Thursday, 31 December 2009
Well, that’s exactly what happened. A couple of months later, while I was away on holiday, there was another request for a Mental Health Act assessment. This time, the AMHP concluded that it was appropriate for him to be detained under Sec.2 for assessment and he was admitted to the local psychogeriatric ward. I have no argument with that – AMHP’s act independently, and two AMHP’s may validly reach different conclusions from the same information. In any case, situations can change, risk factors may vary from day to day, and I am sure that the AMHP who detained him made the correct decision at that time.
A few weeks later I was asked to assess him again, this time for detention under Sec.3 for treatment. When I interviewed him in the hospital he was clearly in a much better physical condition than when I had seen him at home. He was clean, well groomed, had put on weight, and was obviously enjoying the comparatively salubrious environment of the hospital ward. But I had to decide whether, in all the circumstances of the case, it was most appropriate for him to be detained in hospital under the MHA.
There was some evidence of memory problem, he did not remember my visit to him a few months before, was vague about other facts, and he certainly did not regard his home conditions as in any way a problem. When I discussed the reason for my visit he became furious, swearing at me and threatening to harm me. But did this amount to anything significantly different from my previous assessment?
This time he did have a diagnosis of vascular dementia, so certainly had a mental disorder within the meaning of the Mental Health Act, but was it of a nature or degree to warrant his compulsory detention?
I thought long and hard about my decision. And in the end I applied for his detention under Sec.3 as requested.
I was covered legally. There were two medical recommendations. He had a mental disorder. But I still felt uneasy.
What swayed me in the end was the fact that circumstances had now irrevocably changed. My previous decision was about whether or not to remove him from his home. My decision now was about whether or not to allow him to return to his home. With this decision came even greater potential risk to Harry. He had already made it very clear to me that if he were not detained he would insist on going back to the squalor and fire hazard that was his house, and this time would probably be even more distrustful of authority that he had been before. His risks of being at home would be significantly greater now than they had been earlier. If he were ever to have a chance of surviving in a community setting, there would have to be considerable changes in his home circumstances.
And strangely enough, detention under Sec.3 could facilitate that, since any elements of his aftercare package would now have to be paid for by the local authority and/or the NHS. He would no longer be charged for home care, and indeed, any works to improve his home, through a major cleaning programme or even alterations to the house, could also be free of charge. He was wily enough to see that there could be advantages to his continued detention – although he would never admit it.
Tuesday, 22 December 2009
Unless someone had chosen that day to go mad.
It was a snowy evening, very festive. I had had my Christmas dinner, and was settling down in front of the TV, confident I would not get a call, when my home phone rang. Robert was a 30 year old man who lived alone. He had only a minimal history of mental illness. He had been referred to the CMHT a few months before after having had an odd transient psychotic episode following general anaesthetic for minor surgery. I had actually seen him on one occasion, and although I had found him a little odd, he had not displayed any overt symptoms of mental illness and had not been seen again.
His father, who lived in a village some miles from Robert, had decided to invite him for Christmas dinner. Since Robert did not have any transport, his father had picked him up and brought him to his house. His father had found him rather quiet and subdued, but Robert had been like this for some months, so he thought nothing of it.
But as the day progressed, Robert’s father became increasingly worried about him. He appeared very stiff, as if his muscles were seizing up, and had to be helped to the dining table. His father would try to engage him in conversation, and got the impression that Robert was trying to reply, but no words would emerge. Robert had sat motionless throughout the meal, staring at his plate, but had eaten nothing. After the meal, his father had been unable to persuade him to leave the table. He called the duty doctor, who gave him a physical examination and found nothing wrong with him, but was equally unable to persuade him to talk or move. He came to the conclusion that mental illness was the only explanation, and called us.
I managed to locate the duty psychiatrist, who was surprisingly easy to persuade to attend – perhaps he had had a fraught day with his family – and we arranged to meet the GP at the house.
Robert was still seated in the chair at the table. The table had been cleared, and he seemed to be staring intently at the table cloth.
“Hi, Robert,” I began, sitting down at the table with him. “Do you remember me?”
His eyes flickered, as if he were straining to move them in my direction, and eventually they moved enough so that he could see me. However, his neck and body stayed absolutely still. I could see his throat quivering, as if he were trying to speak, but the only sound that came out of his slightly open mouth was a low gurgle.
We asked him a number of questions, but during the 20 minutes or so of the interview the only words he managed to utter, and clearly with much effort, were: “My heart.”
It was impossible to make a further assessment. Our impression was that it was a classic case of catatonic schizophrenia, which can be characterised by a complete inability to move or speak. He clearly needed further assessment, was unable to give any indication of consent, and we concluded that he needed to be detained in hospital under Section 2 for assessment.
When the ambulance arrived, the crew had to physically lift him, still in a seated position, into the ambulance, and he remained in that position all the way to the hospital.
He did indeed have catatonic schizophrenia, and in fact I was called on a number of occasions in subsequent years to assess him, frequently with the same presentation. But never again on Christmas Day.
As I was collating the paperwork and writing up my assessment at the hospital, I suddenly noticed his date of birth. It was the 25th December.
Sunday, 6 December 2009
Miranda was 71. She lived alone in her own bungalow. She had never been married. She had a long history of involvement with mental health services, and had been transferred to the older people’s mental health service when she became 65. She had a history of detention under the Mental Health Act, had had many admissions over the years, and had variously been diagnosed with psychosis and bipolar affective disorder. She was currently on an interesting combination of an antipsychotic, two mood stabilisers and an antidepressant. She had been seen a month ago by her consultant, who had suggested an admission to hospital, which she had politely declined. Earlier in the week she had been seen by a GP who had diagnosed a suspected urinary tract infection and had prescribed her an antibiotic.
Her community nurse had been to see her earlier in the afternoon. She had found Miranda working her way through a bottle of wine, writing a list of music she wanted playing at her funeral. She passed her a suicide note, and asked for her favourite GP to sign her death certificate after the weekend. She was not prepared to go into hospital.
I spoke to the duty GP, who had not seen her today, but was prepared to come out if required. I talked things over with her nurse, and we decided to visit her together so that I could make at least an initial assessment. The nurse had arranged for a bed to be available if needed.
We stood outside Miranda’s bungalow in the November rain, waiting for her to answer the door. She looked at us both, then let us in, seeming resigned to a visit from mental health professionals. She had finished the bottle of wine, and now had a glass of ginger wine in her hand. Although her bungalow was cluttered and somewhat neglected, she had a high quality sound system in her living room, with piles of classical CD’s covering most available surfaces. Bach’s Mass in B Minor, sung by the Sixteen, filled the room. Tears were flowing silently down her face.
She was still working on the list of music for her funeral. It was tasteful but melancholy music: Bach, Handel, Fouré, and some solemn, mournful medieval plainsong for the most part.
“Miranda,” I said gently, “What’s happened? Why are you feeling like this?”
She told me she had been feeling bad for a few days and that she did not know why. She could not think of any incident or trigger. She subscribed to a postal CD company, and had received the CD she was playing that morning. “When I have listened to it to the end, I will end my life,” she said slowly and with the exaggerated dignity that only the intoxicated can manage. Since it spread over two CD’s and lasted nearly two hours, I estimated that we had some breathing space at least.
Things were stacking up against her. As I had gone through the bungalow, I had noticed that her bed was piled high with junk, and had clearly not been slept in for some time. I went into the kitchen to talk to the nurse, and she showed me Miranda’s empty fridge. There was evidence that she was neglecting herself. The nurse told me that Miranda did not usually drink, so her drinking today was perhaps a symptom of her underlying mental condition rather than the cause. I was unhappy about the odd assortment of medication she was taking, and thought that a review of her medication would be a good idea. I was also mindful of the effect a urinary tract infection might be having on her mood and general mental state.
What was clear was that she did need to be in hospital for assessment and treatment, and for her own safety. It was too dangerous to leave her over the weekend. She seemed to have every intention of killing herself before the weekend was out. I was prepared to use compulsion if need be, but wanted her to have the opportunity to preserve her dignity.
