Arguments for risk

Senior practitioner David Godfrey has been trying to improve the
living conditions of an older woman with a personality disorder for
the past seven years. Mike George reports on the difficulties of
providing help to an unco-operative client while giving them a
large amount of independence.

Workforce surveys have highlighted the frustrations felt by many
social workers, particularly about resource constraints and
organisational restructuring. But the job itself can be very
frustrating in itself, for example when despite enormous efforts
made by staff, clients’ situations simply can’t be improved.

David Godfrey, senior practitioner and care manager for mental
health services for older people, says he’s extremely frustrated
about his apparent inability to substantially improve matters for
Doreen Taylor (not her real name). For the past seven years he has
tried to engage with her constructively to improve her situation,
but has met with very limited success.

The main problem is the fact that Doreen has a personality
disorder, which leads her to believe that she has a serious mental
illness and should be in hospital. She has in fact been
hospitalised a number of times, but has never received a diagnosis
other than that of personality disorder.

Nevertheless, her disordered thinking and delusional thoughts
persist, and have given rise to numerous problems, chiefly an
inability or unwillingness to look after herself and her home, and
an inappropriate relationship with her 50-year-old son, who lives
with her.

This behaviour has led her to become doubly incontinent, though
there is no physical reason why she should be so, and an
unwillingness to be mobile, which has on several occasions led to
the development of pressure sores. Meanwhile, the son abuses
alcohol and has frequently attempted to obtain some of his mother’s
benefits money to pay for it.

Godfrey has tried to exercise his duty of care, principally by
trying to maintain her safely in her home, for despite her frequent
protestations that she wishes to be hospitalised, she is also very
anxious to remain living at home with her son.

He has on more than one occasion offered her a residential or
nursing home placement under Mental Health Act 1983 provisions, but
she rejected these, except once after she was in hospital for
treatment of pressure sores. When this happened, a few years ago,
she admitted that she was unable to look after herself, and agreed
with Godfrey’s suggestion that he seek guardianship powers under
the Mental Health Act, principally, he explains, to prevent her son
from taking her out of the nursing home against her will. He has
retained guardianship ever since, with her agreement, and the
situation has been reviewed regularly.

However, she subsequently wrote to the police complaining that
she was being held prisoner in the nursing home. This behaviour led
to the setting up of a mental health review tribunal, which
affirmed that she had a personality disorder and was subject to
depressions and delusional thoughts, and upheld the guardianship
(although this was later discharged when she ceased to recognise
its authority). Shortly afterwards she decided to leave the nursing
home and return to her son.

While she was away Godfrey had arranged for her flat to be
thoroughly cleaned, and, as he had done on previous occasions,
offered her home care assistance: “As usual, she was quite
resistant to this, but eventually accepted it,” he says.

Despite the service her flat quickly became filthy and
unhygienic, and Godfrey began to receive complaints about the home
care staff’s working conditions. He continued to visit regularly in
an attempt to maintain and improve her physical and mental health,
but says that Taylor was generally obstructive, aggressive towards
him on occasion, and would sometimes refuse him access.

She was also inappropriately dressed at times, and both Godfrey
and the care staff became increasingly worried about how she and
her son approached the personal and intimate care that they both
wanted the son to provide. Neither of them were willing to address
this issue, he adds.

“In all other respects her son was unable or unwilling to
improve the home situation. However, I had at times managed to
persuade him to clean the flat, and I wondered whether he might do
more if he had his own social worker. I still believe this might be
useful,” Godfrey says.

As a result of the deteriorating conditions, a case conference
concluded that steps should be taken to obtain a compulsory
admission for assessment under section 2 of the Mental Health Act.
This was done, Taylor appealed, but her appeal was not upheld.
Meanwhile, the flat was cleaned, and she returned home. Once again
the living situation deteriorated, so Godfrey suggested a move to
another flat, partly in order to obtain, “a fresh start”, but also
because they were starting to receive unwelcome attentions from
young people on the housing estate.

