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Social worker Jennifer Dixon faced a difficult situation when she tried to help a couple who were dependent on one another, but needed outside help that the wife was not keen to accept. Henrietta Bond reports

A strong bond is needed to keep a couple together when one of them becomes totally dependent on the other for their physical and emotional needs. When this problem is exacerbated by paranoid behaviour, violence, verbal abuse, and social isolation many might wonder why any partner would choose to continue caring. But as Jennifer Dixon discovered, some relationships withstand the harshest tests of time.

Dixon was contacted by the Pattersons' GP who was worried that Keith was "at breaking point". On her first visit she was struck by the couple's appearance. ''Although they were both under 50 they looked much older. She was a very large lady and clearly the dominant partner in the relationship.

"He was a small, nervous man who appeared worn out. He followed me out to the car and told me things he was too frightened to say in front of her. I invited him to come for a meeting in my office but because her illness seemed to cause paranoia she got very upset if he was out of her sight for a moment, and he wouldn't leave her.

"She was also clearly very suspicious of social workers and neither of them wanted more than basic intervention from home carers. Nor would they consider respite care. They wanted to remain as private and independent as possible.''

Dixon discussed the case with her line manager and they agreed that they should consider offering the Pattersons additional home care hours - disguised in the form of a "companion" who would keep Mary company while Keith had time for himself. She also made a referral to an occupational therapist because she felt that the couple would benefit from an up-to-date assessment on moving and handling.

The occupational therapist rang Dixon to say that she had witnessed Mary punching her husband. Dixon also received reports from the home care agency that Mary was lashing out at care staff.

Dixon referred to Cumbria's mistreatment of adults multi-agency policy and procedures 1993, which directed that she should discuss the situation with the senior worker, who in turn recommended that she involve an approved social worker. This ASW suggested that Dixon should call a case conference. However before this happened reports of Mary attacking a delivery man came to light and Dixon was advised to arrange an emergency meeting with the Pattersons and take along a male ASW for support.

"Mary related very well to this man and told him that Keith was physically and mentally abusive towards her. She kept saying that the marriage was over and asking us to take Keith away. It was quite surprising to hear this because it hadn't been apparent that the abuse was a two-way thing. Keith admitted that he did get angry with his wife because caring for her 24 hours a day was getting too much for him.''

A case conference attended by representatives from the care agency, the occupational therapist, the senior social worker and the couple's doctor took place. A psychiatrist's report was also considered. "The GP advised it was better if we didn't invite the Pattersons to this meeting so we could talk more freely. I felt uncomfortable about this but settled for communicating with them directly afterwards,'' Dixon explains.

During the meeting a range of medical and care concerns were identified. Although Mary's allegations of Keith's abusive behaviour were treated seriously none of the care staff had ever witnessed attacks or seen the bruising which she alleged he had caused. Another issue causing concern was that Mary could not sleep and smoked in bed. Keith was staying awake all night to ensure that she did not set fire to herself. It was agreed that Mary would be offered extra medication at night to help her - and Keith - achieve some rest. It was also proposed that the couple should be offered a referral to a relationship counsellor.

The Pattersons agreed to the offer of a "companion" sitting with Mary twice a week for two hours. "Keith seemed to improve a bit but claimed he had nowhere to go during this time. He was like someone who'd been in prison for eighteen years, with no friends and no outside interests. I suggested things like going to a cafe or looking up old work colleagues. I also suggested attending a carers' group but he declined because his whole life revolved around caring.''

When Keith's health again began to decline and his GP insisted upon respite, Mary fared better in a nursing home than anyone had expected, despite insisting that she had been"abandoned". Keith visited her daily. Although she returned home after three weeks, it was soon apparent that Keith could not cope any longer.

"I was really taken back when I raised the subject of living in a nursing home with Mary, and she said that she wanted to go,'' Dixon explains. "I found out later from the nursing home manager who visited them at home that Keith had admitted that he had slapped Mary because he couldn't cope any more with her constant demands.''

Soon after her admission to the nursing home, Mary was transferred to hospital where she died. "Keith was absolutely devastated. I went to see him soon afterwards and he was saying that Mary had always been 'the only girl' for him. He clearly felt very guilty about not being able to care for her up to the end.

"Despite everything I believe they really loved each other and it would have been wrong for us to intervene more than was necessary. After all, what right has a social worker to interfere in someone's marriage unless they're specifically asked to do so?''

Arguments for risk

· The couple had lived very insular lives and preferred to maintain independence and privacy.

· Keith chose to continue to care for Mary. He had never requested additional help, nor sought help to cope with her violent behaviour. He had no life outside his relationship with her.

· Mary clearly distrusted social workers and might refuse all help if obvious attempts were made to intervene in their lives

· Some of the home care agency workers had built up a long-term relationship with the couple and could monitor the situation

· Despite the enormous strains on their relationship, there were signs that the couple still cared for each other

· A psychiatrist's report on Mary's mental health was inconclusive and there were no grounds for sectioning her despite her violent behaviour

Arguments against risk

· Keith was worn out and frightened by his wife who was physically much stronger than him. He was also racked with guilt

· His health was deteriorating as well as hers

· Mary's paranoia made it very hard for Keith to have any time to himself

· Mary's violence towards care assistants and delivery staff made it likely that agencies would refuse to provide services to the couple

· Mary refused offers of updated lifting equipment, putting additional strains on Keith

· The strain of caring for Mary might have caused Keith to abuse her physically or emotionally