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Declan Henry faced a tough task in trying to rehabilitate a murderer and habitual drug user. His client, who stabbed his father to death, refuses to acknowledge that he has a mental illness, and is expressing a hatred of his mother. Graham Hopkins reports.

The name of the client has been changed.

Case notes

Practitioner: Declan Henry

Field: Deputy manager of a forensic rehabilitation unit for mentally disordered offenders

Location: London

Client: George Kemp, aged 36.

Case history: Kemp has been diagnosed with paranoid schizophrenia and has a paranoid personality disorder. He also has a long-standing habitual drug problem. In 1988, he murdered his father, stabbing him 26 times. He said he felt emotionally abused by his father, who had become an "object of hate" in his life. On being discharged from hospital, Kemp lived for two-and-a-half years in the community. But in 1997 he was recalled to hospital after his mother reported him for growing marijuana in his back garden, since when he has been detained in a medium secure unit (under section 37/41 of the Mental Health Act 1983). Efforts to implement his deferred conditional discharge have failed since November 1999 owing to his refusal to follow his care plan and his continued drug misuse.

Dilemma: Kemp’s unrealistic expectations and, at times, limited view of reality may well set him up to fail, but - given his institutionalisation - may also be deliberately contrived precisely to fail.

Risk factor: Kemp’s inability to accept his mental illnesses, drug misuse, and his growing hatred towards his mother may put himself and others at risk of serious harm.

Outcome: Kemp’s overnight stays at the rehabilitation unit have been successfully completed without attempts to sabotage the care plan and with signs of drug use.

When Declan Henry became the keyworker to George Kemp, a murderer with diagnosed paranoid schizophrenia and a paranoid personality disorder, and attendant drug habit, he knew he had his hands full.

Not just because of the challenge presented by Kemp’s case, but also because he was a murderer - or rather, because of his murder victim. Henry, deputy manager of a voluntary-run forensic rehabilitation unit, had recently suffered the trauma of his own father’s death through natural causes, and here was a client who, in 1988, had brutally murdered his father by stabbing him 26 times: "The loss I was feeling for my own father clashed with the sometimes cavalier attitude that he had towards killing his father," Henry recalls.

His own feelings aside, Henry identified three main risks with Kemp: his habitual drug-taking, his violent history, and his lack of understanding of his mental illness.

"Since being accepted in September 2001, he has sabotaged his placement by taking crack cocaine on at least three occasions," says Henry. "And if he was able to get hold of crack cocaine in a medium secure hospital, out here the opportunity is considerably greater. It’s not a restricted unit. Clients have their own front-door key. Kemp will have to reside here at night in line with Home Office restrictions, but can come and go as he pleases."

Kemp finally began his "afternoon leave" in January. Again, the omens were not good. "On his return from his first unescorted visit," recalls Henry, "he tested positive for cannabis and possibly another substance. We gave him a final warning - any more and the offer of a placement would be withdrawn."

Henry considers that his sabotage tactic may be deliberate: "Maybe there is a lot of anxiety about coming out of an institution," he says. But this is where the unit usually comes into its own. "We work with very difficult clients and we have a heavy emphasis on life skills, which we teach them so they can move on to less supported accommodation or an independent flat," says Henry. "Ideally, they stay with us for between 18 months and two years. We don’t usually look at clients moving on until they have been here at least a year."

Kemp’s perception of reality was, not surprisingly, blurred. He had monthly depot injections (see Factfile, page 41) but complained that they caused trembling as a side-effect. "He doesn’t feel he has a mental health problem and wants to stop having the injections," says Henry. "He feels he was mentally ill at the time of his father’s murder, but that his psychotic illness was induced by drugs. He says he is remorseful about the offence but does not feel responsible because he was unwell at the time. At other times he is not remorseful."

The forensic psychiatrist recommended Kemp’s medication remain unaltered given the major change about to happen in his life. "We felt a review would be more appropriate later on depending on his progress," says Henry.

