Sunday, 27 January 2013

When Service Users Seek to Deceive Part III

For about 15 years, from the early 1980’s to the late 1990’s, I used to do sessions on the Social Services Standby Team. You would cover nights and weekends, as well as doing your fulltime day job.

It always seemed to be that the oddest and most perplexing cases turned up outside normal working hours. Nigel was certainly one of those.

One Saturday afternoon, I received a call from the Charwood Samaritans. They needed the help of a social worker. However, it was not the sort of problem that the Samaritans usually dealt with.

Nigel had turned up at their offices out of the blue in some distress. It had taken them a while to coax the story out of him. They eventually gathered that Nigel had been living in some sort of residential facility in a county about 150 miles from Charwood. They thought he probably had learning difficulties. He told them that one of the staff had shouted at him, so he had decided to leave. He had packed a few belongings in a bag and had left.

He had then gone to the local coach station and had got on a random coach, which had eventually dropped him off at Charwood bus station. Lost and upset, he had found the first place that seemed to offer help.

My first step was to try and find out more about him. If he had left a residential care home, then he would have been reported as missing. I rang the standby social worker for the area he had apparently come from to see if they had an alert out on him. Unfortunately, he was unable to tell me one way or the other.

I decided I would have to see Nigel, and make an assessment of the situation. If he appeared to be a vulnerable person, I would then need either to arrange bed and breakfast for him through the local housing authority, or if necessary, try and find an emergency residential placement for him until we could return him to his home area.

When I arrived, one of the Samaritan volunteers took me through to a side room where Nigel was ensconced with a cup of tea, three sugars, and a sandwich.

Nigel appeared to be in his forties. He was wearing an anorak zipped up to his neck and had a round face and rosy cheeks.

“Hello,” I said to him gently, and told him my name. He peered up at me through the thick lenses of his glasses. “I Nigel, thank you” he replied.

I attempted to find out from him his full name, his address, and a contact phone number. He told me the place he had come from, but was unable to give me names of carers or a phone number.

“The bad man shouted at me,” he said. “I didn’t like it. So I wanted to leave. So I got a coach. I got off here. Here I am, thank you.”

I asked him if he had any sort of identification. He shook his head. I asked him if he had any medication with him. He took a bottle of pills out of his duffel bag and showed them to me. They were anticonvulsant tablets. They came from a pharmacy in the town where he said he had run away from.

It was apparent to me that Social Services would have to look after him until he could be returned to his home county. He seemed far too vulnerable just to arrange bed and breakfast.

Being many years before cheap mobile phones were available, I was reliant on the Samaritans to let me use their phone. They were kind and accommodating. One of them showed me into a small cubicle which contained a small desk, a phone, and a chair. It was one of the cubicles the volunteers used when they were manning the Samaritans’ helpline.

I started to make calls to the social services residential homes that specialised in learning difficulties. I then had to wait while staff talked to managers and managers talked to staff.

After a wait, one of the care homes rang me to confirm that they could accommodate Nigel on an emergency basis over the weekend, until further enquiries could be made.

I went to see Nigel and explained to him what was happening. He seemed a bit apprehensive.

“They won’t hurt me? They won’t hurt me? I don’t like it when they hurt me!”

He suddenly stood up and picked up his duffel bag.

“I go to the bus station. I get a bus, thank you.”

“It’s OK, Nigel, nothing’s going to happen. You’ll be safe.”

He eventually calmed down and allowed me to take him to the care home.

The next day being Sunday, I rang the next social worker on duty and explained the situation to them. They would chase up the local authority where he came from and get some more information, and hopefully arrange for his safe return. And that was the end of my involvement.

I happened to see my standby colleague a week or two later.

“Remember Nigel?” he said. “I got through to his local authority. I managed to speak to someone who knew him. They knew him all right. He’s not from any of their care homes – but they did accommodate him in one a few weeks ago when he turned up on their patch one weekend saying that he’d run off from somewhere in another county a long way away. That is, until they made their own enquiries – and got the same story. Then they sent him on his way! Once we found this out, we confronted him with it and he left, rather quickly. I wonder where he is now?”

There is a postscript to this story.

I was speaking to a social worker in a neighbouring county a couple of years later. I told him the story of Nigel. He immediately recognised him.

“We put Nigel up in one of our mental health care homes for about 6 months,” he said. “Then we had a full psychological assessment done, and it turned out that he had a completely normal IQ and everything. Then he mysteriously disappeared.”

