Is the tearful bride-to-be having second thoughts?
Elaine is 40 years old and a divorced mother of a teenage son and daughter. Her husband had been violent and she had eventually fled to a women's refuge.
Over the past two years she has been in a caring relationship with a 33-year-old refugee from Eastern Europe, who has no children of his own and his status in this country is uncertain. They have attended surgery together in the past to discuss referral for Elaine for sterilisation reversal and are planning to get married soon.
Elaine attends surgery again on her own. She says that she has been having difficulty sleeping lately and she is tearful during the consultation. They have booked the wedding and reception for next month and she has bought her wedding dress. However, they have been arguing recently about lots of small things, particularly if she wants to go out with her friends. She asks you for sleeping tablets so that she can get through the next few weeks.
She denies being depressed or having any doubts about the future of the relationship as he has been very thoughtful and caring up until now.
Dr Helen Crawley
'Eileen has shown the courage to protect herself in the past'
The quickest way out of this is to give her the tablets. But something is wrong and I just cannot ignore my concerns for Eileen, her children and her fiancé.
My most cynical initial thought is that Eileen's fiancé has revealed his true colours now that he has arranged a marriage that will give him the right to remain in Britain. On reflection this is unlikely. They have seen me together as a touchingly devoted couple making plans for future children.
But somebody is unhappy. Is Eileen tearful because her impending marriage is playing on memories of her previous violent relationship?
Now they are to be married, perhaps he expects Eileen to behave in a less Western way and be obedient to him. Whatever the cause, I sense that history may be repeating itself with Eileen once again in a violent marriage. My only consolation is that Eileen has shown the courage to protect herself and the children by fleeing an unsatisfactory relationship in the past.
I would start by asking what she hopes to gain from sleeping tablets. Tablets are not going to stop daytime arguments or make her feel less tearful. I would then gently raise some of the possible underlying issues, and see if any strike a chord.
Time is short they are about to be married so I would offer to see Eileen, and if he agrees, her fiancé, within about a week. It may be appropriate to refer them to a counselling service, but first we need to agree on where the problem lies.
If after exploring the options Eileen simply wants to recharge her batteries with a good night's sleep I would be prepared to give her a few tablets as long as there was no risk of overdose and follow-up arrangements were secure.
In the long-term I will be keeping my eye on any risk to her children and the suitability of sterilisation reversal.
Dr Shah-naz Whitear
'I might suggest delaying the wedding until things improve'
There are many issues at stake here and it will have to be approached very delicately so as not to frighten Elaine away. I would point out to her that I had concerns about her health, poor sleep and tears would suggest that she was feeling low. I would explain that sleeping tablets were not the answer, as they would not take away the factors that were making her feel low. I would spend time trying to gain her confidence and trust.
At the back of my mind I would be thinking that history may have a way of repeating itself. She is a victim of violent abuse and hence vulnerable. I cannot help thinking that her partner, the 33-year-old refugee, is attaching himself to her to help his status in this country. I think it would be impossible to suggest this to Elaine in her present state.
I would have to give her space to express her fears and concerns. She may be thinking back to her previous abuse, or even thinking as I have done about her present relationship.
I would, however, be very supportive and helpful. I would suggest to her even though she denies she is depressed, that I felt she was.
She may benefit from antidepressants which might help her sleep instead.
I would suggest perhaps they delay the wedding until she is feeling and sleeping better and they have resolved their arguments. If he is caring and thoughtful, then he should respect this.
They have been together for two years already, waiting a few months more would not be much longer. Certainly going out with her friends would help her and I would encourage this.
Everything is not going to be resolved in one consultation. She may benefit from some clinical psychological or group work with other victims of violent spouses.
She is going to need a lot of support from myself. It may be useful at a later date, if her partner is agreeable, to meet them both together.
I would have to remain vigilant to ensure she does not become the victim of abuse again.
Dr Colin Wilson
'I would avoid jumping to conclusions over past history'
The first pitfall to avoid is leaping straight into a diatribe about sleeping tablets. In a similar vein I would try to resist jumping to conclusions given this woman's past history. I am also acutely aware of the risk of appearing to be racially stereotyping this woman's partner even though nothing could be further from my mind. Lastly, I would try to avoid telling this woman what to do or how to live her life.
My key priority would be to try to allow the patient to talk uninterrupted for at least 90 seconds. I am aware that as GPs under time pressure we often interrupt too soon, thus missing the patient's real agenda.
The areas I would like to explore encompass her relationship with her children: are they opposed to the marriage? Does she share her new partner's apparent desire for children, given her age? Does she have money problems given the expenditure on her pending nuptials?
I want to find out what form the arguments with her partner take. Is he verbally or physically abusive, how deep is his apparent jealousy about going out with friends?
I would like to know what support she has from friends or other family members and if they are expressing concerns about her well-being.
Having fully explored the problem I would summarise what I understand the situation to be and then discuss options with the patient, encouraging her to come up with these rather than me. I think it unlikely that I would prescribe sleeping tablets, but I would explain this decision.
Success in this consultation would be if the patient left having a clearer understanding of what lies behind her insomnia and feeling better equipped to make choices that are best for her.
If I have gained her trust she would feel able to come back as events develop.