A change of staff at the CMHT meant that I became Perdita’s care coordinator. Perhaps surprisingly, in view of my attempt to section her, she didn’t object to this. In fact, she told me that because of the way I had handled that event, she felt she could trust me.
I got to know Perdita quite well. Splitting her self into several discrete personalities was her way of managing the intolerable emotions which arose as a result of her severe childhood abuse. There were certain triggers to her “checking out”, as she described this process of extreme dissociation, during which one or more of her other “parts” manifest themselves. These usually involve certain stressful situations which she is unable to cope with, as they touch raw nerves relating to betrayal.
The DSMIV defines Dissociative Identity Disorder as “the presence of two or more distinct identities or personality states”. These identities or personality states must recurrently take control of the person's behaviour. The patient must also experience an “inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness”. In my professional career I have only encountered three people with this diagnosis.
Having seen Perdita manifesting these different personalities, I was convinced that she was not putting on these episodes, and genuinely had no conscious control over what happened when the other parts took over.
I have met Mavis, who is charming and polite, and a pleasure to work with. I have also met Mary, who is a small child, who can be mischievous and playful. I had heard all about Grendel, the really angry and destructive one, but had not yet met her.
I worked with Perdita on the basis of damage limitation. I tried to help her to manage her mood swings. We worked together to identify and avoid triggers for her dissociative episodes. We especially tried to keep Grendel under control.
But things don’t always work out.
One morning, I had a call from Perdita.
“I’ve been let down big time by someone.” She told me the details. “I can feel myself going. I’m afraid I’m going to check out. I’m afraid Grendel’s going to take over.”
We talked this through for a few minutes. I suggested a range of risk management strategies that we had put into her care plan. But I had the feeling that “checking out” was going to be unavoidable.
A few minutes later, I got another call. This call consisted entirely of maniacal laughter. I guessed that it must be Perdita. I tried to get through to her, but the chilling laughter went on and on and on. After a while, I realised I was not going to get any sense out of her, and put the phone down.
The phone rang again. More scary laughter.
“It’s Grendel here,” she said. “I’m having a great laugh! I’ve really cut the bitch to pieces this time!” Then she hung up.
I felt I had to respond quickly. I rang the emergency services, asking for an ambulance and police to attend, then went to see her, taking one of my colleagues with me. It was going to be necessary to concentrate on limiting potential damage – damage to Perdita, damage to her house, damage to her daughter, damage to other professionals…
We could hear the laughter from outside the house. The front door was ajar. I went straight in, and we cautiously entered the living room.
Perdita was sitting on the sofa, rocking backwards and forwards as she whooped with laughter. She had an open pair of scissors in one hand, and her other arm was covered in lacerations. There was a fair amount of blood, so it was hard to see how serious the cuts were.
“Give me the scissors, please, Grendel,” I said as calmly as I could.
“You’ll have to give me three good reasons!” Grendel replied, and slashed several more times at her arm.
“Give me the scissors, Grendel,” I repeated as calmly as I could.
“Give me three good reasons!”
“I’m not getting into any games. Just give me the scissors.”
I waited nervously, keeping at a safe distance, until the ambulance arrived, and two paramedics came into the room. The police arrived almost at the same time, and the room was soon full of people in uniform.
Grendel loved it. “You’re very tall, aren’t you?" she said seductively to one of the paramedics, who was indeed exceptionally tall.
He asked to look at her arm, but instead, she slashed away at it again, occasionally holding the blade against her throat, as if she were holding Perdita hostage.
“Give me the scissors,” I said again, in as gentle and unthreatening a way as I could manage. The police and paramedics kept quiet, waiting to see what would happen.
“You’ll have to give me three good reasons!” she said again.
I was going to have to play her game after all.
“OK, Grendel. First, you’re hurting Perdita. Second, Ophelia will be upset if she finds you like this.” (Ophelia, by now 14, was still at school.)
“That’s only two reasons!” Grendel cried, giving her arm a few more slashes.
“And third, you’re scaring the hell out of me!”
I have found that being entirely honest can work well in these situations.
She thought about this for a moment.
“Okay, fair enough,” she replied, and threw the scissors onto the floor. I kicked them away, and one of the police picked them up.
“Grendel, I really need to speak to Perdita.”
“Perdita’s gone away. You’ve got me!”
“I need Perdita. We need to get your arm sorted out. And Ophelia will be home from school soon, and I don’t want her to find all this.”
There was a pause. Perdita’s face sagged and went blank. She slumped forward. Then her head snapped up and the eyes of a small lost child stared into mine, tears running down her cheeks. She looked absolutely terrified, staring with fear at the room full of people.
“Hello there,” I said gently. “Can I see Perdita. Or Mavis. Either of them would be good.”
Her face went blank again and her eyes closed for a moment. Then her face changed. She opened her eyes.
“Oh, hello, Steve,” she said, a little surprised, looking around and taking stock of things. She looked at her arm. “Is it Grendel? Has she been out?”
I recognised Mavis. She would do. She would be able to sort things out. She rolled herself a cigarette and then smoked it while she allowed the paramedic to examine her wounds, and clean and dress them. “My, you’re tall, aren’t you?” she observed. After all, Mavis had not seen him before.
“Steve,” she said. “It’s so nice to see you again.” It was uncanny, but Perdita’s face, mannerisms, and even accent, were quite different when Mavis was in charge.
I negotiated with her. I asked her to stay in charge for the time being. I told her that I would come back later in the afternoon when her daughter was due home, to see Ophelia and explain what had been happening (she was, sadly, used to these episodes), and to check that Perdita/Mavis was safe and in control. Mavis listened to me obediently, making meticulous notes from time to time.
My analysis of the situation went something like this. Once Perdita or "Mavis", the sensible one, can be induced to return, the crisis is usually over. "Mavis" herself was confident that she could remain in control. Her wounds did not require hospital treatment.
I had from the beginning worked with Perdita explicitly on the basis that hospital admission was best avoided during these crises, and the Crisis Team also had little role to play in these situations, once the immediate crisis had passed. This was written into her care plan.
It would also generally not be appropriate to use the Mental Health Act, and would undermine any trust Perdita had in me.
So we worked out an immediate plan. The police would notify Children's Services of the incident, who could be mindful of Ophelia’s needs. Ophelia could stay with her father if required, but would invariably prefer to stay with her mother, and would be under less distress if she was with her. It would not be in the immediate interests of Ophelia to separate her from her mother.
The police and ambulance crew withdrew. I said goodbye to Mavis and reminded her I would be back later to check up on the situation.
As Mavis pulled deeply on another cigarette, she said to me: “Steve, when you see Perdita next, could you try and persuade her to give up smoking? It is such a disgusting habit.”
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