“Miranda,” I said to her. “I think you need to go into hospital for a while. You know what my function is. You know I can detain you under the Mental Health Act if I need to. But I really don’t want to do that. You will have more control over your admission and stay if you go in voluntarily.”
“Can I take my music with me?” she asked.
The nurse nodded. “Yes you can. There won’t be any problem, if you have a portable CD player and headphones.”
Miranda looked into my eyes. Then she looked down.
“Very well,” she said.
Her community nurse and I helped her pack an overnight bag and we found a portable CD player. She got into the back of the car, with her nurse sitting next to her. Miranda seemed relieved, if anything. She talked about the music she loved and gradually her tears dried. We took her uneventfully to hospital.
Friday, 9 October 2009
I first became involved with him when I was asked to write a report for an appeal tribunal after he was detained under Sec.2 MHA for assessment. When I interviewed him he was still plainly hypomanic, with grandiose delusions, although the medication was beginning to take effect.
By the time of the hearing (two weeks after detention) he stood a fighting chance of being discharged from hospital – as long as he kept his delusions to himself. Indeed, he did manage to keep himself under control for most of the hearing, right up until the point where the chairman of the tribunal asked him if he had anything he wished to say to them.
“As a matter of fact,” he said, “I would like you to know that Aphrodite is smiling on you all, you are all blessed by the light of the goddess of love, beauty and sexual rapture. Tonight you will feel the power of her love and beneficence.”
Since the Tribunal decided not to discharge him, he remained as a detained patient, and I was asked to assess him for detention under Sec.3 for treatment. This seemed like a reasonable request.
Gerry may have been acutely mentally unwell, but he had not lost his intellectual capacity. He realised that he was likely to be detained for a longer period if assessed, so he arranged not to be assessed. He absconded from the ward the very morning I was due to assess him. However, unlike most absconded patients, who tend to turn up at home, there was no sign of him, until a day or so later, when his parents received a call from him – in Paris.
He stayed in a 4 star hotel in Paris until the Sec.2 had expired, then returned to this country. He clearly knew something about the Mental Health Act – going to a foreign country is a good way of avoiding it. He managed to remain free for several months, before he completely lost control of his illness and was inevitably detained for treatment.
Wednesday, 16 September 2009
By the time I got there with the psychiatrist, his doctor and his mother it was after dark. There was a surreal atmosphere. Ian lived in a first floor flat, and some of his furniture was stacked up outside on the balcony. His mother had a key and unlocked the door when there was no reply. We entered the darkened hall, where an armchair was lying on its side. The flat was in darkness, all the bulbs having been removed from their sockets. I managed to find some bulbs and turned on some lights so that we could continue the exploration of his flat.
We eventually found Mark in his bedroom. He got out of bed, apparently unconcerned about his lack of clothing, but was very keen for us to leave. He refused to talk to us and insisted that we leave. He appeared very agitated and suspicious. The flat was generally in a very untidy state, which his mother said was not normal for him. On the balance of probabilities we decided that he needed to be admitted to hospital for assessment, and he was detained under Sec.2.
A few weeks later I assessed Ian on Bluebell Ward. There was more evidence of his paranoia and unstable mental state. He talked to me in more detail about his conviction that the whole town were watching him on their TV’s, and discussed his obsession with unarmed combat and the SAS.
He was detained for treatment under Sec.3, was started on an antipsychotic, and after a couple of months was discharged. However, before long he started to default on his appointments with his community nurse, and we were fairly sure that he was not taking his medication.
Things came to a head in the early winter of that year. His family were again reporting concerns about his behaviour, and it appeared he was paranoid again. Another social worker had conducted an assessment, which had been inconclusive because he had been very guarded about his replies.
But concerns continued to mount, and so I found myself outside the door of his flat after dark once more, in the company of the psychiatrist, his GP, his mother and the community nurse. There was again a surreal atmosphere – this time, I noticed that there were blown hen’s eggs with little faces drawn on them situated in strategic places on his balcony. It was almost as if they were keeping watch for him.
This time Ian was a little more welcoming, with a façade of friendliness. He allowed us into his living room, where he told us that everything was fine, that he had not needed any medication, and that he had not had any recurrence of his earlier symptoms. He had an air of confidence about him, perhaps created by having survived the previous assessment. But I had already assessed him twice, I knew a fair bit about his delusional beliefs and odd behaviours.
I asked him about the eggs on the balcony. He suddenly looked very unhappy.
“They’re just eggs,” he said. “I like eggs.”
“But you’ve drawn faces on the eggs. What does that signify?”
He looked lost for a reply, seemed to cast about mentally for a response, and then somewhat to our surprise he took out a long hunting knife, waved it about in a very threatening manner and told us all to leave his flat.
I called the police and explained the situation to them. We had decided that he needed to be detained, and clearly we needed their help.
This was when the police decided to take control.
“We’re going to have to treat this as a siege situation,” the duty Chief Inspector told me. “We’ll need a task force and a trained negotiator. It’ll take us a little while to get them together.”
So for two hours we waited on the ground outside his flat, looking up at his balcony, wondering what was going on in the flat, and feeling rather cold in the late November drizzle.
Then suddenly things started to happen. From around a wall an armed response officer emerged, dressed in full riot gear, cradling a rifle in his arms, and crouched down, pointing it at the flat. A similarly armed colleague chose another vantage point. This was the first time I had ever encountered armed police during an assessment under the Mental Health Act. The sense of unreality about the whole thing went up several notches.
Residents of the other flats started to notice what was going on, and leaned over their balconies, watching intently, talking among themselves.
A van arrived and 6 officers dressed in full riot gear, with riot shields, piled out. A female officer in plain clothes arrived in another car, and introduced herself as the negotiator.
Ian’s mother, understandably shaking, gave them the key to Ian’s flat, and we watched as the riot squad went up the stairs, put the key in the door, and then piled in, riot shields and torches in front of them. I could see their torches flashing as they went from room to room. He must have taken out the light bulbs again. Then they emerged onto the balcony, shaking their heads. He wasn’t there.
At some time in the previous two hours, while we had been watching his front door, he had made his escape by jumping out of a window on the other side of the flat and had gone to earth.
I lodged the section papers with Bluebell Ward, and made sure the police were aware that he was a detained patient and that they should take him directly to hospital if they happened to find him.
And sure enough, a few days later, he was found in the woods, having been living rough just as he had learned from his study of the SAS, living in a bivouac made of branches, and catching, skinning and cooking rabbits with the aid of his rather large hunting knife.
Thursday, 3 September 2009
It looked like being a busy morning: as soon as the Hearing had finished, I had to go over to Bluebell Ward to assess another patient, Terry, for detention under Sec.3. This request had come a day or so before. He had been an inpatient for a couple of weeks after being admitted under Sec.2. I had already arranged for a Sec.12 doctor to assess him to provide a second medical recommendation, so everything was set up.
I had known Denise for about 2 years. She had paranoid schizophrenia. I had been instrumental in getting her properly assessed and treated, since for several months she had been presenting with increasingly bizarre and disturbed behaviour, shouting and screaming and throwing things around in her flat to such an extent that most of her neighbours had given in their notice. I had been trying to engage with her, visiting her at home, and having conversations full of non sequiturs and conversational cul-de-sacs. To Denise, nothing made sense. At some time in the last 15 years, all the books had been changed so that they ceased to make sense to her. According to her, every book in the library had been substituted for ones that made no sense, as had all the magazines in the shops. Worse than that, street signs and place names had been altered, as well as maps and guidebooks. She lived in a perpetual state of perplexity, which must have been terrifying for her. I eventually managed to get her seen by our psychiatrist, and between us we managed to persuade her to agree to an informal admission. She consented to take antipsychotic medication, made an exceptionally good recovery, and had been fine for a year, until she had gone on holiday for a week without her medication. On her return, all her symptoms had returned, only this time she had refused to accept medication, since it, too had been changed and was not real, and she had ended up being detained under the MHA.
This time, however, she was far less cooperative, and did not seem to be responding to treatment. So she had appealed, and we had a Hearing.
A Managers Hearing consists of a panel of 3 Hospital Managers. They have a clerk who records their deliberations and their decision. The patient is invariably present, along with a legal advisor, who represents them. Also present is their consultant psychiatrist, a nurse involved with their care, and their community care coordinator, who is generally a community nurse or a social worker. On this occasion, that person was me. All three will have provided written reports covering their nursing care and progress on the ward, their psychiatric history and diagnosis, and the social and community background of the patient.
