Dressed for the ball

This week’s multi-disciplinary panel comment
on a delicate question of personal choice for a client with
schizophrenia.

Case study

Situation: Lady Hester Chapman is a
44-year-old woman diagnosed with schizophrenia. She is estranged
from her civil servant husband, Sir Ralph, and is resident in a
voluntary sector-run residential care home registered for 12 people
with mental health needs. Her only visiting relative is her niece –
Evelyn Johns – who lives nearby.

Problem: Johns visited Chapman’s care home in
order to register a complaint after having witnessed Chapman
travelling on a bus in the city centre at about 10am. Chapman would
always take the bus – and nearly always at that time – to collect
her benefits. It was a recognised part of her agreed care plan.
However, Johns was upset that Chapman had made the journey dressed
in a ball gown, arm-length gloves and stilettos. When she was
married Chapman used to regularly entertain and be invited to
society balls, gatherings and charity gala dinners. Her dressing in
this way was clearly linked to her past. Johns thought it was
inappropriate for Chapman to dress this way simply to collect her
benefits. She was further shocked to discover that Chapman had been
dressing in this way for some months. The home’s deputy manager
told Johns that it was Chapman’s choice to dress up and they
respected her choice. Johns thought it was not an informed choice
and, if anything, invited ridicule and denied her dignity. What can
the panel suggest?

– The names of the service users and relatives
in the case study have been changed

Panel responses

Amanda Dutton
It seems clear that the dilemma is how to balance
Chapman’s right to choose and Johns’ concern for her aunt’s dignity
while outside the home.

It is unclear how well Chapman’s schizophrenia
is managed and whether she experiences ongoing symptoms. If this is
the case, then Johns’s point of informed choice must be considered.
How able is Chapman to make decisions that she would, if well, feel
were appropriate?

It is stated that Chapman’s regular bus
journeys to collect her benefits are part of her care plan. Is
Chapman on the Care Programme Approach and if so at which level?
Was her niece involved in the planning of Chapman’s care? This is a
sensitive subject and needs to be discussed and agreed amicably
within an appropriate forum that involves all parties.

It may be assumed that Chapman is alone while
getting dressed for these outings. A possibility would be that,
without impinging on Chapman’s privacy, a member of staff is
available to assist her on the days in question. With sensitive
handling and encouragement it may be that Chapman can be encouraged
to wear more appropriate clothing.

It may be suggested to her that she could wear
the ball gown and so on at other times – for instance when her
niece visits or for the evening meal in the home. This may allow
her to feel that there are alternative times for her to “dress
up”.

I feel that an approach such as this would
need to be tried in order to protect Chapman from the increased
risk that she may create when going out in public dressed in this
way.

She is frequently making herself vulnerable to
reactions from the public that could in turn be distressing for her
if not dangerous. An alternative option would be to provide an
escort for Chapman, if she would agree to this.

Chapman may be making an informed choice. If
medically she is assessed to be capable of making such decisions
and of considering any risks then she must be allowed to
continue.

Maybe her niece and staff could talk to her
about risk and their concerns. However, ultimately the choice must
lie with Chapman herself.

Kelvin Lawton
Chapman is deemed to be capable of travelling
independently on public transport and of handling her benefits
payments. She has been dressing in this way for some months. Has
her dressing caused any actual problems? Is she putting herself at
any personal risk when going out dressed in this way? What is
regarded as “normal” dressing? My own recent random survey of
people in my own local multi-cultural city centre provided a wide
variation of outlandish dress styles, many of which do not warrant
a second glance.

I would want to establish if any mental health
professionals are involved in Chapman’s care, other than the
residential care home staff. Is she seen by, for example, a
consultant psychiatrist, social worker or community nurse? If so,
it would be necessary to involve them in a review of Chapman’s care
to include herself, staff and her niece. Important issues to
resolve would be:

– Is Chapman’s mental health as stable as
possible and is she receiving all available care and treatment –
both medically and socially?

– Is Chapman aware that dressing in this way
might bring her ridicule and could identify her as being eccentric
or different?

– Would Chapman feel it more appropriate to
dress in this way in different settings – at meal times or for
meals and activities outside the residential home?

– Has any member of staff been able to talk to
her about the loss of her previous lifestyle?

Her niece is, however, likely to be genuinely
concerned, and her care and interest should be encouraged. If
Chapman is divorced from Sir Ralph and there are no relatives other
than Johns, then, as her niece, Johns would be regarded as the
“nearest relative” under the Mental Health Act 1983. She should
then be informed of her right to request an approved social worker
to arrange an assessment with a view to making an application for
admission to hospital under the act.

The use of compulsory powers, however, is
likely to be unenforceable and counter-productive. Chapman will
already have experienced many losses of choice and lifestyle before
moving into residential care. Further deprivation of her liberty is
likely to be far more distressing than a potential loss of dignity
by dressing in ball gowns and stilettos.

User view

My instinct is to agree with the deputy home
manager that it is Hester’s right to wear the clothes of her
choice, writes Kay Sheldon. The problem is really with other people
being uncomfortable with the way she dresses. Her niece is probably
embarrassed by her aunt’s behaviour. I’m not sure how appropriate
the term “informed choice” is in this context. Informed that others
may judge her to appear ridiculous and undignified?

Unfortunately, we are not living in tolerant
times. Hester is probably being subjected to some quite unpleasant
attitudes when she is out and about. Thought and sensitivity are
needed. The staff at the home should be careful not to jeopardise
the relationship between aunt and niece, who is Hester’s only
visiting relative.

Evelyn’s concerns should be taken seriously,
although not at the expense of her aunt’s free choice; she should
be offered an explanation as to why her aunt might be dressing in
such a manner. It may be possible to enlist Evelyn’s help in
working out a solution that is acceptable to everyone, particularly
Hester herself. For example, Hester must have had other clothes in
her former role. Does she have access to these? Perhaps Evelyn
could help her aunt choose some clothes that are more suitable and
to Hester’s liking.

A member of staff who has a good relationship
with Hester should broach the subject with her, not with the
purpose of getting her to stop but to find out why Hester is
dressing in such a way. It may be that she is not so well and a
doctor’s input would be useful, although I don’t think the
situation should be seen just in terms of illness. Hester has
obviously experienced a dramatic change of circumstances, involving
loss of status, home, husband and probably much more. Dressing in
such a way is obviously linked to her previous identity; maybe she
needs help in coming to terms with her current situation and to
develop a new self-image.

Of course, Hester may well be fully aware of
the stir she is causing by wearing a ball gown to collect her
benefit. I am all too aware of how once you have the label of
schizophrenia anything you do or say may be interpreted as a
symptom of your illness. Perhaps Hester is simply making a
statement, or perhaps she has a rather wicked sense of
humour…?

Kay Sheldon is a mental health service
user