Wednesday, 22 December 2010

Are You Mad? A Merry Christmas Quiz

Are you mad, or just a sandwich short of a picnic? Are you completely sparko-balarmey, or just a bit swivel-eyed? Find out today with the Masked AMHP’s fully peer-reviewed and scientifically validated rating scale!

1. How are you today?
(a) OK.
(b) Not so good, actually, since you ask.
(c) I am perfectly fine and I am taking my medication, honestly.

2. Do you ever hear voices when there’s no-one else there?
(a) No.
(b) Occasionally, just as I’m about to fall asleep.
(c) The voices told me not to tell you anything.

3. Which section of the Mental Health Act detains a patient in hospital for up to 6 months for treatment?
(a) Section 3.
(b) Section 2.
(c) Can’t I go in informally this time?

4. The UK Coalition government is:
(a) an inevitable and acceptable consequence of our democratic system.
(b) a right-wing stitch-up.
(c) a conspiracy by the Lizard People from Procyon 5 to take over the world for their own nefarious purposes.

5. Do you ever feel that you are receiving messages from your TV?
(a) What are you talking about?
(b) I do sometimes feel as if certain programmes have a special significance, now you mention it.
(c) I wish Kate Silverton on BBC 1’s Breakfast programme would stop flirting with me.

6. Do you ever feel that people are watching you, or talking about you, or following you?
(a) No.
(b) I’m too worthless for anyone to be that interested in me.
(c) Who are you looking at?

7. Do you ever feel as if thoughts are being taken out of your head?
(a) No.
(b) I haven’t had any problems since I started to wear a tin foil helmet.
(c) Pardon? I was miles away.

8. Do you ever get the feeling that your mind is being controlled by a radio transmitter located on the far side of the Moon?
(a) Never.
(b) Funny you should say that…
(c) I am perfectly fine and I am taking my medication, honestly.

9. Is antipsychotic medication useful for controlling the symptoms of psychosis?
(a) It can be very effective as a component of the Care Programme Approach, providing this is in conjunction with a comprehensive package of community care.
(b) I prefer to take vitamins and go to Yoga classes.
(c) It is actually possible to palm those velotabs if you’re quick and can distract the nurse.

10. How often do you find an Approved Mental Health Professional and two doctors knocking on your front door?
(a) What’s an Approved Mental Health Professional?
(b) Hardly ever.
(c) I am perfectly fine and I am taking my medication, honestly.

How you score: (a)=0, (b)=1, (c)=2

A score of less than 5: You’re probably not mad at all.
A score of 6-12: You’re a brick short of the full load.
A score of 13+: You’re almost certainly barking. There’s no point trying to hide. We know where you live.

Wednesday, 8 December 2010

Anorexia, the Mental Health Act – and Kayleigh

Anorexia Nervosa is a fairly common mental disorder; the most common age of onset is 10-19 years of age; nine out of ten patients are female. Anorexia is also a mental disorder that can be fatal: chronic starvation can lead to a range of life threatening conditions, including heart problems and kidney failure. Indeed, it is estimated that as many as one in five of patients with anorexia will die each year.

So there shouldn’t be any problem using the powers of treatment in the Mental Health Act with people with anorexia, should there?

That certainly wasn’t the case in the 1990’s. Some mental health professionals did not like the idea of compelling someone with a mental disorder to receive physical treatment (for example, tube feeding or rehydration), and often the MHA was not used, even when a person’s life was at risk.

I could never understand this. As far as I was concerned, anorexia nervosa was a mental disorder within the meaning of the Act, both then and now, and if someone’s life was in danger as a result of this disorder, then I had no ethical problem in using detention under Sec.3 to ensure that they received appropriate treatment. Over the years I have detained several people with anorexia under the MHA, simply in order to save their lives.

Then in 1996 there was the case of Nikki Hughes. Nikki Hughes was a young woman who had suffered from anorexia since her teens, who died in January 1996 as a result of starving herself. The doctors treating her had sought legal advice regarding feeding her without her consent, and they were told that this could lead to charges of assault against the doctors and the hospital. She was therefore allowed to die.

