Origins 6: More of My First Caseload

Part 6 in an occasional series about my early years as a social worker (also known as Reminiscence Therapy.)

May contain triggers for abuse

Bobby’s story has been buzzing around in my mind for months, but I’ve been hesitating to write it down. It is so outlandish as to be almost unbelievable. And yet, when I inherited his case as a very junior, inexperienced and unqualified social worker in the 1970’s, I remember that I just took it all in my stride. Working with such people is just what a social worker does, I assumed. And Bobby’s story somehow needs to be told, somewhere.

Bobby was in his 30’s. He had severe learning difficulties. He lived with his mother and two brothers in a primitive cottage in a small village a few miles outside Charwood.

I began by reading Bobby’s file. Bobby’s file went back to his birth in the 1940’s. At birth, he was formally classified as having severe “mental subnormality”. In fact, his official designation was “cretin”. “Idiot” and “imbecile” were other classifications of “mental subnormality” in common clinical use at the time he was born.

Bobby had a full-scale IQ of around 40. I’m not sure how they were even able to calculate that with any degree of certainty. He also had severe congenital abnormalities. He had gargoylism, which I now know to be a genetic condition characterised by dwarfism, learning difficulties and facial abnormalities. Bobby was a little over 4 feet tall, with a barrel chest and a large head, with eyes that somehow appeared to display awareness and intelligence.

His mother also had learning difficulties, as did two of his three brothers. In fact, they had all been inmates of Fairville, the local learning difficulties hospital at various times, and for various reasons. Fairville, despite its name, was a rather miserable looking Victorian asylum in the middle of the countryside which specialised in “mental handicap”, as the politically correct term for it was in the late 70’s (“mental subnormality” having fallen out of favour by the time I began in social work).

The deeper I delved into the file, the more incredible this family’s story appeared.

In the 1920’s, Bobby’s mother had become pregnant at the age of 15. The father was her cousin. The child was born with learning difficulties. Bobby’s mother was placed in Fairville for being a “moral defective” and spent several years there, although subsequently appeared to have been allowed to have her baby back.

Bobby’s mother then had two more sons. It was unclear who the father was, as she never married. One of them I never met, although he also appeared to have had learning difficulties, and the file recorded that he had been incarcerated in Fairville at some stage for being a “moral defective” after being convicted of sexual offences against animals.

Then Bobby’s mother became pregnant again, and gave birth to Bobby.

The file recorded that the social worker at the time that Bobby was about 8 years old conducted a home visit, and Bobby complained to him that he was prevented from sleeping in his mother’s bed because his elder brother kept throwing him out of the room.

There was an investigation. It turned out that Bobby’s eldest brother was, in fact, also his father.

His brother went to court (it appears they spared Bobby’s mother). He was found guilty of incest and was placed in Fairville as being deemed to be a “moral defective”.

But all that was in the past, long before I became Bobby’s social worker.

So despite the extremely murky history, Bobby lived with his mother, a brother who also happened to be his father, and one other brother. The other brother did not have any learning difficulties, and actually held down a full time job.

So what was my task as a social worker with Bobby?

This mainly consisted of supporting his mother as Bobby’s main carer, as well as troubleshooting the scrapes that Bobby got himself into from time to time.

Bobby was far too disabled to attend the local sheltered workshop for people with learning difficulties (such places used to be called adult training centres), so his main pastime was roaming the lanes of the village while chewing a catalogue. He loved catalogues. The bigger the better. He would put it to his mouth as if playing a harmonica, then chew it.

The villagers in general had a high threshold of acceptance for Bobby and his family. But occasionally I would get letters from the clerk to the parish council complaining about his behaviour. The principle problem was Bobby’s need to urinate from time to time during his village forays. He was oblivious to where he might be, or who might be watching, during these necessary interludes. I would then have to have words with Bobby’s mother and write some sort of ameliorating reply to the clerk to the parish council.

During the two years that I worked with Bobby, I never understood a single word he spoke, although his mother appeared to be able to converse with him, and would then interpret.

