Situation: Dragutin Pavlicevic is a 45-year-old South African who has lived in England for 32 years. He has been diagnosed with paranoid schizophrenia and has monthly depot injections but complains about the trembling side-effects which, he says, make him look nervous. Ten years ago he served a custodial sentence for the attempted murder of his father after attacking him with a Stanley knife. Pavlicevic claimed that his father and his father’s brother, Milan, physically and sexually abused him as a child in South Africa. His father is now terminally ill with cancer and Milan plans to visit Dragutin.
Problem: Following his release from prison he lived for six months in the community but has since been in hospital, secure or medium secure units. Attempts to return him to the community have been stifled by Dragutin’s denial of his mental ill health, persistent drug misuse and claims that he will “finish off” his father next time. For the past two months, he has been free to come and go during the day but rarely ventures out. Since hearing of his father’s illness he has become more agitated and says to he wants to make peace although he has shown no remorse for the attack. He says he also wants to confront Milan about his past abuses – simply to get him to admit to them. The staff are concerned about what he might do but he has yet to leave the unit.
Risks beset Dragutin’s situation. He has few positive facets to his character; he has little insight in to his situation and appears to be stuck in a rut of institutional life.
His life has reached a critical stage in that all the key influences in his life are coming together at the same time. His childhood in South Africa is being brought back to him in a powerful and unavoidable manner and he is being thrown back on his limited coping skills to see him through this traumatic time.
With his uncle arriving, Dragutin similarly wants to make his peace. However, he has carried out a vicious, almost lethal, attack on his father and little progress has been made to address the underlying reasons and enable him to move on from the incident. He has had 10 years to focus on the attack and must have endlessly played it through his mind and attempted to rationalise it and make it manageable.
Yet still he expresses no remorse and has become unsettled with the news of his father’s illness. It is expecting too much of him to put it all behind him and move on at this time when the stage is set to bring all the main players of his life drama together again.
There are so many risk factors present in Dragutin’s situation that any meeting with the father and possibly the uncle would need to be strictly supervised. Dragutin’s future must be considered in planning any such encounter with the father and uncle. It could be a meeting with the father will help him to let go of some of the issues which have stunted his psychological development.
Even now, there is still time for him to resolve these issues and move on in his life. Clearly, the father as the victim of the attack will need to be consulted about any potential meeting. This too, will need careful handling and a rejection by the father could lead to a hardening of Dragutin’s mental health problems.
The entire situation is fraught with difficulties but maybe giving Dragutin back some control might help him to rediscover something good in his life.
Dragutin has had a poor hand dealt to him; his circumstances are bleak and he has poor coping skills. This is exacerbated by long-term exposure to institutional life, a high-risk profile and little chance to prove himself in everyday living situations.
Presumably he showed no significant signs of mental disturbance while in prison to warrant his transfer on a section 47 of the Mental Health Act 1983. After 10 years Dragutin would have become used to the routine and predictability of prison life. Yet the stress of prison life would have exploited his mental vulnerability and tested his psychological stamina.
A large number of the present prison population experience significant mental health problems. There are limited resources to cope and the small specialist “in reach” teams can work with only the most severe of mental health needs. Many long-term mental health sufferers in prison are treated with powerful anti-psychotic medication and become dependent on the long-term tranquillizing effects, helping them to survive.
On release, there can be precious little follow-up. Dragutin’s situation should have been reviewed at the local Mapp (multi-agency public protection) meeting and plans drawn up embracing his family, the public and his own needs. In some areas there is close collaboration between the various statutory agencies and community forensic mental health services work side-by-side with probation and the police, ensuring close support and monitoring arrangements are in place. In other areas, Mapp meetings are fortunate to have even one mental health representative present, and the local community teams flinch at the idea of engaging someone with Dragutin’s “forensic profile”.
It seems that Dragutin has exchanged his prison routine for that of the mental health institution. It’s surprising that he has not reached a point of acceptance and felt guilt for his offence. Probation would have worked closely with the prison to seek some insight and remorse. Dragutin’s substance misuse is going to further destabilise his mental health and there are too many risks to allow him unsupervised contact with his father. The in-patient unit could look at a programme of moving towards a meeting, but given his father’s terminal condition, time is running out.
What seems to be at the bottom of Dragutin’s mental health problems is the alleged abuse he suffered at the hands of his father and uncle. For Dragutin the experiences are all too real and cause the basis for his attack upon his father, writes Helen Waddell.
It is essential that specialist counselling is provided to Dragutin. He obviously has huge issues with unexpressed anger and pain, and a safe environment with a professional he feels comfortable with should be provided in order for him to work through these issues. If he were able to express his anger and pain safely then this may lessen his feelings of need to misuse drugs and his claims that he will “finish off” his father.
Regarding Dragutin’s drug misuse, this will inevitably be making his paranoid feelings worse, and some sort of harm reduction must be provided, depending on what drugs he is using.
It seems extremely unwise for Dragutin to visit his father and Milan to confront them at this time as he is obviously full of rage. It would be better to give him specialist counselling to work through his feelings before he has a face-to-face confrontation that could possibly make his situation worse. It is also obvious that it is extremely important to Dragutin that Milan admits his offences. It would seem Dragutin has not been listened to at any length and he must be allowed to express himself.
It may be the case that Dragutin has been misdiagnosed. His paranoia and other behavioural symptoms may be a result of childhood abuse, in which case depot injections are not dealing with the root cause. Perhaps he needs a change of medication or at least medication for side-effects.
Because Dragutin has served a custodial sentence, he may lack social and practical skills for community living, and this should be worked upon. He is not venturing out alone and it would be a good idea to have more structured outings with staff, reviewed afterwards.
Because Dragutin has been given a diagnosis of paranoid schizophrenia it could be all too easy for the alleged abusers to deny their part in his suffering. True, Dragutin has shown no remorse about the attempted murder of his father, but his desire to “make peace” shows he has very conflicting feelings about this very fundamental relationship that must be dealt with if he has any hope of recovery in the long term.
Helen Waddell is a mental health service user.