She and her son subsequently agreed to move, and initially
accepted home care assistance, before cancelling it. Also, as
Godfrey and his colleagues had become increasingly concerned about
the son’s misuse of his mother’s benefits income, steps were taken
by his department to obtain appointee powers over her benefits.
This was followed by a comprehensive review and a full risk
assessment, which concluded that Godfrey and colleagues from
community nursing services should continue with their work, “to
maintain her, and to contain the level of risk,” he says.

“We have had a very difficult relationship, partly because she
has changed her mind so many times, and partly because I think she
sees my efforts to support her as infringing her rights. Yet I have
a clear duty of care towards someone who is quite vulnerable, and
at risk in several ways, however frustrating the work is at times,”
he concludes.

Arguments for risk

– Despite several admissions to psychiatric hospitals, and a
number of assessments, plus consideration by a tribunal, Doreen
Taylor has not been diagnosed as having a mental illness of a type
or scale which might be deemed sufficient to render her incapable
of making choices and decisions concerning her life.

– She is well known to social services, she has a psychiatric
consultant, a GP, and community nursing staff, all of whom take
some responsibility for her safety and well-being.

– Apart from the problems caused by her incontinence, her self-
neglect has not led to any serious deterioration in her health.

– Despite the son’s obvious limitations, he provides company and
could alert agencies if any very serious risk arose.

– Steps have been taken to protect Taylor’s benefits income.

Arguments against risk

– She has delusional and sometimes suicidal thoughts, and is
emotionally labile.

– She has no insight into her needs.

– Apart from self-neglect, she has occasionally harmed
herself.

– She can and does refuse access to David Godfrey, nursing and
home care staff at times.

– Similarly, she does not appear to want to take advice and help
offered by Godfrey.

– She is a very heavy smoker, which leads to the risk of
fire.

– The sexually inappropriate relationship with her son, allied
with their sporadic verbal aggression towards each other, creates
an unstable and potentially risky home situation.

– Her self-neglect and their neglect of the flat creates
significant risks to their health; it also poses the risk that home
care services could decide to withdraw.

– Despite the precautions that have been taken the son continues
to try to exploit her financially.

Independent comment

Cases such as Mrs Taylor’s present an experienced practitioner
with serious long-term dilemmas, writes Margaret Coombs. The
negative connotations of the diagnosis of “personality disorder”
and the battle to keep her out of hospital may have inhibited
mutual co-operation. In sometimes refusing Godfrey access, was she
making a stand against male control? Would greater contact with a
woman community practice nurse have motivated her to address her
more intimate physical needs, easing referral to a continence
self-care rehabilitation programme?

Many users of mental health services feel disempowered. This may
be true of Mrs Taylor, whose life had long been regulated by the
constraints of guardianship. More recently, she was admitted for
assessment under section 2 of the Mental Health Act. This surprised
me, as she was already well known to mental health services and her
guardianship order had previously been upheld by a mental health
review tribunal. If she had been detained under section 3, she
would have been entitled to free section 117 aftercare
services.

Notions of empowerment lead into the “strengths” model of mental
health care. Clearly, Mrs Taylor has lost her self-esteem and
dignity. In Oxfordshire, the Flexible Care Service for older people
with mental health needs aims “to engage clients in activities they
enjoy and to improve their quality of life.” It has similarities to
a befriending service, with a practical edge, and has recently won
a Department of Health award. A re-assessment under section 2 (1)
Chronically Sick and Disabled Persons Act 1970 might also open up
possibilities for creative or enjoyable activities at home, or
elsewhere with support.

Godfrey thinks her son may need a social worker. Referring the
son for a comprehensive, separate carer’s assessment of his ability
to care effectively for his mother offers a new basis for openly
establishing a mutually acceptable “caring contract” with his
mother and recognition of his needs.

Margaret Coombs is an independent community care rights
adviser