From time to time, I would arrange respite care for Bobby. This was generally in a respite ward at Fairville.

At other times, I would take him and his mother to see the doctor if he became ill. When Bobby developed a cold or other infection, he appeared to become psychotic. It was apparent from the way he moved his eyes and head that he was responding to voices, and during these times would converse unintelligibly with them.

At Christmas, I would take the family a box of groceries. Charwood Social Services would always receive hampers of basic food items at Christmas, and we would then distribute them to needy clients. Bobby’s mother always made sure she was on my list, by writing me a gentle reminder a little before the time.

“I’m just taking the pleasure in writing to you,” she always began, before launching into a request for assistance. She always signed these letters, “Your Sturly”.

With the benefit of hindsight, and in the light of the many years of changes in Society’s attitude to people with learning difficulties, I do wonder whether there was more that I could have done for Bobby and his mother.

It was as if they were fixed by their life experiences, going back to the 1920’s in his mother’s case, and living as they were in a cottage, and a rural community, which had changed little since Victorian times. Bobby’s mother still remembered the old “Poor Law” system, where it was necessary to defer to those with power over you in order to get even basic support. And there was always the risk of being branded a “moral defective” and being locked up in an asylum if you didn’t toe the line.

But, paternalistic or not, at least the social services department was assisting the family to stay together in the community in which they had always lived.

When Do You Intervene When Someone’s Suicidal?

The inquest on Bryan Jobson, who lived in Leeds, was concluded on 1^st May 2013. Mr Jobson hanged himself with a noose suspended from his loft hatch in February 2011.

 

What was particularly remarkable in this case, and which resulted in the inquest being reported not only in the Yorkshire Evening Post, but also in the DailyMirror, was that two mental health nurses from the local Crisis Team had visited him the day before he killed himself, and saw the noose hanging from the open loft hatch, with a chair directly underneath it.

 

It is reported that Mr Jobson, who was 44, had previously attempted suicide, that his relationship with his wife had broken down, and that he had recently experienced the loss of others close to him. The visit by the two nurses was in response to a call he had made to the Crisis Team.

 

It was reported that one of the nurses, who saw the noose and chair, told the inquest: “We were thinking about legal aspects. We are not allowed to touch things without their permission. I know it seems ridiculous, but we have rules to abide by.”

 

The nurses left him after gaining an assurance from Mr Jobson that he would not take his own life and would engage with the Crisis Team.

 

I do not know all the circumstances of this case other than what I have read in the press, and do not wish to comment further on this specific case, except to say that, from the inquest report, it is clear that these professionals were caring and experienced people who were acting in what they genuinely felt were the best interests of Mr Jobson.

 

However, the situation those two workers found themselves in does merit further examination.

 

Community Mental Health Workers often find themselves in the position of having to make an assessment of risk. This can be in a routine assessment, when a patient reveals a history of self harm or suicide attempts, or tells the interviewer that they feel suicidal and have plans to end their life.

 

It can also be in situations of acute risk, where the worker discovers that a patient has been stockpiling medication with suicidal intent, or has purchased a hose to connect to their car exhaust, or has made a noose or other ligature.

 

In these situations, a professional has to make a decision as to whether or not further action needs to be taken, such as arranging for a hospital admission, or considering conducting an assessment under the Mental Health Act.

 

In all cases, the risk of harm to the patient has to be balanced with the need to allow the person self determination and to respect their privacy and personal rights.

 

Certainly our local Mental Health Trust’s Policy on Self Harm encourages positive risk taking, which is described as “a person centred approach focusing on the service user’s strengths and the support required to enable them to take control over their behaviour.”

 

I often work with people who deliberately self harm, typically by cutting themselves, although there can be a wide range of self harming behaviours. It is important to distinguish cutting as a means of releasing distress, with cutting designed to cause serious harm or even death.

 

But what do you do when a patient reports that they not only have the means to take their own life, but also have the stated intent?

 

It is reported in Bryan Jobson’s inquest that the nurses were prevented from touching the property of a patient because of “rules that had to be abided by”.

