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Case notes   

Practitioners: Ann Humphreys, team manager, and Louisa Traherne, senior practitioner. 

Field: Care management and assessment, adults' services. 

Location: Staffordshire. 

Client: Elaine Bradshaw is a 34-year-old woman with learning difficulties. She has acute epilepsy and diabetes, conditions  that have made her health worse over the years.  

Case history: Elaine was living at home with her mother, Laura Blaine, and her stepfather, Mike Blaine, who spent a lot of his time working away. Because of this, Laura depended largely on Elaine not only for help around the house but for companionship. The mother and daughter relationship is an undoubtedly volatile but close one. Elaine does not get on too well with her stepfather. Elaine says, "He gets angry and tells me off and tells me what to do". She also has a history of diagnosed depression and has frequently overdosed on her medication, causing hospitalisation. Because of this her mother became unrelenting in her supervision of Elaine, worrying that if she wasn't watched all the time she might take her own life.  

Dilemma: Although Elaine's situation at home was troubling, she was close to her mother. 

Risk factor: No matter what alternatives were offered it seemed that Elaine's mother was able to grind her down psychologically into returning home. 

Outcome: Elaine has been placed successfully into a community home where she is free from abuse and where her confidence and independence are continuing to grow.   

It is not unusual for parents of people with learning difficulties to see their son or daughter as a permanent child. The emotional and psychological cotton wool they wrap around them, while intended to protect, more often suffocates development and independence - and can easily cross into abuse. This was the situation that faced senior practitioner Louisa Traherne and her manager, Ann Humphreys, when they took over the case of Elaine Bradshaw, a 34-year-old woman with learning difficulties.

Four years ago, after a request for day services, Traherne and Humphreys carried out a full assessment of Elaine's care needs.

Placed in a day service, which she had previously attended, Elaine soon disclosed to Traherne and other staff that there had been abusive incidents at home. "She said that she had been hit by mum, had had her hair pulled and once had run out of the house only to be dragged back kicking and screaming," says Traherne.

Worryingly, the mother, Laura Blaine, had also set up video cameras in the house to watch Elaine's every move. "Because she abused her diet and medication, mum wanted to make sure that she wasn't overdosing and set up these Big Brother-style cameras so they could watch her all the time," she says.

Laura could not see how this was abusing her daughter's privacy and dignity. After each disclosure, Elaine was asked whether she wanted to involve police. Traherne says: "Once or twice she said 'yes', but generally speaking she said, 'No, absolutely not'. Police carried out initial interviews but Elaine would decline to take things further."

Psychologically, the Blaines treated Elaine like a child. "I worked with her mother to redress that. I appreciated that she was trying to protect her in many ways but she was actually old enough and able enough to take responsibility for own well-being. Unfortunately, her diet and medication were the only things she had control over - and so she would abuse those because she knew if she was put in hospital she would be out of her home situation."

In hospital, Elaine would repeat the pattern as soon as she was about to be discharged. She would store up her medication and take it all: "Hospital was preferable to home," says Humphreys.

As her home life was the root of her problems, Traherne placed Elaine in a care home some distance away. "For about four weeks she held out well and didn't want to see or speak to mum. But after a couple of phone contacts with her she was wavering. After a meeting on neutral territory she buckled and wanted to be home again," says Traherne. "Mum was saying 'You want to come, don't you?' It clearly wasn't a question - there was no choice being offered," she adds. And within a few days Elaine was home.

Despite the situation, home did have its advantages - the dog, her own room and, for all her faults, her mum. "She missed them," says Traherne.

But soon Elaine turned up at a local home. Since then, Traherne and a determined staff team have worked with Elaine "to bring her out of herself". The staff encouraged her to do more for herself. "She fought against that for a bit but then accepted it - and that helped give her the confidence she needed," says Traherne.

Her mother's acceptance may have been more due to her own poor health after a lengthy spell in hospital. Even so, on Laura's return home, according to Humphreys, "one of the first things she did was ring here and ask for Elaine to come home. You could tell on the phone that she wasn't the strong woman that she was, but still determined to have her daughter home. This was her need - companionship."

Elaine still goes home for the occasional weekend and says Laura always tries to make her stay but she tells her, "no, I'm going home on Sunday evening and that's that".

Six months into her placement Elaine is settled and blossoming. "The improvements are noticeable in Elaine's physical appearance. At home she didn't often change her clothes, wash her hair or really look after herself, even though she was able. Now she looks great. Her confidence is far better - she'll tell you want she wants now," says Traherne. Clearly, with the shearing of the cotton wool wrapped around Elaine the young girl, Elaine the independent woman is looming large.

Arguments for risk 

• While Elaine's relationship with her mother was volatile and, at times, physically and emotionally abusive, there was an undoubted bond between them. It was important to remove Elaine from the family's influence, stand her on her own two feet, and then re-introduce family contact, but on Elaine's terms. 
• Psychologically, the family repeatedly "persuaded" Elaine to return home, often using treats - weekends away, going out - to add to the pressure. Elaine is an adult with capacity to consent, but her vulnerability was being expertly exploited and this needed to be countered. 
• Elaine's health needs were being met. She was being seen by a diabetic nurse, her acute epilepsy (she was having three grand mal seizures a week) was being monitored and her depression was being treated by a consultant. But she was socially isolated. It was only when a social network opened up through the day service and her trusting relationship with Traherne that she began to disclose the abuse.   

Arguments against risk 

• Although a picture is painted of poor parenting, Elaine herself was capable of manipulating a situation. "She had been in and out of day services for many years and had tended not to settle. It's always been a bit unsure whether mum pulled her out or she chose to leave independently," says Traherne.  
• Elaine always used to hide behind her mother. She would say: "I can't do that unless mum says so." Traherne says: "You were never quite sure whether it was what mum said or whether it was just what she felt herself." Perhaps work should have been done with both to explore how their relationship could become less volatile at home. 
• It appears that over the years the acute epilepsy had taken its toll on Elaine's physical health. According to Traherne, she was having three grand mal seizures each week and more attention might have been paid to this condition. With her mother's poor health, the two could have been more supportive of each other.   

Independent comment

I am struck by the parallels with cases of domestic violence where the victim's attachment and loyalty to the perpetrator sabotages attempts at providing safety, writes Alan Corbett.  

We find a complex relationship of love, hate, dependency and fear that needs to be worked through. The progress made by Elaine and her workers is but the first step in a long process. Elaine has many positive changes on which to focus. She also has many losses to mourn. Her mother, for all her violence and manipulation, remains her mother, someone with whom she has now to re-negotiate a relationship based on clear boundaries.  

While concerned at Laura's abuse of Elaine, I would consider what support Laura now needs. She has lost someone she viewed as an extension of herself, from whom she could not separate, and in whom disproportionate need was invested. I would have concerns about her emotional health and how she copes with a life that seems isolated.  

Her abusive behaviours should be viewed as communications of deeper trauma. In some of the cases dealt with by Respond, it has been useful to think with parents about the role played by their adult child. Has Elaine protected Laura from considering fully her own needs?  

Psychologically, both women need longer-term support so that they can eventually see each other as separate beings. Only then can we be sure that the strides Elaine has taken will continue.  Alan Corbett is director of Respond, and member of the Adult Protection Alliance. More on Respond at www.respond.org.uk