CASE STUDY
(All names have been changed)

SITUATION: Fifteen-year-old Richard Barnes lives with his parents Etta and Nigel in a large detached house. His mother has an anxiety disorder and his father, who gave up his advertising career some years ago to spend more time at home, soon began finding Etta more and more irritating and difficult to deal with, and subsequently took to drugs and alcohol.

PROBLEM: Richard has been excluded from his private school because of behavioural difficulties. His relationship with his father has been deteriorating over the past two years. Nigel, especially while drinking, will be excessively hostile to and critical of Richard who feels that both his parents nag him about not being very successful at school, having little drive or ambition. Richard has begun stealing from his father's wallet, when his father becomes too drunk to notice, and has started to buy his own drink and drugs. Etta's anxiety also incites Nigel's anger and he has threatened, pushed and slapped her - often in view or hearing of Richard. He is irritated by her obsession with cleanliness and tidiness which includes repeatedly needing to wash her hands and dusting and vacuum-cleaning through the house (despite a cleaner coming in each morning). Richard's untidiness causes confrontation with his mother which heightens Etta's anxieties into panic attacks filling Richard with both anger and remorse. The school has referred Richard to the child and adolescent mental health service.

Panel responses
Kate Vaughan

One of the first things I would be looking to clarify is what alternative arrangements have been made with regard to Richard's education. While he is at home with little or no structure to his day or week he is unlikely to make significant changes in his life. I would like to know if Richard is on course to sit his GCSEs; if so I would be advocating that a school place is provided locally. Unfortunately, many local authorities are severely limited when a young person is excluded as schools can refuse to accept them.
If his behavioural difficulties have led to serious disruption he is less likely to gain a place within another school and may be provided with minimum tuition, perhaps at a pupil referral unit. I believe Richard is in need of a personalised education package comprising of drug and alcohol awareness as well as formal academic study.

Ideally, a referral to a mentoring scheme would offer him the opportunity to build a meaningful relationship and gain a role model from an adult who is able to offer consistent support. The mentor could explore some of Richard's interests, hobbies or introduce him to new experiences, thus diverting some of his energy and anger into constructive and meaningful activities. Nigel also needs to be given a clear message that violence towards his wife is unacceptable.

The adults within this family need support in their own right; Etta for her anxiety, panic attacks and OCD, and Nigel for his substance use and anger and aggression. After a period of individual work I would like to see this family brought together for some family work to enable each of them to be open about their experiences, gain an understanding of each other and work towards resolution of some of the difficulties.

The adults need to understand the impact of their behaviour on Richard. He needs to be empowered to challenge and deal with the negative parenting roles he is experiencing. Forward movement will depend on his parents' willingness to deal with their own problems and address some of their own needs. It is a lot to ask of Richard to take on these issues himself and in many ways can be seen as an abusive situation to leave him with all the family's unresolved issues.

David Glover-Wright

Richard has been identified as the client in what essentially is a dysfunctional family. Richard is an easy target for both parents and a foil to their own underlying problems. There are rigid and inflexible relationships within the family. These make it difficult for Richard to make any headway given the prevailing instability in his life.

Most people known to the mental health services are already marginalised and disadvantaged by their circumstances. Richard's parents don't match this criterion and are unlikely to find their way in to the mental health system. Substance misuse and a disregard of others' needs are likely to have been an integral part of the father's life, while the mother is unlikely to seek help for her problems given her rigid behavioural routines and social conventions.

They seem unaware that the family's structure is fragile and at the point of breaking. Disturbed and aggressive behavioural outbursts have begun to break through, with Richard the weak point in the family system. He is deeply affected and unable to sustain any semblance of normality at school. Richard does not have the social sophistication to keep the negative forces of his family suppressed and concealed. He is the outward representation of his parents' emotional instability and desperately needs assistance to understand the impact his family is having on him.

Ideally Richard needs a positive role model in the form of a mentor or counsellor to help him look at his problems in the context of his family. After preliminary work, his family could be involved possibly through the organisation of a family group conference. His parents need to have an opportunity to hear how Richard has been affected by their behaviour while at the same time having an opportunity to vent their own feelings. Skilful co-ordination of the conference could allow the family to begin identifying how each need help dealing with their own problems.

Richard's father needs to evaluate his own situation and question why his relationships have become so dysfunctional. He needs to develop a positive and caring outlook. Family group conferencing can offer alternative perspectives to the dominant ideologies in the family preventing Richard being saddled with the unbearable burden of his parents' problems.

USER VIEW

Seeing Richard's difficulties in isolation from those of his parents' probably won't help him very much, especially in the long-term. There seems to be a triangle of emotion and tension fuelled by resentment, with each person's distress feeding off the other two. At some point, the family are going to have to work together to improve the situation but, first, I think each person needs to concentrate on their individual issues before they can work constructively as a unit, writes Kay Sheldon.

Richard is suffering because of his parents' relationship problems. He is likely to be feeling guilty and angry. He may feel responsible for his parents' difficulties, believing he is letting them down by his poor performance in school. His lack of motivation is likely to be linked to low self-esteem and confidence.

Richard's self-worth needs to be built-up. He should be encouraged to talk about his feelings. It is important that Richard feels in control of what's happening and his views sought and valued. It may be helpful for Richard to have a medium such as art or music to help him express his feelings.

It seems that Richard's school is supportive, having referred him for help. The mental health services, with Richard's and his parents' agreement, should engage directly with the school, including the teachers themselves. If Richard is likely to return to the same school, a plan for his return should be worked out. It may be that a change of school may be beneficial. Richard should be fully involved in these decisions. He should understand, agree with and even suggest the conditions of his return with regard to his behaviour. At an appropriate point, extra support and tuition could be arranged.

Richard's mother has her own mental health issues. She could be encouraged to visit her GP to access support to help her manage her anxiety and obsessional behaviour. The physical abuse that Etta is experiencing from her husband should be tackled head-on. It should be made clear to her that she does not have to put up with this and various options discussed with her. This could include input from social services, a voluntary organisation or even the police.

Nigel should also be made aware that physical violence is not acceptable and that, by resorting to violence and using alcohol and drugs, he is not proving to be a good role model for his son. At the same time, Nigel could be offered counselling and support to tackle his own issues constructively.

Kay Sheldon is a mental health service user