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.

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).