Case Study – Ruth
Ruth is a 42 year old woman who lives in a two bedroom Council flat with her 21 year old daughter Megan and dog Ruby. She has a history of frequent contact with a range of health and social care agencies over the past three years.
Ruth had a very unhappy childhood. She was born the youngest of three siblings. Her father, a mechanic, George, was a bullying man who physically and emotionally abused his wife (Ruth’s mother Ada) and Ruth. Her mother was emotionally cold towards Ruth. Ruth had been unplanned. As far as Ada could see all the problems in the family had started with Ruth’s birth. This also coincided with George losing his job, starting to increase his drinking (alcohol) and money worries. They had moved to a new home in a prosperous suburb.
Ruth recalls hiding in the cupboard under the stairs or building dens in the garden to where she would retreat with her pet dog. School was a miserable experience. At best she was ignored, at worst repeatedly bullied. She left school with no qualifications and started working at a dog kennels. She found this work very rewarding.
Around this time her mother unexpectedly decided to leave her father. Neither Ruth nor Ada would have any further contact with this man. Her older siblings had become independent adults none of whom would welcome any further contact with George Ada or Ruth. Ada insisted that the 16 year old Ruth live with her. She continued to emotionally abuse her. At the age of 17 Ruth was raped by man posing as a salesman at the door. Ruth left home at the age of 19 when she married Peter.
Peter and Ruth had one child, Megan. The marriage ended when Megan disclosed sexual abuse by Peter at the age of 15. The case never reached court due to insufficient evidence. After leaving Peter, Ruth devoted herself to training to be a teacher. She was determined that she achieve a degree of financial security. The access course progressed well and, after a lot of support from her university, she qualified as a teacher.
She has never taught. She suffered what she calls a ‘breakdown’ shortly after qualifying. A number of events, according to Ruth, may have contributed. These are: financial insecurity; a burglary during the night at her home; the accumulated stress of the degree; longstanding difficulties around self esteem, confidence, anxiety and what she calls panic attacks; that she has for the first time in her life used alcohol as a way of managing these problems- although, she acknowledges, it hasn’t worked that well; threatening behaviour from local youths culminating in her car being set alight; and concerns about Megan’s well being.
Ruth’s sees her ‘breakdown’ as being characterised by; very poor sleep, guilt and shame about her daughter’s abuse and her subsequent dependence on her daughter over recent years; taking overdoses of prescribed medication; using alcohol excessively and problematically; flashbacks; hearing voices and visual hallucinations; isolation; fear of social contact – only going out alone to walk her dog in the early hours of the morning; and getting stuck in repeated patterns of cleaning up around the house.
Ruth and Megan are very close to one another and in many ways dependent upon one another. Megan has recently started university in her home town and had hoped to live independently. Her mother has become increasingly emotionally distressed over the past three years so Megan has moved back in. Ruth feels guilty about this and Megan feels somewhat resentful.
A number of services have been involved. These are some of the perspectives on Ruth which you might get from making contact with those services, and some perspectives from Ruth and Megan
Accident and Emergency:
Ruth has been a regular presenter here over the past three years. She comes in via the ambulance service. She is usually very tearful and has taken an overdose in the context of being intoxicated with alcohol. She is usually quite ambivalent about whether or not she wants treatment. She usually presents with her daughter. Sometimes she is referred to the A&E based Mental Health Crisis Team. There is a sense that some of the staff are losing sympathy with her. They continue to check that she is medically fit and refer her on if need be.
Ruth has been referred to this service on a number of occasions by members of the Community Mental Health Team. She is offered appointments, getting Ruth to appointments involves arranging for her to be escorted by someone she trusts, like her daughter, or social worker, which is quite resource intensive. She remains close to silent and very distant at these appointments, and is discharged by the service. The view of the Clinical Psychology Department is that Ruth isn’t ready yet to engage in therapy. She has been discharged from this service.
Ruth has had multiple diagnoses: post traumatic stress disorder; borderline personality disorder; schizophrenia. She currently has the borderline personality disorder diagnosis. She has been prescribed a variety of types of medication. Sometimes it can help to calm her down at night but there is a sense that it doesn’t work properly because of her alcohol consumption. There is also a strong reluctance to prescribe because of the risk of overdose. Frequent referrals have been made to a specialist day therapeutic community The Haven, to Clinical Psychology and to the Community Alcohol Team but she never engages consistently.
There is little more that we can do clinically. There is a feeling that acute hospital admissions are only appropriate as a last resort to manage immediate risk to self. She is usually quite ambivalent about being admitted. She will express ideas of self harm with plans to carry them out (overdoses), will agree to admission, then change her mind shortly after being admitted, yet continue to state that she wants to end her life. This leaves the clinical team torn and split as to what to do next. On occasions she has been briefly detained under section 2 Mental Health Act 1983/2007.
Community Alcohol Team:
Ruth has attended for a couple of assessments. The pattern seems to be that she drinks heavily when her symptoms are at their worst. She only started drinking over the past 3 years. She doesn’t say much when she comes and never attends any further appointments so she is discharged from the service.
Megan: I have so little time to devote to my studies let alone any sort of social life because of all the time given over to caring responsibilities. We have money only for the basics of living. I feel very isolated. It is difficult to talk about low these things affect me. I feel very torn between my own needs and those of my mum.
Ruth: I desperately want to get some control back over my life. I want to feel safe in my own home not thinking all the time about whether someone will break in or whether my property is at risk. I want Megan to be able to go back to university. I feel so dependent on her. I just don’t have anyone else now. I wish I could trust people more. Sometimes I speak to the man next door when we are in the garden together and we talk about our vegetables and it is really nice, really normal. A lot of people round here call me a freak. They see me talking to myself, usually just trying to reassure myself and think that I am crazy. My car was my lifesaver, it meant I could get to the shops with Megan and at least drop her off at university. I need another one but the insurance money won’t be enough. With my income I can scarcely afford to run one anyway. Megan has no money either. I still love my gardening. My back garden is really secure. I know it sounds silly but I talk to the plants. Sometimes in the house I see things coming out of the walls, horrible faces. Megan can’t see them. I think I am going crazy. I rely so much on Megan. I just can’t seem to trust anyone else. That’s why I clam up when I see all these special workers. I could cope with Sue, the social worker, bless her, she seemed to go out of the way for me but she’s off sick. I could really trust her but maybe she had too much of me – maybe that’s why she is off sick. All the rest seem to be telling me what to do, what they can or can’t do for me or to me. I know I have let them down. I am never sure if I am really wanted on the ward, or in A&E. I come out feeling guilty, almost with a sense of shame. The other services just send me letters saying that I am discharged. The woman at the alcohol team once refused to see me because I smelt of alcohol. They never seem very flexible. It is always on their terms. They say that I need firm boundaries.
Case study question
Drawing upon the case study, critically discuss how social, medical and other perspectives might inform assessment, working relationships and interventions when working with Ruth alongside a multi-disciplinary team.