The Hearing was fairly informal, with the managers introducing themselves and explaining what was happening. They then discussed aspects of the reports with their authors. The patient’s legal representative is also able to cross examine each participant and question their report, and will present the wishes of the patient to the Hearing.
The patient is able to make direct representations to the Managers as well. Denise took full advantage of this, pointing out that the reports did not make sense, that her medication was not real medication, that she did not really have schizophrenia or indeed any other mental illness, and that it was the world itself that was ill. I detected a note of desperation in her lawyers summing up at the end.
After due consideration of the merits of her case, the Managers declined to discharge her from detention.
One task down, another to go. It was all going quite smoothly. However, on arriving at Bluebell Ward, I was told that there was an urgent assessment under the MHA back in town, and was given the mobile phone number of a health visitor. Intrigued, since health visitors (community nurses who look after the welfare of preschool children) do not usually get involved in Mental Health Act assessments, I rang her.
She had just visited a new mother, a young Latvian single parent who had only been in this country for a couple of months. She had arrived heavily pregnant and had duly delivered a baby a few weeks ago. The health visitor was very concerned about both mother and baby. She feared the mother had post natal depression, and was not coping with the baby. She also had no money, and no entitlement to state benefits because of her nationality. To top it all, she had no other relatives in this country, and did not speak any English. The health visitor had spoken to the patient’s doctor, who had told her to arrange an assessment under the Mental Health Act.
This was when my sometimes almost supernatural ability detected an opportunity to avoid getting involved. The doctor had not actually seen the patient. She was not known to the local psychiatric services. There had been no exploration of alternatives to compulsory admission, such as informal admission, or home treatment. In any case, Woodland House did not have facilities to accommodate a mother and baby, so maintaining her in the community in some way would be likely to be in the best interests of both the patient and her baby. Children’s Social Services needed to be involved. I pointed all this out to the health visitor, and suggested that the doctor should see the patient himself first, and then ask the local Crisis and Home Treatment Team to make an initial assessment.
Having dealt with that, I attempted to clear my mind and get into an appropriate state of relaxed alertness for my planned assessment.
Terry also had a diagnosis of paranoid schizophrenia. He was reported to be creating considerable management problems for the nursing team because of his erratic and at times disturbed behaviour. His symptoms included paranoid delusions that he was being poisoned, severe thought disorder, and flight of ideas.
I saw him alone in an interview room. Terry smiled amiably at me as I explained who I was and why I was there.
“I see,” he said, “Only a genius or professor can section me.”
“I’m afraid I’m neither of those. Terry, can you tell me something about how you came to be admitted?”
“I open the box of Pandora – that means that I am nothing, but aware.”
I left him time to elucidate, but he subsided into an amiable silence.
“Er, Terry, do you think you are unwell at present?”
“It is because my National Insurance number belongs to the parliament of Scotland. You see, the angels of the world are flying over my house, and although I am wise, they can see me for what I am.”
“Right… Do you think the medication you are taking is helping you?”
“I have a high level of testosterone because of my proximity to women. The tablets help me to discharge my energy. It is all the same in the cosmos.”
He continued in this vein for several minutes, warming to his incomprehensible topic. I had not the faintest idea what he was talking about, and at the soonest available opportunity I thanked him for his cooperation and told him I had to now go and consider my decision.
“You are not part of the blue circle. Nobody speaks for a moment. There are millions of people. They implanted two chips in my shoulder. Two veins go from these chips into my heart,” he said to me, smiling, as he left.
I confess that it did not take me long to reach a decision.
Thursday, 13 August 2009
Derek, however, was really scary.
Back in the days when I used to do shifts in the generic out of hours team as well as doing the day job (I’m far too old for that now), referrals from police stations made up a significant amount of the workload. The police station in the county’s only city was a frequent source of these calls. It was a regular occurrence to visit its custody suite, which was in the subterranean bowels of the building with no natural light.
It was fairly late in the evening. Derek, a man in his mid 40’s, had been detained under Sec.135 after behaving bizarrely and aggressively in a public place and I was called to assess him under the MHA. He was apparently an intelligent man, with a degree in engineering, but had convictions for a range of violent offences.
From the comparatively bright and inviting reception area, I was led down several flights of stairs to the custody suite. Derek had already been seen by the duty doctor, and while I waited for the duty psychiatrist to arrive I decided to see him.
I followed the custody sergeant to Derek’s cell, at the end of a long corridor lined with heating pipes and ducts with the cells opening off. The custody sergeant looked uncomfortable.
“You’d better watch this bloke,” he said uneasily. “Don’t trust him.”
Long before we reached Derek’s cell, I could hear a loud and regular pounding sound echoing down the corridor. The custody sergeant’s unease was rubbing off on me. As we came nearer, I could see water flooding out from under the cell door. I couldn’t help wondering what on earth was going on in there.
Derek was monotonously pounding his cell door. The officer called through the grill to him to back off and then unlocked the door and opened it. Looking into the cell, I could see that Derek had tried to flush his shirt down the toilet in the corner of the cell, blocking it and causing it to overflow, covering the floor of the cell with water.
Derek had his back to us when we entered. Since his shirt was halfway round the U-bend, Derek was naked to the waist. He turned round and glared at us.
I felt a surge of shock. He only had one eye. He stared balefully at me with his one eye, but where the other should have been was just an empty pink socket.
My first thought was that he must have flushed his eye down the toilet. This did not help me to maintain my composure. My voice probably sounded a little shaky when I introduced myself.
He put his hand in his pocket and brought out his second eye, which was made of glass. He popped it into his mouth, sucked on it for a moment, and inserted into the empty socket. He then examined me more closely, as if this action had improved his vision. Although this went some way to improving his appearance, it was hardly reassuring. (I learned later that he had lost his eye at the age of 12 while trying to make homemade fireworks in his bedroom).
The officer led him to an interview room. I stood on one side of the desk, with Derek and the officer on the other side and tried to interview him. He was hostile and asked me who I was. He did not appear impressed when I explained. He was clearly agitated and his mood was elevated. At a guess (I did not have access to his medical records) I thought he had bipolar affective disorder and was probably hypomanic. He kept leaning across the desk and getting his face as close to mine as possible. I didn’t like this. I also didn’t like it when he raised his fist and made as if to punch me in the face, stopping his fist just centimetres from my nose. I don’t know how I didn’t involuntarily recoil.
It didn’t take long for me to conclude my assessment, and I indicated to the officer that he could return him to the cell. I was relieved that I had survived the process without needing a visit to the casualty department. When the officer came back to me, I could see that he was trembling. It did not actually help to know that a police officer was even more scared than I was.
“I don’t mind a bit of aggression in this job,” he confided. “But these mental ones – they really put the wind up me.”
Once the duty psychiatrist had seen him (I decided not to take part in that interview) we were in no doubt that he needed to be detained under Sec.2 for assessment. In view of his volatility and potential for aggression, it was decided to transport him in a police van. He was not happy about this, and swore at me as he was led to the vehicle, each wrist cuffed to a police officer, with two others as escorts.
I went on to the hospital to alert them to the admission, and got there before him. I stood back as he was led down the corridor, but at least felt safe, since he was handcuffed and flanked by two big policemen. I made sure that I was far enough away to be out of danger should he decide to lunge at me.
But as he passed me, he turned to look at me once more, swore, and then spat full in my face.
It’s things like that you remember for a long time.
Scary Post Script. It turned out I got off lightly. A couple of years later I was talking to a social worker who worked in the regional secure unit. I discovered that Derek was a patient there. He was detained under Sec.37/41 (a form of detention imposed by the criminal court for serious offences, which means that a patient can only be released with the consent of the Home Secretary). He had blinded someone by throwing acid into their face.
Saturday, 1 August 2009
This understandably creates problems when assessing people under the Mental Health Act: not only do you have to find an interpreter as well as two doctors, but you then have to make judgments as to the mental state of someone at another remove, trusting the interpreter to give an accurate translation of the patient’s answers, and then trying to assess whether these responses constitute evidence of mental disorder. An interpreter shaking their head and telling you that the patient is “speaking nonsense” is not good enough: you need to know what kind of nonsense they are speaking. It’s like trying read a book while wearing boxing gloves.
