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.

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