned at the previous case conference. It read that: “Whenever I visited the family, everything seemed to be in order. The reason for this could be that all visits were pre-arranged so that the family were aware that I was coming and they would put things in order before I visited them. There was no reason for me to ask questions or to probe further into situations that appeared to be normal” The Head teacher asked her why she had not said this when they met the first time. Debby responded that she was stunned by the revelations made by the two teachers who carried out the home visit. However, her explanation was seen as an after-thought to exonerate herself from blame, but nobody at the conference voiced their objections to this late admission on Debby’s part. The head teacher asked Amina to narrate her recollection of what Stella told her that went on at home. Amina said that whenever they went on their lunch break together that Stella had little to eat; sometimes she only had a bag of crisps or a piece of fruit. She knew that Stella’s step sisters nearly always brought lunch boxes to school. Amina said that whenever she asked Stella why she did not bring a lunch box like her sisters to school, that Stella would smile sadly but would say nothing. Amina added that when she invited Stella to her birthday party, that Stella had thanked her but had declined the invite. She went on to say that on two other occasions when she had invited her friend, Stella for a sleepover at her home, that she also made excuses and did not come. Amina said that she felt that something was wrong because Stella’s two sisters often described how they enjoyed themselves at the various parties that they had attended. She had demanded to know why Stella was not able to attend parties with her sisters or to accept the invitations to come to her house for a sleepover or for her birthday party. She said that she had asked Stella if the Ahmed’s were really her birth parents. Stella answered that they were. But Amina could not understand why she was treated differently. Amina added that when she saw that the probing questions were making her friend uneasy, that she decided to stop. A few days after this conversation, Stella had opened up and told Amina that she had work to do at home and that she could not attend parties. She added that she worked till late at night and was woken up early in the morning while the others were still in bed, to prepare breakfast for the family. Amina told the panel that her friend had informed her that she worked so hard that she was often too tired to do her homework. Except for the foster parents, everyone at the conference was wide eyed at what Amina had said. The head teacher cut Amina short and she asked Stella to tell them what had been going on at home since her placement with the Ahmed family. At first, she was too scared to speak in front of the foster parents. But egged on by the head teacher, Stella began to narrate the story of her life with the foster family. At first, her story came out in dribs and drabs. Then it began to flow steadily until she was able to speak in a normal tone, rate and pitch of voice. She described how the first six months were wonderful. She said that they took good care of her and the girls were like the sisters that she never had, but things began to change gradually until she realized that she was the only person who did most of the housework. She was sent into the kitchen to cook for the family straight after school. She cleared up after meals and she also did the washing up, the laundry as well as the ironing. She said that when she asked for time to do her homework, Mr Ahmed would shout at her. So her school work suffered. She narrated how she worked until midnight and sometimes well past midnight before she could go to bed. She added that all her clothes were ‘hand me downs’ from the girls as she was not allowed to have new clothes. The Head teacher asked her what the rest of the family did while she worked. She responded that they watched television, played games or sat telling stories. The Head teacher then asked her where her parents were. Stella replied that her parents were in Ethiopia. She explained that they had sold everything that they owned to send her abroad so that she would have a better chance in life than what they had. She was asked if she had told her parents about the situation in her foster home. She answered that she had no money to phone them. An Ethiopian family who she met on her way home from school had a phone at their house and that she could have asked them to inform her mother about what was going on with her, but that she had no money to call them from a phone booth. Horrified at what he had heard, the Head teacher asked Mr Ahmed why they had not bought a mobile phone for Stella as nearly all the children at the school had mobile phones. There was no response. He asked the foster parents if their two children had mobile phones. Mrs Ahmed answered in a somewhat muffled voice that they did. The Head teacher asked them if they were not provided with funds with which the child to be cared for? Again, there was no response from the foster parents. He now shouted at them, more out of anger than out of a need to be heard. He wanted to know the truth “Have you been using a child placed in your care as a domestic slave?” he asked them rather bluntly. It was a rhetorical question. “You were being paid to look after her but instead you chose to abuse your position of trust.” Everyone at the conference looked on in shocked silence. Mr and Mrs Ahmed bowed their heads in shame. The head teacher stormed out of the room in fury, perhaps to stop himself from doing or from saying something outrageous or unprofessional. He came back after about a few minutes, his eyes looked so fierce that the others held their breaths and looked elsewhere. He sat down silently rubbing his hands together for a short while and then he announced that the conference had to be suspended as it was now a matter for the police. He told Debby, the social worker that he was disappointed with the quality of her work. He chided her for her failure because she could have noticed the changes in Stella’s physical appearance and her behaviour both of which would have led to the relevant questions being asked. He added that the situation could have been halted earlier if she had been more observant. Debby decided not to respond to the head teacher’s remarks at this time, as it might inflame the situation even more. The head teacher rang the police and reported the case to a police officer. On overhearing this, Stella cried out in fear that she did not want the police to arrest her foster parents. She said that she would have nowhere to live and that she had no other close relatives living in the country. But the Head teacher told her that it was not up to her to make the decision as she was a ward of the state. It was then decided to remove her from her foster home immediately. Two police officers responded to the head teacher’s call. They arrested the Ahmed’s and escorted them to the police station for further questioning. Stella was taken to the police station along with her foster parents. She was examined by the police doctor. He recommended a further psychiatric evaluation. This took place at the local accident and emergency (A&E) department after which she was admitted into the Children’s and Adolescents Mental Health Services. After a brief admission, it was decided that she should be discharged as she had no formal psychiatric diagnosis. The physical changes, both in her body and in her behaviour were deemed to be normal reactions to what she had gone through at the hands of her foster family. However, she had nowhere else to go as the Ahmed’s had been relieved from any further involvement in foster care. Their names were removed from all fostering services and they were charged with child abuse. During her time on the ward, Stella repeatedly asked to be allowed to go home. It was difficult for her to understand that what had happened to her was a criminal offence and that she would not be allowed to return to the same abusive environment where she had suffered for about five years. Paradoxically, she still loved this family from whom she had just been rescued. Stella repeatedly begged to be allowed to go home. When staff explained to her that it was no longer her home, she found it hard to understand or to accept. Even after several attempts were made to explain to her why she could not return to her former home, she kept on asking to be discharged back into the care of the Ahmed family. In order to reduce the level of her distress at not being allowed to return to what used to be her home, a series of insight building sessions were arranged for her with her named nurse and a child psychologist. Her desire to return ‘home’ is a well-known and common behaviour of victims of abuse. They become attached to the abusers and would in some instances, come to the abuser’s defence. It took several insight building sessions to get Stella to understand that she had suffered abuse at the hands of the Ahmed’s, in at least three spheres. The first sphere of abuse was emotional; the second sphere was physical abuse, and the third was financial abuse. Emotionally, she was starved of parental affection; physically, she was used as a slave to do all the housework; and lastly, the Ahmed’s were paid to look after her but they had used all the funds that were meant for her upkeep for their own needs; that was financial abuse. Meanwhile, social services searched for a temporary placement for her. She would remain in the temporary placement, in the care of another foster family until she reached her eighteenth birthday. She would then become a fully-fledged adult. A temporary placement was eventually found for her, and she was discharged to the new foster family. She was to remain in the care of the new foster family until her eighteenth birthday when she would be allocated a flat of her own and welfare benefits for her other needs. She could then start life as an adult. Treatment was not planned because after a series of thorough reviews of her case, the medical team had decided that due to the absence of any symptoms of mental illness, that she had no formal psychiatric disorder. The recent changes in both her physical appearance and in her behaviour were her natural responses to the abuse that she had endured from her former foster parents. Meanwhile, she would remain in the care of the Child and Adolescent Mental Health Services until her eighteenth birthday. As most of her needs were social rather than psychological, a social worker from the Child and Adolescent Services was allocated to her to help her with the implementation of the outcome from her discharge ward round. She was subsequently discharged into the care of a newly allocated social worker. RELAPSE PREVENTION:

