Monday, 15 October 2012

On Assessing People Who Conceal Their Symptoms

Over the years, I have frequently found myself in a position where I have had to assess someone under the Mental Health Act where their presentation on assessment is directly at odds with the reports from relatives and other professionals of their behaviour and symptoms.

What is the AMHP supposed to do in these situations? While it is important for the AMHP to “interview in a suitable manner” and reach their own conclusions about the need or otherwise for admission to hospital, it is not sufficient to take the patient’s reports at face value; the AMHP also has to be satisfied “in all the circumstances of the case” that the patient needs to be admitted, whether formally or informally. It is therefore essential for the AMHP to obtain information from relatives and carers, as well as other professionals who have had involvement with the person.

One has to be very careful in weighing up this evidence. On the one hand, people who may be depressed and suicidal, or seriously and dangerously psychotic, may be fully aware that if they are truthful about their symptoms, they are likely to be admitted to hospital against their will. After all, if your intent is to take your own life, you won’t want an AMHP interfering with your plans by detaining you in hospital.

Equally, if you know beyond doubt that there is a global conspiracy initiated by alien invaders from the Dog Star designed to prevent you from achieving your potential as the saviour of the world, you are likely to believe that the nosy AMHP asking you probing questions is simply part of the nefarious plot.

On the other hand, someone may have unusual but not necessarily psychotic beliefs; while you personally may have difficulty in believing that Jesus visited the American continent and left the evidence on gold plaques which later mysteriously disappeared, many people do believe this, and most are probably not thought disordered.

It is also not unknown for people to make malicious and false allegations about the mental health of their relative. I have had a number of demands from estranged husbands to assess their partner under the MHA because they are clearly unreasonable and deluded in objecting to their applications for custody of the children.

A good illustration of these difficulties is the case of Siobhan. Siobhan was a single woman with a school age daughter who lived in a local authority house in Charwood. Her mother, who was originally from the Republic of Ireland, also lived in Charwood. Over a period of more than 10 years, I received a number of requests from her mother to assess Siobhan under the MHA.

On the first occasion, Siobhan’s mother reported a range of behaviours and incidents that anecdotally seemed to indicate that she may be psychotic. However, when I formally assessed her, Siobhan presented at entirely free of any symptoms of mental illness, presenting as warm and appropriate. We took no further action.

A few months later, however, we received a letter from the GP saying that Siobhan had been taken by her mother to the Republic of Ireland and had been admitted to a psychiatric hospital there. She had been diagnosed with paranoid schizophrenia and started on depot injections of antipsychotic medication. She was now back in Charwood and needed the CMHT to give her injections.

I was bemused. Did she or did she not have a psychotic illness? The nurse who gave her her injections found Siobhan to be much as I had, warm, appropriate and without symptoms. But then that could be due to the medication. After a year, Siobhan decided she did not want her depot any more. She disengaged from mental health services. We were not unduly concerned, as we only had anecdotal evidence that she had a mental illness.

A year later, Siobhan’s mother again contacted the CMHT. Siobhan had a partner, and was pregnant. She and the partner were both concerned about Siobhan’s mental health. Both her mother and her partner came to the CMHT to see me. They reported that Siobhan believed that she was not giving birth to a human baby, but to an alien. She had told her partner that she was preparing to be transported to another planet when her alien baby was born. She was neglecting herself and her daughter, and keeping her daughter off school for no good reason.

These were very disturbing reports. I arranged to assess her at home with the CMHT psychiatrist and her GP.

We arrived late afternoon. She answered the door and welcomed us warmly in, even though she was not expecting us. Her daughter and a friend from school were there, playing a game in the living room. Siobhan was preparing a meal for them in the kitchen.

Throughout the assessment, Siobhan again presented as rational, calm, warm and cooperative. The house was in good order, and her daughter appeared well and relaxed. Siobhan denied having said any of the things reported, but said that she and her partner had been having problems and she was unsure if she wanted the relationship to continue.