In response to this case the Mental Health Act Commission issued guidance in 1997, stating in part that some patients "may not be able to make an informed choice as their capacity to consent may be compromised by fears of obesity or denial of the consequences of their actions". The Care Quality Commission issued updated guidance in 2008 (Guidance on the treatment of anorexia nervosa under the Mental Health Act 1983). While the CQC believes “that it is only in its most severe manifestations that anorexia nervosa may be considered to require compulsory admission” they advise that detention is justified “in rare cases of serious threat to health, where compulsory feeding may be necessary to combat both the physical complications and the underlying mental disorder.”

However, there have continued to be cases where people with anorexia have died, when use of the MHA may have prevented it. In 2004 Samantha Price died from heart failure at the age of 22. Her family maintained that she should have been detained under the MHA, but the South West London and St George's Mental Health NHS Trust said that “forcing patients to come into hospital for treatment against their will simply does not work with patients like Samantha”.

As recently as this year Jonathan Edwards died of complications arising from his anorexia. Newspaper reports of the inquest (Swindon Advertiser, 29th June 2010) stated that his mother had told the coroner “that her son’s only hope of survival was to be sectioned and forced to eat by trained eating disorder specialists.” Despite the CQC and other guidance, it was still stated at the inquest as fact that “as Jonathan acknowledged his condition and periodically asked for help, to section and force feed him would have been illegal.”

I recently received a request from the Charwood Child and Adolescent Mental Health Service (CAMHS) to assess Kayleigh for detention under the MHA for treatment. She was just 17, and had a 2½ year history of anorexia nervosa. During that time, she had had two informal admissions to the regional children’s anorexia unit. Two weeks before referral, she had had an acute medical admission with a severe infection, as a result of poor nutrition, and had nearly died. She had also suffered damage to her heart because of the anorexia, but persisted in playing in the local basketball team, even though she had been warned that such exertion could be dangerous.

A couple of days before I saw Kayleigh, her care coordinator had calculated her Body Mass Index as less than 14 (20-25 is normal), and her blood pressure was dangerously low. Even though there was evidence that her very poor physical condition was putting her life at imminent risk, she remained in denial that she was not feeding herself adequately, and there was evidence that she was “water-loading” when she knew she was going to be weighed in order to deceive her workers.

A further concern was that her mother, with whom she lived, was colluding in some way with Kayleigh, and was herself in denial of the seriousness of her daughter’s condition.

Her CAMHS consultant, another Sec.12 doctor and I went to see Kayleigh at home. We expressed our concerns about her current condition, and the fact that she was still losing weight, despite her recent medical admission. However, she was not prepared to consider a hospital admission.

“I am all right, you know,” she said. “I’ll be fine as long as I can have therapy and treatment at home.”

“But therapy clearly hasn’t been working for you,” I said. “You nearly died a couple of weeks ago, but you still don’t seem to think there’s a problem. Do you want to die?”

“No, of course not. I enjoy life. I like playing basketball.”

I noticed that her knuckles were grazed. “What happened to your hand?” I asked her.

“Oh, just had an argument with a wall. I punched it out, that’s all. It’s nothing.”

This eventually led in to an admission that she had been cutting herself over the last few days. She also admitted that she had told her care co-ordinator that she had been feeling suicidal, and was also afraid that her mother might kill herself if Kayleigh wasn't there to keep an eye on her. There was obviously a lot going on.

Despite all this, she didn’t come across as being clinically depressed. But there was overwhelming evidence that her anorexia was controlling her. If it continued, she might very soon, within a matter of days, reach a point at which her body would not be able to recover from the damage that had been done. We concurred that she was unable or unwilling to consider that her behaviour was placing her at grave risk, and that she was powerless to modify her behaviour or recognise the risks. As she undoubtedly had a mental disorder within the meaning of the Mental Health Act, and it was clear that the only way she was going to receive necessary care and treatment was through admission to hospital, we completed an application for her to be detained under the MHA.

Of course, that was only half the problem. Once the decision to detain had been made, I knew that the specialist unit where she had been before had no beds, and the only bed that had been identified was in a private hospital with a child and adolescent ward over 70 miles away. And I would have to get her there. This is a common problem with children and adolescents. Young people under the age of 18 cannot be admitted to an adult psychiatric ward, and there are no suitable beds at all in the county in which I work.

We also had to inform Kayleigh’s mother of the decision. As we anticipated, she was not pleased. I informed her of her rights as nearest relative, which include the right to apply to the hospital for the discharge of her daughter, and she informed me of her intention to exert her rights at the soonest available moment. Kayleigh also expressed her intention to appeal against her detention.

