Dangerous liaison

Declan Henry faced a tough task in trying to rehabilitate a
murderer and habitual drug user. His client, who stabbed his father
to death, refuses to acknowledge that he has a mental illness, and
is expressing a hatred of his mother. Graham Hopkins
reports.

The name of the client has been changed.

Case notes

Practitioner: Declan Henry

Field: Deputy manager of a forensic rehabilitation unit for
mentally disordered offenders

Location: London

Client: George Kemp, aged 36.

Case history: Kemp has been diagnosed with paranoid
schizophrenia and has a paranoid personality disorder. He also has
a long-standing habitual drug problem. In 1988, he murdered his
father, stabbing him 26 times. He said he felt emotionally abused
by his father, who had become an “object of hate” in his life. On
being discharged from hospital, Kemp lived for two-and-a-half years
in the community. But in 1997 he was recalled to hospital after his
mother reported him for growing marijuana in his back garden, since
when he has been detained in a medium secure unit (under section
37/41 of the Mental Health Act 1983). Efforts to implement his
deferred conditional discharge have failed since November 1999
owing to his refusal to follow his care plan and his continued drug
misuse.

Dilemma: Kemp’s unrealistic expectations and, at times,
limited view of reality may well set him up to fail, but – given
his institutionalisation – may also be deliberately contrived
precisely to fail.

Risk factor: Kemp’s inability to accept his mental
illnesses, drug misuse, and his growing hatred towards his mother
may put himself and others at risk of serious harm.

Outcome: Kemp’s overnight stays at the rehabilitation unit
have been successfully completed without attempts to sabotage the
care plan and with signs of drug use.

When Declan Henry became the keyworker to George Kemp, a
murderer with diagnosed paranoid schizophrenia and a paranoid
personality disorder, and attendant drug habit, he knew he had his
hands full.

Not just because of the challenge presented by Kemp’s
case, but also because he was a murderer – or rather, because of
his murder victim. Henry, deputy manager of a voluntary-run
forensic rehabilitation unit, had recently suffered the trauma of
his own father’s death through natural causes, and here was a
client who, in 1988, had brutally murdered his father by stabbing
him 26 times: “The loss I was feeling for my own father clashed
with the sometimes cavalier attitude that he had towards killing
his father,” Henry recalls.

His own feelings aside, Henry identified three main risks with
Kemp: his habitual drug-taking, his violent history, and his lack
of understanding of his mental illness.

“Since being accepted in September 2001, he has sabotaged his
placement by taking crack cocaine on at least three occasions,”
says Henry. “And if he was able to get hold of crack cocaine in a
medium secure hospital, out here the opportunity is considerably
greater. It’s not a restricted unit. Clients have their own
front-door key. Kemp will have to reside here at night in line with
Home Office restrictions, but can come and go as he pleases.”

Kemp finally began his “afternoon leave” in January. Again, the
omens were not good. “On his return from his first unescorted
visit,” recalls Henry, “he tested positive for cannabis and
possibly another substance. We gave him a final warning – any more
and the offer of a placement would be withdrawn.”

Henry considers that his sabotage tactic may be deliberate:
“Maybe there is a lot of anxiety about coming out of an
institution,” he says. But this is where the unit usually comes
into its own. “We work with very difficult clients and we have a
heavy emphasis on life skills, which we teach them so they can move
on to less supported accommodation or an independent flat,” says
Henry. “Ideally, they stay with us for between 18 months and two
years. We don’t usually look at clients moving on until they
have been here at least a year.”

Kemp’s perception of reality was, not surprisingly,
blurred. He had monthly depot injections (see Factfile, page 41)
but complained that they caused trembling as a side-effect. “He
doesn’t feel he has a mental health problem and wants to stop
having the injections,” says Henry. “He feels he was mentally ill
at the time of his father’s murder, but that his psychotic
illness was induced by drugs. He says he is remorseful about the
offence but does not feel responsible because he was unwell at the
time. At other times he is not remorseful.”

The forensic psychiatrist recommended Kemp’s medication
remain unaltered given the major change about to happen in his
life. “We felt a review would be more appropriate later on
depending on his progress,” says Henry.