 

I am not actually aware of any National or local guidelines or policies that prevent a mental health professional from taking action designed to reduce the risk of death or serious self harm.

 

Certainly, on the local psychiatric ward, one of the first things staff do when someone is admitted is to inspect their property and remove anything that could be used to harm themselves, or cause harm to others, such as razor blades, laces, belts, or other things which could readily be used as a ligature. This goes equally for informal as well as detained patients.

 

To reinforce such basic commonsense steps to safeguard vulnerable people, the Mental Capacity Act is designed at least in part to provide guidelines on what constitutes reasonable action to take to safeguard people who lack capacity.

 

One of the fundamental principles of the Mental Capacity Act is that anything done should be in the best interests of the person. However, “people have the right to make decisions that others might think are unwise. A person who makes a decision that others think is unwise should not automatically be labelled as lacking the capacity to make a decision.” (MCA Code of Practice Ch2.)

 

It should not therefore automatically be assumed, just because someone is stating the intent to end their life, that they lack capacity.

 

But any person, not just a mental health professional, is able to make an assessment of risk and take appropriate action in order to protect another.

 

A very basic example is that of a small child who is about to step into the path of a lorry. Their carer will make an instant assessment of the risk of harm if the child were to step off the kerb, and would then act to prevent the child from doing so.

 

The same would apply to an adult with learning difficulties who lacked capacity and was oblivious to the danger.

 

Not long ago, I was working with a woman with severe depression. She confided to me during one of my visits that she had been systematically going round the local pharmacies and had been stockpiling paracetamol. She made it clear that she was intending to take these tablets.

 

I asked her to let me have the tablets and give an undertaking that she would not attempt to take her own life. She agreed to this. We were able to involve the Crisis Team, who worked with her until the risk subsided, and we were able to avoid a hospital admission.

 

But what if she had refused to give me the tablets? While I would not have felt able to physically snatch them from her, I would have taken account of this refusal in terms of the additional risk it posed, made a brief assessment of her capacity to make the decision to refuse, and would have initiated an assessment for her detention under the Mental Health Act.

 

And if she had been in the act of swallowing the tablets, then indeed, I would have forcibly removed them from her.

 

After all, what would I rather have to do? Justify my decision to a court, because the person was suing me for interfering with their property, or to a disciplinary panel because I had broken some rule or another?

 

Or justify my decision to an inquest?

On the Joys of Supervising an AMHP Trainee

The Masked AMHP unobtrusively observing his AMHP trainee while she is leading a Mental Health Act Assessment

I’m currently a practice educator for one of our Approved Mental Health Professional trainees from the local AMHP course. It’s a real pleasure. I’ll tell you why.

 

AMHP trainees by definition are qualified and experienced workers. Our current intake consists of a mixture of social workers and nurses. My own trainee (or candidate as they’re known by our course), whom I’ll call Floella, mainly because it’ll wind her up, is exceptionally experienced. (Hi Floella!). She’s been a mental health nurse for over 30 years, working mainly with older people.

 

AMHP trainees are largely responsible for organising their own learning, with guidance from the practice educator. This means that during the 8 week placement, Floella has arranged a large variety of observation visits, and has also, in conjunction with the other trainees, arranged to shadow the local AMHP rota, in order to gain opportunities to shadow other AMHP’s conducting Mental Health Act Assessments.

 

Which is just as well, as until last week, the Masked AMHP had not had a single MHA assessment that coincided with Floella being present at my CMHT. Sometimes that’s how it goes.

 

AMHP trainees have to shadow a minimum of 6 MHA assessments. They also have to complete a fairly intensive and detailed portfolio (the course is after all at Master’s level), which much include evidence of an exhaustive list of competencies, all of which are essential in order to practice as a fully blown AMHP.

 

The practice educator has to directly observe the AMHP trainee conducting at least two pieces of work, which must be face to face contact with service users. The practice educator has to provide supervision, oversee the learning opportunities available to the trainee, and ensure that the portfolio meets the requirements of the course. All in 8 weeks.