Since the consultant had indicated to me that there were no imminent medical reasons why she needed to be transported in an ambulance, I offered to take Kayleigh, with her mother, to the hospital. I knew from bitter experience that the local ambulance service would be less than keen to transport a patient to a hospital so far away, and would therefore delay it until the shift change. I could foresee a delay of 5 or 6 hours before an ambulance would arrive, which would not be in the interests of the patient, who would just get more and more wound up waiting – and I confess it would not be in my interests, as I could see that I would not get home until late evening.

Kayleigh’s mother somewhat reluctantly agreed to this. I suggested that we went straight away (it was about 1pm), but mother asked for an hour to get things ready and to have some lunch. I agreed to this, although later on wondered quite how much of a lunch Kayleigh was going to have, and when I returned to the house I half expected the two of them to have disappeared.

But they were both present and ready to go, and by now more resigned to the inevitability of the admission. I took them to the hospital without incident.

And Kayleigh’s still alive.

Thursday, 25 November 2010

An Encounter with Grendl

I wrote about Perdita in my post “The Section 2 That Wasn’t” in January 2010. She has a diagnosis of Emotionally Unstable Personality Disorder and Dissociative Identity Disorder. She has several alternate personalities, including Grendl, who is extremely wild and destructive and angry, and Mavis, the “normal” one, whose job is frequently to clear up after Grendl.

Since that MHA assessment, a change of staff in the CMHT meant that I became Perdita’s care coordinator. Perhaps surprisingly, in view of that event, she did not object to this. In fact, she told me that because I had handled the situation in the way that I had, she felt she could trust me.

I’ve got to know Perdita quite well. Splitting her self into several discrete personalities appears to be her way of managing the intolerable emotions which arose as a result of her severe childhood abuse. There are certain triggers to her “checking out”, as she describes this process of extreme dissociation, during which one or more of her other “parts” manifest themselves. These usually involve stressful situations which she finds impossible to cope with, as they touch raw nerves relating to betrayal: anything to do with being let down, or an event that is likely to provoke extreme anger, can trigger these episodes.

Dissociative Identity Disorder (which used to be known as Multiple Personality Disorder) appears to be far more common in the US that in the UK, at least, if published literature is anything to go by. The DSMIV definition requires “the presence of two or more distinct identities or personality states”. These identities or personality states must recurrently take control of the person's behaviour. The patient must also experience an “inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness”. Physiological causes, eg. epilepsy, or the effects of drugs or alcohol, have to be ruled out. In my professional career I have only encountered three people with this diagnosis.

I used to be somewhat sceptical about the reality of this disorder until I actually started working with people with this mental health problem. Having seen Perdita displaying these different personalities, I am convinced that she is not putting on these episodes, and genuinely has no control over what happens when the other parts manifest themselves. I have met Mavis, who is charming and polite, and a pleasure to work with. I have also met Mary, who is a small child, who can be mischievous and playful. I had heard all about Grendl, the really angry and destructive one, but had fortunately not actually met her.

I work with Perdita on the basis of damage limitation. I try to help her to manage the mood swings which are a feature of emotionally unstable personality disorder. We work together to identify and avoid triggers for her dissociative episodes. We especially try to keep Grendl under control.

But things don’t always work out.

One morning, I had a call from Perdita.

“I’m afraid,” she said. “I’ve been let down big time by someone.” She told me the details. It sounded bad. I had a sinking feeling. “I can feel myself going. I’m afraid I’m going to check out. I’m afraid Grendl’s going to take over.”

We talked this through for a few minutes. I suggested a range of risk management strategies that we had put into her care plan. But I had the feeling that “checking out” was going to be unavoidable.

A few minutes later, I got another call. This call consisted entirely of maniacal laughter. I guessed that it must be Perdita, having checked out. I tried to get through to her, but the chilling laughter went on and on and on. After about 10 minutes, I realised I was not going to get any sense out of her, and put the phone down.

The phone rang again. More scary laughter. The caller then introduced herself.

“It’s Grendl here,” she said. “It’s such fun. I’m having a great laugh here! I’ve really cut the bitch to pieces this time!” Then she hung up.

I didn’t bother to try and get hold of a psychiatrist. It would cause too much delay. I went out immediately, dragging one of my somewhat reluctant colleagues with me, just in case. It was going to be necessary to concentrate on limiting potential damage – damage to Perdita, damage to her house, damage to her daughter, damage to other professionals…

We could hear the laughter from outside the house. The front door was ajar. I went in without knocking, and we cautiously entered the living room.

