The referral came via an educational welfare officer to a department of family therapy in the U.K: three children had recently moved to the area with their parents and were causing concern at the school they attended.

The referral information only provided a rough address, so it was not possible to make a telephone call to contact the family in the usual manner. That afternoon I drove to a marshy area near a beach to a collection of derelict beach huts. It was the beginning of winter with the wind blowing off the sea and the rain beating down. I was looking for a blue hut - in the end, I selected a rather shabby hut with blue paint peeling off - exposing the wet wood beneath. It was off the beaten track surrounded by shrub with a rudimentary uneven path made of brick rubble leading to an entrance. There were drab curtains drawn at the windows – it all looked forlorn bleak and damp. I tapped gently on the door and after a while, a woman partially opened it. She edged outside shivering in the cold shutting the door behind her to find out who I was and what I wanted. It was obvious that she wanted to keep me outside of the hut; she seemed to be very wary and nervous. I explained to her that the school had some concerns about the children settling in and that I was calling to see if I could help. She apologised but said she’d have to ask her husband.

I waited outside - a while later she came out again saying “I am so sorry, but my husband does not want to see anyone from the authorities”. I began to explain to her that I quite understood when a voice from inside shouted

“She can come in Jen.”

Jen visibly relaxed a little and invited me in. The only space was taken up with a double bed. Two upended orange boxes served as chairs and a very makeshift primus stove was in a corner. There was no evidence or indeed space for a tap or a toilet inside, so I presumed they were outside. It was beyond comprehension how a family of five could live in such cramped difficult and unhealthy conditions, particularly during the winter.

The woman introduced herself as Jen and said, “This is my husband, Dave”. Dave was lying on the bed covered in blankets – obviously a large man – bespectacled with a black beard. I had the distinct feeling of “being in the presence of ” he exuded grandiosity! Dave took over telling me his story while Jen put on the kettle – the English way, to make tea.

I learnt that they were a cockney family of five, one little girl aged five and two boys six and eight. The couple wanted a more natural life by the sea where their children could grow up safely out of the rat race. They came from London where Dave had worked as a docker. They had sold up in London and purchased a piece of land which they thought came with permission to build a house. However, once they had moved from London it transpired that the plot did not have the necessary planning permission. Desperate the family dipped into their savings and purchased the blue hut with some of the money intended to build the house.

At first sight they appeared to be a good well-intentioned couple wanting what was best for their children but as I became more informed this was not necessarily the case. At the beginning of the autumn term the children had to start attending a school – a statutory obligation. Moreover, without any form of transport, the family needed to live within walking distance of a school. They had purchased the hut to tide them over. Jen did not talk, but I noticed Dave would include her in the decisions they had made saying ‘we’ when it was pretty obvious Jen was not allowed to have any opinions of her own. Dave was not complaining or indeed concerned about the living arrangements, but I could see that as winter set in life had become impossible particularly for Jen. There was no refrigerator, or washing machine and no television to occupy the children during the long dark evenings – nothing. How Jen managed to feed, clothe, and care for the family was difficult to imagine. Why had Dave taken to his bed been another issue?

Dave related how they, meaning him, didn’t want contact with anyone and that he was against the children having friends. Jen interjected and said, “But Dave the school seems to be good, and the parents are welcoming”?

Jen’s comment provoked Dave into a furious outburst. In front of me, he said

“Jen listen to me, how many times have I told you not to speak to anyone”?

She apologised “Lots of times Dave - I am so sorry.”

“See what I have to put up with?” He appealed to me.

I could see quite clearly why the children were reacting. I could also see that Jen was in a miserable and precarious position scared to provoke Dave. Life for her was only tolerable if she agreed with everything he said and reinforced his need to be dominant and admired. Trying to appease her husband on the one hand and probably attempting to reason with the children on the other if they upset him in such appalling conditions was the recipe for illness.

However to be in a position to learn more and to help them I also needed to remain in contact with them even if it meant colluding by appearing to boost Dave’s ego. For this reason, I could not empathise or intervene on Jen’s behalf – although I wanted to. Dave had shown in a relatively short time his absolute lack of empathy and disregard for his wife. He was also naive believing that I did not see through his behaviour.