The psychiatrist, the GP and I retreated to my car to have a discussion. The contrast between Siobhan’s presentation and the reports of the relatives simply did not fit together. I was inclined to go with my impression of Siobhan as she was today, except – this time it was not only her mother reporting psychotic symptoms, but her partner as well. She was pregnant – what if she really did think her unborn child was an alien? What risks to the child might arise from that?

We all felt deeply uncomfortable with the decision, but eventually we decided to believe the mother and partner, and with heavy heart I made an application for Siobhan to be detained under Sec.2 for assessment.

Siobhan took it all with calm resignation. We made arrangements for her mother to look after Siobhan’s daughter and take the friend home, and Siobhan packed a bag and came with me to hospital.

For a fortnight, Siobhan was observed and assessed on Bluebell Ward. During that time she was not given any medication. Also during that time, she did not display any symptoms of mental illness. After 14 days, the section was discharged and she went home.

Despite having displayed no symptoms of mental illness, she did agree to seeing a nurse from the CMHT. She gave birth uneventfully to another daughter, and there appeared to be no problems.

Four years later, Siobhan’s mother again came to the CMHT in a state of agitation. She told us that Siobhan had assaulted a number of people and had also broken her own window. She was insisting that she was mentally ill and needed to be in hospital. While she was telling us this, the police arrived. They had gone out to see Siobhan at mother’s request, and she was not prepared to let the police into the house. The police were expressing concern, as Siobhan’s two children were also in the house.

I decided to go out with her nurse and the police. When we arrived at the house, the police had gained entry. We found Siobhan in the sitting room.

Throughout the interview Siobhan presented as understandably stressed, but nevertheless calm and collected. Her manner and affect were entirely appropriate for the situation, and she did not reveal any symptoms of thought disorder. She said that she had been pressured by her mother and had broken the window as a response to this. She readily admitted that there had been times in the past when she had been unwell, and was aware of her early warning signs. She also said that she wished to continue taking her present medication.

I saw both of Siobhan’s daughters. They both appeared unperturbed by the situation. They were clean, well dressed, and well nourished. They happily reported to me what they had had for breakfast and lunch (cereals, and meatballs with rice respectively). There was no evidence that the children were neglected or in danger. The house was untidy but not dirty, and appeared to be in good decorative order. Again, there was no evidence of significant neglect in the house. I concluded that there were no grounds to consider admission to hospital either formally or informally.

I suggested to Siobhan that we could arrange a meeting with herself, her mother, her nurse, her psychiatrist, and me, to try to reach some agreement about a course of action. Siobhan readily agreed to this idea. I arranged to call in to see her the next morning.

We returned to the CMHT and saw Siobhan’s mother in the presence of two police officers. She was very agitated, and was reluctant to listen to what we had to say about our assessment. She became quite abusive. The police officers were clearly irritated by her. They told her not to harass her daughter, and they wanted Siobhan to be told to inform the police if her mother harassed her further.

The next morning I visited Siobhan as arranged. There was no reply, but the lights were on upstairs and I saw that a venetian blind was momentarily opened.

I phoned her from my car.

“Hello,” I said. “This is The Masked AMHP. Can I come in and see you?” I knocked again, but again there was no reply. However, I heard noises from inside and heard her tell the children to stay in a room.

I phoned her again.

“Do you know who I am?” she screamed down the phone at me.

“You’re Siobhan,” I replied calmly.

“No I’m not,” she shrieked, “I’m her Royal Highness, the Queen of the World!”

“Siobhan, can you let me in?” I asked her, approaching the door again. I heard her thump the inside of the door and then she turned up the stereo to full volume.

I returned to the car to phone her one more time.

“I’m the fucking princess!” she bawled at me when she answered.

It was clear that she was not going to let me in, so I retreated back to the CMHT.

I called the police and explained what had happened. They agreed to go out straight away, especially as the children were inside the house with her.

I returned rather quickly with Siobhan’s GP. There wasn’t time to get a Sec.12 doctor.