Perdita was sitting on the sofa, rocking backwards and forwards as she whooped with laughter. She had an open pair of scissors in one hand, and her other arm was covered in lacerations. There was a fair amount of blood, so it was hard to see how serious the cuts were.

“Give me the scissors, please, Grendl,” I said as calmly as I could.

“You’ll have to give me three good reasons!” Grendl replied, and slashed several more times at her arm.

I realised I was going to need assistance. I wanted to avoid a hospital admission if possible, but I did need back up. I used my mobile to ring emergency services, and asked for an ambulance and the police to attend. I tried to explain as objectively as possible what was happening, but it wasn’t easy with Grendl’s intolerable laughter filling my ears.
Give me the scissors, Grendl,” I repeated, while I waited for the ambulance and police to arrive.

“Give me three good reasons!”

“I’m not getting into any games. Just give me the scissors.”

I waited nervously, keeping at a safe distance, until the ambulance arrived, and two paramedics came into the room. The police arrived almost at the same time, and the room was soon full of people in uniform.

Grendl loved it. “You’re very tall, aren’t you?" she said seductively to one of the paramedics, who was indeed exceptionally tall.

He asked to look at her arm, but instead, she slashed away at it again, occasionally holding the blade against her throat, as if she were holding Perdita hostage.

“Give me the scissors,” I said again, in as gentle and unthreatening a way as I could manage in the circumstances. The police and paramedics kept quiet, waiting to see what would happen.

“You’ll have to give me three good reasons!” she said again.

I was going to have to play her game after all. “First, you’re hurting Perdita. Second, Ophelia will be upset if she finds you like this.” (Ophelia was her 14 year old daughter, who was still at school.)

“That’s only two reasons!” Grendl cried, giving her arm a few more slashes.

“And third, you’re scaring the hell out of me!” Being honest often works well in these situations.

She thought about this for a moment.

“Okay, fair enough,” she replied, and threw the scissors onto the floor. Grendl could be reasoned with, after all. I kicked them away, and one of the police picked them up.

“Grendl, I really need to speak to Perdita.”

“Perdita’s gone away. You’ve got me!”

“I need Perdita. We need to get your arm sorted out. And Ophelia will be home from school soon, and I don’t want her to find all this.”

There was a pause. Perdita’s face sagged and went blank. Her head leaned forward. Then her head snapped up and the eyes of a small lost child stared into mine, tears running down her cheeks. She looked absolutely terrified, staring with fear at the room full of people.

“Hello there,” I said gently. “Can I see Perdita. Or Mavis. Either of them would be good.”

Her face went blank again and her eyes closed for a moment. Then her face changed. She opened her eyes.

“Oh, hello, Masked AMHP,” she said, a little surprised, looking around and taking stock of things. She looked at her arm. “Is it Grendl? Has she been out?”

I recognised Mavis. She would do. She would be able to sort things out. She rolled herself a cigarette and then smoked it while she allowed the paramedic to examine her wounds, and clean and dress them. “My, you’re tall, aren’t you?” she observed. After all, Mavis had not seen him before.

“Masked AMHP,” she said. “It’s so nice to see you again.” It was uncanny, but Perdita’s face, mannerisms, and even accent, were quite different when Mavis was in charge.

I negotiated with her. I asked her to stay in charge until Perdita could return. I told her that I would come back later in the afternoon when her daughter was due home, to see Ophelia and explain what had been happening (she was, sadly, used to these episodes), and to check that Perdita/Mavis was safe and in control. Mavis listened to me obediently, making meticulous notes from time to time.

My analysis of the situation went something like this. It made a sort of sense. Once Perdita or "Mavis", the sensible one, can be induced to return, the crisis is usually over. "Mavis" herself was confident that she could remain in control. Her wounds were examined and did not require hospital treatment. Hospital admission is best avoided during these crises, and the Crisis Team also have little role to play in these situations, once the immediate crisis has passed. It would not be appropriate to use the Mental Health Act, and would undermine any trust Perdita had in me. The police would notify Children's Services of the incident, who could be mindful of Ophelia’s needs. Ophelia could stay with her father if required, but would invariably prefer to stay with her mother, and would be under less distress if she was with her mother. It would not be in the immediate interests of Ophelia to separate her from her mother.

