Wednesday, 24 April 2013

When Service Users Seek To Deceive Part IV

The Masked AMHP assessing "nature or degree" in the hit Edinburgh Fringe play "How to Survive a Mental Health Tribunal -- Missus"

The following account may contain triggers for self harm.

It’s nearly 10 years since I last had any contact with Eunice, but I still think about her from time to time.

Eunice was, and still is a mystery. I don’t think I ever really did get to the bottom of what was happening with her. I don’t suppose I ever will.

Eunice was in her 50’s. She was married to a man somewhat older than her. He was a bank manager. When he retired, they moved to Charwood, and bought a large house on an upmarket estate.

Her consultant psychiatrist from the area where she had lived wrote a letter of referral to the CMHT. It described her as a “pleasant, polite and deferential lady” with a long history of depression. More unusually, she had consistently recounted a long history of having been physically and emotionally abused by her husband. More than that, she also described a history of having been the victim of systematic physical and sexual abuse by a group of men, including her husband, who would come to her house and abuse her in various unspeakable ritualistic ways. The psychiatrist had never been able to corroborate these stories. He had once invited her husband to come to an appointment, but the husband had not attended.

I conducted an initial assessment with a female member of the team. Eunice was a tiny, birdlike woman who had very poor eye contact. She frequently trembled during the assessment, and often appeared to be in great distress. She recounted a history of childhood emotional and sexual abuse at the hands of her father. She was an intelligent woman who went to university and obtained a degree in English Literature, then met and married her husband and became a housewife and mother to her son and only child.

It was noticeable that her arms were covered with a silvery criss-cross of scarring consistent with many years of self harming with a sharp object. However, when I asked her about the scarring, she denied that she had ever deliberately self harmed, claiming instead that these were inflicted by her husband and others during their abuse of her.

When I came to write up my assessment, I concluded that “Eunice's overall presentation is consistent with a history of chronic sexual, physical and emotional abuse as a child, and her accounts of this abuse, and her beliefs and reactions revealed when discussing it, ring entirely true. However, her accounts of the sadistic abuse over many years by what appears to be an organised ring is necessarily very hard to believe. This is not a description of conventional, if that is the word, "satanic" or "ritual" abuse.”

Despite my reservations, my approach with people who reported childhood abuse has always been to believe them unless I had evidence to the contrary.

I worked with Eunice for over 5 years in total. Initially, I attempted on a number of occasions to persuade her to allow me to report her allegations to the police and the Adult Protection Team. She would never allow me to do that. I explored with her as gently as possible the nature of the abuse. Some of it involved reports of her husband deliberately inflicting pain on her, an example being when he allegedly burned her with an electric iron. She showed me the burn on that occasion.

There were in fact several times when I saw injuries on her, including what appeared to be rope burns on her wrists and ankles. On one occasion she told me that she had been taken by car, with a hood on her head, to somewhere in the countryside, where she had been tied up and then subjected to a range of appalling ordeals. But she would never let me intervene.

I continued to persevere with her, trying to improve her self esteem and assertiveness to the extent that she would permit me to take action over this apparent abuse.

In one review I noted:

The injuries I have seen on Eunice are consistent with systematic and organised abuse. However, these injuries could as easily have been self inflicted as caused by others. There are three possible explanations for the reported abuse:
1. She is the victim of an organised ring of sadists of whom her husband is a member.
2. She has a longstanding and consistent, but untrue delusion that she is the victim of this abuse, caused by a psychotic state.
3. The accounts of the abuse as an adult are hysterical inventions and all the injuries are self inflicted and consistent with Munchausen's Syndrome, possibly arising as expressions of genuine childhood abuse.
She will not give me permission to speak to her husband, and has refused offers to help her leave him and go to a safe place, saying she is afraid not so much of what they might do to her, but that they might harm her adult son.

After a couple of years of working with Eunice, her husband unexpectedly and suddenly died of a heart attack.

Although Eunice expressed considerable grief, I also saw this as a possible new start for her. Now her husband was dead, she might be able to forge a new life for herself, free of abuse.

I enlisted the help of a female support worker from the team, and together we helped her to clear her house of her husband’s effects. I had secretly hoped to find some corroborating evidence relating to her husband’s double life, but there was none.

The support worker began to work with Eunice, and over several months Eunice’s mood appeared to improve. I even caught her smiling occasionally during my sessions with her.

Then she began to tell us that she was again receiving visits from the men.

She reported to us that one of them had left an obscene message on her answering machine. Unfortunately, she had erased it.

On another occasion, she told us that a video had been posted through her letter box containing compromising scenes involving her husband and herself, and a threat to send it to her son. However, the “visitors” then took it back.

Still working on the basis that what she told us was true, in spite of some misgivings (why did she always dispose of the objective evidence), I encouraged her to increase her security, including having a spyhole installed in her front door, installing a chain, and also ensuring that her other doors and windows were secure. I even suggested that we have a CCTV camera installed, but she would not agree to this.

Then one day, when I visited her, I found her in a state of intense distress. She said that the previous afternoon there had been a ring on her doorbell. She said that when she opened the door, one of the men was there. She eventually revealed, over a long period interspersed with tears and trembling, that he had forced his way in, and had then dragged her upstairs where he had tied her up and abused her.

She showed me what looked like fresh rope marks on her wrists and ankles.

I told her that this could not be allowed to continue, and that I would have to report it to the police.

