Thursday, 25 June 2009

Is it a sin to section Jesus Christ?

The call came from the local police. They had a 19 year old male in the cells on a Sec.136. He had been found walking the streets in the middle of the night stark naked. When asked to give his name, he told them that he was Jesus Christ.

I spoke to his mother on the phone to get some background. She told me that he had been involved in a car accident a year ago in which his friend was killed. He subsequently became involved in a local evangelical Christian church. He had successfully completed his “A” Levels and then spent his gap year travelling around Asia. He was due to go to University in a few weeks time. He had no history of mental illness, but his mother told me that he was a regular user of cannabis, ecstasy and PCP, and that he had been behaving increasingly oddly over the previous few days.

I went out to assess him. The consultant, the duty GP and I crammed into his cell to see him, as he refused to come out to the interview room. Martin was sitting cross-legged on the floor, completely naked. He had refused all attempts to cover him. He was wearing handcuffs, having refused to allow the police to remove them.

He smiled beatifically at me as I entered, blessed me and told me that he forgave me for my sins. I thanked him and asked him why we would not let the police take the handcuffs off.

“Martin needs to be punished,” he answered. “I am Jesus, the Second Coming. My Dad is God. I am presently inhabiting Martin’s body, as he was killed in a car accident a year ago. Martin is the spawn of Satan, you see.”

“That’s interesting,” I said. “The problem I have is this. I have several times seen people who thought they were Jesus Christ, and they have invariably turned out not to be.”

He considered this, the smile faltering momentarily on his face. Then the sunny smile reappeared and he said, “I’ll prove it to you, my son. I have many powers. I can read your thoughts.”

“Okay, so what am I thinking right now?”

He studied me for a while, then replied: “You’re thinking I’m crazy.”

“Well,” I said, “that really is uncanny.”

We left him in his cell in order to discuss our conclusions. Although he had no previous history of mental illness, it was clear that he was psychotic. It was possible that this had been triggered by drug use, and that the car accident may have contributed to this episode. However, he was so florid there was no option but to detain him under Sec.2 MHA for further assessment.

I returned to Martin’s cell to inform him what was happening. He turned his awesome smile on me as I explained.

“I have made an application for your detention in hospital under Sec.2 of the Mental Health Act. This means you will be detained for up to 28 days. I had to make this decison based on the balance of probabilities: what is more likely, that you are indeed Jesus Christ, as you say, or that you are mentally ill. I am afraid that it is more likely that you are mentally ill than that you are the Second Coming. You do have the right to appeal against this decision.”

His smile completely left his face and was replaced with a poisonous glare. For the first time during the assessment, he appeared to be irritated.

“I died on the fucking cross for you!” he snarled as I left the cell.

A happy ending: Martin made a rapid recovery in hospital. He probably did have a drug induced psychosis. He went to university as planned.

Wednesday, 24 June 2009

My First Mental Health Act Assessment (Part II)

Fast forward to 1981. After two years working as an unqualified generic social worker I did a two year Certificate of Qualification in Social Work course (in those days the training was only two years, and the official social work qualification was the CQSW), and then returned to work in my old area office.

I had been qualified for about a year when the new area officer, Gerald, called me into his office.

“We’ve got a request for a Mental Health Act Assessment. Fancy doing it?”

“I’m not sure I’m qualified to act as a Mental Welfare Officer,” I replied nervously. “I haven’t had any training or anything.”

“Have a look on your social work warrant. What does it say?”

I looked at my ID card. The front had a passport photograph of me, sporting the obligatory long hair and beard of a male social worker of the time, along with my name and the local authority. The back said who and what I was and had the signature of the Director of Social Services. In rather small print in one corner there was a statement which I had never bothered to study: “The holder is authorised to act as a Mental Welfare Officer for the purposes of the Mental Health Act 1959.”

I read this out.

“There you go then,” Gerald said, and proceeded to give me the details of the request.

And that was my full initiation into the arcane world of Mental Welfare Officers.

The person I had to assess was an informal patient on one of the wards of the local Victorian asylum which thankfully no longer exists. Peter was a married man in his 40’s who had been admitted because he was believed to be delusional. Although he had initially agreed to the admission, he was now suspicious that the hospital was a part of the conspiracy against him.

I spent an hour reading up on the Mental Health Act and the relevant sections. I was desperately trying to remember the training I had had on my social work course and the things I had learned from observing a few assessments carried out by other MWO’s. Then I went to the ward to interview the patient.

He seemed pleased to see me.

“This will explain everything,” he said, giving me an exercise book filled with neat handwriting.

I started to read it. It detailed his life when working as an engineer in an African state that had previously been under colonial rule. He had basically lived, with his wife, in a post colonial enclave, which, he said in his account, was run by the Masons. He had never been much enamoured of the Masons, and when he discovered that they were providing local women to single (and married) British men for “personal services”, he decided to blow the whistle on the whole thing.

The Masons had, of course, objected to this, and, according to him, had made it impossible for him to continue working there and he had then returned to his home town in England. Even there, he told me, he had continued to be hounded by the Masons, who were preventing him from getting work and were making his life not worth living.

“And now,” he said, after I had read at least some of the exercise book, “they’re getting to me here. They’re drugging me, they don’t want me to tell. They want to kill me!

I had little difficulty in reaching the conclusion that Peter was extremely unwell, and was displaying clear symptoms of psychosis, including paranoid delusions. The consultant had already completed a medical recommendation, and another doctor had already been to assess him and had left his recommendation. Although I was unable to contact his nearest relative to discuss the assessment with her, I duly completed an application under Sec.25 for assessment (this was the 1959 Act, remember).