The police and ambulance crew withdrew. I said goodbye to Mavis and reminded her I would be back later to check up on the situation.

And in the midst of mayhem and madness there is (unintentional) humour.

As Mavis pulled deeply on another cigarette, she said to me: “Masked AMHP, when you see Perdita next, could you see if you can persuade her to give up smoking? It is such a disgusting habit.”

Friday, 12 November 2010

Diogenes Syndrome and the Mental Health Act

Members of the public often become very alarmed and even affronted and incensed about people in the community who chose to live in unusually squalid or insanitary conditions. Complaints may be made to the police or social services, with demands that “something” must be done about them. In extreme cases, there can be considerable media publicity about people found dead in their homes surrounded by filth and clutter.

Social Services are often the first to be contacted about such people, as are secondary mental health services. Over the 35 or so years I have been a social worker, I have worked with many of these people. While the majority of them exhibit signs of eccentricity and often an unwillingness or inability to engage in social interaction with others, I have found few of them to have had any significant mental illness or disorder. Often, the focus of work with them has been, not necessarily to significantly change their living conditions, but to support them in the way of life they have chosen while trying to reduce risks to their health and safety, and to protect them from the antagonism of the local community.

I’ve already written on this blog about a couple of cases where I have assessed people who were living in conditions deemed unacceptable or hazardous: Harry, an elderly man, whom I wrote about in July and December 2009, and Stella, a middle aged woman, in October 2010. The psychiatric grounds for detention of Harry were tenuous, and Stella, although eccentric, showed no signs of mental illness.

I was recently asked to assess Bernard, a man in his 50’s who was living alone in such conditions. His GP had made an urgent referral after being called out to him by the local Police Community Support Unit. She reported that: “The house is uninhabitable and is a health risk to the patient and his neighbours. There are strewn newspapers and garbage piled high to the ceiling in the rooms, the walls are coated with black dirt. His feet are purple and his toenails are about 10 cm in length. I could not see beyond the dirt on his feet to tell if he has gangrene. He will need a mental health assessment for the possibility of Diogenes Syndrome.”

Pretty nasty, then. Very alarming. Something certainly had to be done. So I decided to see him for a preliminary assessment with a nurse from the CMHT. In the meantime, something niggled at me. Bernard? Bernard? Hadn’t I assessed someone under the MHA in the dim and distant past with that name? Looking through my records, I discovered that I had indeed assessed someone of the same name and age, but with a different address, all of 18 years ago. I had a dim recollection of the circumstances: he had been living with an elderly aunt and uncle who had both died and he was in the process of being evicted from their council house as he did not have a tenancy. All I could now recall was that I had not detained him under the MHA, and he had not become a patient of the CMHT.

When we arrived his front door was open and he was standing in the lobby with a pile of shoes in front of him trying to find a pair that would fit. This meant that we could see the state of his feet. I could confirm that his toenails were actually only 1 or 2 cm long ( ½ inch rather than 4 inches), and that his feet were extremely dirty. He eventually managed to put a suitable pair of shoes on and was able to attend to our visit. He had long, greasy hair, a straggly beard partially obscuring his grimy chest, and was wearing a stained and filthy waxed jacket, and, as far as we could see without looking too closely, very little else.

Although he invited us into the flat, in view of the smell emanating from the open doorway, and the fact that the door could only open a little way because of the junk in his hallway, meaning that we would have to squeeze through the narrow, and very dirty opening, we decided to conduct the assessment in the lobby outside.

Throughout the assessment, he presented with excellent recall of dates and events throughout his life. He immediately recognised me from our encounter 18 years previously, and recalled the exact year and the circumstances. He was orientated in time and place. There was no evidence of dementia.

In fact, on interview, Bernard presented with no evidence of mental disorder. He certainly fulfilled the criteria for a diagnosis of “Diogenes Syndrome”, but as I have observed before, that is not in itself a mental disorder. There was no evidence of psychosis or delusional thinking. Objectively he did not appear depressed, and stated that he did not think he had any mental health problems. Although there appeared to be a history of anxiety, he did not present as anxious, and in fact welcomed the opportunity to converse with us. He did not express any significant concern about his living conditions, although did admit that the house was untidy, and did not feel that he needed any help to sort it out. In short, despite the objectively appalling state of his living conditions and personal hygiene, there was no evidence that this had arisen as a result of a mental disorder, and there was consequently no evidence at all that could justify his detention in hospital under the Mental Health Act. Indeed, he did not even meet the eligibility criteria for receiving services from the CMHT.