 

This is in marked contrast to supervising a social work student on placement. For a start, the placement is a lot longer. A social work student may have no previous experience at all of mental health, and may therefore need a considerable run in time, during which they may merely observe, get used to the nature of the work required, and learn the specific protocols and paperwork. They will be working on placement towards developing fairly basic competencies, in contrast to the competencies required to practice as an AMHP.

 

So what of Floella? As I said at the beginning, being her practice educator has been a real pleasure. From day one she was able to provide evidence of her confidence and skills. All I have really needed to do is observe, facilitate, review her burgeoning evidence portfolio, and ensure that she is using her skills and knowledge in the appropriate way to inform her practice under the Mental Health Act.

 

Oh, and once or twice to remind her that the role of the AMHP is distinct from the role of mental health nurse. (Don't take a patient's pulse while undertaking a MHA, unless they're clearly comatose.)

 

As an AMHP trainee’s shadowing experience on MHA assessments progresses, they are expected to take on an increasingly active role in the assessments themselves.

 

And I needed to see that myself before the placement ended. I needed to observe her directly during a MHA assessment.

 

This is not to say that Floella had not seen the Masked AMHP in any sort of MHA related action. She had observed me presenting a report to a Managers Hearing. She had witnessed me revoking a CTO. She had attended S.117 review meetings. But no actual MHA assessments (that is, a request to assess a patient for admission under either Sec.2, 3, or 4).

 

So, since merely being in the physical presence of the Masked AMHP had not resulted in an actual MHA assessment materialising, I decided that we would base ourselves at AMHP headquarters for the day. This office is based at Charwood Hospital. If necessary, we could cold call the wards to see if they might like a Sec.2 patient considering  for a Sec.3, or if they had a brand new Sec.5(2) that needed reviewing.

 

Floella and I discussed her learning requirements. She had already had a good cross section of formal assessments, including obtaining a Sec.135 warrant, and an assessment of someone with learning difficulties. We concluded that it would be good for her to assess an older person, since although she was used to working with older people with mental health problems, the act of assessing as an AMHP under the MHA was a distinct function. We also thought it would be good to assess someone already in hospital for a Sec.3.

 

You never get what you wish you, do you?

 

But sometimes you do. We got a call late morning. An elderly man in his late 80’s. Ralph had been admitted to the older people’s unit about 6 weeks previously under Sec.2 suffering with severe depression. He had then remained as an informal patient and had appeared to be improving until his blood sodium levels plummeted because of his antidepressant. The medication had to be stopped, and as a consequence his mood dipped again, he stopped eating and taking fluids, he lost weight and became physically very frail. His Consultant wanted to detain him under Sec.3 in order to give him ECT.

 

Floella took charge of the assessment process, while I sat back with a coffee and observed.

 

She contacted the ward and spoke to the Consultant. She obtained background information. Ralph had a history of depression going back over 20 years, and had benefited from ECT in the past.

 

She contacted a Sec.12 doctor and arranged a time to undertake a joint assessment.

 

She identified and contacted the Nearest Relative, who was Ralph’s daughter, as Ralph was a widower. The NR did not object to the proposed Sec.3, although had some concerns about the ECT.

 

Floella checked out the legislation. Sec.58A of the MHA was introduced by the 2007 changes. It covers Electro-convulsive Therapy. ECT can be given in an emergency, or if the patient agrees, or if the patient lacks capacity but it is considered to be in their best interests. However, a significant change is that ECT cannot be given under any circumstances if the patient has made an advance decision concerning treatment.

 

Floella confirmed that no advance decision had been made.

 

We went to the ward and Floella led the interview. It was clear that Ralph was physically very unwell, was extremely depressed, and, although he showed no signs of dementia, he was clearly unable to give informed consent about treatment, and would be likely to refuse in any case.

 

Floella reached the conclusion that Ralph was suffering from a mental disorder “of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital”, that “it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section”, and that appropriate medical treatment was available. It is correctly not the role of the AMHP to reach a decision concerning the merits or otherwise of any particular form of treatment.

 

I agreed with her, and completed the application.