The situation called initially for practical management. I would usually consider paying a visit to the school but in this particular case, I decided this course of action would be unhelpful. If Dave found out that I had visited the school, any involvement with the family would most certainly be stopped, of that I was sure. Initially, the aim was to manage the situation by getting treatment for Dave. If this could be achieved, the children and Jen, I knew from my own personal experience as a family therapist could quickly respond positively.

The most pressing need was to maintain acceptance by both the parents. Needing more time to assess the situation I said goodbye suggesting I would return? Judging by their reaction, that did not appear to be a problem, which felt like progress.

Returning the next day they appeared moderately pleased to see me. This time, I wanted to understand Dave and his psychopathology. It was not difficult to engage with him he seemed to enjoy the attention. He talked animatedly about his childhood in London and being an only child. He particularly enjoyed pointing out his achievements and responsibilities. Jen would brighten up nodding appreciatively, but if she interjected he would tell her not to interrupt and appeal to me saying

“You see what I have to put with”?

He described his work as a docker. More explicitly that he was a crane driver and how he would spend every day high above London loading and unloading the ships in the docks. I encouraged him by showing genuine interest and saying how responsible he was. At no time was it appropriate to talk to Jen or to confront his controlling behaviour towards her. My role was to remain the only person outside the family to be accepted. - They had not even registered with a local doctor which was most unusual.

Dave described how he began to feel estranged from the world beneath when he was poised high above London in the crane. He explained that once he was in the crane he had to remain in the cab until the end of the working day. He described that as he looked down from the cab, the world far below seemed to be hostile and in turmoil.

At some stage during this time in London, he began to persuade Jen that to safeguard their family from this ‘hostile’ environment they needed to cut all ties with their families in London and move to the safety of the seaside and country.

Depersonalization, Ackner [1] and further described as feeling disconnected or estranged from one’s body, thoughts, or emotions usually combined with narcissism and paranoia appeared to be what Dave was experiencing.

Suddenly from happily recalling his achievement and aspirations and explaining his dream he switched to the present and said: “I want to kill the planning officer who turned down my plan to build a house”. At that moment, this appeared to be a distinct possibility it did not seem to be just an idol threat.

The children came home from school, and as I showed some interest towards them, they began to talk about their day. Dave did not like me engaging with the children he quickly turned on them and accused them of not helping him, and of acting inappropriately. He went to demeaning lengths to make each one say sorry and admit to how inappropriate and bad their behaviour was. Jen looked on too frightened and afraid to defend them – and not knowing if I agreed with her husband or not.

During this altercation, Dave appeared to resent not being in the spotlight and kept looking at me appealing for my support and my sympathy.

He then attacked Jen, blaming her for the bad behaviour of the children.

I left once again to reconsider the right path to take. There was no doubt in my mind as to the danger the family were in. The situation was precarious. It would only need a crisis to trigger an irretrievable reaction by Dave. Such as one of the family becoming ill perhaps a child getting influenza or some such illness - which was in the circumstances a distinct possibility?

Deciding what course of action to take during a supervision session with the consultant child psychiatrist and other members of staff, I said that I would like to discuss this particular family. Concluding by suggesting that I should try to refer Dave to the adult psychiatric service? The consensus was: could anyone do any better than me? I gave considerable thought to their view but decided that the situation was severe and merited the right action. This was a risky move on my part. At the time, there appeared to be an unwritten rule within the Family Therapy Centre that one didn’t refer to the adult service. I was not a party to the reason, but I suspected it could have been based on rivalry.

I decided to go against my colleagues and that I should contact the psychiatrist.

The adult psychiatrist in charge of the area was relaxed, and he suggested that he accompany me on a domiciliary visit. I felt I needed to pave the way for the visit so once again I visited the couple on the marshes and Dave, and I talked. Jen hovered and listened clearly very nervous. It was quite evident that as Dave realized the precariousness of the family circumstances the situation had become more dangerous. As I have said, I never confronted Dave. Moreover, he never admitted any responsibility for the situation, but nevertheless, by now he did appear to acknowledge that he needed help and that the situation was unsustainable.

