Gerry was a 19 year old young man whose father was a banker. He had attended a private school and had done very well academically. He was in the middle of his gap year prior to commencing a degree in Art History at university when his behaviour became more and more erratic and grandiose. He used his new credit card to pay for the publication of a book of (truly awful) poetry from a vanity publisher, made plans to hire a recording studio and session musicians to record a rap album, and had announced to his parents that he no longer needed to sleep because his brain was receiving energy directly from the cosmos.
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.
However…
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.
Friday, 9 October 2009
Wednesday, 16 September 2009
Ones That Got Away (Or Tried To) Part I
I already knew Ian. At the beginning of the year I had been called out to assess him at his flat. His family had contacted the GP because he had been saying "funny" things, and his behaviour had become increasingly odd. He was very paranoid, and had been carrying a hammer around for protection. He had told his family that he believed he was being gassed, that gas was coming out of the electricity fittings, that people on TV were talking to him, that he was "not going to be here much longer" and was "going to die". He was becoming increasingly reluctant to allow even family members into his flat.
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.
We left.
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.
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.
We left.
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
Just Another Day
First thing in the morning I had to go to Woodland House, our local psychiatric hospital, to attend a Managers Hearing for a patient detained under Sec.3 MHA. Denise had been detained a couple of weeks previously, and had appealed. Patients have the right to appeal against their detention under the MHA. Their case will first be heard by a panel of Hospital Managers: these are essentially unpaid volunteers rather than NHS employees, who have an interest in the functioning of the psychiatric hospital. They have the power to discharge a patient from detention. If they refuse to discharge the patient, the patient can then appeal to a somewhat more judicial Tribunal, which is a panel consisting of a lawyer, a consultant psychiatrist, and a lay person.
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.
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
The Mental Health Act Assessment of Fear
One thing I have learned as an AMHP is never to show patients that you are frightened of them. (Come to think of it, hints and tips for AMHP’s would be a good subject for a future blog). I have been in numerous situations over the years where I have anticipated danger or been threatened with harm, but have in reality been physically assaulted only rarely, and generally where I have misjudged a situation. (Mmmm. There’s another subject for a future blog.)
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.
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
Lost in Translation
Over the last few years our comparatively quiet rural town has experienced an influx of workers from the European Community. They have come in distinct waves. First it was the Portuguese, who found that they could earn enough in a few years in this country from seasonal work on the land and factory work processing food and vegetables to return to Portugal and buy their own farm. Then there was an influx of Eastern Europeans with similar ideas – in particular, Poles, Latvians and Lithuanians (often, it seems, graduates prepared to do menial work for more money than they could earn in their own countries following their professions, or young people wanting to make enough money to return to their home country and go to university). Best estimates put the current population of non English speaking EU nationals in the town as 10-15%.
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).
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
Is Diogenes Syndrome a Mental Disorder?
Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.
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?
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
“God told me not to answer the door!”
Jenny has the dubious distinction of being the person I have assessed under the MHA more than any other, a total of 11 assessments over a 7 year period. She is a good example of a “revolving door” patient, ie someone with a severe and enduring mental illness complicated by an unwillingness to engage with services, and a reluctance to take medication, who frequently relapses.
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.
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.
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