An interesting article in Clinical Geriatrics (Volume 13 - Issue 8 - August 2005: “Diogenes Syndrome: When Self-Neglect is Nearly Life Threatening” -- Badr, A, Hossain, A , and Iqbal, J) gave a similar case study. Although concentrating on the geriatric aspects of Diogenes Syndrome (most of the people I have seen have not been elderly) the article reaches some interesting conclusions. The authors quote Karl Jaspers, who: “proposed that this condition does not constitute a newly occurring psychopathological entity, as the whole picture is understandable from each subject’s personality and stressful life events. He emphasized that the characteristics of the premorbid personality play an integral role in the pathogenesis of the syndrome. His view of this syndrome was that it represents a lifelong subclinical personality disorder, probably of a schizoid or paranoid type, that turns gradually into gross self-neglect and social isolation.” In other words, it is something that can slowly creep up on slightly odd people over a long period of time

This analysis would certainly accord with my own experience of people with this presentation, and would certainly apply to Bernard, who reported that he had received psychiatric care, including ECT, as a teenager, although it was unclear why, and until his aunt and uncle had died had always lived in the households of others, and had therefore probably never acquired the skills to maintain his own household.

So what could be done with Bernard, and others like him? Since he could not be said to lack capacity, the “best interests” powers under the Mental Capacity Act, which permit people to take actions on behalf of a mentally incapacitated person on the basis that the action is in their best interests, would not apply to him. People have a right to make “unwise decisions”, providing they have capacity to do so. This could include such “unwise” actions as drinking too much alcohol, marrying someone you hardly know on a whim in Las Vegas, or refusing to wash for months or years.

Possibly the only route to addressing Bernard’s circumstances through legislation rather than gentle persuasion would be Sec.47 of the National Assistance Act 1948, which provides powers of “removal to suitable premises of persons in need of care and attention.” Although it might be thought that an Act created by the new landslide Labour Government just after the Second World War would long ago have been repealed, this still remains on the statute books.

This is a legal power that is quite often talked about in social work circles, but very rarely used. It has to be established that "The person is suffering from grave chronic disease OR being aged, infirm, or physically incapacitated, is living in unsanitary conditions AND the person is unable to devote to himself and is not receiving from other persons proper care and attention AND his removal from home is necessary either in his own interests or for preventing injury to the health of, or serious nuisance to, other persons". If all of these conditions can be satisfied, the person can then be taken to a hospital or a care home for medical treatment or care against their will.

I have only ever been involved in one such case in my entire career, and that was over 30 years ago. It involved an elderly lady living alone who was no longer able to manage and was becoming increasingly frail and weak. Although she did not have dementia, she consistently refused all offers of help and support. An assessment under Sec.47 of the National Assistance Act 1948 was undertaken, involving a “community physician” but when it came to it the lady, clearly impressed by this doctor’s title, agreed to go into hospital voluntarily.

However, even this power is now more than likely to fall foul of more recent legislation. The Department of Health has suggested that Sec.47 could be in breach of the Human Rights Act. In a brief guidance document published in August 2000 ("The Human Rights Act, Section 47 of the National Assistance Act 1948 and Section 1 of the National Assistance (Amendment) Act 1951"), it reasonably notes that use of this section may breach Article 5 – the right to liberty, and Article 8 – the right to respect for private and family life. So gentle and persistent persuasion to accept assistance probably remains the only option for trying to help people like Bernard.

Phew! A bit of a dry and technical post today, perhaps. Back to foul language and more threats of bodily harm to AMHP’s next time.

Tuesday, 26 October 2010

Green Lycra and Fairy Wings

It began as an out of the ordinary referral, and then just got stranger and stranger...

The call came from the Criminal Justice Liaison Nurse. He had been asked to assess Stella, a 62 year old woman in Charwood Police Station, who was under arrest on suspicion of attempted murder.

“I’m at the station now,” he said. “I’ve just seen her. She can’t seem to stay on topic, and gives long rambling answers to even the simplest questions. I asked her a question about a next of kin, and she replied ‘I usually I do everything in 12’s and 24’s because I used to be a Playboy Bunny’. She just isn’t making any sense. I don’t think she’s fit to be interviewed. She needs an assessment under the Mental Health Act.”

