Honesty wins the day

Case notes 

Practitioners:   Pat Harvey, social worker and Ian McAlpine, team leader, community care and community development. 

Field: Older people’s services. 

Location: Glasgow. 

Client: Sheena Warnock was 87 years old when she was referred to social work services following a non-accidental injury. She had a joint tenancy in a council property with her son, Derek, 63, a recovering alcoholic who had been living with her for about 13 years, following his divorce. Sheena had recently become mildly confused. 

Case history: At her day centre Sheena had broken down in tears to her keyworker saying that her son had been assaulting her. She had extensive bruising on her wrist and hand and was emotionally distressed. The duty social worker, Harvey, visited Sheena to interview her in the company of her keyworker – “so that there would be someone she knew and trusted, rather than this stranger coming in, saying ‘What’s all this about?'” Harvey says.  

Dilemma: Although being assaulted by her son, Sheena still wished to return home and hoped for things to return to how they used to be. 

Risk factor: With Sheena’s dementia, returning her to the care of her son, with his own physical and mental health difficulties, could result in more assaults.  

Outcome: Derek has come to terms with his need for help and support, which is now in place, resulting in him being able to care more successfully for his mother.

When we think about older people being physically abused it is often the case that the abusers come from within the family – sons and daughters abusing their parents. What we perhaps don’t imagine is that the son or daughter may well also be an older person.

This was the situation faced by social worker Pat Harvey following a referral from an older people’s day service. Sheena Warnock, 87, who attended the centre once a week, had been unusually emotionally distressed. Sheena, with extensively bruised hand and wrists, disclosed to her concerned keyworker that that she had been physically attacked by her son.

“She was mildly confused but was able to give a full account of what had happened,” says Harvey. “She was very protective of her son. She was very quick to praise his good points, saying things weren’t always like this.”

Having made sure that Sheena didn’t need any medical assistance Harvey discovered that “she was determined to go home. We decided that she should go home as normal with the day care transport and that I would be there when she got home to discuss some of the underlying problems with her son,” says Harvey.

Along with another worker from the older people’s team, Harvey visited Sheena and Derek’s home to discuss the circumstances of the emergency referral and to carry out an assessment. “As you can imagine,” adds Harvey, “this was a very, very difficult interview.” Taken by surprise, Derek was “initially hostile and aggressive. He was tearful and was clearly a man under extreme pressure.” It proved challenging enough to get Derek calm enough to talk rationally.

“An interesting thing about this case was that as his mother’s health deteriorated, Derek’s own health suffered. He had significant cardiac problems and had a poor prognosis. His consultant could do no more for him,” says Harvey.

The tandem troubles of facing his health problems – he was, after all, struggling with his own mortality – coupled with an increasingly confused and demanding mother, particularly her wandering and incontinence, had simply overwhelmed him.

Harvey, witnessing Derek’s initial anger and irrationality, seriously wondered whether it would be safe for Sheena to remain at home. However, Derek phoned his sister, and the family, who were surprised to find out what had happened, provided a calming influence.

The family removed immediate concerns about Sheena’s safety but, says Harvey, “there were other underlying issues that needed resolving – around carer stress and support.”

An adult protection case conference was called. “I chaired the conference and that was difficult also,” says team leader Ian McAlpine “because the son wasn’t admitting it – then half way through he did; he said he had hit her. He also accepted all the problems that he had. So, that was quite an emotional breakthrough for Derek. By admitting it, it allowed him to say that he wanted to change, to get better and do right by his mum – and he was prepared to accept help. It was crucial that he recognised what he had done.”

Sheena’s injuries had been caused, it transpired, from Derek trying to haul his mother back into the home after she had started to wander. Nonetheless, with Derek’s acknowledgement of his actions, the workers felt there were grounds for managing the risks more successfully. “A lot of the anger was his own fear: everything was overwhelming and he felt unable to deal with it alone. It was good for him to receive recognition from the department that the work he was doing as a carer was valuable,” says Harvey.

Derek was put in touch with a carer support project and given plenty of information. Sheena’s day care was increased, and a new sitting service for people with dementia – a four-hour evening support service – was introduced, both of which encouraged Derek to take some time out and do some things for himself. “The other thing he found helpful was that as a department we were saying that we would not leave him to deal with this unsupported; we will be there for him,” says Harvey.

Honesty won the day. “Without that honesty I think there would have been a problem,” agrees Harvey. “Quite often families will cope in isolation and not be truthful with other family members about how difficult things are. They are worried about losing face as often there are sibling rivalries and disputes – especially when it comes to the care of a parent, particularly a mother. His willingness to be open and engaged was crucial to the successful outcome of our care plan.”

Arguments for risk

• Derek admitted the abuse and recognised the need to be helped “No doubt the management of risk in this case would have been totally different if this man hadn’t acknowledged the fact that he assaulted his mother. We would have struggled with him but as soon as he admitted that we felt we could work with him and build services to support him and his mother. We needed this man to work with us,” says McAlpine.
• Sheena was clear that she wanted to return home and wanted things to go back to the way they were
• Derek’s increased caring role with Sheena’s dementia, and his own health problems combined to create a crisis point. “We recognised there was a lot of love, respect and commitment there – but this was clearly at breaking point,” observes Harvey.
• With an excellent support package now available, Derek is more able to continue successfully in his caring role.

Arguments against risk

• Derek’s prognosis is not good and his mental health will struggle as his physical health deteriorates. Add to this his mother’s dementia and Derek’s ability to cope must be seriously questioned. Even with support there are bound to be times of pressure and crisis – will he cope?
• Clearly social work services were concerned about Derek although everything turned on his acknowledgement of his situation. What if this hadn’t happened? “Derek may well have assaulted his mother again and that would have been our problem – for this lady to have been assaulted again by him would have given us grave concern. And, I think, that would have been a risk that we would have been reluctant to take in this case. We would have been looking at residential care for his mother,” suggests McAlpine.
• The expectation upon carers to continue that role as they themselves become older, frailer and less able to manage, can be intense and intolerable.

Independent comment  

Some professionals have been seduced by the simplistic notion of zero tolerance for elder abuse. Sheena Warnock’s story reminds us that the picture as seen by older people themselves is rarely so simple, writes Jef Smith. Sheena was obviously frightened by her son’s violence, but it was only one element in a relationship which has lasted for more than 60 years and still gave her some satisfaction. Hasty action might have secured her from further physical attack, but at considerable cost. 

In response to the growth of the carers’ movement, there has been some reluctance in recent years to recognise carer stress as a cause of abuse, but this case shows that sons and daughters often have problems of their own which can spill over with drastic consequences for the parents for whom they are caring. Quite apart from his alcoholism, Derek was seriously ill. Coping, on top of that, with a mother with early-stage dementia brought near-intolerable pressure.   

The critical factor was Derek’s eventual honesty, his ability to talk with his family, and his insight. Continued denial would have left Sheena very exposed, but his acknowledgement that his anger was a central problem made it possible for him to accept help. The measures introduced – the carer support project, increased day care, and the sitting service – constitute a sensitive and minimally invasive package. The risk was greatly reduced without closing the door to further action if the situation were to deteriorate.   

Jef Smith is a writer, trainer and consultant in care for older people.