From time to time I think of Nigel, traveling the country, turning up in distress, like a lost person with learning difficulties, in need of care and shelter, being taken in and looked after, at least until the truth about him was found out, then moving on again. What drives someone to live their life like that?

He’s not the only one who does it. I knew of another case which happened in our county, of a young girl, apparently in her early teens, who presented herself one day, wearing a nightie and clutching a teddy bear, claiming to have been abandoned. She was placed with foster carers for several months, until it was discovered that she was actually 25 and had the tenancy of a flat in another part of the country.

Does it constitute a mental disorder, or is it simply a means to an end, a way of being looked after without any responsibilities? How many are there like Nigel and the “little lost girl”? And how many are so successful that they’re never found out?

Sunday, 20 January 2013

When Service Users Seek to Deceive Part II

Borrowed from the excellent Little People Blog
Warning: this post may contain triggers for abuse.
During the more than 20 years that I have been based in a CMHT, I have worked with literally hundreds of women and men who have been the victims of childhood sexual abuse, rape and domestic violence.
One of the greatest fears that abuse survivors have when they disclose their abuse is that they will not be believed. That is one of the reasons why, as a matter of basic practice, I always believe what service users tell me. After all, I often tell them, why would anyone want to make up those sorts of stories?
I also often say to those people that out of the hundreds whose stories I have heard, there has only ever been one who did not tell the truth.
Trudy was 25 years old when I first met her. She already had a considerable psychiatric history, including depression, anxiety, and bulimia, and had recently had a spell as an inpatient. She also had dependency problems with amphetamines and other drugs. As a result of all this, she had split up from her husband, and he had got custody of their two children.
When I assessed her, she told me, without going into any detail, that at the age of 16 she had gone to live with an older man whom she described as a gangster. While she lived with him, she was terrorised by him, and had to endure nameless sadistic practices, until she had eventually managed to escape his clutches and move to another part of the country.
Through copious tears, she described a range of symptoms of post traumatic stress disorder, including nightmares, flashbacks and intrusive thoughts and memories.
She decided that she needed to disclose the details of the abuse she had suffered at the hands of this man.
However, she was very avoidant. She would cancel appointments, or forget to come, or find other reasons why she could not attend. This pattern continued for over two years, with far more cancellations and DNA’s than actual sessions.
When we actually did have a session, she would frequently become so distressed and tearful that she was unable to speak.
Eventually, we devised a plan in which Trudy would write about specific incidents at home, and she would then bring the printed account to the session. I would then read it through, and it became possible for her to begin to debrief these events. His abuse of her, according to these exceptionally graphic and lurid accounts, was almost unimaginably sadistic. It was not surprising that she had been traumatised by this relationship, and that she now found it so hard to deal with it.
However, she reported that things were gradually improving as a result of these sessions. The trouble was, we would have one or two good sessions, then there would be a series of cancellations or no shows.
During this time Trudy had a number of acute psychiatric admissions. Various sorts of medication were tried, with little success. At the time, the CMHT did not have a clinical psychologist, but a psychologist from another team showed me how to practice EMDR (Eye Movement Desensitisation and Reprocessing), a technique in which the subject recalls a traumatic event while the therapist moves a pen or other object from left to right in front of their eyes. The technique is supposed to disconnect the emotion from the event, and hence to reduce the traumatic recall.
I tried this technique with Trudy, with quite remarkable results. She reported an improvement in her emotional response immediately. We therefore did several sessions, and the improvement continued.
Trudy worked hard to regain control over her life. She stopped abusing amphetamines. She started to do volunteer work, she went on a diving course, she began to address her weight problem, and on our last session she told me she was planning to take an HGV course. She was discharged from the CMHT.
It was very gratifying to see the change in Trudy, and to feel that I had in some way helped her.
Then a few months later, she unexpectedly turned up at the CMHT asking to see me urgently.
I took her into an interview room. She presented in a way I had never seen her before. She seemed agitated, but also almost elated.
“Masked AMHP,” she said to me, “There’s something I need to tell you. You know all that stuff I told you about, about that relationship? None of it was true. I made it all up. None of it happened. And when I went into hospital? I just pretended to have those symptoms.”
I didn’t know quite how to respond. I didn’t know quite how I felt. How could she have deceived me so well? And not just me – how could she have pulled the wool over the eyes of all the inpatient nursing staff and psychiatrists?
“Why do you think I did that?” she asked me imploringly. “Why did I make all that stuff up?” She seemed desperately eager for my response.
"Well,” I said at last. “There is a mental disorder called Munchausen’s Syndrome. That is when someone pretends to have an illness, and feigns the symptoms, and often convinces medics that they are really ill. It’s more usually about physical illness. Such people often end up having many operations and courses of treatment.”
“I see,” she said, as if this was a remarkable revelation. “That sounds like me, doesn’t it?”
“Then there’s Munchausen by proxy, where a parent pretends their child is ill, or even feeds them poison to make them ill, and then seeks medical help.”
Her eyes lit up.
“But I used to do that!”
“What?” I said.
“I pretended that my son was having epileptic fits. He had all sorts of tests, he was even admitted to hospital for a while. He was on medication. Of course, there was nothing really wrong with him.”
These revelations were even more difficult to process. Although her children were no longer in her custody, I knew I would have to report what she had told me to Children’s Services.
“You need to help me,” she continued. “I need help. You see, even though the other stuff wasn’t true, what is true is that my Dad sexually abused me when I was a little girl.”
“What was the nature of the abuse?” I asked her.
“I can’t actually remember anything. But I know he abused me, and I need help.” But her presentation was incongruent with what she was saying. Her eyes were wide. They glittered. She was excited.
“We can’t do any more today,” I told her. “You were discharged from us months ago. You’ll have to get your GP to refer you again.”
However, she moved out of the area shortly afterwards. I never saw her again.