5. WAS HE A SCAVENGER?

THE PRESENTING SCENARIO ON ADMISSION: Sule was admitted via the accident and emergency (A&E) department. His friend Andy had taken him to the A&E with what appeared to be symptoms of a psychotic nature. He appeared to be hearing and responding to external stimuli or “voices”. On further assessment, it was felt that he also had delusional symptoms. He appeared paranoid, distracted and he had failed to answer questions correctly. In order to implement a detailed assessment, a bed was found for Sule on an acute mental health ward for adult males between the age of eighteen and sixty-five. BACKGROUND TO THE PRESENTING PROBLEMS: On further assessment, nursing staff observed that his behaviour was reasonably appropriate when he thought that he was alone with Andy. But when he was with other patients, there were observable psychotic symptoms. On mental health wards, nursing staff generally come to work dressed in mufti. The rationale behind this are two-fold. Firstly, the pilot scheme that was conducted a few years ago proved that patients benefitted from this dress code. The patients who took part in the pilot scheme displayed a marked reduction in the fear that they displayed towards nursing staff prior to the implementation of the pilot scheme. During the trial period of the pilot scheme, nursing staff went about their normal duties but it appeared that patients were more relaxed and they often forgot that the nurses were among them. Previously, patients were subdued in their behaviour when nursing staff were around but now, they were bolder in their interactions with one another when they thought that they were on their own. It showed that the changes in their behaviour could be due to the fact that they had seen themselves as being at the lower end of a power relationship between staff and patients. Secondly, it helped to minimize the paranoia surrounding the belief that hospital staff were out to “get them” and to have them locked away permanently. On the flip side, when nursing staff dressed in mufti sat among the patients, after a while, the patients forgot that nursing staff were in close proximity to them. This situation provided opportunities for closer observation of the patients’ behaviours which were later fed back to the ward team at ward rounds. The information so provided was useful for the formulation of the patients’ treatment plans. Nursing staff are also able to hold normal conversations with patients which helped to develop rapport with them. Such conversations encouraged patients to build up a trusting relationship with nursing staff and this improved the nurse-patient therapeutic relationship. Such rapport enabled patients to open up to staff, detailing their anxieties and their hopes. It was during one of these communal interactions that Sule, not realizing that the person sitting two spaces away from him was a member of the ward’s nursing team, said that he actually had no mental illness but that he had learned the symptoms of psychosis from a friend who suffered from a mental illness. He stated that his reason for doing so was to convince his friend to accompany him to the A&E department and to speak to the A&E staff on his behalf. Sule knew that Andy was familiar with the medical terminologies used in hospitals and that he would be able to be his ‘advocate’ at the hospital. He hoped that doing so was more likely to get him admitted into hospital. His aim was to pretend to be mentally ill so that he could receive the benefits to which the mentally ill were entitled. He had perfected his display and his mimicry of some of the physical symptoms of psychosis which he had observed in his friend, Andy. With Andy’s help, he was actually able to convince the team of doctors, nurses, and other therapists at both the A&E and later at the ward rounds that he was indeed mentally ill. The consultant was a bit sceptical about how some of the symptoms had stopped and started again when he asked Sule about them. He appeared to have some degree of control over some of the symptoms which ran against the usual stream of the symptoms that he presented. However, it was difficult to understand or to accept why anybody would go to such lengths just so that they could be admitted into hospital. Why would anybody in his right mind want to be admitted into a hospital for the mentally ill. After much deliberation, he had reluctantly agreed that medication should be prescribed to relieve some of the symptoms that were deemed to be most distressing to Sule. In order to ensure compliance, nursing staff encouraged patients to demonstrate to them, that they, the patients have indeed swallowed the medication which had been administered to them. This was achieved by asking the patient to have some water to drink to wash down the medication. Secondly, nursing staff would speak to the patient. If she or he was unable to respond, it would show that the medication was still being held in their mouths. A third method to ensure that medication had been swallowed was to administer it in liquid or intramuscular forms whenever that became necessary. In addition to these, patients’ movements were observed after medication was administered to them, to ensure that they did not head straight for the toilet as some patients quickly ran into the toilet to induce vomiting the medication by regurgitation. These simple methods of ensuring compliance with treatment have proved effective time and time again. The methods of applying gentle pressure continued until compliance had been achieved. It was thus difficult for patients to avoid taking medications that were prescribed for them while they were on admission on the ward. So Sule was not able to avoid compliance with his treatment while he was on the ward. During the course of his stay on the ward, he was allocated a care co-ordinator who would follow up his care in the community post his discharge from hospital. A one bedroom flat was subsequently allocated to Sule. He was also allocated a monthly financial benefit for his food, other supplies, as well as for the payment of rent, water, electricity and other bills. As soon as he was discharged from the hospital however, he threw away all the medication he had been given on discharge from the ward. He was overjoyed that he had achieved his goals by lying and deceiving those who cared for him at the hospital. After a few weeks, the symptoms for which he had received treatment whilst he was on the ward began to manifest themselves. He now actually had symptoms of mental illness for which he required treatment in the hospital. The next time when his care co-ordinator visited him, an urgent admission had to be organised to get him back into hospital. This time, the symptoms were quite severe. Sule now had a drug induced mental health problem! Sule initially arrived in the United Kingdom on a student visa. His parents’ business was flourishing at the time and money was not an issue. He had lived in a rented flat, received regular remittances of funds for his university fees as well as for his supplies and up-keep. Unfortunately, there had been a sudden change in government in his country which plunged economic activities into a downward spiral. His parents’ business was adversely affected by the political upheaval in his country so much so that his parents were unable to send money to him for his fees, accommodation and food. When Sule found himself in this situation, he visited a childhood friend, Andy who had also come to the United Kingdom to study. Andy’s parents had bought a two bedroom flat for him and his sister who was also a student. Andy now lived alone in the flat that he used to share with his sister as she had moved in with her boyfriend a couple of months ago. Sule related his predicament to Andy and he asked if Andy could rent the now vacant bedroom to him. Andy agreed and Sule moved in with him. Sule soon realized that like himself, his friend Andy no longer attended lectures, but the reasons were completely different. He had stopped attending lectures because his parents were no longer able to send money to him for tuition, rent or food. In Andy’s case, he was unable to cope with any strenuous intellectual activity. During conversations, Sule also observed that there were changes in some of Andy’s behaviour and speech patterns. Andy was frequently distracted. He also regularly took some medication. At first, Sule thought that Andy was doing illicit drugs or that he was taking vitamin supplements. Peter, who Andy introduced to Sule as a friend visited frequently and at regular intervals. During these visits, the conversation between Peter and Andy often included “compliance” with medication, “side effects”, his sleep pattern, nutrition and elimination. The regularity of Peter’s visits and the nature of the conversation between him and Andy led Sule to start to wonder who Peter really was, and why he was always bringing up these questions about “compliance and side effects”. Peter always asked these questions while Andy gave detailed responses to each question. Sule later learnt from Andy that Peter was Andy’s Care co-ordinator! “Why and how did you get a Care co-ordinator?” Sule asked Andy “I developed some problems and had to be admitted into hospital,” Andy replied. He added that after he was discharged, Peter was allocated to him to look after him at his home as his Care co-ordinator “Why do you need to be looked after by someone else? Can your sister not do that?” Sule asked “No,” Andy replied. “This is different. You see, Peter is responsible for my wellbeing which includes my health, my food, my accommodation as well as any other needs that may arise. He is not only interested in my medication but he looks into several other things for me.” “So he pays your rent too?” Sule asked “No, my parents bought the flat. But if I did not have my own accommodation, Peter would have helped me to get a place from the council. People with mental health problems receive these as benefits from the state,” Andy concluded. From then on, Sule began to plot and to scheme as to how he could get onto this ‘gravy train’ as he called it. He was so desperate that he began to mimic Andy’s behaviour pattern. At first, Andy thought that Sule was making fun of him. However, when Andy protested his annoyance at being ridiculed by his friend, Sule, told him that he was not making fun of him but rather that he wanted to learn how to present himself to mental health services so that he could get on the benefits scheme too. He explained that he had become an indigent student because his parents were no longer able to support him. He begged Andy to teach him the correct terminologies for each symptom that he observed in Andy’s behaviour. Andy tried to discourage Sule from following this path as, first of all, he would be found out sooner or later; and secondly, it was fraudulent. Sule pleaded with Andy for several weeks. He informed Andy that he could not take up a full time job because he was in the country on a student visa. He begged Andy to help him so that he could complete his education and then go home to his parents. Andy finally relented and he agreed to help Sule. They had been friends since primary school and he could no longer stand Sule’s daily whinging and moaning. He gradually grew sympathetic towards Sule’s plight and began to teach him how to behave if he was to pretend to be truly mentally ill. Eventually, Sule was able to convince Andy to accompany him to the A&E department and to help him to get admitted into a mental health hospital. When the truth about his case came to the attention of the ward team, reactions were mixed. Some staff members were visibly saddened by the desperation that drove him to take such a drastic measure in order to complete his education. Others found it funny and said that he got what he deserved. The need to look beyond the obvious became a lesson for all the professions on the ward. From then on it became a part of the standard assessments conducted on the ward to include detailed investigative information gathering into the personal circumstances of each patient, and where possible to offer medication free treatment for about a period of two weeks. This method of assessment helps to ascertain if the patient actually had the symptoms that they presented on admission. It also helps to exclude the impact of physical health problems on the patient’s mental state; pseudo symptoms; or deliberate mimicry of certain symptomology before treatment was fully started. Sule responded to treatment fairly quickly on the second admission. He was treated with empathy and understanding by all who knew how he had become mentally ill. The focus was now on how best to reduce or possibly to eliminate his symptoms while at the same time working hard on reducing his medication. It was like walking a tight rope. Sule’s case was received with mixed feelings whenever it came up in discussions, as he was in a difficult position and that he had seen Andy’s life style as a possible solution to his problems. Was he really a scavenger? Or was he just a desperate young man looking for a way out of a tight corner in which he found himself? TREATMENT PLAN: Sule was to be under the direct supervision of a doctor from the ward team after his discharged from the ward. It was thought important that a doctor who knew the details of his case history would supervise his treatment after he was discharged from the ward until he could be safely transferred to a community team. Sule’s medication was to be gradually reduced wherever possible, while at the same time other means of managing his symptoms were to be explored. Because of the delicate nature of Sule’s treatment, he was advised to visit the ward doctor who was responsible for his treatment while he was on the ward once a week. The visits were to be slowly tailed off in the following way. He was advised to begin with a visit every Friday afternoon for one month; this was to be reduced to forth nightly visits for two months, and later to a monthly visit, until it was safe for him to be discharged from the ward team to the community team. Sule had already been allocated a care co-ordinator to help to monitor his wellbeing as well as to ensure that he continued to receive his housing and other benefits that he would be entitled to. RELAPSE PREVENTION:

6. I LIKE IT, I WANT IT!

THE PRESENTING SCENERIO ON ADMISSION: Samson was a twenty-three year old young man who has a range of mal-adaptive behaviour patterns which regularly got him into trouble with other people as well as with the police. It was often difficult to decide whether he actually had a mental illness, a learning difficulty or was he just a bad person? He was generally described as having bad behaviours in addition with poor impulse control. The question remains that as he did not fit into any classification of formal mental health problems, it remained unclear if his behaviour and his responses to stressors were driven by mental illness or by bad and unacceptable behaviour. BACKGROUND TO THE PRESENTING PROBLEMS: He had presented with episodes of elated mood brought about by excessive angry responses to various situations. Quite often, he seemed to have failed to fully understand what was going on around him. For instance, if he wanted something that belonged to someone else, he simply reached for it and took it. He would make no effort to ask the rightful owner’s permission to do so. His explanation was often that he liked it. He did not seem to understand or to accept that the other person also liked the object and he would want to keep it for his own use. On the current admission, he had been arrested by the police who were called in to remove him from a neighbour’s home. The neighbour caught Samson wearing his new shirt. When the neighbour asked Samson to return the shirt to him, he refused and kicked the neighbour on the shin. An altercation broke out. While the two men were locked in a fight, a bystander rang the police. The two of them were asked what the problem was. Samson stated that his neighbour asked him to return the shirt that he was wearing to him. The police then asked the neighbour why he had asked Samson to give the shirt to him. The neighbour explained that the shirt belonged to him and that he just wanted his shirt returned to him. He added that he could prove that the shirt was his. At this point, Samson had jumped in and began to shout that he liked the shirt and that he had a right to keep it. The neighbour told the police that he could identify the shirt as his own because he marked all his clothes and some other belongings with a unique symbol and at a particular place. He took off the shirt that he was wearing, turned it inside out, and showed the symbol that he had marked on the labels of all his clothes to the police. But when Samson was asked to take the shirt off so that his neighbour could locate the symbolthat he claimed that he had marked on the shirt, Samson refused to do so. After much persuasion by the two police officers, Samson took the shirt off and handed it over to one of the two police men. It was then handed over to the neighbour for identification. The neighbour turned the shirt inside out and pointed out the symbol exactly where he said it would be. The police returned the shirt to the rightful owner but Samson lunged at him in an attempt to take it back. He insisted that it had become his shirt because he liked it and he had worn it for a few days. In order to prevent further violence from breaking out, the police cuffed Samson and removed him from the scene. He became verbally abusive towards the police officers which led them to believe that he could have a mental health problem. He continued to argue unreasonably and he was about to punch one of the police officers when he was quickly stopped with the help of the second officer at the scene. For this reason, he was taken to the police station to be booked and also to be assessed by the police doctor. He was too angry to co-operate with police instructions and he continued to be verbally abusive towards the officers. It was then decided that he should be taken to the 136 Assessment Suit at the local mental health hospital for a review. After a brief assessment at the police station, the police doctor recommended that Samson might benefit from further assessment as he remained emotionally charged throughout the time that he was at the police station. The police doctor referred Samson to the local mental health hospital for admission. Nursing staff on the ward recognized him instantly, as he had been admitted to the ward on a couple of other occasions before. He was subsequently admitted for further assessment by the ward team. His mother was invited to the ward rounds. She told the ward team that Samson had always had whatever he desired. She added that because he was an only child, he had not acquired the skills and the habit of sharing things with other people. She said that he had always taken whatever he wanted simply by stating that he liked it. As the discussion continued, it transpired that there had not been a father figure in Samson’s life. He was self-willed and a law unto himself. As he grew older, he began to lord it over his mother. He was the man of the house. It was he who decided what was done in their home and as his mother wanted to please him so as to maintain some level of peace and quiet at home, he got away with his bad behaviour. But outside the home, he often ran into difficulties as other young men his age would not tolerate his arrogance or allow him to lord it over them. His behaviour has been the cause of many altercations and fights in which he was regularly involved. When he went out, his mother often had to be called to sort out one issue or another. His present admission to hospital was a typical example of the sort of episodes that his mother had been called to sort out. People generally sympathized with his mother so, he often got away with his unreasonable demands. However, on this occasion, the neighbour refused to allow Samson to have his shirt and due to the level of the disturbance that followed, the police became involved. The neighbour said that he liked the shirt and that was why he had saved up to buy it. He added that it cost him quite a bit and he was not willing to give it to Samson just because he said that he liked it. Samson could not understand why the neighbour wanted the shirt returned to him. According to him, in the past, other people allowed him to keep whatever he said he liked. He argued that the neighbour had a job and that he should buy another shirt. One of the police officers asked him why he did not get a job and buy his own shirts. At which he retorted that he could not find a job. His mother blamed his behaviour on two things. The first was that it was her fault because if she had had more children, it would have helped Samson to learn some social skills. Her second reason was partly blamed on the fact that he was unable to grasp simple concepts as he had not attained any qualifications at school. During further questioning, his mother informed the ward team that he had achieved all his childhood milestones and that he did fairly well at school. He did not like to read, and he had a poor or short attention span when they watched television together at home. He could not hold a reasonable conversation for longer than a few minutes before he stormed off to do something else. He had no hobbies or interests of note, and he had never had a job, or showed any interest in finding one. Apart from these odd behaviours, there was a marked absence of signs or symptoms of either a psychotic or an affective disorder which would have indicated the presence of a mental health issue. It was decided that he should be sent for a psychometric test to determine his intellectual ability. The result of the test showed that his IQ was slightly below average. However, it was thought that it should not affect his understanding of simple facts of life about relationships or life in general. A referral was made to the Learning Difficulties Unit fur further investigations. The results from this department indicated that he was not intellectually challenged to a degree that required any of the interventions offered by the department. His mother seemed to blame herself for how he had turned out. She felt that part of his problems stemmed from the fact that she was not educated. She lamented that had she been educated, she might have done better by him. But this line of argument may not necessarily be true as some other young men who grew up in similar situations like his, had turned out right. He appeared to have a mean streak for always wanting to have his own way. It did not bother him if other people suffered as a result of his decisions and preferences. It was indeed an uphill task to get him to understand that other people may take exception to his views on the ownership of items or his behaviour towards them and their belongings. He was also unaware that his behaviour depicted extreme selfishness on his part and a lack of consideration for other people’s feelings, needs, or rights. He was often surprised at the reaction of other people towards his behaviour and his utterances, but he did not see any reasons to change some aspects of what they objected to. Attempts to get him to reason in what might be termed ‘socially acceptable ways’ fell on deaf ears. It was difficult to classify what was wrong with him. His behaviour did not fall under any formulation of mental health problems or learning disabilities. It was perceived as a form of mal-adaptive behavioural patterns which might have resulted from a combination of his personality traits, limited intellectual development and poor upbringing. It could be arguable that his behaviour was as a result of his unwillingness to accept his mother’s attempts to teach him social values which included respect for other people as well as respect for other people’s belongings. His problems were compounded by his belief and his attitude that he was more knowledgeable than everybody else. He rebuffed any attempts to correct him, even in the face of his being unable to solve simple day to day matters. In exasperation, his mother had given up trying to teach him the right way to go about various things. She felt that her efforts were perhaps a complete waste of time like the story of the man who took his horse to the stream but could not force it to drink. Her continued attempts only led to rows or outbursts from him. In order to avoid these unpleasant upheavals, she decided not to bother with him anymore and to just take each day as it came. The ward team had also arrived at a similar conclusion as his mother. However, the consultant decided to refer him to the Challenging Behaviours Unit for an assessment. His mother was advised to encourage him to comply with the instructions of this unit and if possible, to attend the assessment sessions with him. He reluctantly accepted the instructions that he was given and he subsequently attended the appointments which were arranged for him. However, at the end of the assessment by the Challenging Behaviour Unit, no significant deficits were identified, except an unbending desire to do exactly as he pleased. He grew up doing just that and it was perhaps too late in the day to get him to mend his ways. When he realized that the team here were on the verge of giving up on him like the other two previous teams had done, he agreed to try some aspects of behaviour modification therapies which were offered to him. The fact that he had accepted to try some of the interventions offered to him proved to some extent that he could control his behaviour if he wanted to. He was subsequently transferred to this unit to help modify some aspects of his behaviour. DISCHARGE PLANNING:

7. THE SCOOP

THE PRESENTING SCENARIO ON ADMISSION: David turned up on the ward with two women. One of them was his wife Mandy who was a well-known patient. She had suffered a relapse soon after she was discharged from the ward. It was highly unusual for her to have relapsed so soon after she was discharged. Moreover, she appeared unduly restless, agitated and tearful. Her speech had also deteriorated rapidly within a short period of time, against the prognosis of expert advice. It was not clear why she struggled to express herself. Although she suffered from a debilitating illness, it would not have affected her speech pattern so adversely in such a short time. Her behaviour was thought to have also been affected by the level of agitation, restlessness and tearfulness that were so readily noticeable. BACKGROUND TO THE PRESENTING PROBLEMS: David informed the nursing staff that Mandy had become quite unmanageable at home due to the increased level of her symptoms. He added that he thought that something had gone seriously wrong and he had taken her to the Accident and Emergency (A&E) department where it was decided that she should be readmitted into a ward for observation and treatment. Mandy was admitted and David left with the other woman, Elsie. As soon as they left, a positive change was observed in Mandy’s behaviour. She stopped crying. The agitation and restlessness also subsided. These sudden changes in her behaviour led the admissions nurse to ask her what went on between her and the two who had just left the ward. She spoke slowly, halting to form the words and sentences before saying them. Mandy was losing her speech. Piece by piece, the nurse began to understand that her anguish was due to the breakdown in her relationship with David, exacerbated by Elsie’s presence. It gradually became clear that David had left her and was now with the other woman who had accompanied them to the ward. A note was made about the changes in Mandy’s behaviour as well as what she had been able to say to the nurse. David was invited to the ward round for a discussion with the ward team. Again, he came with Elsie. David described how Mandy had become increasingly difficult for him to look after at home. He added that Elsie had also been helping to look after her. It was at this point that Mandy began to scream that David left her for Elsie. She was escorted out of the ward round to spare her further anguish while the ward team tried to get to the root of Mandy’s situation. David became edgy and abrupt. His answers to simple question were short or circumspect. He was unwilling to say what his relationship with Elsie was or why she had attended the ward round as she was not Mandy’s relative or friend. She had also not been invited by either Mandy, her family or the ward team. Generally, ward round discussions were held in such a way that only close family members and professions were invited. It was important that a patient’s privacy and confidentiality were protected so those in attendance were often professionals, trusted family members or someone who was invited by the patient. If the ward team deemed it necessary to invite some other persons to a ward round, the patient’s consent would be sought before that person was invited to attend the ward round. For this reason, the session was brought to an abrupt end as Mandy had not been asked nor had she given her consent for Elsie to be present at her ward round. The consultant asked the ward round nurse to invite Mandy’s brother, Edwin to see him before Mandy’s next ward round. When they met, Edwin informed the consultant that David had left Mandy but that he continued to live in Mandy’s flat. Edwin was asked to explain what he meant by his last statement, “that David had left Mandy” when they were both known to be still living together. Edwin explained that David had started a new relationship with another woman. He said that matters became more complicated when David brought his new girlfriend to live with him in Mandy’s home. Elsie moved into Mandy’s home with David but without asking Mandy if it was alright to do so. The flat belonged to Mandy. She inherited it from her mother after her mother passed away. Mandy was the eldest of their parents’ children and flat was given to her in their mother’s will. Edwin explained that after Elsie moved in with Mandy and David, that a gradual deterioration in Mandy’s health became quite noticeable. It seemed that David no longer had enough time to look after Mandy as he used to do before Elsie moved in with them. He was often out with Elsie, shopping, eating out and going to the pub, cinema or attending parties. Some days, Mandy would have nothing to eat as she was left at home on her own. She was unable to cook or to prepare a simple meal like a sandwich for herself so she had to go without. Edwin stated that on one occasion, when he paid an unannounced visit to his sister, he found Mandy sitting on the bed, weeping. He added that she was alone in the flat and she looked unkempt in her appearance. She also seemed to have lost some weight. What was more concerning, he said, was that the front door was left open and that anybody could have come in. He added that he ordered a take away for Mandy and fed her. He said that he had stayed with her until David returned before he left. He also said that he was too angry to discuss the matter at that time for fear of saying or doing something that he might regret later especially if David reacted in a way that might affected Mandy’s care adversely. On another occasion when he had stopped at Mandy’s, she was alone in the flat again! He waited for David to return. When David returned, he was followed into the flat by Elsie, Edwin went on. They both seemed to be intoxicated. Elsie went into the bedroom straight away and changed into her pyjamas before she returned to the living room. Edwin said that it was then that he realized that Elsie also now lived in Mandy’s flat. He asked David why his sister had been left at home alone again. Instead of answering the question, David became verbally abusive towards him. Edwin stated that this behaviour was so unlike David that he had to leave quickly as he feared that David was under the influence of alcohol and might become violent. He said that he knew that David would not hurt his sister and that she was not in danger. He reported that he returned the next day to talk to David about his behaviour the previous night, and also to discuss his sister’s care with him. But when he arrived at Mandy’s home, he found her at home and again, alone. He said that he decided to wait for David to return but after waiting for over an hour, he became so angry that, on this occasion he decided to take his sister home with him and they left. When David returned, Mandy was not at home. David searched all parts of the flat but Mandy was not in the flat. David was now in a real state of panic. He did not want to contact the police as it was less than twenty-four hours since he last saw Mandy. Moreover, he would be readily accused of neglect and financial abuse without being given a chance to give an account of what had gone on. David asked Elsie to stay in the flat and to ring him if Mandy returned before he did. He began a frantic search for Mandy in the neighbourhood. He could not bring himself to ask the neighbours because some of them who observed the changes in his relationship with Mandy, would not answer his questions. Some neighbours no longer spoke to him. For these reasons, he ran back and forth looking for Mandy around places where he felt that she might have wandered off to. He could not ring Edwin because if he did, Edwin would have asked him to explain to him, how Mandy was able to leave home on her own. He said that he had not seen either David or Mandy since then. At the end of his discussion with the ward team, he was invited to the next ward round to participate in his sister’s care planning. This time, both David and Elsie were also invited to the ward round. The aim was to discuss Mandy’s current situation and to use the information gathered during the various discussions to formulate the best possible care package for her. At the ward round however, it became clear that since David and Elsie become partners, that he no longer provided the same level of care that Mandy used to receive from him in the past or what she needed at the present time. Mandy’s health had gradually deteriorated over the years. It has now reached a point where she was unable to meet do most of her own activities of daily living independently. As Mandy’s dexterity and cognitive functions deteriorated, she became even more dependent on David so much so that caring for her began to be burdensome. What made matters worse was her grief over loosing David. At first, she was distraught but due to her declining ability to express herself, she could only weep, while her facial expression was tortured and distorted. David said that the memories of their marriage haunted him as the life that they had once shared together as husband and wife was slowly ebbing away. Things became increasingly difficult for David so that he began to look elsewhere for comfort. It reached a point in which it looked like he was now only interested in Mandy’s benefits. She received quite a substantial sum of money each month because her needs were quite complex. David was also being paid an Attendance Allowance for looking after her needs. On the surface, it looked as if David was a heartless man who was exploiting a helpless invalid. But when he spoke at the ward round about the difficulties, that he encountered on a day to day basis,, it became clear that he was not the monster that people thought he had become. Some of the neighbours would not speak to him since Elsie moved in. Some were so angry that they crossed the road when they saw him coming. Such hostile behaviours were unhelpful and they added to the pressures in his life. During the discussion, David was asked how things were between him and Mandy. In response, he described the difficulties he encountered with looking after his wife. He spoke passionately about how beautiful their life had been before the onset of Mandy’s illness. He said that they met at school several years ago and they got married almost as soon as he found a job to support both of them. He recalled how good life was until Mandy was diagnosed with a debilitating illness. He added that the doctors advised him not to panic as there was a lot of help out there. He said that they told him that the diagnosis was not conclusive and that Mandy would be seen by an expert in that field for more information or confirmation of what was to come. Shortly afterwards, he escorted Mandy to the appointment to see the expert. He described his disappointment when the diagnosis was confirmed. He recalled how they went home in silence but still holding hands. He promised to look after her and to keep his marriage vows. He described how people, including friends and family encouraged him to leave Mandy because he was too young to be lumbered with such a long-term problem. He said that he thanked each person for their advice but told each of them that he loved his wife and would not abandon her because of an illness. He described how he had given up his job to care for her in spite of various people’s opposition to this. He said that just watching her downward progress was so emotionally draining that he feared that he might break down under the strain of the slow and painful process that they were both going through. He described how he had suffered a lot over the years, watching as she gradually deteriorated before his very eyes. He described how it hurt to watch the woman he loved and married wasting away but that he could not do anything to help her. He added that at the beginning, his love for her blinded him to what the future held in store for both of them. But that with the passage of time, he began to feel extremely lonely and deprived of a normal life as she could no longer even hold a simple or meaningful conversation. He said that things grew worse over the years, especially as she gradually became unable to do almost anything at all for herself. He explained that the disease progressed more rapidly than was expected, so much so that she needed to have most of her activities off or daily living done for her by him. She was slowly losing her speech too, and found it hard to swallow and her mobility was also in decline. Providing full physical care for her reduced her to almost the state of a dependent baby. He reminded the team that his wife was only thirty-eight years old and that she should be in the prime of her life. He said that although he knew that she suffers from a degenerative disease, that the speed of her deterioration became so extremely rapid that he felt as if he was swimming against the tide. David was weeping profusely at this point. It was this state of affairs, he sobbed, that had driven him to drinking and later to his involvement with Elsie. His story was so moving that everyone at the ward round was teary-eyed. The look on their faces showed t the degree of empathy that they felt for David. David’s explanation was followed by a long interval during which nobody spoke. The silence was palpable. It was only broken when Edwin asked him why he did not seek help from Mandy’s family or from social services. David ruminated for a while before he spoke. He replied that at first, he was quite happy to look after his wife. He said that after a while, he began to feel overwhelmed by the enormity of what he had to do, but that with hind sight he now realised should he should have asked for help. He said that the second reason why he had not sought help was that he felt that it was his responsibility to look after his wife. He gave an account of how he spent each day. The account showed that he was ‘on duty’ twenty four hours a day. It seemed to be a gruelling and tiresome life. Mandy’s care co-ordinator was asked why she had not observed that David was struggling or that he needed help. In her response, she explained how David protested vehemently whenever she broached the subject with him. He often said that he was doing well even when he appeared drawn and exhausted. She described various attempts that she had made to convince David to accept one form of help or the other, but that he always turned them down. She presented a pamphlet, a copy of which she said she had given to David a few months before, to see if the information contained in it would help to change David’s mind, but that David showed no interest in the help that were on offer. She further explained that the pamphlet had a list of professional, as well as voluntary sector organisations where various levels of assistance were available, but that David showed no interest in any of them. After a lengthy discussion on the best way forward, the team arrived at the following conclusions. TREATMENT PLAN:

8. HE RETURNS!

9. MAD OR JUST BAD?

10. WE JUST WANT A BIGGER HOUSE

THE PRESENTING SCENARIO ON ADMISSION: This case involves an African family who originally came from East Africa. The eldest a son suffers from a serious and enduring mental illness. He had frequent admissions on the ward and was well known to services. In addition to his mental health problems, he also used illicit drugs which he claimed was part of his culture. Unfortunately, the drug was classified as a vegetable and could be easily obtained from the local shops and market stalls. According to him, every evening after dinner, all his family members sat around a table to chew the drug. But he was the only one to suffer a degree of adverse effect from chewing these “vegetables”. People with such problems were classified as having dual diagnosis, meaning that they fitted into two diagnostic labels, for instance, mental illness and substance misuse. BACKGROUND TO THE PRESENTINGPROBLEMS: When he suffered a relapse, he was extremely difficult to care for on an open ward as he was both verbally and physically aggressive, sexually disinhibited and chaotic in his behaviour. He often required an initial admission into a secure unit for a few weeks as he caused chaos on the ward. The level and frequency of his aggression could not be managed on an open ward at that time and the disruption that he caused to services impacted on the care of other patients on the ward. For these reasons, he often had to spend a few weeks at a secure unit until he was calm enough to be transferred to an open acute ward to receive the treatment that he needed. He had just been transferred back from the secure unit to an acute ward the previous week, having already spent four weeks at the secure unit. He also had a history of sexual assault on women. He was reported to be frequently hanging around the under pass near where he lived. He waited for unsuspecting women who were returning from work and he grabbed them as they entered the under pass. He would then proceed to assault them and run away before help arrived. During a previous admission, his father informed the ward team that he had also violated most of his sisters. Fifteen of them all lived together in a four bedroom council house. The situation gave him access to the sisters’ bedroom at night while they were asleep. The ward team decided to see if the problem could be addressed as part of his expanded treatment plan. His parents were invited to the ward round to provide more information to the team and to take part in agreeing on a plan for the treatment of their son. However, when the parents were asked how best they felt that the ward team could help to meet the family’s needs, the mother replied that she wanted a bigger house as she wanted to have more children. Asked how many children she had at the moment, she replied that she had thirteen children “Why do you want more children?” “To get more money,” she answered. The whole team were stunned by her responses. They did not know whether to laugh or to get angry. On one level, their complete lack of understanding of basic issues was ridiculous. On the other hand however, it was as if they had just arrived from another planet. In order for the family to understand the purpose of the ward round and to be able to participate meaningfully in the care planning, another attempt was made to explain the process to them. It was rephrased and explained to the family a second, a third and a fourth time. But the explanations were like talking to a brick wall or squeezing water from a stone. The mother did most of the talking. From what she said, her mind seemed to have been made up even before she came to the ward. She repeated her request for a bigger house so that she could have more children and receive more benefits. The reason why they were invited to the ward or why benefits were given to people, was completely lost on her. She demonstrated a total lack of any understanding of the reasons behind either the provision of social housing or social benefits to the needy. As far as she was concerned, these were sources of income. It also became clear that none of the fifteen members of the family worked; they all depended on the state for their livelihood. They could not see anything wrong with that. None of the four adult off-spring were interested in further education, apprenticeship or taking up unskilled jobs. Their mother could not understand why the discussion had moved from Abdul’s treatment to why her other children were not working. She said that they were alright the way they were and that what they did or what they did not do was none of the hospital’s business. She concluded that all they wanted was a just bigger house. The consultant asked Abdul’s mother what she thought about the sexual assaults that her son had repeatedly inflicted on various girls and women. She answered that he was a man. All the people in the conference room looked at one another in total disbelief. Nobody spoke for a while. The silence was almost palpable. After what seemed like an eternity, the consultant broke the silence. He said that it was now clear that these people lived outside the laws which governed the lives of the rest of the British population. It was not just their illiteracy that got in the way, the problem was more that of a totally different existence which was at variance with the rest of society. They saw any attempt to pull them up to face up to the realities of life as other people saw it, as some kind of unfair treatment against them. The way that they perceived things made it extremely difficult for them to engage in meaningful discussions with the ward team. The consultant added that as the matter had come to his attention, that he was duty bound to see to it that it was flagged up to other services because it was a breach of the law which affected public safety. He stated that after the ward team had exhausted all avenues at its disposal that the last resort might be to transfer Abdul to forensic services. In the light of the foregoing, the ward team decided to focus on clinical issues for the time being. Other arrangements would be made for another conference with the family in the near future. In the meanwhile, arrangements were also made for a social worker from the family’s country of origin to organise a series of visit to the parents and to gradually explain the following issues to them:

The plan included to reconvene another case conference when the social worker informed the ward team that Abdul’s parents have understood how things work in the United Kingdom. For the time being, the plan was to concentrate on Abdul’s treatment. The focus was now to be on Abdul’s mental health issues, his drug use or drug abuse and his unacceptable sexual behaviour. He found the whole idea funny and giggled continuously throughout the period of the lengthy discussions. He was asked to share what he found so amusing with the team but he could not articulate whatever it was that he found so funny. There he was, dressed in a woman’s blouse, probably his mother’s blouse, which he wore over an ill-fitting pair of shorts. He did not see anything that was remotely out of place in his manner of dressing. Instead, he seemed to be laughing at the team for wasting their time over issues he considered minor or irrelevant. In the end, it was decided to overlook his behaviour in order to focus on the formulation of care plans which would address the three major areas of his needs. The first area of concern was his mental health issue. Although he accepted that he had a mental illness, he did not believe that he needed any treatment. Mental health professionals refer to this as a “lack of insight”. Abdul stated that chewing the vegetable with his family kept him mentally alert. He added that he felt better after chewing the vegetable than when he took his prescribed medication. He said that he felt that the vegetable helped him more than the prescribed medication because the medication gave him adverse side effects. By his own admission, he has serious compliance issues. His presentation was almost always in an acute phase. He was impatient, restless and agitated throughout the discussions as if the team was wasting his time. In order to gain his interest, participation and consent, the team asked what side effects he had experienced and if he had spoken to his care co-ordinator about them. He replied that he did not tell his care co-ordinator about his difficulties with the medication that was prescribed for him. Again, it sounded like another confirmation that he had not been taking the medication that was given to him after he was discharged at the end of his last admission. His description of one of his symptoms agreed with a symptom known as a poverty of thought. In order to know whether Abdul understood what was being said, and also to ensure that his symptom was diagnosed correctly, the consultant rephrased the question. The Consultant asked Abdul again. “Why did you not tell your care co-ordinator about the side effects?” “What will he do?” Abdul replied rather rudely. A long explanation about why side effects were to be reported to care co-ordinators followed. It was not clear whether Abdul was listening or not. At the end of the long winded monologue, he was asked if he understood what had been said and if he agreed with it. His response proved that he was still stuck to his idea that chewing the vegetable was a better solution as, it was readily available at his home whereas speaking to his care co-ordinator would involve making an appointment to see him and taking trip to his office “Where do you get these vegetables?” the doctor asked him “My father buys it from the market.” Drug use was the second area for discussion. A discussion about the classification of the “vegetable” followed. At the end of it, it seemed that there was nothing that could be done to reduce the ease of access to this drug by vulnerable persons. The problem was that the vast majority of people from that region of the world chewed the vegetable regularly but only a few people seemed to suffer any harm from that habit. These are people who appear to have a predisposition to mental health problems. At the end of the discussion, the consultant decided to contact the Drugs Team regarding monitoring the effects of this vegetables on service users who may be known to be chewing it. They were also asked to consider collecting data regarding the prevalence of its adverse effects on users. The data would be used for briefing on the possibility of the reclassification of the vegetable. In planning Abdul’s care, the team decided to include a weekly visit by Abdul to his care co-ordinator’s office in his next care plan. It was hoped that these visits might help to make it more likely for him to go along with this plan. His care co-ordinator would use the visits as opportunities to find out more about his compliance issues as well as any adverse side effects he might be experiencing from his prescribed medication. While on admission on the ward, his mental state improved quickly because it was possible for his compliance with prescribed medication and adverse side effects to be monitored closely. He also had little or no access to the psychoactive vegetable which he admitted to chewing with his family after dinner every evening. More importantly, he had no access to unsuspecting women and girls who he was reported to attack as they went about their businesses. The third area of his care planning was his inappropriate sexual behaviour. It was common knowledge around here so his movements around the hospital were closely monitored to prevent such an incident within hospital grounds. For this reason, he was only allowed escorted leave. This means that he was always accompanied by nursing staff when he went out on leave from the ward. As such an incident had never been reported while he was on admission, it was safe to conclude that his problems firmly lay outside the boundaries of the hospital which were outside the control of the hospital teams. Getting his parents on board still remained an uphill task as they seemed to live in a fairyland where people did as they pleased without fear of consequences or reprisals. However, it was hoped that once they understood the gravity and the full implications of Abdul’s behaviour, that it might become easier for them to come on board and help to deal with it. At the moment, he got off lightly because in the past, when charges were brought against him, he got off on grounds of diminished responsibility. Because of his mental illness, he was deemed to have offended while he was mentally unstable. In response to the question about why he assaulted women and girls, Abdul stated that it was “fun”. He was asked what he thought that the women felt about being assaulted, he answered that it must be “fun” for them too. He did not express any remorse or sympathy for the women who he attacked. This lack of remorse seemed to suggest that he had no control or sympathy for his victims. He actually stated that he felt it was ‘fun’ for them too. For this reason, it was felt that he posed a danger to unsuspecting young girls and to women who used the under pass regularly. His mother had confirmed earlier that Abdul no longer went into his sisters’ bedroom at night. This assertion seemed to agree with the consultant’s line of argument. It indicated that he had lost interest in the victims he had already assaulted them. He just simply moved on to the next victim. The consultant suggested that he seemed to get his ‘kicks’ from the violence, and from the over-powering of his victims rather than from the sexual act itself, as he generally lost interest in the victim and moved on to target another person. The ward team’s hopes were dashed at the next ward round. The family repeated all the demands that they had made at the previous meetings. They did not make any mention of the points that the social worker discussed with them. They came across as if they lived outside of society’s norms, laws, rules and regulations. Two words sprang to mind – the “iron curtain”. Their mind-set was almost impossible to penetrate. All the efforts that were made by the ward team to get them on board appeared to have been a total waste of time and resources. These were scarce resources that could have been invested in the care of more responsive patients. The team decided that it would be best to wait until there was a significant improvement in Abdul’s mental state before the more serious issues could be discussed again. At the moment, Abdul found whatever was being said so funny that he giggled throughout the discussion. A junior doctor in the ward round asked if Abdul’s behaviour was a symptom of his illness or not. He suggested that Abdul should not have been laughing at them or at the system which allowed him to get away with his misdemeanours. The consultant asked him which specific behaviour he had in mind. The junior doctor answered that it was his prolonged giggling. He said that his mood seemed to be incongruous with reality, which in this case was the seriousness of the discussions at hand. At this point, the consultant said that he felt that the prolonged giggling was a symptom of the psychotic illness from which Abdul suffered. He added that it might be helpful to ask Abdul why he was giggling. Abdul responded by asking the consultant what he meant by giggling. The Consultant explained that he was referring to Abdul’s prolonged laughter. Abdul said that he did not know why he was laughing, but that he just felt like laughing. The Consultant now explained that the prolonged giggling was in fact a symptom of Abdul’s illness known as “incongruity of affect”. He gave three reasons why he felt that it was a symptom of his illness:

