Case Notes

Practitioner: Jacqui Pointon.

Field: Nurse specialist, community child and adolescent mental health team.

Location: North west England.

Client: Lisa Dickens, now a 17-year-old young woman, is an only child of a family who had previously been unknown to social services. Both parents are respected professional workers.

CASE HISTORY: Lisa had been identified at school as having learning problems in literacy, which was felt to be the root cause of her consistent disruptiveness and her absconding. Concerns increased as she began passing out, seemingly suffering from seizures while in class resulting in hospitalisation. After an initial assessment the paediatrician felt there was no organic cause but was concerned that there might be an underlying mental health problem, possibly stress-related. At this point Lisa was referred to the community child and adolescent mental health team.

Dilemma: Lisa’s condition was seemingly linked to traumatic experiences but as she was unable to talk about these early on, decisions affecting her safety could not be guaranteed.

Risk factor: As Lisa disclosed more about past physical and sexual abuse, professionals felt they had to act on this information to make her safe, but she threatened suicide - a real possibility - if confidentiality was broken.

Outcome: Lisa is set to move into semi-independent accommodation, her college life is thriving and she hopes to have a career in a caring profession.

For some the past is a dark, scary, no-go area. But if sense is to be made of the present and if hope is to form part of the future, the past must be faced, tackled and understood. So it proved in the case of Lisa Dickens.

Lisa, a disruptive influence at school, caused concern with her tendency to lose consciousness. "There was a feeling at the time," says Jacqui Pointon, nurse specialist with the community child and adolescent mental health team, "that she had an emotional conversion disorder She was converting emotional feelings into physical outcomes - losing consciousness, seizures and panic attacks. Something was making her feel frightened and worried."

Pointon began meeting Lisa weekly, on the same day at the same time, to try and establish some therapeutic boundaries. "Lisa was also having unusual experiences - strange memories and thoughts, and was finding it difficult to discuss what these might be about." she says. "It also became apparent that she had been cutting herself for maybe two years."

Pointon quickly realised that face-to-face talking wasn't going to work with Lisa, but using art might. "We'd put up big sheets of paper - and she'd start to paint stories about a third person. I felt this was her beginning to tell her story," she says.

Lisa, through art therapy, began to talk about a young girl being hurt physically and sexually by a stranger. She couldn't say who he was or describe him. Unfortunately, around this time Lisa took an overdose.

She was admitted to a local paediatric ward which had, with support and training from Pointon and colleagues, set up an adolescent section with its own policies and procedures. Thus the staff were better equipped to care for the often complex and challenging referrals jointly managed by CAMHS.

"Lisa began to talk about not feeling safe at home. She asked for respite foster care," says Pointon. However, after another overdose she was placed into a children's home for a time-limited stay. "Her behaviour improved," says Pointon. "Her self-harming reduced, her school attendance was much better and she stopped being so disruptive. And she talked about feeling safer."

Lisa also talked more about this stranger, becoming more explicit about the nature of the abuse. "Lisa had disclosed brutal attacks but did not want anyone to find out, threatening suicide if they did. On the other hand, she was clearly indicating that her safety and, indeed, life was very much in danger," says Pointon.

"This gave us a huge dilemma over confidentiality," she recalls. "I agreed with Lisa that child protection information would need to be passed onto social services but they would hold and manage that. We didn't guarantee that it would never be used, but would only be so with her consent." It was decided to take her parents out of the information loop. Following a further overdose, which put her into a coma, her request for an out-of-borough foster placement was agreed.

After much torment, Lisa revealed that her abuser was, in the main, a family member inside the home, and not outside as first disclosed. In response care proceedings were started. However, she was unable - because of the time-span involved and the inflexibility of the system - to pursue her allegations through the courts.

Lisa was aware, as she approached 16 that her age would affect the services she could receive. "I reassured her that I would carry on working with her until the team felt it was therapeutically beneficial to transfer her on, rather than do so just based on her age," says Pointon. "I was her most consistent figure. And because she was disclosing more and more it wasn't appropriate to transfer her."

A new foster placement was arranged and this family worked well with Lisa building her self-esteem and helping her re-engage with education, to the extent that she won, significantly, the student of the year award: "She's most pleased about that," says Pointon.

Now 17, Lisa is in her second year at college, aiming at further education and a career in caring. "I'm really optimistic about her," declares Pointon, "despite how awful things have been, she has always been able to engage with people."

Arguments for risk

The traumas suffered by Lisa as a very young girl would not surface easily. Pointon had been the consistent figure throughout her time since referral. Lisa's permanently allocated social worker had also been there for most of the time. Pointon and Lisa's social worker had developed a good relationship. Lisa trusted them - they had to maintain that trust through confidentiality.

Lisa's eventual disclosure that a family member in the home was her abuser, showed that Pointon was correct in deciding not to inform Lisa's parents of her later disclosures.

Lisa was, through successful art therapy, disclosing more and more detail. It could surface in bits and pieces. The work needed to be long-term, and Pointon consistently had to be there for her.

Lisa's record of self-harming and overdoses made it clear that threats of suicide must not be taken lightly. One overdose had left her comatose. Her disclosures and confidentiality had to be managed sensitively.

Arguments against risk

Lisa was a very mixed-up young individual. The history she was slowly dredging up was changeable and could be considered unreliable. Her self-harming and drug and alcohol overdoses could be seen, as with her disclosures, as attention-seeking.

It might be argued that Lisa's detail-changing as to who or how many people had been sexually and physically assaulting her was to do with seeing if she would be believed, kept safe and protected, and whether what she said would be passed on to others, and so on. On the other hand, it might be considered that she was simply testing the boundaries to see what she could get away with.

Lisa's family were respected members of the community. There had been no involvement with social services before.

At her request Lisa was moved very far away from her home. This meant that Pointon would have travelled great distances - and at a cost in time and money - to continue with the therapeutic input.

Independent Comment

From an early stage, Pointon found herself suspecting strongly that the situation was quite a dangerous one for Lisa, writes Patrick Ayre.

But Pointon lacked the hard facts which would have made decision-making relatively easy. Our responses to suspected abuse sometimes suggest that if we are well-trained in interviewing and supportive in our approach, young people will share with us clearly and unequivocally the most intimate and frightening aspects of their lives. However, Pointon understood that our willingness, indeed our ability, to give an account of what has happened to us may be seriously affected by the emotional turmoil caused by both the events themselves and our fears about what disclosure may bring. She was content to be patient and move at Lisa’s own speed, not dismissing her account because it was "odd".

In the course of this careful work, Pointon also had to deal with dilemmas over confidentiality, parental involvement and the allocation of scarce resources. While the decisions made were difficult ones, in each case they reflect an understanding that the well-being of the child must always be our primary concern. This understanding was displayed not only in the work of Pointon herself, but also within a wider system which was able to manage the confidentiality so as to minimise the risks and to allocate resources according to need rather than arbitrary service-led criteria.

Patrick Ayre is senior lecturer, department of applied social studies, University of Luton