Kemp’s violent history was also a crucial factor. He had been violent towards fellow patients but not staff. He hadn’t spoken to his mother after she informed on him, since when she has replaced his father as his new object of hate. She is "in hiding" in France.

Kemp - who has attempted suicide twice and has self-harmed at least three times over the past 10 years - was very capable of hostility. "My first experience came when I attempted to address his drug problem," says Henry, who admits his forthright tactics were possibly stirred by memories of his own father. Kemp’s initial response was: "I no longer have a drug problem - it’s in the past." But Henry knew he had taken drugs six weeks previously, and had spent over £28,000 on crack cocaine (he rented out a flat he owned) and was in debt with a bank loan. "In retrospect," says Henry, I feel I went too far," he concedes, "and our relationship deteriorated. He was angry with me for challenging him and I felt inadequate as a practitioner by his response to my approach."

At a three-way clear-the-air meeting Henry, his manager and Kemp discussed these difficulties, with Kemp eventually accepting that Henry would remain as his keyworker.

The relationship has clearly improved. Kemp, aware of the expectations placed upon him, has begun his twice-weekly overnight stays and has remained drug-free. Henry is confident that Kemp’s full-time trial period will soon begin. "Our main source of work from now on will be containment. It doesn’t sound like much, but given the complexity of a client like this, it will be an achievement," says Henry.

Arguments for risk

• Kemp has displayed an ability to live in the community in relative safety, but was unable to deal effectively with his drug use. Targeted work within this area could lead to a successful transition.
• He has, at times, shown remorse for killing his father and has blamed his mental illness for his actions.
• Kemp has been institutionalised for a long time and the thought of having to deal with the outside world may be at the root of his attempts to sabotage his community placement. Skilled help could see him overcome this fear.
• Kemp is stable and well. Henry is confident that he is capable of making a focused effort to deal with his situation positively.
• Living in an environment that permits freedom of movement (excepting the need to remain at the unit at night) allows Kemp some independence and choice that would be denied him in hospital.

Arguments against risk

• Kemp is a murderer and habitual drug user. He has at times displayed a less-than-remorseful attitude to the murder. He has also, time and time again, relapsed into drug use from cannabis (which is potentially harmful considering his mental health and medication) to crack cocaine.
• He can seemingly obtain drugs relatively easily - even when a patient at a medium-secure hospital. Moving him into a more independent lifestyle will only raise the temptation and access to drugs.
• Kemp is very able to scheme and manipulate. Challenged by Henry, he demanded that he be removed as his keyworker. This could indicate an unwillingness to tackle his behaviour constructively.
• If living more independently, there is a real risk that Kemp will stop his depot injections.
• As the new object of hate in his life, his mother is clearly at risk from harm. Although she is in hiding, she may return or, indeed, Kemp may try to find her.independent comment

Independent comment

Henry’s approach demonstrates the value and centrality of a therapeutic relationship, writes Tom Dodd. It is understandable that the weight of Kemp’s history alone (it has been 14 years since he killed his father) would tip the balance in favour of a containing and less-flexible regime.

The experience of paranoid disorders often means that the individual is less likely to take responsibility or see their role in the detrimental things that happen in their lives. Kemp may find it difficult to get pleasure from relationships, he may construe any comments as criticisms and blame the "persecutor". As his keyworker, Henry will need to take a cautious but intensive approach, while at a pace that is acceptable to Kemp because he is likely to disengage easily. If the aim of intervention is to modify Kemp’s beliefs and behaviour, then he is less likely to fail.

The service’s relationship with Kemp is likely to be over a period of years. To maintain opportunities for Kemp, the keyworker will need continued and comprehensive support from the multidisciplinary team. The care package is complex and will need a detailed rationale, with contributions from a number of sources. Such decision-making requires transparency and clarity from everyone involved. The more risks that are evident - and this case highlights many - the greater the imperative to take a team approach, sharing decision-making, accountability and responsibility.

Tom Dodd is co-ordinator for assertive outreach at the Sainsbury Centre for Mental Health.