Saturday, 12 January 2013

The Masked AMHP Featured in

The Masked AMHP was recently featured on's site in the Frontline series. Banging on about clustering and Payment by Results again. Here is the post in full. It can also be found here
I am a mental health social worker and Approved Mental Health Professional working in a community mental health team. My AMHP role means that I have the power to apply for the compulsory detention under the Mental Health Act of people with mental disorder. However, this is a power I do not take lightly, and indeed, most of the time I am advocating for people with mental health problems and attempting to keep them out of hospital.

I’ve been writing the Masked AMHP blog for the last 4 years. Having been involved in the training of social workers for many years, I thought that writing about the reality of the job of social work in mental health was a good way of giving an insight for those interested in the nature of my job. I wanted to be both informative and entertaining. I hope I have achieved that.

The knowledge that mental health practitioners, and the service users with whom they work, have of the day to day experience of having a mental health problem could and should be used to inform policy in this area. We know the effect that mental illness has on people’s life opportunities; we see and experience on a daily basis the positive and negative effects of social policy. Imaginative and joined up social policy initiatives can have a profound effect on the ability of people with chronic mental disorder to live full and productive lives and to contribute to their communities.

The move away from hospital based mental health provision to community services in the 1980’s and 1990’s was immensely important. It placed a wide range of mental health professionals, including doctors, social workers, nurses, psychologists and occupational therapists together in teams which were focused on providing efficient and cost effective services within the communities in which service users lived. And when it was adequately funded, it worked very well.

However, in recent years, policy changes focused on reducing expenditure at whatever social cost, and based on the ideology of the Private Sector being best, threatens to destroy the best aspects of community based mental health services.

The radical refocusing of the NHS, which fully comes into effect this April, has already had a disastrous effect on service provision, with Mental Health Trusts being forced to redesign their services according to year on year swingeing cuts in funding. Not only are many hospital beds being closed, but frontline clinical staff are also being cut to an alarming extent: typically, 20% of frontline staff, the people who actually work face to face with people with mental health problems, are being axed.

An integral part of this redesign is the concept of Payment by Results. Although this was apparently designed and approved by the Royal College of Psychiatrists, it does not obviously bear the signs of having been constructed by people with first hand experience of mental illness. Rather than focusing on how mental illness affects people in their daily lives, it concentrates on identifying their symptoms and then designating them to “clusters” of symptoms. These then define the treatment package that they should receive.

Although that sounds superficially patient centred, in fact the true reason for clustering service users is so that these clusters can be used as a “currency” for the allocation of financial resources. This is an explicit intention of the policy.

And once you have defined individuals in terms of their “clusters”, then it becomes possible for agencies and organisations outside of the NHS to bid to provide the treatment packages defined by these clusters. This lays the NHS open to piecemeal privatisation of services, leaving only the most difficult patients to be treated by an impoverished rump of the NHS. This is exactly what is currently being proposed in changes to the Probation Service.