And what had actually happened to result in Stella’s arrest?

“She called for an ambulance late last night. When the crew arrived they found her husband with a knife protruding from his ribs. The police were called and arrested her. Her husband’s in Charwood Hospital now being patched up.”

I arranged for our local psychiatrist and a Sec.12 approved doctor to attend with me. I checked our local records, but Stella had no psychiatric history, so when we arrived at the police station we had very little information to go on. The only thing I’d been able to find out was that her husband had spent a brief time in Charwood psychiatric unit over ten years ago being treated for “alcoholic hallucinosis”. This was another term for the “DT’s” – vivid and frightening hallucinations resulting from acute alcohol withdrawal. He obviously had a history of alcohol abuse.

The custody officer gave us more information about the circumstances of Stella’s arrest. The police had attended; finding a man with a knife sticking out of him and with only one other person in the house, his wife, Stella, they reached the likely conclusion that the uninjured person had inflicted the wound on the injured person, and had therefore arrested Stella. The police do have suspicious minds.

“The reports we’ve had from the hospital so far suggest that the husband is mentally ill himself. He says there are people hiding under his bed who want to kill him. He says he stuck the knife into himself. They think he’s psychotic. They’re arranging for him to have a mental health assessment as well,” the custody officer told us. “And we’ve had reports from the officers investigating the incident that seem to indicate Stella’s known in the area for being ‘different’ to say the least.”

We had Stella brought to the doctor’s room in the custody area, so that she could be interviewed “in a suitable manner”. In fact, the doctor’s room is far from ideal: it’s a poky little room, always too hot, with a desk, two chairs, a treatment couch, a fridge for forensic samples, and a toilet cubicle. It meant that two of us had to perch on the couch while interviewing her. However, it’s somewhat better that interviewing someone in a cell.

Stella was a slight woman, conservatively and appropriately dressed, with evidence of good self care. She seemed intelligent and articulate. She maintained good eye contact with us throughout, and cooperated fully with the interview.

I began by explaining to her why we were being asked to interview her, then we asked her to tell us what had happened the previous evening. She proceeded to tell us at great length everything she had done that evening, giving us a minute by minute account of the entire evening. We were quite keen for her to tell us how her husband had came to have a knife in his abdomen, but she would not be diverted from answering the question in as much detail as possible. She had gone out on her bike (she does not drive) to the supermarket for some items, and had then gone to visit a friend. She give us more details than we wanted of what they had said to each other and how many cups of tea she had drunk. She had eventually returned to the house at 2200 hrs. She said she felt there was something wrong with her husband, as he seemed to be staring at something in the corner of the room and was mumbling as if talking to someone. In an effort to snap him out of it, she suggested they have a cup of tea, and he had then abruptly got up and gone into the kitchen. After a while, as she had not heard the kettle, she went into the kitchen herself, but he was nowhere to be seen. She saw blood on the floor near the sink and followed a trail of drips until she eventually found him collapsed in the toilet with a knife sticking out of his stomach. She had then rung for the ambulance.

Throughout our interview, Stella appeared lucid and ocoherent. There was no evidence of being under the influence of alcohol or drugs. She denied any use of illegal drugs, currently or historically. She was fully orientated in time and place. There was no evidence of dementia, or emotional lability or abnormal mood. In fact, there was no evidence at all of any mental disorder. The only thing of note was that she seemed somewhat detached, with little evidence of emotional distress at either the situation she was currently in, or of the events that had led up to her arrest for attempted murder. But this in itself was not sufficient to cause us undue concern.

“The person who spoke to you earlier said something about you ‘thinking in 12’s and 24’s’. Could you tell us a bit more about that?” I asked her. On the face of it, this seemed at the very least an unusual, if not irrational, comment to make. She explained that when she was in her 20’s she had trained as a Playboy bunny. This mainly entailed learning how to work in a casino, including operating the blackjack and roulette tables. This, she told me, required an ability to calculate quickly in multiples of 12. She went on to say that she had never actually worked as a bunny girl, as she had not liked the uniform. A rational, plausible and satisfactory explanation.

The two doctors and I had a discussion about the assessment. It was our unanimous conclusion that, whatever may have occurred that night at her home, Stella was not suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital under the Mental Health Act. Although she had gone into inordinate length and detail when questioned, this did not amount to evidence of mental disorder: she did in fact “keep on topic”, and the content of her account was at all times lucid and rational.

