Confidentiality agreement

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