On this particular occasion I actually encountered the problem before I received the referral. Looking out of the window of the CMHT, I saw a teenage girl sitting on the pavement while a much older man and woman whom I took to be her parents attempted to persuade her to get into a car. She resisted entreaties and threats, lashing out at them with her fists if they got too close. Eventually she was persuaded to get into the car, which then sped off.
Not long after, the girl’s GP rang up. Benedita was Portuguese. Her parents had brought her to the surgery. The GP had seen her with an interpreter, and was concerned by her agitated, aggressive and irrational behaviour. Back in Portugal she had been under a psychiatrist and had been prescribed antipsychotic medication. The parents had a letter (in Portuguese, of course) from the psychiatric services there giving a diagnosis of “polymorphic psychotic disorder”. Could I assess her under the MHA?
I decided to make at least a preliminary assessment while the interpreter was available (the surgery had so many Portuguese patients that they even had an interpreter on their staff). Within a few minutes I was at the GP surgery, accompanied by one of the Community Psychiatric Nurses from my team.
The interview was even more complicated than I was expecting. Benedita was not only Portuguese, she was also born without hearing. She communicated with her mother through a combination of idiosyncratic Portuguese and her own form of sign language which only her mother understood. We therefore had to give questions to her mother, who would then communicate with Benedita with a bewildering combination of speech and signing. Benedita would then use speech and signing to answer, her mother would tell the interpreter what she had said, and the interpreter would then translate it into English for my benefit.
Ideally, we would have involved an interpreter with a knowledge of sign language (but that would have added yet another layer of potential confusion) and a psychiatrist with knowledge of the effects of hearing impairment on mental health (but the nearest was 100 miles away). So we decided this was the best assessment we were going to manage in the circumstances.
Through this convoluted means we managed to obtain some idea of her mental state. We gathered that Benedita knew she was going to die. The reason for this was that her cousin had taken some pictures of her, but was not allowed to. And this was all because the Chemistry teacher in her home town in Portugal had told her to go to the toilet, when everyone knows she has to hold on or else. From time to time, without provocation, she would suddenly attack her father, striking him over the head, which judging by his resigned acquiescence he was probably accustomed to.
We thought she probably was psychotic. The GP had already prescribed appropriate medication, but she had not yet taken it. We thought that would be a good idea. We also thought a tranquilliser would be a good idea in the short term, in order to reduce her agitation. We watched as her mother persuaded Benedita to take the medication. She gradually calmed down.
I was unhappy about admitting her to hospital. They wouldn’t be equipped to properly assess her, Benedita would be unable to communicate her needs and would become even more distressed, and she would probably end up being heavily sedated. She needed to stay with her mother if possible. But how were we to keep Benedita and her family safe and ensure she had the care and treatment she needed?
Her parents told the interpreter that they had been thinking about a trip back to Portugal. This seemed like a very good idea. She could be seen by her Portuguese psychiatrist who could then decide what to do next. Although a little ragged around the edges, I felt that this was an acceptable alternative means of providing the care and treatment Benedita required (Para 4.4 Code of Practice of course).
So her mother booked a flight for herself and Benedita, and they returned to Portugal a few days later. Sometimes the expedient option is also the best (or at any rate the least worst).
Wednesday, 22 July 2009
He likes cats, and encourages strays to enter his home through an ever open catflap in his front door, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm, and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.
The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.
Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.
The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker, and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission, and gives a graphic description of what will happen to anyone who tries to make him go to hospital.
This is when the Masked AMHP is brought in. I speak to the psychogeriatrician, who has visited Harry a couple of times, and who clearly is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate, and provides me with a medical recommendation.
I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has basically always been a difficult man, who subjected him to physical abuse as a child and made his mother’s life a misery. He rings him at least once a week, and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to.
I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. We also arrange for the police to be on standby. On the basis of the evidence, I am already leaning towards a decision to detain for assessment.
The house is exactly as described. We enter his living room, where he sends nearly all his time. Cats sidle around the heaps of rubbish.
Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. His answers reveal him to be orientated in time and place. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I talk to him in more detail about the purpose of our visit, he becomes hostile, and asks us to leave.
But I need to discuss the assessment with the GP and social worker. We huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The first legal requirement, that the patient has to be suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital, is not fulfilled. The GP agrees with me. On this basis, I am unable to justify a detention in hospital even for assessment.
By this time, Harry is justifiably annoyed with us, since he realises we are talking about him and he doesn’t like it. He starts to insist that we leave, shouting and repeating this into my face. He does not let me tell him that he would be satisfied with the outcome of my assessment, and bundles us out of his house.
Some sixth sense tells me the social worker is not happy with the outcome of the assessment. On the pavement outside, I discuss the reasons for my decision with him.
Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have life styles others find unacceptable or repugnant. It is often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community as much as possible in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.
Harry could probably be described as having Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself; a study of patients with this syndrome concluded that only half actually had a mental disorder. (Diogenes Syndrome: a clinical study of gross neglect in old age (Clark AN, Mankikar GD, Gray I, Lancet 1975 Feb 15;1(7903):366-8). Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.
Things continue to deteriorate. He persists in making abusive and unreasonable calls to the out of hours service. The carers continue to complain about the rats. By now, they appear to be approaching the size of small hippos. The social worker arranges for a visit with an environmental health officer.
Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.
After lunch, we gather on the pavement outside Harry’s house with the GP. The social worker approaches. He visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as conducting an expedition into the overgrown garden. He could find no evidence of the presence of rats whatever – no rat runs, no droppings, no urine, no evidence of chewing – nothing.
This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to introduce an antipsychotic into his medication in order to see whether or not this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.
I suspect that I have not heard the last of Harry. I will probably be asked to pay him another visit sooner or later. (Unless they ask another AMHP to assess him!) The pressure is likely to continue to mount on me to detain him under Sec.2 for assessment. After all, it would only be for up to 28 days, and only for assessment. At what point should I conclude that there really is no alternative?
Thursday, 16 July 2009
Assessment 1: She was first referred as an emergency by her GP. I assessed her at the CMHT with a community psychiatric nurse. She was 29. She had recently dropped out of a computer studies degree, reporting that the tutor and other students on the course were targeting her and trying to hack into her computer.
She talked freely to us about the problems she was experiencing: "I've been targeted, you see. I'm being stalked via the internet. They are doing it in such a clever way to make me think I'm mad. My computer plays music I haven’t chosen – they’re trying to send messages to me through songs. They’ve included hidden words in the beat of the music.
“And that’s not all – they’ve bugged my house, they’ve put in hidden cameras and they’re broadcasting me on the internet.”
This was possibly the first example I had come across of computer related delusions – once upon a time psychotic people would complain that they were being broadcast on the radio, then that their TV’s were talking to them. Now it was computers.
There was no doubt that she was very unwell, and quite probably we were seeing the first onset of paranoid schizophrenia. Cannabis was also somewhere in the mix. But I didn’t detain her on that occasion, as she was cooperative and agreed to take antipsychotic medication.
Assessment 2: Three weeks later the CMHT Consultant asked me to assess Jenny again. She had attended for an outpatient appointment with him. She was still psychotic, but had insight, and also was still agreeing to take medication. So I again concluded that she did not need to be detained, but continued to monitor her closely in conjunction with the CPN. Gradually, her psychosis subsided.
Assessment 3: A month later the GP again asked for an assessment. Jenny had stopped taking her medication and her symptoms had returned. However, this time there were also religious delusions. She agreed to restart medication, and I again decided to hold fire on a compulsory detention as long as she cooperated with her CPN.
Two weeks later, while I has away on holiday, she was assessed by one of my ASW (at the time) colleagues, since she was not taking her medication, and was detained under Sec.2.
Assessment 4: A month after my previous assessment I got a request for assessment for detention under Sec.3. Although she was taking medication on the hospital ward, she did not think she was mentally ill, would not agree to stay informally, and would not agree to continue with medication. A Sec.3 for treatment was the only option.