 

Floella then wrote the AMHP assessment report that should be left on the ward with the application, informed the patient and the NR of the decisions that had been taken, and the assessment was completed.

 

I think I’d like to take an AMHP trainee with me on every MHA assessment I am called to do.

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.

Stalemate.

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.

Are CTO’s Any Good? Observations on the OCTET Trial

 

I recently read the abstract of the OCTET research into the use of Community Treatment Orders for patients with psychosis published in the Lancet on 26^th March 2013. I’ve only read the abstract because, despite the research being funded from public money via the National Institute of Health Research, the full report is only available behind a paywall. So I apologise now if I’ve missed something important.

 

The burgeoning use of CTO’s since 2008 to manage mentally disordered people in the community is something I have written about on a number of occasions, if only because it has become an increasingly large part of an AMHP’s work – the AMHP has to endorse an application for a CTO, an extension of a CTO and the revocation of a CTO. All these require assessments, reports on the assessments, and these actions also often precipitate a Managers Hearing or a Mental Health Tribunal, both of which require the writing of a report and attendance at the hearing.

 

The trial selected detained patients with a diagnosis of psychosis. The total sample consisted of 333. Half the sample (166) were discharged on a CTO and the other half (167) were made subject to extended Sec.17 leave. Sec.17 leave is a process whereby a patient is not formally discharged from detention under Sec.3 Mental Health Act, but allowed out of the hospital on leave. They can be recalled at any time, with little formality.

 

The object of the research was to see if CTO’s reduced readmission. They monitored the samples for 12 months. Their conclusion was that “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.”

 

The message from this research seems to be unequivocal: CTO’s don’t work, and therefore shouldn’t be used.

 

AMHP’s and Psychiatrists clearly do not want to be engaging in practices which could be regarded as oppressive and/or counter productive: we’d all much prefer that patients should stay out of hospital and to use the least restrictive means to achieve that. The initial response to these conclusions would therefore appear to be a reluctance to subject anyone else to a CTO.

 

But how much credence can we give to this research?

 

A number of things strike me as making the results not as unequivocal as they at first seem.

 

The first is the size of the sample. They looked at 166 patients who were subject to Supervised Community Treatment. However, since 2008, when CTO’s were introduced, until March 2012, which is the most recent date for which figures are available, a total of 14,295 people have been placed on CTO’s. This means that their sample accounts for less than 1.2% of the total up to March 2012. This, to me, seems to be a very small sample on which to be base such serious and potentially far reaching conclusions.

 

The second is the selection of only people with a diagnosis of psychosis, which according to the abstract were those with schizophrenia. In my experience, CTO’s are not only used for people with schizophrenia, but are also often used for people with bipolar affective disorder, eating disorders, and other diagnoses. Would outcomes have been different if bipolar affective disorder had been selected, or if there had not been a restriction on diagnosis at all? We can’t possibly know without further research.

 

The third is the comparisons used. The two samples were people on CTO’s versus people subject to Sec.17 leave.

 

The Code of Practice does not exactly encourage the use of extended Sec.17 leave. In fact, the CoP (21.9-10) states:

“When considering whether to grant leave of absence for more than seven consecutive days, or extending leave so that the total period is more than seven consecutive days, responsible clinicians must first consider whether the patient should go onto supervised community treatment (SCT) instead… The requirement to consider SCT does not mean that the responsible clinician cannot use longer-term leave if that is the more suitable option, but the responsible clinician will need to be able to show that both options have been duly considered."

 

In practice, extended Sec.17 leave should only be used sparingly, and only for very good reasons. Yet, it appears that for the purposes of the study, patients “were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients)”. Is this within the spirit of the MHA and the Code of Practice?

 

In the real day to day world of working within the MHA, Sec.17 leave is not an alternative to discharge on a CTO. It does not therefore seem to be a valid comparison. It might have been more useful to compare outcomes for patients discharged on a CTO with patients discharged with no CTO at all. What would the figures have shown with these two samples? We can’t possibly know without further research, but they may have shown a more positive result for CTO’s.

