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.


  1. Wow. All I can add to this is never, ever, let them know you don't know what you're doing, always say to yourself, at least I know more than them!

  2. Long ago I also used to do some of those scary Sections. I particularly remember a psychiatrist who used to go to examinations in the community with a huge and fully loaded syringe. In a melee this provided an additional worry. Would it be the patient, the doc or the social worker who would end up getting the injection.

    Nowadays of course, The police hit squad is call out to deal with mental health emergencies.