The police had managed to gain entry. I found Siobhan curled up in a foetal ball under the stairs. She looked up at me as I knelt down beside her.

“Are you my daddy?” she asked me.

 I detained her under Sec.4.


  1. It's very helpful for report writing and general arse-covering purposes if someone you're assessing demonstrably exhibits serious psychotic symptoms during the interview (and this disconnection from reality can easily be related to potential risk of harm) but I don't think it's strictly necessary for this to happen to meet the criteria for admission under the Act. People with dementia may exhibit some evidence of a mental disorder during an interview, typically, poor recall or being muddled but generally nothing very alarming without this diminishing them being a risk to themselves due to inadvertent self neglect, guerilla DIY activities, a different attitude to road safety or whatever.

    The difficulty is often having to evaluate uncorroborated reports from supporters. I think I, like your Police colleagues, would have been starting to wonder about Siobhan's mother's intentions and perhaps also, her mental health. Shows the importance of staying with an assessment: well done you for the follow up appointment.

    Good post.

  2. On the last occasion, Siobhan probably was psychotic, otherwise she would have had a rational attitude the time it takes to get rid of you. Maybe, if she was not dangerous, she should have been allowed to live in her own special world, not detained, but I don't think we'll agree on that. Your job is, after all, to police irrationality and take away the irrational people. However, I can't believe she was detained before, when she was clearly normal, and for two weeks at that! That's outrageous! If someone is capable of faking normalcy for the purpose of avoiding unwanted psychiatric intervention, I would say that the person is rational. If he or she is, in fact, irrational the rest of the time or secretly harbouring some irrational belief (the one about alien invaders is a good example), then that is the person's choice, and you should respect that. Doing what it takes to get you off his or her back proves that the individual in question is, in fact, capable of being rational by your own criteria and that whatever behaviour you would find irrational or inappropriate is, in fact, freely chosen. You should respect that choice. I am not sure why people must be forced to live in your reality if they really cannot, but if they can and still choose to live in their own reality instead, they are making a perfectly valid and rational choice that should be respected.

  3. Monica, I'm not sure if we can validly call a fellow AMHP's decision 'outrageous' when we're not in the thick of an assessment ourselves. Sure, it sounds a bit iffy to me, but the AMHP makes it clear he agonises over the decision, finds it difficult to weigh up the conflicting aspects of the assessment and only makes his decision 'with heavy heart'. Faced with a 50/50 decision, what often decides is a kind of 'sixth sense', not always easy to describe in rational, logical terms.
    But in the light of that decision, I'm possibly more surprised at the subsequent assessment decision not to admit after Siobhan had 'assaulted a number of people'. This, let's call a spade a spade, dangerous and criminal behaviour is never explained, so to my mind the risk factor is definitely present.
    The account also ends very abruptly with the S4 (definitely justifiable!) and I'd like to know what happened thereafter.
    But I enjoyed the article and there's plenty of food for thought there!

  4. She had not necessarily assaulted a number of people. That's just what her mother said. Her mother could have been lying. Family members are, in fact, known to resort to such tricks when they believe that securing treatment for their relative (or getting their relative off their back through hospitalization) justifies the means.

  5. Monica. I think it's inaccurate to say people are detained for being irrational. There also has to be significant risk to themselves or others. In this case there was the children to consider. Recently a mother killed her children due to her 'irrational beliefs' and mental health services were found to be partly to blame. also the masked AMHP explained how it is possible to mask symptoms as part of a delusional process. Just because someone is delusional doesn't mean they are not clever. I have worked with clients as a care coordinator and an AMHP for many years without considering a MHAA when they have been overtly delusional as there have been no significant risks to themselves or others.

    Having said that the prognosis for the treatment of schizophrenia worsens the longer it goes untreated so there is an argument for use of forced treatment in the interests of the persons health if it is assessed that the likelihood of accepting treatment at any time in the future is low. There is a difference between irrational thinking and psychosis.