Once I realized this, my fear was that in these dire circumstances he could act: kill himself, the planning officer or even his family. Whenever he lost face, he became aggressive and became desperate feeling cornered. So with a considerable degree of trepidation, having first enlisted the involvement of the psychiatrist unbeknown to Dave or Jen, I suggested we invite a doctor to visit? – [I never said psychiatrist]. I went on to explain that a doctor could make some helpful suggestions and may provide some help.

Jen visible became very scared; this was clearly a step too far for her.

Eventually, Dave said, “I’ll go along with that”. His agreement was on his terms, in his home - proving he was in control, and, what’s more, the attention was on helping him!

The psychiatrist and I decided to travel the last few hundred yards to the blue hut in one car – I was nervous and not knowing the psychiatrist I wanted to maintain the inroads I had made so far with Dave. I felt the whole consultation needed to be as low key as possible. The psychiatrist took the initiative and knocked on the door then peeped inside. He was used to this situation. “Anyone at home?” he asked. Seeing there was no room for four in the hut he suggested we sit in his car. Dave came outside in his pyjamas wrapped in a blanket and sat in the front seat of the car with a discernable grandiose demeanour next to the psychiatrist while I sat in the back. The psychiatrist skilfully engaged with him and listened while Dave told him the story. Dave concluded by saying “I aim to kill the planning officer”.

Deferring to Dave for his agreement the psychiatrist suggested that we needed to confer alone to discuss what help could be offered. Dave agreed and returned to the hut leaving us sitting in the car. The psychiatrist thought Dave was a threat to himself, the family and the planning officer, and that he should be in the hospital. We both felt, if possible, Dave should go to the hospital as a voluntary patient. It was left to me to try to persuade Dave. The alternative was a compulsion order. This meant that if Dave failed to agree to go into hospital voluntarily then, the psychiatrist told me he would sign the necessary papers with the mental welfare officer. Moreover, he would advise the officer to take the police with him. The psychiatrist also said he wanted the children to be away – preferably at school if this happened.

We were both worried about Jen. The psychiatrist left.

I went back to the hut and explained to Dave and Jen that the doctor suggested a short spell in hospital to help him regain his health. Somewhat shocked Dave took the news surprisingly well - he agreed: I felt it was preferable for me to take him to the hospital in my car in preference to an ambulance.

He was given a bed for the next day. I rang the ward before setting out to collect Dave to explain to the charge nurse that the situation was volatile. However, if Dave was respected and perhaps offered tea on arrival, this was the best chance of success. Dave was ready when I arrived, and we left - Jen waving him off but upset. I could have arranged an ambulance, but I did not want to risk him changing his mind feeling that any minor upset could have led to his refusal to go to hospital voluntarily. Dave had shown himself to change from being affable one second to being menacing the next. For all I knew he might have drawn a gun shot me and absconded with my car.

However, the journey turned out to be uneventful.

I became apprehensive when we drove through the entrance of the psychiatric hospital. Fearing that something might suddenly alert him to where we were going. Mentally ill patients can behave strangely – only the week before a patient had laid right across the entrance to the hospital so that everyone had to step around her. I just hoped that something similar wouldn’t happen that day.

We walked down the long corridor our footsteps echoing annoyingly and came to the ward and went in – thankfully the door was unlocked. The staff was on the alert and welcomed Dave with the tea. I left after Dave had been admitted - relieved that we had got this far. My job now was to return to Jen and talk with her, something I had felt inappropriate in the company of Dave.

I took Jen to visit Dave during his time in the hospital. He was doing very well, proud to be helping the other patients with “advice”. He was discharged three weeks later, stabilized.

The next step was to get Dave earning again, but jobs in this area were few and far between. In the UK at that time companies by law needed to employ a quota of physically challenged employees. Once Dave was at home, I was able to persuade him that this route would be the easiest way for him to obtain employment. He did not like the idea at first, but he gradually came round to seeing the advantages. Contact was made with a company who wanted security staff to man the entrance to a famous factory. The job entailed checking the security of people going into the company, by operating a gate and waving people through once they had showed their passes. This position was ideal - it met all Dave’s needs: He was required to wear a uniform, he was in control, he commanded respect, and he was once again the bread winner. He took his work very seriously, and the company were delighted with him. His symptoms subsided, and he became more affable.