It felt good. It had been a comparatively straightforward assessment – the patient was already in hospital, and was displaying clear signs of mental illness. I felt I had managed the whole thing rather well

A few days later, I visited his wife to discuss the situation with her. I told her about the contents of the exercise book, and his belief that the Masons had been conspiring against him.

“Oh yes,” she said. “All that’s true. It did happen. It really got him down. We had to leave the country because of it.”

A month later I completed my second Mental Health Act Assessment when I detained him under Sec.26 of the 1959 Act, for treatment. He was still clearly unwell, but this time he had a diagnosis of depression.

Friday, 12 June 2009

My First Mental Health Act Assessment (Part I)

It was 1976. I had my first job as an unqualified social worker (most social workers were unqualified in those days) in an area office with a mixed rural and semi urban catchment area. I had been working there for 2 months when Gordon, the area officer, called me into his room.

“Would you like to come out with me on a Mental Health Act assessment?” he asked.

Gordon was in his late 50’s. Before the major reorganisation of national social services a few years previously (arising from the Seebohm report, for those who may be interested), he had been what was known as a Mental Welfare Officer. Mental Welfare Officers were what we would now call AMHP’s. MWO’s were created by the Mental Health Act 1959, which introduced the concept of the independent lay person who made final decisions about detention in hospital based on the recommendations of doctors.

Of course I said yes. I was completely new to social work, and keen for experience.

The assessment was on a lady in her 50’s. She was the manager of a social security office. Her GP had rung Gordon because neighbours were reporting that she was wandering around in her garden dressed in nothing but her nightie. It was a chilly November morning, so this was a matter of some concern.

Gordon told me that she was known for this. She would go for months or years without any problems, then one day would wake up and be completely bonkers. A spell in hospital invariably sorted her out.

We met the GP at her house, a nice bungalow in the countryside. We didn’t bother to knock on the door, since we could see her wandering around in the garden in a diaphanous negligee. To see a woman of that age (or any woman come to that) so scantily clad was at the time quite a shock to me, but Gordon took it in his stride.

Gordon put on a rather scary fixed smile which I assume he thought was reassuring and the three of us approached her.

“Hello, June,” he said, “What seems to be the problem?”

She turned and looked at us. She looked at me with an interest that alarmed me. This was the first mad person I had ever seen. What might she do?

“I came out to see the fairies,” she eventually replied. “They’re everywhere. They’re so lovely.”

“Yes, they are, aren’t they?” Gordon replied. I assumed he was “humouring” her. “Why don’t we go inside? It’s quite chilly out here isn’t it?”

She allowed herself to be led through the garden into her house, her bare toes sinking into the damp grass as she went.

Gordon and the GP had a discussion in her kitchen. It didn’t take long. The GP filled in a form and then Gordon filled in another form. This was known then as a Section 29, when someone was detained with only one medical recommendation. Under the 1983 Act it would be a Section 4, which should only be used in cases of dire emergency. However, in those days it was almost impossible to get a psychiatrist to leave the safety of the ward, and Section 29’s were a not uncommon way of getting people to hospital, when the consultant would then convert it to a Section 25 at his leisure.

“Why don’t we go for a ride in my car?” Gordon asked June. “Just put on your coat and come with me.”

“Where are we going?” she asked.

“Just for a nice ride,” he said reassuringly.

I knew even then that this was not the right way to relieve someone of their liberty. Shouldn’t you always tell the truth, even to someone who seemed to be quite literally “away with the fairies”?

Throughout the drive to the hospital, Gordon continued with a stream of reassuring lies, and as we drew up outside the ward he told her that “it would only be a few days. You’ll have a nice rest and be right as rain in no time.” He knew she would probably be in there for several months; hospital admissions generally seemed to be much longer than they are now.

Gordon’s approach seemed to me to be dishonest and underhand. I did not feel he gave June the proper respect. I resolved that I would do my best never to deceive, mislead or patronise a mental health patient, should I ever become a Mental Welfare Officer.

Monday, 1 June 2009

The little girl with the rat on her shoulder

I always find it fascinating how certain forms of dementia can produce the most vivid and outlandish of hallucinations in older people. One man was troubled because “there are 3,474,263 people in my room and they won’t go away.” When I went to assess another elderly man he had pulled up his fitted carpet and piled all his furniture in the corner of the room. When I asked him why he had done this he told me that “there’s lots of calves coming out of the floor and I’m trying to find out where they’re coming from.” There was also a pair of dogs with a litter of pups in the corner, and he would not go into his bedroom because “the ceiling’s covered with thousands of spiders.”

Ethel was an elderly lady with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He sleeps in the garden now – I can’t sleep because I don’t know what he’ll be up to next.” When I assessed her last year, she was adamant that this man existed. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under Sec.2 MHA, and on discharge agreed to take medication and accept a package of home care -- although she was still absolutely convinced there was a man living in her garden.

A few months later the older people’s psychiatrist came to see me. The man in the garden was causing Ethel more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.

I went round with the psychiatrist, Ethel’s GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder. The man was “getting on her nerves.”

Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.

In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state. The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect. It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.

In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment, and this time we decided to go for a Sec.3. “I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.

She complained of chest pains on the way to hospital. I began to panic inside – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.

“But I haven’t had anything to eat today,” she said.