At the same time that these finance led, rather than needs led, changes in mental health service provision are being made, the reductions in welfare benefits will be implemented.

In an article published in the Guardian on 09.01.13. Aydin Djemal, the chief executive of the Disability Law Service, which provides legal advice to disabled people, says "Austerity is already hurting the most vulnerable, but in truth the greatest impact is yet to be felt." The article goes on to say “Local authority cuts will start to kick in after April, hitting social care services and charities which support disabled people. Legal aid funding will be drastically cut back, and more benefit reforms will kick in. ‘We expect to hear more and more cases of disabled people having their basic dignity taken away from them,’ says Djemal.”

It is a depressing prospect for both mental health services users and those professionals still trying to help them.

Friday, 4 January 2013

Powers, Rights and Functions of the Nearest Relative

The Masked AMHP (with briefcase) informs the Nearest Relative of their rights -- with hilarious consequences. Publicity shot for the West End Hit “Principal Changes in the Mental Health Act 2007 – Missus!”
The Nearest Relative, as defined within the Mental Health Act, has an important role to play.
The Reference Guide (Chapter 33) states:
“33.2 The Act confers various rights on patients’ nearest relatives in connection with detention, supervised community treatment (SCT) and guardianship under the Act.
33.3 These include rights to:
• apply for detention or guardianship;
• object to approved mental health professionals (AMHPs) making applications for admission to hospital for treatment or for guardianship; and
• (with various exceptions) discharge patients or (in certain cases) apply to the Tribunal instead.
33.4 Nearest relatives are also entitled to be given information in respect of patients in a variety of circumstances.”
Let’s have a look at these rights and powers in more detail.
The Nearest Relative’s power to apply for detention or guardianship
The NR has had this power since the 1959 Mental Health Act. Having practiced under the 1959 Act for a couple of years, I am aware of anecdotal accounts of  Nearest Relative applications under the 1959 Act. While rare, they were certainly not unheard of. The ones I knew about generally seemed to involve some form of skulduggery by the Consultant Psychiatrist who was making the assessment, who conveniently provided the forms for the NR in the knowledge that, had they asked a Mental Welfare Officer, as they were known in those days, the MWO would have been unlikely to have made an application.
Given that the whole point of Approved Social Workers (and AMHP’S) was to provide a professional with extensive knowledge and expertise in mental health and the law relating to mental health who wasn’t a doctor, it was something of a surprise to me, and to others, when the 1983 Act did not abolish the right of the NR to make an application.
It was even more of a surprise when the 2007 Act, which amended the 1983 Act and created AMHP’s, also did not abolish this right.
The Act and the Guidance to the Act cannot seem to quite make up their minds as to whether or not to approve of one relative sectioning another relative. The wording of the Act always gives either/or AMHP or NR. The Reference Guide, however, states:
“AMHPs must make an application if they think that an application ought to be made and, taking into account the views of the relatives and any other relevant circumstances, they think that it is “necessary and proper” for them to make the application, rather than the nearest relative (my italics)” (2.36)
This almost seems to imply that an AMHP has to make a specific reasoned decision to make the application themselves, rather than letting the NR do it as the default.
However, the Code of Practice seems to have a much firmer view on the use or otherwise of the NR in these circumstances. 4.28. states:
“An AMHP is usually a more appropriate applicant than a patient’s nearest relative, given an AMHP’s professional training and knowledge of the legislation and local resources, together with the potential adverse effect that an application by the nearest relative might have on their relationship with the patient.”
It further goes on to say:
“Doctors who are approached directly by a nearest relative about making an application should advise the nearest relative that it is preferable for an AMHP to consider the need for a patient to be admitted under the Act and for the AMHP to make any consequent application… Doctors should never advise a nearest relative to make an application themselves in order to avoid involving an AMHP in an assessment.” (4.30)
But then, having stated quite unequivocally the preference for an AMHP to undertake an application under the Act, it goes on to say:
“An AMHP should, when informing the nearest relative that they do not intend to make an application, advise the nearest relative of their right to do so instead. If the nearest relative wishes to pursue this, the AMHP should suggest that they consult with the doctors involved in the assessment to see if they would be prepared to provide recommendations anyway.” (4.79)
I have to say that I have some difficulty with this. If, as an AMHP, I have made the professional decision, based on an extensive assessment of all the circumstances of the case, that an application for detention is not appropriate, why would it be ethical to then advise the NR that, although you are not going to make an application, they can do so themselves?