Kemp’s violent history was also a crucial factor. He had
been violent towards fellow patients but not staff. He hadn’t
spoken to his mother after she informed on him, since when she has
replaced his father as his new object of hate. She is “in hiding”
in France.

Kemp – who has attempted suicide twice and has self-harmed at
least three times over the past 10 years – was very capable of
hostility. “My first experience came when I attempted to address
his drug problem,” says Henry, who admits his forthright tactics
were possibly stirred by memories of his own father. Kemp’s
initial response was: “I no longer have a drug problem – it’s
in the past.” But Henry knew he had taken drugs six weeks
previously, and had spent over £28,000 on crack cocaine (he
rented out a flat he owned) and was in debt with a bank loan. “In
retrospect,” says Henry, I feel I went too far,” he concedes, “and
our relationship deteriorated. He was angry with me for challenging
him and I felt inadequate as a practitioner by his response to my
approach.”

At a three-way clear-the-air meeting Henry, his manager and Kemp
discussed these difficulties, with Kemp eventually accepting that
Henry would remain as his keyworker.

The relationship has clearly improved. Kemp, aware of the
expectations placed upon him, has begun his twice-weekly overnight
stays and has remained drug-free. Henry is confident that
Kemp’s full-time trial period will soon begin. “Our main
source of work from now on will be containment. It doesn’t
sound like much, but given the complexity of a client like this, it
will be an achievement,” says Henry.

Arguments for risk

• Kemp has displayed an ability to live in the community in
  relative safety, but was unable to deal effectively with his drug
  use. Targeted work within this area could lead to a successful
  transition.
• He has, at times, shown remorse for killing his father and has
  blamed his mental illness for his actions.
• Kemp has been institutionalised for a long time and the thought
  of having to deal with the outside world may be at the root of his
  attempts to sabotage his community placement. Skilled help could
  see him overcome this fear.
• Kemp is stable and well. Henry is confident that he is capable
  of making a focused effort to deal with his situation
  positively.
• Living in an environment that permits freedom of movement
  (excepting the need to remain at the unit at night) allows Kemp
  some independence and choice that would be denied him in
  hospital.

Arguments against risk

• Kemp is a murderer and habitual drug user. He has at times
  displayed a less-than-remorseful attitude to the murder. He has
  also, time and time again, relapsed into drug use from cannabis
  (which is potentially harmful considering his mental health and
  medication) to crack cocaine.
• He can seemingly obtain drugs relatively easily – even when a
  patient at a medium-secure hospital. Moving him into a more
  independent lifestyle will only raise the temptation and access to
  drugs.
• Kemp is very able to scheme and manipulate. Challenged by
  Henry, he demanded that he be removed as his keyworker. This could
  indicate an unwillingness to tackle his behaviour
  constructively.
• If living more independently, there is a real risk that Kemp
  will stop his depot injections.
• As the new object of hate in his life, his mother is clearly at
  risk from harm. Although she is in hiding, she may return or,
  indeed, Kemp may try to find her.independent comment

Independent comment

Henry’s approach demonstrates the value and centrality of
a therapeutic relationship, writes Tom Dodd. It is understandable
that the weight of Kemp’s history alone (it has been 14 years
since he killed his father) would tip the balance in favour of a
containing and less-flexible regime.

The experience of paranoid disorders often means that the
individual is less likely to take responsibility or see their role
in the detrimental things that happen in their lives. Kemp may find
it difficult to get pleasure from relationships, he may construe
any comments as criticisms and blame the “persecutor”. As his
keyworker, Henry will need to take a cautious but intensive
approach, while at a pace that is acceptable to Kemp because he is
likely to disengage easily. If the aim of intervention is to modify
Kemp’s beliefs and behaviour, then he is less likely to
fail.

The service’s relationship with Kemp is likely to be over
a period of years. To maintain opportunities for Kemp, the
keyworker will need continued and comprehensive support from the
multidisciplinary team. The care package is complex and will need a
detailed rationale, with contributions from a number of sources.
Such decision-making requires transparency and clarity from
everyone involved. The more risks that are evident – and this case
highlights many – the greater the imperative to take a team
approach, sharing decision-making, accountability and
responsibility.

Tom Dodd is co-ordinator for assertive outreach at the
Sainsbury Centre for Mental Health.