Assessment 5: Her CPN asked me to assess her again two years later (she had already had another detention under Sec.3 in the meantime that I had not been involved with). She had stopped her medication and had been smoking a lot of cannabis. She believed that she was in direct communication with God and that her house was being bugged. The Royal Family and security services were also conspiring against her because of her special relationship with Prince Charles. The interview was complicated by her rolling and then smoking a spliff while I was talking to her. She was extremely paranoid and accused me of having special powers (which in a way I did, since I used my special powers to detain her under another Sec.3). Unfortunately, the local hospital had no beds, so she had to be admitted to a private hospital 70 miles away. That was a long day.
Assessment 6: 10 days later, we received a call from this (very expensive) private hospital to say that Jenny had left the ward three days earlier, and should they therefore discharge her from the Sec.3? I will not here repeat what I said to the hospital.
I went to her home and sure enough she was there. She let me in, a spliff in her hand, and I informed her that since she was a detained patient, under Sec.138 of the MHA I had to take her back to a hospital. She took the view that it was a fair cop, and fortunately, the local ward now had beds, so, once she had finished her spliff, she packed a bag and I took her to hospital. (OK, I know this isn’t strictly speaking an MHA assessment, but it is an inherent duty of an ASW/AMHP.)
Assessment 7: 6 months on, it was again being reported that she was not taking her medication, preferring the strongest cannabis she could buy. However, on assessment with the CMHT psychiatrist, she presented as quite well, with good insight, and certainly not detainable on the day.
Assessment 8: But this was not the case 2 weeks later. When, at the request of her care coordinator, I turned up with the psychiatrist and GP at her house we found chaos. Her gas boiler was hanging off the wall and there was smashed crockery littering the floor. I asked Jenny about the damage, and she told me: “The Royal Family and the rest of the inhabitants of Earth are watching me. I know, because they’ve been making my heating click in a special way.”
I asked her whether these experiences might be explained by her mental illness, but she denied this, telling me: “God’s told me I’m not delusional.”
She was detained under Sec.3.
Assessment 9: Nearly a year passed before I again had to pay a visit to her home, again with a psychiatrist and the GP. It was reported she had been smoking a lot of Skunk (always a bad sign for Jenny), and she had hurled abuse through the window when her CPN had tried to visit her. However, on this occasion, she was not going to allow us in. After a discussion on the pavement, we concluded that it was not justified to use a Sec.135 and force entry. She again must have realised that the game was up, because two days later she presented herself at the Accident & Emergency department of the local hospital, and was admitted informally to the psychiatric ward, where she remained for a few weeks.
Assessment 10: A month after her discharge the police were called to her house during the evening, and she was admitted informally to hospital again. After a week or so, she was detained under Sec.5(2) and I was called to assess her for another Sec.3.
Jenny was very upset and tearful in the interview. This was because God “is not very nice”. She told he had first appeared to her when she was 6, and that she was a “chosen person”: chosen “to speak the word of God”. But this was a difficult burden, because “God thinks more of football and singing than protecting. I hate communicating with him when he’s not acting normal”. Then she broke down, sobbing, “I don’t know if I can live like this because God won’t leave me alone”.
Following this admission, she was taken on by the local Assertive Outreach Team, who work with patients who frequently relapse or are difficult to engage. In the next three years, there was only one further admission to hospital.
Assessment 11: A call from the Assertive Outreach Team consultant. Jenny was smoking skunk again, messing about with her medication, carers expressing concern, etc.
She did let us in this time. Initially she presented to us as quite together, although told us that she didn’t need mental health any more. It was suggested that it might be an idea for her to come into hospital, but she was against this: “I need to be with God having my hair done tomorrow.”
She admitted that God was speaking to her again. We suggested that she was again mentally unwell and needed to go into hospital, and we were going to admit her under Sec.3. She was unhappy about this.
“You know,” she said, “God told me not to answer the door. It’s really going to piss Him off if I don’t have my fucking hair done tomorrow!” She stormed out of the room.
Just as I was wondering whether we were going to need the police, she came back with a packed bag.
“Let’s go,” she said. Perhaps she was beginning to learn something.
To date she has not had a further admission. Perhaps God has finally left her alone.
Saturday, 11 July 2009
As well as having a few more assessments under the 1959 Act under my belt, those to be designated as ASW’s had actually had some training in the new Act, so this time I felt a little more prepared when I received my first request for an MHA assessment under the 1983 Act two weeks later.
I was on call, and the request came in the early evening. Her name was Emma. She was in her 30’s, married with two young children, with a diagnosis of bipolar affective disorder. She had been seen by her GP earlier in the day, but had removed herself from his presence when it looked as if he might be considering admitting her to hospital. She was now in a police station about 25 miles away from the town where I worked, detained under Sec.136, having been removed to a place of safety from a public place by a police officer who had reason to believe she may have been mentally disordered. She therefore had to be assessed by an ASW and a medical practitioner.
(All the sections in the 1959 Act changed in the new 1983 Act – Sec.25 became Sec.2, Sec.26 became Sec.3, Sec.29 became Sec.4 – with the exception of Sec.136, the only Section the police could impose, which remained the same. We ASW’s assumed it was because the police would never be able to remember a new number, but perhaps we were too cynical.)
Before I went out to see her, I took the precaution of visiting the GP, who was still in surgery, and got more information. She had been going high for a few weeks, and had managed to obtain a bank loan, purchase a franchise with an international cosmetics chain, and had opened an office in the town, despite having no experience in this field whatever.
I obtained from him two medical recommendations – one for Sec.2, and another for Sec.4 – just in case – and then set off for the police station.
When I interviewed her, Emma seemed quite calm. She was clearly extremely tired, having not slept for several days, but sensibly recognised that it would be a good idea to go home, take some medication, and get some sleep.
I decided that, having assessed her, she did not need detaining, and could therefore be discharged from the Sec.136. The police sergeant thought otherwise. He had read Sec.136 of the Act, which stated that the purpose of detention under Sec.136 was for the person “to be examined by a registered medical practitioner and to be interviewed by an approved social worker”. Since she had not been examined at the police station by a medical practitioner, he could not allow her to leave the police station. He was probably right. However, my interpretation of the Act at that time was that since she had been assessed by a medical practitioner that day, she did not need assessing again by another medical practitioner in order to fulfil the requirements of Sec.136.
After a considerable and sometimes heated discussion, he acceded to my superior knowledge and allowed me to take her back to her home town, with a female special constable as an escort.
What an interesting journey that was. Once we had set off, Emma started to go high again. I realised that she was rapid cycling. As we drove, she became more and more charismatic, and even appeared to physically increase in stature. It was an awe-inspiring sight. A messianic glow seemed to emanate from her being as she told us about her plans for world domination through the cosmetics industry. I was becoming steadily more alarmed the more I drove – would the car be big enough for the three of us, or would she continue to inflate indefinitely until the car burst asunder? The female special constable however, with very little experience of mental illness, was drawn completely under Emma’s spell. Not only did she take issue with my opinion that Emma was mentally unwell, but she was even considering investing her life savings in Emma’s scheme.
At last we arrived at her home. By then I had serious misgivings about leaving her with her husband and children in this state, and when her husband saw her, I could tell he was even less happy than I was. She had no intention of taking her medication and going to bed; she was instead going to her new office to order even more of the cosmetics, right then, and then she was going to see her solicitor to get a divorce.
I knew that chaos would ensue if I were to leave her, and in those days without mobile phones I suddenly felt extremely tired and lonely and isolated. Why on earth did I ever decide I wanted to be an ASW?
In an attempt to regain control of the situation I calmly but firmly indicated to her that this was not a wise thing to do, that she was extremely unwell, and that she really had no option but to go to hospital. Somewhat to my surprise, she agreed that I could indeed take her to hospital, so before she could change her mind I marched her to the car, again accompanied by the female special constable, who by now realised that something was severely amiss with Emma and was now reluctant to sit next to her, or even be in the same vehicle, and drove the 15 miles to the hospital, knowing that if I could get her safely ensconced on the ward, then if necessary we could keep her there on a Sec.5(2).
