Collateral damage

CASE STUDY
(All names have been changed)

SITUATION: Fifteen-year-old Richard Barnes
lives with his parents Etta and Nigel in a large detached house.
His mother has an anxiety disorder and his father, who gave up his
advertising career some years ago to spend more time at home, soon
began finding Etta more and more irritating and difficult to deal
with, and subsequently took to drugs and alcohol.

PROBLEM: Richard has been excluded from his
private school because of behavioural difficulties. His
relationship with his father has been deteriorating over the past
two years. Nigel, especially while drinking, will be excessively
hostile to and critical of Richard who feels that both his parents
nag him about not being very successful at school, having little
drive or ambition. Richard has begun stealing from his father’s
wallet, when his father becomes too drunk to notice, and has
started to buy his own drink and drugs. Etta’s anxiety also incites
Nigel’s anger and he has threatened, pushed and slapped her – often
in view or hearing of Richard. He is irritated by her obsession
with cleanliness and tidiness which includes repeatedly needing to
wash her hands and dusting and vacuum-cleaning through the house
(despite a cleaner coming in each morning). Richard’s untidiness
causes confrontation with his mother which heightens Etta’s
anxieties into panic attacks filling Richard with both anger and
remorse. The school has referred Richard to the child and
adolescent mental health service.

Panel responses
Kate Vaughan

One of the first things I would be looking to clarify is
what alternative arrangements have been made with regard to
Richard’s education. While he is at home with little or no
structure to his day or week he is unlikely to make significant
changes in his life. I would like to know if Richard is on course
to sit his GCSEs; if so I would be advocating that a school place
is provided locally. Unfortunately, many local authorities are
severely limited when a young person is excluded as schools can
refuse to accept them.
If his behavioural difficulties have led to serious disruption he
is less likely to gain a place within another school and may be
provided with minimum tuition, perhaps at a pupil referral unit. I
believe Richard is in need of a personalised education package
comprising of drug and alcohol awareness as well as formal academic
study.

Ideally, a referral to a mentoring scheme would offer him the
opportunity to build a meaningful relationship and gain a role
model from an adult who is able to offer consistent support. The
mentor could explore some of Richard’s interests, hobbies or
introduce him to new experiences, thus diverting some of his energy
and anger into constructive and meaningful activities. Nigel also
needs to be given a clear message that violence towards his wife is
unacceptable.

The adults within this family need support in their own right; Etta
for her anxiety, panic attacks and OCD, and Nigel for his substance
use and anger and aggression. After a period of individual work I
would like to see this family brought together for some family work
to enable each of them to be open about their experiences, gain an
understanding of each other and work towards resolution of some of
the difficulties.

The adults need to understand the impact of their behaviour on
Richard. He needs to be empowered to challenge and deal with the
negative parenting roles he is experiencing. Forward movement will
depend on his parents’ willingness to deal with their own problems
and address some of their own needs. It is a lot to ask of Richard
to take on these issues himself and in many ways can be seen as an
abusive situation to leave him with all the family’s unresolved
issues.

David Glover-Wright

Richard has been identified as the client in what
essentially is a dysfunctional family. Richard is an easy target
for both parents and a foil to their own underlying problems. There
are rigid and inflexible relationships within the family. These
make it difficult for Richard to make any headway given the
prevailing instability in his life.

Most people known to the mental health services are already
marginalised and disadvantaged by their circumstances. Richard’s
parents don’t match this criterion and are unlikely to find their
way in to the mental health system. Substance misuse and a
disregard of others’ needs are likely to have been an integral part
of the father’s life, while the mother is unlikely to seek help for
her problems given her rigid behavioural routines and social
conventions.

They seem unaware that the family’s structure is fragile and at the
point of breaking. Disturbed and aggressive behavioural outbursts
have begun to break through, with Richard the weak point in the
family system. He is deeply affected and unable to sustain any
semblance of normality at school. Richard does not have the social
sophistication to keep the negative forces of his family suppressed
and concealed. He is the outward representation of his parents’
emotional instability and desperately needs assistance to
understand the impact his family is having on him.

Ideally Richard needs a positive role model in the form of a mentor
or counsellor to help him look at his problems in the context of
his family. After preliminary work, his family could be involved
possibly through the organisation of a family group conference. His
parents need to have an opportunity to hear how Richard has been
affected by their behaviour while at the same time having an
opportunity to vent their own feelings. Skilful co-ordination of
the conference could allow the family to begin identifying how each
need help dealing with their own problems.

Richard’s father needs to evaluate his own situation and question
why his relationships have become so dysfunctional. He needs to
develop a positive and caring outlook. Family group conferencing
can offer alternative perspectives to the dominant ideologies in
the family preventing Richard being saddled with the unbearable
burden of his parents’ problems.

USER VIEW

Seeing Richard’s difficulties in isolation from those of his
parents’ probably won’t help him very much, especially in the
long-term. There seems to be a triangle of emotion and tension
fuelled by resentment, with each person’s distress feeding off the
other two. At some point, the family are going to have to work
together to improve the situation but, first, I think each person
needs to concentrate on their individual issues before they can
work constructively as a unit, writes Kay Sheldon.

Richard is suffering because of his parents’ relationship problems.
He is likely to be feeling guilty and angry. He may feel
responsible for his parents’ difficulties, believing he is letting
them down by his poor performance in school. His lack of motivation
is likely to be linked to low self-esteem and confidence.

Richard’s self-worth needs to be built-up. He should be encouraged
to talk about his feelings. It is important that Richard feels in
control of what’s happening and his views sought and valued. It may
be helpful for Richard to have a medium such as art or music to
help him express his feelings.

It seems that Richard’s school is supportive, having referred him
for help. The mental health services, with Richard’s and his
parents’ agreement, should engage directly with the school,
including the teachers themselves. If Richard is likely to return
to the same school, a plan for his return should be worked out. It
may be that a change of school may be beneficial. Richard should be
fully involved in these decisions. He should understand, agree with
and even suggest the conditions of his return with regard to his
behaviour. At an appropriate point, extra support and tuition could
be arranged.

Richard’s mother has her own mental health issues. She could be
encouraged to visit her GP to access support to help her manage her
anxiety and obsessional behaviour. The physical abuse that Etta is
experiencing from her husband should be tackled head-on. It should
be made clear to her that she does not have to put up with this and
various options discussed with her. This could include input from
social services, a voluntary organisation or even the police.

Nigel should also be made aware that physical violence is not
acceptable and that, by resorting to violence and using alcohol and
drugs, he is not proving to be a good role model for his son. At
the same time, Nigel could be offered counselling and support to
tackle his own issues constructively.

Kay Sheldon is a mental health service user