I arranged for a female police officer to interview Eunice in the presence of the support worker. She was told that, for a formal investigation to take place, she would have to make a formal complaint and have a medical examination. She said that she could not tolerate submitting to a physical examination, as it would remind her too much of her abuse.


Eunice continued to give periodic reports of visits from the men, and accounts of their continuing abuse of her. Sometimes she would show us injuries – rope burns, bruises.

After a few more months of this, I discussed the case with a female officer from the local Adult Protection Unit without telling Eunice. She said she would make some discreet enquiries prior to any further action. I assumed she meant that she would do some background police checks on Eunice’s husband. She came back to me, saying that they would not be able to do anything further without interviewing her.

Eunice reluctantly agreed to this.

I was pleased about this – the Adult Protection Officer was extremely experienced and might just be able to get somewhere with Eunice.

She interviewed Eunice on her own, at her home, coincidentally the day after Eunice had reported yet another “visit” and with accompanying rope marks on her wrists.

The Officer reported back to me afterwards. She did not consider that Eunice was being abused in the way she described. This was on the basis of the content of Eunice’s account, her body language during the interview, and exaggerated and incongruous reactions to touch, etc. She also based her conclusions on her experience of interviewing rape victims as well as people known to have made false allegations.

I decided that I should change focus with Eunice. I reviewed her Care Plan with her, pointing out that it appeared she would prefer me to sit and listen rather than try to impose change on her that she feels unable to achieve. She gave me a list of concerns which I tried to address, some practical, some emotional. One thing was her car wing mirror, which was hanging off. I looked at it for her, and was able to fix it easily and quickly. Eunice appeared delighted in a childlike way by this, even smiling spontaneously.

For the next few sessions, I became a handyman, replacing light bulbs that she could not reach, fixing a latch on her back gate, fixing a leaking tap. While I did this, she sat and talked to me about her mixed feelings of grief and relief over the death of her husband. I did not mention the “visitors” and neither did she.

Then one day she abruptly announced that she was moving. Her son, who lived in another county, was arranging for her to live in a bungalow nearby to where he lived. He was taking over her house and was going to let it out.

Within a month, she was packed and gone.

I confess to a sense of relief. She was no longer my problem.

A few months later, however, I received a letter from her. She said that she did not know what to do, as the “visitors” appeared to have tracked her down, and were again entering her house at will and abusing her in various terrible ways.

I wrote back, telling her that she had to report it to the police, and should also let her son know.

I never heard from her again.


  1. A hard situation to be put in. If there are safeguarding concerns with a service user can you not intervene anyway in that situation?

  2. As stated - Unless she is willing to co-operate there is little the police and Mental health services can do.

  3. I'm sorry but I really don't get it. Usually, I'm saying that you should leave people alone. However, I don't see why you wouldn't be able to lock her up in a safe place or why you don't think that she is delusional. Her story doesn't make any sense. If she has enemies or people who are keeping an eye on her, they would spy on her or they would kill her. Nobody would just keep coming to her house to abuse her. Even though I normally tend to be against this course of action, I would say, take her away. Men can't come and get her in a locked ward. If she's just making up stories, she will stop while they are totally unbelievable, such as in a locked ward, and perhaps permanently if each time she tells her stories, she gets locked up again. If she gets caught lying to the police, she should get arrested. Prison, too, is a way to lock her up but a good excuse is needed. On psychiatric grounds, why weren't her stories enough? They were clearly untrue.

  4. Monica - Just because someone makes up stories doesn't always mean there mentally ill!

  5. Another patient said that she was "her Royal Highness, the Queen of the World!”. Eunice's story was only slightly more believable. But is that even relevant? The lying had to stop. Either Eunice was truly delusional or she would have seen that her lies are not tolerated and she would have stopped. As a matter of fact, if she told such lies and didn't believe them, that may only mean that she was not psychotic. She still had a problem. On the other hand, if her story was true, at least by being incarcerated or hospitalized, she would have been protected.

    1. Monica, there are infinite gradations of mental disorder, with varying degrees of capacity (and culpability). I thought your basic argument was that people ought to be given the maximum freedom, whatever the consequences.

    2. It's because here, removing Eunice from her home would actually solve a practical problem as opposed to simply forcing someone to accept treatment (treatment largely consisting of harmful medication). In this particular case, with or without medication, and whether Eunice would have been in hospital, in prison, in a nursing home or in any such supervised setting, the idea is that it would be impossible for those men to come there, not without being seen by the staff of that establishment, anyway.
      They wouldn't have come or Eunice would likely have stopped pretending that they were. Now, of course, if she just continued to make up such stories while locked up, it would have been perfectly clear that they couldn't possibly be true.

    3. Can we not see all of her stories as a form of self harm? If we assume they weren't true, which does seem the most likely reality, her constant thinking up, physically harming in order to make them real, then recounting them to services certainly seems to amount to harm. It is, however, harm to a limited extent.

      For example, if you knew a SU was cutting daily, but with fresh, clean blades and never in a life threatening way, you would not "lock them up". Though they would be experiencing harm you'd have to balance this against the harm caused by entirely depriving them of their freedom.

      In my mind this case is of a similar nature. Yes she was "self harming" and causing physical and emotional pain to herself and yes if she was put behind locked doors you'd theoretically remove these imaginary attackers but would it be worth it? Would it really improve her life enough to justify detention, I don't think it would.

      However if the harm did increase dramatically and she came with considerably more severe injuries you might change your decision.