By 11.00 pm we arrived at the hospital, and we walked down the long, dim, silent corridors until we at least reached the ward. I sat her down in the nursing office with the admitting nurse, beginning to allow myself to feel relief. This was when she drew her trump card.
“I’m not staying,” she said.
“But you agreed that you would go to hospital.”
“I agreed that I would go to hospital. I didn’t agree that I would be admitted!” She gazed at me in triumph. She had outwitted me.
But I had my own trump card. I left the room for a few minutes, filled in a form, and returned.
“Emma,” I said to her, “you are now detained under Sec.4 of the Mental Health Act 1983. That means that you have been admitted for assessment for up to 72 hours. There is no right of appeal against that decision.”
The Consultant converted this to a Sec.2 the following day, which of course did provide her with the right to appeal. So two weeks later I had my first Mental Health Review Tribunal of the 1983 Act. But that’s another story.
Thursday, 25 June 2009
The call came from the local police. They had a 19 year old male in the cells on a Sec.136. He had been found walking the streets in the middle of the night stark naked. When asked to give his name, he told them that he was Jesus Christ.
I spoke to his mother on the phone to get some background. She told me that he had been involved in a car accident a year ago in which his friend was killed. He subsequently became involved in a local evangelical Christian church. He had successfully completed his “A” Levels and then spent his gap year travelling around Asia. He was due to go to University in a few weeks time. He had no history of mental illness, but his mother told me that he was a regular user of cannabis, ecstasy and PCP, and that he had been behaving increasingly oddly over the previous few days.
I went out to assess him. The consultant, the duty GP and I crammed into his cell to see him, as he refused to come out to the interview room. Martin was sitting cross-legged on the floor, completely naked. He had refused all attempts to cover him. He was wearing handcuffs, having refused to allow the police to remove them.
He smiled beatifically at me as I entered, blessed me and told me that he forgave me for my sins. I thanked him and asked him why we would not let the police take the handcuffs off.
“Martin needs to be punished,” he answered. “I am Jesus, the Second Coming. My Dad is God. I am presently inhabiting Martin’s body, as he was killed in a car accident a year ago. Martin is the spawn of Satan, you see.”
“That’s interesting,” I said. “The problem I have is this. I have several times seen people who thought they were Jesus Christ, and they have invariably turned out not to be.”
He considered this, the smile faltering momentarily on his face. Then the sunny smile reappeared and he said, “I’ll prove it to you, my son. I have many powers. I can read your thoughts.”
“Okay, so what am I thinking right now?”
He studied me for a while, then replied: “You’re thinking I’m crazy.”
“Well,” I said, “that really is uncanny.”
We left him in his cell in order to discuss our conclusions. Although he had no previous history of mental illness, it was clear that he was psychotic. It was possible that this had been triggered by drug use, and that the car accident may have contributed to this episode. However, he was so florid there was no option but to detain him under Sec.2 MHA for further assessment.
I returned to Martin’s cell to inform him what was happening. He turned his awesome smile on me as I explained.
“I have made an application for your detention in hospital under Sec.2 of the Mental Health Act. This means you will be detained for up to 28 days. I had to make this decison based on the balance of probabilities: what is more likely, that you are indeed Jesus Christ, as you say, or that you are mentally ill. I am afraid that it is more likely that you are mentally ill than that you are the Second Coming. You do have the right to appeal against this decision.”
His smile completely left his face and was replaced with a poisonous glare. For the first time during the assessment, he appeared to be irritated.
“I died on the fucking cross for you!” he snarled as I left the cell.
A happy ending: Martin made a rapid recovery in hospital. He probably did have a drug induced psychosis. He went to university as planned.
Wednesday, 24 June 2009
Fast forward to 1981. After two years working as an unqualified generic social worker I did a two year Certificate of Qualification in Social Work course (in those days the training was only two years, and the official social work qualification was the CQSW), and then returned to work in my old area office.
I had been qualified for about a year when the new area officer, Gerald, called me into his office.
“We’ve got a request for a Mental Health Act Assessment. Fancy doing it?”
“I’m not sure I’m qualified to act as a Mental Welfare Officer,” I replied nervously. “I haven’t had any training or anything.”
“Have a look on your social work warrant. What does it say?”
I looked at my ID card. The front had a passport photograph of me, sporting the obligatory long hair and beard of a male social worker of the time, along with my name and the local authority. The back said who and what I was and had the signature of the Director of Social Services. In rather small print in one corner there was a statement which I had never bothered to study: “The holder is authorised to act as a Mental Welfare Officer for the purposes of the Mental Health Act 1959.”
I read this out.
“There you go then,” Gerald said, and proceeded to give me the details of the request.
And that was my full initiation into the arcane world of Mental Welfare Officers.
The person I had to assess was an informal patient on one of the wards of the local Victorian asylum which thankfully no longer exists. Peter was a married man in his 40’s who had been admitted because he was believed to be delusional. Although he had initially agreed to the admission, he was now suspicious that the hospital was a part of the conspiracy against him.
I spent an hour reading up on the Mental Health Act and the relevant sections. I was desperately trying to remember the training I had had on my social work course and the things I had learned from observing a few assessments carried out by other MWO’s. Then I went to the ward to interview the patient.
He seemed pleased to see me.
“This will explain everything,” he said, giving me an exercise book filled with neat handwriting.
I started to read it. It detailed his life when working as an engineer in an African state that had previously been under colonial rule. He had basically lived, with his wife, in a post colonial enclave, which, he said in his account, was run by the Masons. He had never been much enamoured of the Masons, and when he discovered that they were providing local women to single (and married) British men for “personal services”, he decided to blow the whistle on the whole thing.
The Masons had, of course, objected to this, and, according to him, had made it impossible for him to continue working there and he had then returned to his home town in
“And now,” he said, after I had read at least some of the exercise book, “they’re getting to me here. They’re drugging me, they don’t want me to tell. They want to kill me!”
I had little difficulty in reaching the conclusion that Peter was extremely unwell, and was displaying clear symptoms of psychosis, including paranoid delusions. The consultant had already completed a medical recommendation, and another doctor had already been to assess him and had left his recommendation. Although I was unable to contact his nearest relative to discuss the assessment with her, I duly completed an application under Sec.25 for assessment (this was the 1959 Act, remember).
It felt good. It had been a comparatively straightforward assessment – the patient was already in hospital, and was displaying clear signs of mental illness. I felt I had managed the whole thing rather well
A few days later, I visited his wife to discuss the situation with her. I told her about the contents of the exercise book, and his belief that the Masons had been conspiring against him.
“Oh yes,” she said. “All that’s true. It did happen. It really got him down. We had to leave the country because of it.”
A month later I completed my second Mental Health Act Assessment when I detained him under Sec.26 of the 1959 Act, for treatment. He was still clearly unwell, but this time he had a diagnosis of depression.
Friday, 12 June 2009
It was 1976. I had my first job as an unqualified social worker (most social workers were unqualified in those days) in an area office with a mixed rural and semi urban catchment area. I had been working there for 2 months when Gordon, the area officer, called me into his room.
“Would you like to come out with me on a Mental Health Act assessment?” he asked.
Gordon was in his late 50’s. Before the major reorganisation of national social services a few years previously (arising from the Seebohm report, for those who may be interested), he had been what was known as a Mental Welfare Officer. Mental Welfare Officers were what we would now call AMHP’s. MWO’s were created by the Mental Health Act 1959, which introduced the concept of the independent lay person who made final decisions about detention in hospital based on the recommendations of doctors.
Of course I said yes. I was completely new to social work, and keen for experience.
The assessment was on a lady in her 50’s. She was the manager of a social security office. Her GP had rung Gordon because neighbours were reporting that she was wandering around in her garden dressed in nothing but her nightie. It was a chilly November morning, so this was a matter of some concern.
Gordon told me that she was known for this. She would go for months or years without any problems, then one day would wake up and be completely bonkers. A spell in hospital invariably sorted her out.
We met the GP at her house, a nice bungalow in the countryside. We didn’t bother to knock on the door, since we could see her wandering around in the garden in a diaphanous negligee. To see a woman of that age (or any woman come to that) so scantily clad was at the time quite a shock to me, but Gordon took it in his stride.