“For these reasons,” he said, “I would lean towards an incongruity of affect as the reason or the symptom for his sustained giggling. In my opinion, I have no doubt that it is a symptom of his illness. “Alright”,” said the consultant. “Let’s leave it at that.” Turning to the ward team, the Consultant said, “Do you all agree with my diagnosis? Is there an alternative view? If there isn’t, any questions?” But no further questions were brought up. In concluding the matter, he said “My decision at this time, is to overlook his behaviour for the time being in order to focus on the formulation of care plans that would address the three major areas of his needs.” The team answered in the affirmative “In light of the fact that Abdul has no intention to adhere to his treatment plan, are as follows:

11. ABIDING LOVE

THE PRESENTING SCENARIO ON ADMISSION: Samuel was a man in his mid-thirties. He was well known to services as he was what was described as a “revolving door” patient. This means that he had several admissions each year. It seemed as if he looked forward to coming onto hospital on admission. He was first admitted in his late teens and he has been repeatedly readmitted into hospital due to the frequent relapses which he suffered. At first, it was unclear why he relapsed so frequently as, he was concordant with his treatment plans. There was no question about compliance issues because he appeared to like to take his medication, at least, that was the nursing observation while he was on the ward. He had been tried on various medications, each of which seemed to control his symptoms at first, but he became resistant to it shortly afterwards. This was described as a “treatment resistant illness”. He continued to relapse a short while after he was discharged from hospital and he had to be readmitted soon afterwards. BACKGROUND TO THE PRESENTING PROBLEMS: Samuel was a polite, pleasant and charming young man when he was well. But when unwell, he became extremely loud, intimidating and disruptive. He is about six feet four inches tall, and well built. His voice boomed when he spoke and he loved to tower over others. His mere physical appearance was intimidating so that when he was emotionally aroused, his demeanour became so frightening that people kept their distance from him. Some patients discreetly referred to him as the “Incredible Hulk” On this occasion, the triggering factor was an argument with his friend. The friend started a horse play with Samuel without realizing that Samuel was on the verge of another relapse. He kicked Samuel but Samuel did not respond. Unaware of Samuel’s diminished cognition, he kicked him again. Samuel responded by lifting his friend off the floor and slamming him down hard. His friend lay on the floor. He did not respond to attempts to get him to stand up. Samuel ran outside to get help. An ambulance was called as his friend was unresponsive to prompts to get up. By the time that the ambulance arrived, Samuel had stormed out of the building and had marched down the road towards the hospital. The police were called to arrest him and to take him to the hospital but before the police had arrived, Samuel had already presented himself to the hospital. He reported that he had killed his friend but that he did not mean to kill him. It was then that the police arrived and he was cuffed. He co-operated with police instructions without any resistance on his part. He explained to the police and to the hospital staff that his friend provoked him into a fight. He was so remorseful that he was now crying like a child. He repeated that he had mistakenly killed his friend. Some of the ward staff who knew him were called to the scene to calm him down and to escort him to the mental health ward to be readmitted. When he recognised the staff who had been called to escort him to the ward, he rushed forward to explain to them what had happened. They were able to help him to calm down fairly quickly. He was taken to the ward where he was well known. He had often been admitted to this same ward and his symptoms were well documented in his hospital notes. His illness was a classic case of a serious and enduring mental illness of a psychotic nature. His symptoms included hearing voices which he said, told him what to do. He recalled how these voices told him to go to Liverpool on foot. They insisted that he must not board a train, a cab, a bus or any other form of transport. He recalled that it took him more than one week to walk from London to Liverpool. Other symptoms he described included seeing frightening creatures or apparitions which other people said they could not see; other symptoms he described were feelings that things were crawling on his back; feeling that people were against him and were always talking about him; and he also described some delusional thoughts patterns. Samuel was seen by his named nurse in a one-one therapeutic session. During the session, the nurse asked him where he had stayed during his trip to Liverpool. He answered that he slept rough at shopping malls when night fell and then he continued to walk towards Liverpool the next morning. He described how other homeless people helped him. On the first night, he said that a homeless man gave him a blanket, and another offered him a large coat which he used as a pillow. They shared their food with him and they helped him to sort out a safe place to spend the night. This pattern of assistance repeated itself at the various places where he sheltered for the night until he reached his destination. He added that he spent two nights in Liverpool and then he returned to London, this time again, he walked back. He recalled another occasion when the voices told him to jump out of a fourth floor window but he could not obey that command because he could not pull out the iron bars that were built into the walls of the window. The nurse asked him why he had to do whatever the voices told him. He responded that if he refused to do as they said, that they would send the terrible masquerades and demons to chase him around. He explained further, that whenever he disagreed with the voices, that they sent the frightening demons to kill him by tearing him into shreds with their finger nails which were like talons. He stated that he believed that the demons would kill him if they caught him and so he has to run away from them. He described another occasion when he refused to do what the voices told him to do. He said that the voices called upon the demons to chase him down the street and to make sure that that they killed him this time. He described how in his attempt to run away from the demons, he ran in front of a moving vehicle. He said that the driver swerved to avoid running him over but in doing so, that the driver crashed the vehicle into a building. He narrated how ambulances, fire engines and police vehicles raced to the scene as people had been injured in the crash. He said that the demons stood by laughing but he had to run as he feared that he would be arrested for causing the accident. The driver and the other passengers in the vehicle were taken to a local hospital by ambulance. They were treated and those who sustained only minor injuries were discharged but the driver who was unconscious was kept in hospital for further observations and treatment. When the driver eventually woke up, he was interviewed by the police. He described how he had to swerve in order to avoid a man who dashed across the road in front of him while he was driving at a reasonable speed. He said that it was while trying to avoid running the man over, that he crashed the vehicle into a wall. His account of the incident was corroborated by the shop keeper across the street who witnessed the accident. The description of the man who ran across the road fitted Samuel’s. The vehicle had been taken to the police station for examination. It was previously thought that the driver lost control of the vehicle probably because he might have been under the influence of drugs or that he might have fallen asleep at the wheel. According to the police mechanics, there was nothing wrong with the vehicle. The brakes were in good working order. All the other parts of the vehicle were in good working condition too. The investigation had to be moved back to the hospital for the clinical results of the state of the patient’s health. The results of the blood tests were all normal. There were no traces or proof that there were drugs of any description in his blood. The only question that was left was, had the driver fallen asleep at the wheels? The witness account from the shop keeper agreed with the account given by the driver. Moreover, the other passengers in the vehicle confirmed that the driver had been chatting and joking with them before the crash. On the basis of these three witness statements, the police investigation concluded that it was reasonable to accept that the accident was caused by the man who was reported to have ran across the road while the vehicle was speeding down the road. The nurse asked him if he thought that the voices and the images were real. He answered in the affirmative. He went on to describe how he was sure that they were real. He asked the nurse if she could not see them standing outside the interview room She answered that she could not see anyone standing outside the interview room. He looked surprised that the nurse could not see the demons who he said he was sure, were standing right in front of her. It was difficult to disabuse his mind from these abnormal perceptions as he was convinced beyond any doubt that they were real. Such were the strength of the symptoms he said that he suffered on a daily basis. He claimed that he felt persecuted by these experiences but that he was powerless against them. Listening to his description of how these abnormal perceptions affected him pulled at the listener’s your heart-strings. He asked the nurse whether these things were happening to other people, and if not, why were they happening to him? He was clearly worried and distressed about these experiences and he hoped to receive some explanation about how to get rid of them. The nurse explained that the voices and the images were symptoms of his illness and that the medication prescribed for him, was supposed to help control these symptoms. He seemed not to be convinced by the response that he received from the nurse. He told her that he always took his medication because he wanted to be well but that he relapsed even while he was taking the medication. He asked her why that was happening. By this time, the thirty minutes that was allocated for the therapeutic session had come to an end. The nurse advised Samuel that she will arrange for one of the doctors to see him and to answer his questions in more depth. On a previous admission, he informed the nurse that he had changed his name by deed poll. He did not want to be called Samuel any longer as he now wanted to be known and addressed as Abiding Love. The nurse thought that he was joking but he brought out the deed poll certificate which showed his new name as Abiding love. He said that the voices commanded him to change his name. He explained that he should not be addressed as Abiding, but as Abiding Love or just Mr Love. The changes were made in his nursing notes and all other documents were his name appeared. Such was the strength of the hold that the symptoms had on him. Nursing staff knew how dangerous it was to laugh at the change of his name and they advised other patients to step outside if they could not control their feelings about his new name. It was soon accepted and became quite normal for others to ask for Mr Love or Abiding Love. Some people still found it funny. Others didn’t. After all, they argued, that was what he chose to be called. And so it has been since then. Earlier during this admission, Mr Love went out on leave from the ward escorted by a nurse. As they walked down the major road, they met one of Samuel’s relatives. He informed them that Mr Love’s friend made a full recovery from his injuries that he sustained when Samuel lifted him up and threw him down onto the floor just before his admission. He added that his friend had been discharged from hospital and that he had moved away from the neighbourhood where he used to live. It was a piece of good news that cheered him up. He said that it was the best news he had heard in many years, because he had feared that he might be sentenced to prison for killing his friend. During this time, Mr Love responded well to treatment and he was now ready to be discharged from the ward. At his discharge ward round, the consultant asked him what had led to this present admission “I was not feeling well. My friend started to kick me. I knew that he was playing but I told him that I was not up to it as I was not feeling well. He kicked me again, and I told him to stop because I wasn’t well enough for such rough play. But he kicked me yet again. Then I lifted him up and threw him onto the floor. He lay there motionless. I called his name several times but he did not respond. Somebody called the police and an ambulance, and they came and took him to the hospital. That is what led to my admission this time. What is going to happen to me?” Samuel asked “That is why I asked you about what led to this admission,” replied the consultant “I thought that I killed my friend but when I went out with one of the nurses, we met my relative. He told us that my friend did not die. He said that he recovered consciousness after a few days in hospital and that he has now been discharged from the hospital. He went on to say that my friend has moved away from this area.” The consultant responded by stating that, “First of all Mr Love, I do not know what will happen to you. From the information that I have, your friend says that he will not press charges. However, I am not sure whether the case will be passed on to the Public Prosecution department. If this happens, I will write to them on your behalf because I have known and treated you for several years. Do not worry too much about what will happen to you, but in future, try to control your temper.” “I always try to control my temper. I told him that I was not feeling well three times but he did not listen,” Mr Love explained “Alright, I am going to discharge you today. You can go back into the ward to wait for your TTOs.” After Mr Love left the conference room, the consultant remarked, that “This is a sad case of a young man who does his best to remain well, but that the odds are heavily piled up against him. I took his case to the consultants monthly meeting last month,” he continued. “We bring such complex or difficult cases to this forum to put our heads together in an attempt to use our collective skills and experiences for the benefit of our patients.” “In Samuel’s case, oh, I mean Mr Love’s case, I have exhausted all the options available to me. I have used various combinations of anti-psychotic medication and even went above the BNF (British National Formulary) guidelines to see if he would respond to treatment and remain well for longer periods in the community, without being readmitted into hospital so frequently.” “But nobody at our meeting had anything new to suggest. I have already tried all the suggestions that were put forward to me at previous meetings, but they only worked for short periods of time before he suffered another relapse. There is only one option left and that is a referral to forensic services. If his friend had died, he would have gone down on a murder charge. But because of the nature of his illness, he probably would have been sent to a high security facility like Broadmoor. He seems not to know how strong he is. Moreover, the hallucinatory experiences he describes are too strong for him to ignore. For the protection of the general public I am going to ask for an early referral to be made to the forensics.” A referral has to be made to forensic services for consideration As at this present time, there was nothing else that the ward team could offer him, except perhaps to review his relapse indicators and to formulate another care plan which would reflect the degree of the risk that he posed to the public. TREATMENT PLAN:

RELAPSE PREVENTION:

12. A COVER FOR MURDER

13. TELLING IT LIKE IT IS

THE PRESENTING SCENARIO ON ADMISSION: Betty was a sixty year old woman who lived in the community. She was visited once a week by a nurse who worked in the community known as a Community Psychiatric Nurse or CPN for short. During these weekly visits, Betty often came across as being too dependent on her daughter, Helen. She often moaned that her daughter left one thing or the other unattended to. Most of the time, what she complained about was some little chore which she appeared quite capable of doing. Betty’s daughter had a full time job and was also her mother, Betty’s main carer. Betty stayed at home all day while her daughter was at work. After work, Helen would stop at the shops to buy groceries, and on getting home, she cooked for both her mother and herself. Helen was in her early forties and single. They spent most evening watching television together and chatting. Betty was believed to be suffering with an affective disorder and was looked after at home by a Community Psychiatric Nurse (CPN) who visited her once a week. She was always impeccably dressed and looked quite healthy. There was nothing about Betty which remotely suggested that she was ill, except that she said she was always very tired. BACKGROUND TO THE PRESENTING PROBLEMS: At first, it appeared as if Helen was her only child. It soon became apparent that she also had a younger daughter, Daisy who was married. Daisy lived in the outskirts of London with her husband and two children. She visited her mother and sister almost once a week. When she visited, Daisy brought some groceries, toiletries, and a new piece of clothing for her mother or some other items for the house. She would spend an hour or two and then rush off to pick up her children from the minder or to meet her husband for some engagement or the other. Sometimes, she visited with her husband and the children. Betty complained that Daisy was not helping to look after her. She said that Helen was left to carry the burden of looking after her while Daisy dropped by now and again. That was far from the truth. Betty was widowed young. She brought up her two daughters single-handed. While they were growing up, Daisy realized that their mother waited for them to come home from school to perform chores which she had seen her friends’ mothers doing. At first, she used to help but as time went on, she would not forgo her other engagements to do the washing up, laundry or vacuum cleaning and other chores which she knew that her mother could have done while they were at school. It continued when they went to college. By this time she had literally removed herself from these domestic chores as she believed that their mother could do them if she wanted to. Helen trained to become an accountant while Daisy worked at the local bank. Daisy met Stephen at work. They dated for a short time and got married soon after an engagement party. She moved in with her husband and they had two children in rapid succession. Helen continued to live at home with her mother. She has had a few suitors but things failed to work out between her and any of them. She had recently met Josh at a conference where she represented her employers. They started to date. On the first date, Josh came to the house to pick her up for an evening out. Her mother appeared quite pleased that Helen had finally met someone she considered suitable. She asked him where they were going. He responded that they were just going out for drinks at the new night club down town. She asked the name of the street where the night club was located and he told her the name of the street. He thought that she was just making conversation and made nothing of it. However as soon as they settled down at a table for the first drink at the night club, a message was announced. The message stated that Helen was required to contact the local hospital immediately. Both Helen and Josh hurried to his car and drove off to the local hospital. On getting to the hospital, they were ushered into a cubicle where her mother was lying on the bed. As soon as she set eyes on them, she told the hospital staff that she wanted to go home with her daughter. The doctor told them that they would like to keep Betty overnight for further observation but she insisted that she was well enough to go home. She was discharged against medical advice and she was driven home with Helen in Josh’s car. Once they got home, Betty surprised both Helen and Josh by her sudden and complete recovery from what appeared to be a serious illness. Josh stayed for a short while and then left. On a second date, Betty again asked for the details of where the two were going. Josh gave her the full address and the description of the cinema they were going to. Halfway through the movie, a message was announced for Helen to proceed urgently to the reception. Helen got up, followed by Josh. When they got to the front desk, they were told that Helen should contact a number which had been left for her. On ringing that number, she was told that her mother had been brought to the local hospital by ambulance. Josh drove her to the hospital. When they got to the hospital, they found Betty lying on a bed at the Accident and Emergency department. As soon as she saw Helen and Josh, Betty asked the hospital staff to discharge her. They drove home silently. Josh stayed for a short while, made some excuses, and left. The following day, Josh met with Helen at work and he discussed Betty’s sudden illnesses and the equally sudden and unexplained quick recovery with her. Josh felt that these illnesses were getting in the way of their relationship but Helen spoke passionately in defence of her mother. Josh had warned her that it had better not happen again. A few weeks later, Josh came to pick Helen up for a meal at a restaurant at a hotel in the centre of London. It was the anniversary of the day that they first met. They drove into London, but could not find a parking space. They drove back into the Whitechapel area where Josh worked and park beside Josh’s office and then they rode on the underground train back into central London. They walked briskly to the restaurant and settled down for a celebratory meal. The service was prompt and the food was good too. However half way through pudding, a waiter came over to their table with a telephone. Both Josh and Helen looked at each other in horror. The waiter informed them that a message had been left for Helen. He handed a piece of paper to her. She accepted it, her hand shook slightly. She looked at the piece of paper and saw a telephone number that was written on it, she turned to look at Josh. The expression on his face was that of anger. Helen remembered that he had warned her that if her mother called them home from a date again that it would signal the end of their relationship. She knew that he had meant every word of the threat. The waiter asked if she wanted to use the phone that he had brought to the table or if she would like to come to the hotel manager’s office to use a phone there. He added that it would be a bit more private if she chose the second option. Helen jumped at the chance offered by the second option as she would be able to speak to her mother in private and secondly, it will give her time to think about what to say to Josh. She rang the number and asked to speak to her mother. The voice at the other end of the phone answered that he was the doctor. Helen’s heart skipped a beat. She asked if her mother was alright. The doctor responded that her mother was alright but that she had asked for Helen to come to take her home. Helen asked to speak to her mother but the doctor told her that her mother was waiting for her at the reception. Helen thanked the doctor and replaced the phone. She stormed back to the table where Josh was waiting for her. When he saw the expression on her face, he immediately knew it was her mother that had disrupted their dinner once again. He got up from the table slowly and walked towards the exit with Helen following behind. He did not ask her about the telephone call. He continued to walk slowly towards the tub station. Helen walked behind him until they got to the station and boarded the tube. When they arrived at Whitechapel station, he turned and he looked at her for a long time but he said nothing. This time, the expression on his face was of pity rather than anger. They got into his car and drove to the hospital to pick up Helen’s mother and then drove back to her home. Nobody spoke during the journey home until they got to their destination. Now indoors, Josh asked Helen’s mother what the matter was with her. She refused to look at him or to answer his question. He asked her if she was now alright, but she still refused to respond to Josh’s question. Josh was now really angry. He told her that he was now going to tell it like it really was. He accused her of wasting the time of the ambulance service and that of hospital staff when she did not need their services at all. He explained to her that other people could have been denied the use of these services while the services were being diverted to attend to a perfectly healthy person. He asked her to explain to both Helen and to him, why she was doing it. Again, she did not answer. Her refusal to answer any of his questions further infuriated Josh. He told her that she had disrupted their dates on three occasions, and asked her why she had done so. He asked her how the ambulance men got into the house when they responded to her 999 calls as there were no signs of forced entry on all the three occasions, that they came into the house to take her to the hospital. As she refused to answer this last question, Josh said that he would answer the question himself since Betty refused to respond. Josh stated that Betty deliberately left the door unlocked with the key dangling in the key hole, she then rang for an ambulance and then gently lay on the floor. When the ambulance service arrived, they gained access into the house without difficulty as the door was not locked. They would have found Betty lying on the floor and took her to the hospital “Please correct me if I am wrong,” he said. But she did not answer. Josh told Helen that it was a pity that she could not see what her mother was doing to her. He went on to describe how she had called them away from an evening out on two previous occasions and that this was the third time. He told her that her mother would go to any length to prevent her from forming any lasting relationship or ever getting married. He said that Helen’s mother wanted her to remain single so that she could continue to live at home with her to look after her for the rest of her life. Josh told Helen’s mother that she had been married and she had two children but that she has been actively working hard at ensuring that her daughter would not have the same opportunities that she herself had enjoyed earlier in her life. He accused her of being a selfish and a bitter woman who was determined to stop her daughter from living her own life. Helen’s mother began to sob. This was how it dawned on Helen that it was not a mother’s love that kept her single but rather that it was her mother’s wickedness and selfishness that was in the way of her happiness. Josh asked Betty to save her tears for Helen as she could not deceive him with her crocodile tears. He asked her why her younger daughter only visited once a week. His plan was to show Helen what her mother was doing to her. Helen sat next to Josh looking as if she had seen a ghost. She was speechless and motionless. It seemed as if the idea and the effect of her mother’s actions had not crossed her mind before now. She had always believed that her mother loved her more than she loved her younger sister, Daisy. Turning to Helen, Josh stated that Daisy was the clever one as she had understood their mother’s scheme and she had worked her way out of it early in her life. He told Helen that he loved her but that it was over between them because Betty, Helen’s mother would not allow her to get married or to have a life of her own. He said that he could have just walked away quietly but that he felt so sorry for Helen that he had to let her understand what was happening to her. He added that he knew how loyal Helen was, not only to her mother but also to him, so he had decided to show her what she could not see as her loyalty had blinded her to the truth about her own situation. As he made his way towards the door, he turned to have a last look at Betty. He said to her, “I am sure that I am not the first one but for Helen’s sake, I hope to be the last man to have to walk away.” Betty looked away. She did not respond to what Josh had just said to her. He asked her who she thought would look after Helen when she grew old, having had no husband, no children or grandchildren? Again, Betty ignored Josh’s remark. After that last statement, he opened the door and left. He never returned. The breakdown of the relationship between Helen and Josh had a significant effect on Betty. After this encounter with Josh, Betty had to pull herself together to help with some house hold chores as Helen was actively looking for a flat. She did not threaten her mother or even discuss the plans for her future with her mother. She simply began to go out with the girls from her office after work. She came home late and tired. She went to bed soon after she got home. She did not need to tell her mother about her movements, who her friends were or any of her plans for the future. In fact, she had not held a decent conversation with her mother since Josh left. Betty got the message, loud and clear that Helen would move out shortly and she would refuse to visit her mother. The next time when the care co-ordinator visited, she met Betty cleaning her kitchen. She could not believe her eyes. She congratulated Betty on the improvement she was making in helping with some of the housework. She asked Betty how such a feat was achieved. Betty said that she just wanted to contribute in looking after the house because it made her feel better. The care co-ordinator praised her and encouraged her to keep it up. Gradually, Betty took on more and more of her domestic chores as she was convinced that Helen would move out as soon as she found suitable accommodation. On her next visit, the care co-ordinator met Betty at the front of her home. She held a shopping trolley in one hand. She said that she was on her way to the shops. The care co-ordinator was dumbfounded. When she recovered from the shock, she offered Betty a ride to the shops in her car. She made a new appointment to visit Betty so that both of them could spend quality time working out Betty’s new care plan to reflect the new changes in her life. TREATMENT PLANNING: Betty had made massive improvements in meeting her own needs. Her anxiety levels seem to have disappeared since Helen moved out. Her anxiety was now seen to be a result of her fear of Helen’s eventual marriage or moving away from home. Now that that was history Betty had pulled herself together to face her life independent of Helen. There was no longer a need for the CPNs weekly visits as Betty has been meeting her own needs adequately and independently. The weekly visits were down-graded to two weekly visits. It was further reduced to monthly visits in preparation for Betty’s discharge from the community team’s services. Her medication was discontinued as she no longer needed it. RELAPSE PREVENTION:

14. THE MASK

15. TWO LIMOS

PRESENTING SCENARIO ON ADMISSION: Chris was brought into hospital by several police officers. He was in a rage, claiming that the police officers had ‘maltreated him’ meaning that they had treated him roughly. His speech was pressured perhaps because he was so angry that he could not speak in a normal tone, speed or pitch. He was shouting at the top of his voice and was verbally abusive towards the police officers. He boasted that he would deal with them and that he would teach them the lesson of their lives. He refused to sit down or to co-operate with the nursing staff until a nurse who knew him well on his previous admissions arrived for duty. It was then that he related as to why he thought he had been brought into hospital. His mood was elated, he expressed sexually inappropriate views about the newly qualified female nurses on the ward and he was also disinhibited in his choice of words and mannerisms. He subsequently calmed down and was admitted for further assessment and treatment. BACKGROUND TO THE PRESENTINGPROBLEMS: Chris was a married man in his mid-thirties when he came to the attention of mental health services. He was a university graduate and he had a good job before the on-set of his illness in his mid-twenties. He was charming and well-spoken when he was well but when he was ill, he was chaotic, loud, disruptive, abusive and grandiose. He was well known to mental health services and he was often admitted into hospital on a section of the Mental Health Act as he did not recognise the symptoms of his illness to present to the hospital on his own. He often believed that he was just “very happy” and that he wanted to share his happiness with others. In this area of work, such a belief and its attendant behaviour are referred to as a ‘lack of insight’ The current admission was triggered by his attempt to kidnap his children. His marriage had been dissolved because of his frequent disruption of family life. After each admission and the subsequent discharge back to his family, he generally discontinued his prescribed medication and began to drink heavily. He came home in the early hours of the morning and woke up his wife and the children on a regular basis. His wife’s attempts to get him to come home before midnight often led to altercation and occasionally, to physical violence. Neighbours would call the police and he would have return to the hospital. After several episodes of violence, admission, readmission, and discharge, his wife filed for a divorce. But after the divorce, he refused to stay away from the family home. He came over whenever he wanted to, and he caused a disturbance not only in the home of his wife and his children, but also the neighbours who were often drawn into these upheavals were affected. At last, his wife filed for a restraining order and he was given a restraining order not to visit his wife and children at home, and not to come within a hundred yards of their home. He resorted to visiting the children at school. He brought chocolates, biscuits and fizzy drinks to the children but he warned them not to tell their mother. One day, the youngest child brought the chocolates home. When his wife found the chocolates in her son’s school bag, she demanded to know who gave them to him. After the children admitted that their father often came to see them at their school, his ex-wife went back to the courts to request that the restraining order should be extended to include the children’s school. The school was informed that Chris was not to visit the children at the school. He was now cut off from seeing his children at home as well as at their school. But when he suffered another relapse, he drove his car to the gate of the children’s school and waited for them to come out. When they eventually emerged, he offered to drive them home in his car but he told them that their mother must not know about it. They were happy to ride in his car again and so they climbed into the car. However, instead of driving towards their home, he turned on the automatic locks on the doors of the car and started speeding in the opposite direction. When he ran through a red light his oldest child protested but he shouted at her to keep quiet. He continued to drive at top speed. He was spotted by the traffic police who were on patrol in the area when he ran through the red traffic lights. When the police attempted to flag him down, he laughed out loudly and increased the speed at which he was driving. The police also noticed that there were children in the back of the car and that the children were crying, so they called for reinforcement from other traffic police patrol cars. He eventually brought the car to a stop when he realised that he was surrounded by police cars driving towards him from different directions. He came out of the car to inform the police officers that the children were his. One of the police officers spoke to the children while another spoke to him. Two police men began to search the car. The children had informed the police that Chris was their dad and that he came to their school to take them home but instead of driving towards their home, that he was racing in the opposite direction. The policemen asked the eldest child for their mother’s telephone number. When they rang her, she informed the police about the restraining orders. She informed them that he suffered from a serious mood disorder and she pleaded with them to take him to a mental health hospital where he was well known to the staff. She asked if she could drive down to pick up her children but the police reassured her and encouraged her stay at home to wait for the children to be brought home by police transport. The police brought the children home to their mother. Chris was taken to the hospital and he was readmitted. It eventually became clear that Chris had kidnapped his children with the intention of moving to Cornwall to set up home with them there. On assessing his mental state, he was found to be in a manic phase of his illness with an elated mood, pressure of speech, irritability, flight of ideas and grandiose ideations. His car was driven back to the police station in London by a police officer. It would remain there until he was well enough to come to fetch it. It was not the first time that he had to retrieve his car from the police station. On a previous admission, Chris had informed staff that he was now at par with a high ranking politician who was known to have two luxury cars of the same make and was nick-named “two limos”. Chris stated that he was now at par with the politician because he too had purchased two identical luxury cars of the same make. Although Chris was on social welfare and incapacity benefits, he felt that he could compete with a high profile political figure. He argued that they were at par as each of them owned two luxury cars of the same make. The difference however, was that Chris’ cars were second hand cars whereas the politician had bought two brand new cars. Chris loved designer clothes and he made sure that everybody saw his new clothes. They were usually fake or illegal copies of designer items but that meant nothing to Chris. He was just such a terrible peacock. These are just a few examples of his grandiose ideas when he was in a manic phase. His wife was invited to a ward round but he demanded that she should not take part in the discussions or in making decisions about his future because she had obtained restraining orders against him and that she had denied him access to visiting his children. She was asked to leave but she was invited to speak to the ward team at the end of the ward round after Chris had left the conference room. She described the difficulties she had had with managing his illness at home as he had refused to comply with his treatment plan each time, after he was discharged from the hospital. His drinking made matter worse. He also lived far above his means, and he spent all his benefits on fancy items. He also borrowed heavily on his credit cards and regularly overdrew his bank accounts. He did not make any financial contribution towards the children’s welfare but spent his benefits on himself. The information that she provided helped to review and to formulate new care plans for him. At his discharge ward round, the consultant reminded Chris that they had discussed the question of his substituting alcohol for his prescribed medication. He told Chris that he was a well-educated man who knew exactly what he was doing. He advised Chris that it was his choice to be well or to continue to go up and down like a yoyo. He chided him for not heeding medical advice even though he had been told that with each relapse that he suffered, his brain was being irreparably damaged bit by bit and that there would come a time when he might not respond well to treatment. He warned Chris that the choice was his to make. TREATMENT PLAN:

16. FRIENDS?

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