Despite this being an explicit requirement in the Code of Practice, I suspect that many AMHP’s would not go out of their way to bring this to the attention of NR’s.
And, considering that the decision-making in many assessments is a group process which involves discussion between the medical practitioners and the AMHP, and that they then reach a unanimous decision to detain or not, for the AMHP to then suggest that the NR consults with the doctors “to see if they would be prepared to provide recommendations anyway” seems disingenuous to say the least.
Then the Code later on seems to contradict itself:
“If the nearest relative is the applicant, any AMHP and other professionals involved in the assessment of the patient should give advice and assistance. But they should not assist in a patient’s detention unless they believe it is justified and lawful (my italics).” (11.15)
If the AMHP and other professionals involved think that detention is justified and lawful, then the AMHP is going to make an application. If, however, they do not think it is justified and lawful, why on earth are they going to advise the NR of their powers to make the application?
Having laboured this point at considerable length, I have to say that neither I personally, nor any of my ASW/AMHP colleagues, have ever come across an application for detention made by a Nearest Relative. And the chances of a NR making a unilateral application for guardianship, when the local authority would have to give its approval, seems even more unlikely.
Actually, I will qualify that previous statement. I have on one occasion come across the use of the Nearest Relative Application form under the MHA 1983. I'll tell you about it, if you'd like to know.
I was once asked to attend Charwood Psychiatric Unit to assess a patient who had been admitted the previous night. They were coy over the phone about the circumstances of the admission.
When I arrived, the charge nurse took a piece of paper out of the patient's file and gave it to me. He told me that when the ambulance had arrived at the hospital the previous night, the patient had it in their hand.
It was a most extraordinary document. It was the Nearest Relative Application form for admission under Sec.4 MHA. The form had been completed by the patient's NR, and signed. However, in the space for the NR to state the reasons why a second medical recommendation could not be obtained, the patient's GP had written: "I hereby certify that this patient needs to be detained under the Mental Health Act." The GP had then signed and dated it.
There was another unusual thing about this document. It had been torn into several pieces, and then sellotaped back together again. It was explained that when the admitting nurse had examined the documentation, their first response was to tear it up and throw it in the bin. However, they had then later regretted this, and had tried to put it back together again.
In any case, it did not provide authority for the patient's detention.
This is probably a good illustration of why it is generally best to leave the assessment to an AMHP.
In practice, the NR is usually very thankful that the AMHP is taking the initiative and making the decisions about detention. Most NR’s would be very unhappy about being responsible for the detention of their relative, and with reason think that doing this could jeopardise their future relationship with the patient.
The NR’s right to object to an application for admission for treatment or guardianship
This is something I’ve covered extensively in other posts on this blog. (See here and here.) Both the Act and subsequent case law make it very clear that the AMHP must take considerable steps to attempt to consult with the NR, as the courts take very seriously this right and expect the NR to been given the opportunity to exercise their rights in this respect.
Of course, if the NR does object, there are remedies; in particular, the AMHP can go to court and have the NR displaced, if they are considered to be acting unreasonably. However, this is something of an intimidating and onerous task for a beleaguered AMHP, and they are unlikely to get a lot of help from their legal department.
The NR’s right to discharge a patient
While the NR has a right to apply to the hospital managers for the discharge of their detained relative, a number of impediments are placed in the way of achieving this. Sec.25 states that they must give 72 hours’ notice in writing to the managers of the hospital. However, even were the NR to do this, the psychiatrist then has 72 hours to block the application.
Although this is something that AMHP’s have a duty to inform the NR when they make the decision to detain someone, in practice, if they ever tried to exercise this right, all the patient’s psychiatrist has to do is fill in  Form M2, “Report barring discharge by nearest relative”. The consequence of this is that “any order for the discharge of the patient made by that relative in pursuance of the notice shall be of no effect”, and as if that is not enough to deter the NR, “no further order for the discharge of the patient shall be made by that relative during the period of six months beginning with the date of the report.”
So all in all, the rights of the Nearest Relative are far less straightforward than the Reference Guide would imply, and there are a number of impediments to their exercise of these rights which can mean that they are often of little practical use.