Gordon put on a rather scary fixed smile which I assume he thought was reassuring and the three of us approached her.
“Hello, June,” he said, “What seems to be the problem?”
She turned and looked at us. She looked at me with an interest that alarmed me. This was the first mad person I had ever seen. What might she do?
“I came out to see the fairies,” she eventually replied. “They’re everywhere. They’re so lovely.”
“Yes, they are, aren’t they?” Gordon replied. I assumed he was “humouring” her. “Why don’t we go inside? It’s quite chilly out here isn’t it?”
She allowed herself to be led through the garden into her house, her bare toes sinking into the damp grass as she went.
Gordon and the GP had a discussion in her kitchen. It didn’t take long. The GP filled in a form and then Gordon filled in another form. This was known then as a Section 29, when someone was detained with only one medical recommendation. Under the 1983 Act it would be a Section 4, which should only be used in cases of dire emergency. However, in those days it was almost impossible to get a psychiatrist to leave the safety of the ward, and Section 29’s were a not uncommon way of getting people to hospital, when the consultant would then convert it to a Section 25 at his leisure.
“Why don’t we go for a ride in my car?” Gordon asked June. “Just put on your coat and come with me.”
“Where are we going?” she asked.
“Just for a nice ride,” he said reassuringly.
I knew even then that this was not the right way to relieve someone of their liberty. Shouldn’t you always tell the truth, even to someone who seemed to be quite literally “away with the fairies”?
Throughout the drive to the hospital, Gordon continued with a stream of reassuring lies, and as we drew up outside the ward he told her that “it would only be a few days. You’ll have a nice rest and be right as rain in no time.” He knew she would probably be in there for several months; hospital admissions generally seemed to be much longer than they are now.
Gordon’s approach seemed to me to be dishonest and underhand. I did not feel he gave June the proper respect. I resolved that I would do my best never to deceive, mislead or patronise a mental health patient, should I ever become a Mental Welfare Officer.
Monday, 1 June 2009
Ethel was an elderly lady with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He sleeps in the garden now – I can’t sleep because I don’t know what he’ll be up to next.” When I assessed her last year, she was adamant that this man existed. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under Sec.2 MHA, and on discharge agreed to take medication and accept a package of home care -- although she was still absolutely convinced there was a man living in her garden.
A few months later the older people’s psychiatrist came to see me. The man in the garden was causing Ethel more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.
I went round with the psychiatrist, Ethel’s GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder. The man was “getting on her nerves.”
Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.
In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state. The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect. It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.
In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment, and this time we decided to go for a Sec.3. “I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.
She complained of chest pains on the way to hospital. I began to panic inside – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.
“But I haven’t had anything to eat today,” she said.
Saturday, 23 May 2009
“Hi there, it’s Shirley Adams. I’m ringing about Leroy. I think we may need to section him.”
I knew Shirley. She was the consultant psychiatrist with the Assertive Outreach Team. I also knew Leroy. In fact, I first met Leroy in the 1970’s when he was only 14 years old and I was a very young social worker working at the time with young offenders. They called it Intermediate Treatment back then (I never did understand what “Intermediate Treatment” meant).
Leroy came from just about the only black family living at that time in the small rural town where I work. He and his brothers had consequently suffered a degree of prejudice, especially from the police. For example, while a white 14 year old in the 1970’s would probably have been ignored or just given a verbal warning when caught riding a bicycle without lights, Leroy was taken to juvenile court. He was one of 5 brothers, three of whom in adulthood developed bipolar affective disorder. In fact, I had detained one of his brothers under the Mental Health Act in the past. I had also detained Leroy under the Mental Health Act on two previous occasions, the first time 18 years ago, and more recently three years ago. He was now in his mid forties.
I still vividly remembered the last time I had been involved with him. He was in the habit of disengaging from the community psychiatric team, and would then stop his medication, take lots of amphetamine, and end up with an acute admission, frequently from the police station. This time he had been an informal patient, but had decided to pop home to his flat without bothering to tell anyone, and had not returned. The ward rang to ask if we could get him back. I had gone out with Pam, our criminal justice liaison nurse, and had tentatively knocked on his door, expecting no answer, or at best a distinct lack of cooperation with our plan.
Instead, he immediately opened the door, welcomed us as if we had come to confirm his jackpot win on the National Lottery, and said: “Thank God you’ve come. Please, please take me back to the hospital. It’s terrible here – the TV’s talking to me!” We decided to oblige, but then wished we hadn’t – he became increasingly bizarre during the journey to the hospital, at one point telling me that I was an alien from Alpha Centuri, and then telling me that, although he was not gay, he nevertheless wanted to kiss me – “on the lips”. Once returned to hospital, I detained him under Sec.3. Unfortunately, I then became the focus of some of his paranoid beliefs, and at one stage during his hospitalisation he announced that he wanted to kill me. Even when he had recovered, he remained hostile towards me. That was when he was taken over by the Assertive Outreach Team.
So when Shirley rang me and mentioned Leroy’s name, I felt a degree of trepidation. This feeling increased when she told me that his mental state had been deteriorating over the last few weeks, they believed he was taking amphetamine again, and thought he might have also stopped his medication. His relatives had reported that he had broken his mother’s window the previous week and appeared to be very agitated. Shirley therefore wanted to pay him a visit with an AMHP and another doctor to conduct a formal assessment under the MHA.
Since there was no other AMHP available (there are only two of us in my team), I had no choice.
The following morning Shirley, another Sec.12 doctor and I called at the time he normally expected the Assertive Outreach Team to visit him. He opened the door and to our surprise readily invited us into his flat. Although he eyed me up a little suspiciously, he remained civil and calm, even when we told him the purpose of our visit.
He told us that he had given up “puff and speed” a week ago, and that he had doubled his medication, including his olanzapine and lithium (this did worry his consultant, because he had been known to become lithium toxic in the past). There was some evidence of elevated mood and disinhibited behaviour, eg he lifted up his teeshirt to display his stomach to show us he had lost weight, and talked to us in detail at one point about the colour of his “poo”, but there was no evidence of delusions or hallucinations. He admitted that he had had a disagreement with his mother last week and had “bricked” her window, but said that he had seen his mother yesterday and offered to pay for the repair. He did tell us that he had noticed that car registration numbers looked “phonetical” – twisted and reversed, but this was the only real evidence of abnormal thought processes. We were in his flat for over 45 minutes, and throughout that time he remained amiable and composed. At one stage he agreed to an informal admission if that was considered necessary. He agreed to maintain engagement with the Assertive Outreach Team and said he would cooperate with any community treatment plan.
We slipped into his kitchen to discuss our decision. We were unanimous in feeling that a detention under the MHA could not be justified on the basis of this interview, even taking into account the reports of his relatives. We told him the news, Shirley warned him not to tamper with his prescribed doses of medication and arranged with him for further visits from team members, and then we left.
Two weeks later he was admitted to Bluebell Ward in the middle of the night in the company of the police, and was quickly detained under Sec.3.
Moral: AMHP’s and psychiatrists are not infallible.
Sunday, 3 May 2009
For those who don’t work in the mental health field, I will give a more detailed explanation. The MHA gives powers to apply for the detention in hospital of people with mental disorder. Specific sections of the MHA lay down these powers, for example, Section 2 allows someone to be detained for assessment for up to 28 days, and Section 3 allows detention for treatment for up to 6 months. Normally two doctors make recommendations that someone should be detained, and the AMHP then makes the final decision and completes the application. Once all the paperwork has been completed and the AMHP has signed his or her application, that person is then formally detained under the MHA, even if they are not yet in hospital. The formal detention gives the AMHP powers to arrange for the patient to be taken to hospital against their will, by whatever means necessary. This will usually involve an ambulance, and may also involve the police.
To talk about “sectioning” someone is therefore a form of shorthand: “Fred’s going hypomanic again. I think we’re going to have to section him.” (Instead of: “I think we’re going to have to assess him under the Mental Health Act to see if he needs to be detained.”) “Adele took an overdose and was sectioned last night.”(Instead of: “Adele was assessed under the Mental Health Act and detained in hospital.”)