With Dave having a job, the couple was able to secure a mortgage and buy a shop with living accommodation above. Jen made a great success of the shop and everyone loved her. The children settled at school and were integrating well into the community.

In retrospect and reconsidering the dynamics: Clearly Dave’s immediate problems were most probably precipitated when he was isolated in the crane high above London. His absence of empathy led to the speculation that the nature of his narcissistic disorder and the accompanying grandiosity must have existed before. In all probability, anyone with a reasonably balanced personality would not have become disordered in similar circumstances. The appeal of working in the crane cab in isolation may have been a consequence of his personality disorder; he was at the top of the hierarchy while working, he was also a loner alone! Finding another job within the dockyard once he became depersonalised was the most obvious solution and the least extreme though this did not fit his need for status and the need to fuel the underlying psychopathology.

Such a personality needed from an early age to be reined in or disciplined – but speculatively as an only child and perhaps adored by his parents this never happened. Dave was now a large, powerful docker, not someone with whom to cross swords. He didn’t socialize or mix well with his work mates. Jen never confronted him she played an entirely subservient and submissive role. She was the antipathy of Dave possibly selected by him for that very reason.

The risks involved in this particular case were not for everyone. The case could have been referred to social services who would have dealt with it differently: most likely taking the children into care. Alternatively, Dave could have been allocated to the psychiatric service. However the behaviour of the children was the only visible indication that the family were in trouble, they had become the cause of the referral.

The psychiatrist commented, afterwards that he would have had spent less time with Dave. Moreover, he would have called for outside help, which may have provoked Dave into becoming hostile, and less cooperate in the ward. Maybe even killing someone. Moreover, Dave would not have had the support after discharge from the hospital. However, I was a family, therapist and I knew that to remain a supportive husband and provider he needed a job. Without the esteem of a job to reinforce the underlying psychopathology I knew he would deteriorate so I found him a job and paved the way for him to get it. Attending interviews with him etc.

I moved on, and I did not have the opportunity to check up on the family again. Years later when I coincidently happen to read the obituaries column in the local press. It reported the death of Jen. She died of cancer at just fifty-four. This news awakened my research finding Thomson [2] and the causal relationships between premature deaths following a depressive illness. Also, Selye’s [3] stress hypothesis. Eysenck 1988a -”Cancer – prone people, as opposed to coronary heart disease prone people tend to be overly cooperative, appeasing, unassertive, over – patient, avoiding conflict, seeking harmony. They are compliant, defensive, suppress the expression of emotion, and are unable to deal with interpersonal stress, which leads to feelings of hopelessness/helplessness and finally depression. This, in turn, leads to high cortisol levels and so to immune deficiencies”, by Grossarth- Maticek and Eysenck [4].

I wondered if cancer was the real cause of Jen’s death. Alternatively, was cancer secondary to a life of complete subordination? This some may conclude is an arbitrary conclusion but nevertheless I was first a therapist and then a published researcher on personality. My subjective hypotheses were formulated as a therapist which were then objectified as a researcher.

It would have been so easy to presume that with the children doing well in school, with Dave happy in his job, and even Jen making a success of running the shop that it was a successful intervention. However, in my opinion, it was not. Sadly Jen would have remained bullied and subservient, always on tender-hooks. She would be the recipient of the unrelenting psychological stress associated with Dave’s personality. The medication/psychiatric treatment restored Dave which enabled me to facilitate him to his former ability to work. But in my opinion it did not erase the underlying psychopathology characteristic of a personality disorder: a stable and enduring pattern of perception, and an exaggerated sense of his own importance, and complete lack of empathy. My research experience Wendy [2] together with the close contact I had with the family led me to believe that Dave’s personality disorder was an important causal factor of Jen’s premature death. Yes I anticipate that this speculation for some is a step too far but I stand by my belief. For I was bought up inspired and influenced by giants in the field of psychosomatic research: Hinkle and Wolff, Cassel, Canon, Henry, Selye, Querido and others, meticulous researchers in the field.