 

I have been working with people on CTO’s for several years now. These have been people with diagnoses of psychosis, bipolar affective disorder, and anorexia. While my own sample is tiny, and I would not want to draw any firm conclusions from my experience, I would say that overall, CTO’s have helped to keep patients out of hospital who otherwise would have been “revolving-door” patients.

 

I recently looked for research into the numbers and efficacy of the use of CTO’s for people with eating disorders. There was hardly anything to be found. In fact, this trial appears to be the first significant piece of research into CTO’s in this country.

 

That is why I would like to see much more research into the use of CTO’s, on much larger samples, using more realistic comparators, and looking at other diagnostic groups, before making a blanket decision to stop endorsing new CTO’s.



How to Displace the Nearest Relative, as Told to Sooty

What’s that, Sooty? You want to know what to do if a patient’s Nearest Relative unreasonably objects to making an application for admission under Sec.3 Mental Health Act?

Well, Sooty, that’s an interesting question. Let’s just put the question in context for our readers, shall we?

Let’s say that Sweep became mentally ill and needed to go into hospital for treatment. But Sweep doesn’t want to go into hospital, so an AMHP has to section him.

What’s that, Sooty? Sweep’s completely mental anyway? That’s not a nice thing to say, is it, boys and girls?

Anyway, let’s get back to our example. The AMHP has to consult with Sweep’s Nearest Relative if he wants to detain him under Sec.3 for treatment. But the Nearest Relative can object to this. If that is the case, then the AMHP cannot proceed with the Sec.3.

What’s that, Sooty? Is Harry Sweep’s Nearest Relative?

That’s a good question, Sooty. Sooty’s full of good questions today, isn’t he, readers? Well, Harry can’t be Sweep’s Nearest Relative because Harry is a human being and Sweep is a glove puppet.

No, Sooty, Richard can’t be Sweep’s NR for the same reason. No, it doesn’t matter how often he puts his hand up Sweep’s backside, he will never be his NR within the meaning of the Act.

Remember, the Nearest Relative is the Nearest Relative is the Nearest Relative.

Anyway, this is just a hypothetical situation, Sooty.

What’s that, Sooty? What does hypothetical mean? Well, it means that it’s not real, it’s made up.

What’s that, Sooty? Am I made up? No, Sooty, The Masked AMHP is a real person, but he’s got a pretend name.

Anyway, this is where displacement comes in. You see, Sooty, if the AMHP thought that Sweep’s NR was being unreasonable in not allowing the AMHP to section him, the AMHP can apply for the NR to be displaced.

There are lots of different things in the Mental Health Act, Sooty. It’s a bit like the ingredients in a cake. When you mix them all up and cook them, then a nice big Act comes out at the end.

What’s that, Sooty? You’d like to make a nice lemon meringue pie? Well, you can get on with that while I carry on explaining to all the boys and girls about displacing the NR.

I’ll tell, you what, I’ll hold the bowl while you put the ingredients in and mix them all together.

So, the AMHP has to go to court and see the Judge in order to get the NR displaced. The AMHP should ask the patient if they have any preferences, otherwise the AMHP can nominate someone, such as the local AMHP lead, or the Director of Adult Services, to act as the patient’s NR.

Now careful squeezing that lemon, Sooty – ouch, it’s gone right in my eye!

Now where was I? Oh yes, the court can then appoint that person if they are satisfied that the NR has acted unreasonably. They can even appoint someone else, anyone they like, in fact.

What are you doing with that whisk, Sooty? You’ve got egg white on my tie!

So, has that answered your question, Sooty?

Now careful, Sooty, try and keep the whipped egg white and the icing sugar in the bowl.

My, that’s nice and light, isn’t it, Sooty?

What’s that, Sooty, it’s so light you can lift the whole bowl over my head?

Watch out, Sooty, you’re going to spill it...

Ooooooh! Sooty, look what you’ve done now! You’ve emptied the bowl all over my head! It’s dripping off my ears!

Oh, Sooty! You are a naughty bear! I’m going to have to get cleaned up now!

Bye bye, readers. Bye bye!

When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.