Although I confess to using this term when talking to other professionals, I don’t necessarily feel entirely comfortable about it. Is it jargon? Does it demean or depersonalise people with mental disorder? I would never use the term with a patient, and always explain exactly what is happening when an assessment is taking place. This is not only good basic practice, it is a legal requirement. That is why I try to avoid using the word in this blog or in the written reports I have to provide when sectioning (sorry, detaining) someone.
Friday, 24 April 2009
Her name rang a bell. I looked in my records and realised that I had detained her under Sec.2 nineteen years previously. I realised that I actually remembered that assessment. She had then presented in an extremely bizarre fashion. On interview she was drinking glass after glass of water, could not keep still, was unable to engage in any sort of conversation, and would periodically walk out of the room into her back garden and scream “FUCK OFF!!” at the top of her voice, before coming back in and sitting down again as if nothing had happened.
Her records showed that she had subsequently had involvement with community mental health services for health anxiety, rather than psychosis, and had received more than one course of cognitive behavioural therapy.
Whatever her history, she was presenting as an acute emergency. I tried the local psychiatrist to see if she could attend, but she was unable to. In the circumstances, I decided I should go out and assess the situation without obtaining a psychiatrist, since the nearest available Sec.12 approved psychiatrist was about 30 miles away, and there really didn’t seem time to ring round to find one.
Within a few minutes of receiving the call I was at Mavis’s house – it was easy to find, as there were an ambulance and two police cars parked outside. As I approached the open front door, I could hear her shouting and swearing, and it became clear that she was presenting in a similar way to how she had all those years ago. Her vocabulary consisted mainly of the word “fuck”, and no-one seemed to have any control. I introduced myself and asked her if she remembered me. She actually appeared to recall my involvement with her in the past, but still told me to fuck off, as there was nothing wrong with her except that she had Aids.
Taking the partner to one side, I found out that she had had major surgery because of cancer a few months ago. His mother had died two weeks ago, and Mavis had attended an outpatient appointment just a few days ago in connection with something that had shown up on X-Ray on her lung. Although there was in fact nothing to worry about, it appeared this was the tipping point which had apparently precipitated a reactivation of her health anxiety and a stress-induced psychosis. She believed she had Aids, despite having several times had negative blood tests, and was displaying delusions relating to sex. She refused to consider medication, including her insulin and usual prescribed medication, would not agree to seeing a psychiatrist, and the carer was quite clearly at the end of his tether. I therefore decided the best course of action was to detain her under an emergency Sec.4 with a single medical recommendation from the GP, on the basis that obtaining a second medical recommendation would involve undesirable delay. He was very pleased to oblige, and gratefully scuttled off to his more normal patients.
With an ambulance crew and the police present, what could possibly go wrong? She would be in the local psychiatric unit within half an hour.
I rang Bluebell ward, our local admission ward.
“Hello, I’m an AMHP and I have just detained Mavis under Sec.4 and need a bed.”
“Will that be a female bed?”
“Mavis is a female, yes.”
“We don’t have a female bed.”
“Well how about Snowdrop ward?”
“I’ll ask them... (pause)… They haven’t got a bed either.”
“How about a leave bed?”
“There’s no-one on leave.”
“I happen to know Janice is on leave at the moment.”
“Janice is back for the ward round.”
“Can you find out from the ward round if they’ll be discharging anyone?”
OK… (Another pause)… No they’re not.”
“Look, I need a bed urgently.” I explained why. “Can I speak to the bed manager?”
“She’s in the 136 suite and can’t be contacted at present.”
“What about the charge nurse?”
“I’m just a bank nurse. Do you want to speak to someone else?”
“Yes, how about the charge nurse?”
“I don’t know where he is.”
“I have someone on a Sec.4 who needs a bed urgently. You will have to find one.”
“Do we have to find a bed?”
“Yes, you do.”
“I’ll try and find somebody and ring you back.”
A paramedic came up to me. “Can we get this patient off to hospital now?”
I screamed inside.
“There doesn’t seem to be a bed. I’m trying to get one. God knows where it’ll be. The last time there wasn’t a bed the nearest bed was 70 miles away.”
After half an hour of waiting outside the patient’s house, with the carer, and the patient, becoming more and more agitated and distressed, I decided to ring someone at the Crisis Team, whose offices happened to be next door to the ward.
I explained the situation.
“I’ll go into the ward round and see if I can sort something out.”
Ten minutes later my phone rang. “There’s a bed on Snowdrop Ward.”
And finally off we went.
Thursday, 16 April 2009
One Friday afternoon I was contacted by an older people’s social worker requesting an assessment of an 85 year old lady, Mary. It was reported that neighbours the previous evening had seen smoke billowing out of her kitchen. She is a widow who lives alone and has been diagnosed with vascular dementia. The social worker had visited her this morning and reported that she appeared agitated and had soiled herself. I initially suggested that if there had been a fire, there may have been a risk of smoke inhalation, etc and that perhaps an ambulance should be called so she could be checked out medically. I also suggested that since she was suffering from dementia, the MCA could be used to provide her with physical medical intervention. The social worker insisted that this was not appropriate, saying that Mary had had a mental capacity assessment (although seemed unclear of the outcome), and that only an assessment under the MHA would be suitable.
I went to see the lady’s GP to ask him if he could attend an assessment with me. He was on duty, looked extremely harassed and seemed about to cry when I asked him to. I went through the list of Sec.12 doctors. They were nearly all either on holiday, already committed to an assessment, or were otherwise unavailable. After over an hour on the phone, I was only able to find one Sec.12 doctor.
I established that Mary has home carers visiting her twice daily. In view of the above I rang the social worker back, saying I was having problems getting the full complement of doctors, and enquiring as to whether additional home care could be provided over the weekend as an alternative to admission. The social worker insisted that this was not feasible.
I eventually managed to persuade the GP to meet with me at the patient’s house with the one Sec.12 doctor, who at least happened to be a phsychogeriatrician. (“Couldn’t you do the assessment with the psychiatrist and then just call me when the papers need signing?” “No.”)
By late afternoon I was finally at the patient’s house. The social worker was there, as well as one of the carers. The psychogeriatrician arrived and began an examination of the patient. It very soon became clear that, even if she did have dementia, she had bad cellulitis and also possibly had an acute infection. The psychiatrist was not therefore prepared to consider a detention under the MHA. I went to look for the social worker, and was given a note by the carer to say that she had gone, and had informed the Nearest Relative, a son who lived 100 miles away, that we would be admitting her to the local psychiatric unit. The GP arrived and concurred with the psychiatrist, and prescribed an antibiotic. The kitchen fire was not nearly bad as had been described, and having talked to the home carer, there did not seem to be any significant deterioration in the patient’s mental state to warrant action being taken then and there, especially since the current problem seemed to be physical illness rather than mental disorder, and I spoke to the son who was already on his way to visit his mother over the weekend. I alerted the Out of Hours service of the action taken, and the possible need for extra home care over the weekend.
End of story? No. Having spent the weekend ruminating over the assessment, I concluded that I had been set up. The social worker really wanted Mary to go into residential care, but did not think they could do it under the MCA. So the social worker thought that if an admission under the MHA could be engineered, it would then be much easier to transfer the patient from hospital to residential care.
And still it rumbled on. Over the next few weeks the local Community Mental Health Team became involved with Mary. The local psychogeriatrician agreed to undertake a formal assessment of capacity. He visited Mary and concluded that, now the infection had cleared up, Mary did indeed lack capacity. He was also prepared to consider that an admission for assessment might be justified. So I again went out with the patient’s consultant and her GP, and this time, based on the two medical recommendations, and taking into account a significant deterioration in the patient’s condition, including a recent fall and a mild head injury which she had refused to have treated, I completed an application for detention under Sec.2, and Mary was admitted to hospital. A month or so later she was transferred to residential care.
So why didn’t I detain her a month earlier? Well, apart from the Sec.12 doctor not being willing to make a recommendation, it seemed to me that, even though Mary did not want to leave her home, and had on several occasions turned ambulance crews away when she had had falls, nevertheless, if she lacked capacity and it was in her best interests, then she could still have been taken to hospital, or even a residential care home, and could have avoided a stay on a psychogeriatric ward.
Such are the trials of the AMHP.