I went into the custody office to inform the custody officer that it was our view that Stella was fit to be interviewed. The custody officer gave us a look.

“You’re sure about that, are you?” he said. “Perhaps you’d better have a word with the officer dealing with the case.”

He called the officer in, a detective sergeant.

“We’ve interviewed several of the neighbours,” she told us. “Stella’s known locally as ‘Psychedelic Stella’. One of the neighbours told me she’d known her for 10 years and had ‘never had a sensible conversation with her’. They told us she was ‘not on the planet’. They’ve said she often rides round on her bike wearing ‘green lycra and fairy wings’. You should see the house. It’s in a right state. You’d think they were under siege. You can hardly get to the front door.”

Whether or not Stella did indeed ride her bike dressed in green lycra and fairy wings, it still did not justify detaining her under the Mental Health Act. I saw no reason why this should influence our decision.

“But what if we interview her and decide to bail her?” the detective sergeant asked.

“Then she’ll go home,” I answered. “At the present time both her account and that of her husband seem to corroborate each other. Of course, if there is evidence that she was the perpetrator and he was just covering up for her, then a further psychiatric assessment might be appropriate.”

The custody officer and the detective sergeant did not seem that impressed with our conclusion. But there was still no reason to change our mind.

However, the next day the psychiatrist and I did decide to make further enquiries of our own. We sent Stella an appointment to see us at the CMHT, and I spoke to the medical ward where Stella’s husband was being treated. He had been fortunate. He had missed damaging any internal organs. He had had a psychiatric assessment and had been started on a course of chlordiazepoxide and was already much better mentally. I knew exactly what that meant: it is a treatment for the symptoms of acute alcohol withdrawal; he had had alcoholic hallucinosis again.

Then I had a call from the detective sergeant. They were satisfied the injury had been self inflicted. They had released Stella on bail, but the officer, who was from the local Domestic Violence Unit, now had other concerns. Could I advise whether Stella’s husband, if he was capable of stabbing himself while suffering from the DT’s, might also be capable of harming his wife? Of course, I couldn’t give an opinion, but this made it more imperative to have an opportunity to talk to Stella about the situation.

I tried to make contact with Stella, but no-one seemed to have her mobile number. So I went out to their house. The front verge was crammed with old cars. The front garden contained two old caravans, both crammed full of junk. The rest of the garden was so overgrown, it was difficult to push through to the front door. I could see now what the police had been talking about.

There was no reply when I knocked. I tried to peer through the windows, and could see rooms piled high with rubbish. It seemed difficult to imagine how they might live in this place. It was also difficult to imagine the neat and tidy woman I had interviewed inhabiting this house.

I eventually managed to get Stella’s number, but there was never any reply when I rang it.

A few days later I made contact with the hospital again. Stella’s husband was medically fit for discharge. But did I think he ought to go back to his wife? And was the CMHT going to offer him any follow up?

The CMHT had not had a referral for him. I spoke to the hospital psychiatrist who had assessed him on the ward. Since his initial psychotic presentation was the result of acute alcohol withdrawal in the context of a chronic alcohol problem, the psychiatrist concluded that there was no role for the community mental health team; this was a case for the local alcohol problem service, if he was prepared to accept that he had a problem.

The day before the appointment with us, Stella left a message with our administrative staff. She wouldn’t be keeping the appointment. I rang her number again, and this time she answered. I began to try to explain to her why we would like to see her, but after a few moments she interrupted me.

“If you think I’m going to put myself through another interrogation like the one in the police station, when there’s nothing at all the matter with me, you really must think I’m mad. Goodbye.” She hung up.

And that’s it. A lot of untidy loose ends and unanswered questions. All very unsatisfactory.

But I can’t say I blame her for not keeping that appointment.

Thursday, 16 September 2010

When Mental Health Act Assessments Go Bad

While reading my blog, you may have been thinking: “Hey, this guy is so cool and experienced, I bet he never makes any mistakes!”


Francis was a 21 year old man still normally living with his mother in a small village a few miles outside Charwood. He had been working in Ibiza during the summer, and had somewhat unexpectedly turned up again in the UK having been put on a flight by persons unknown. Friends in this country had been tipped off, and had picked him up from the airport. Concerned at his bizarre behaviour, they spent a few days attempting to “treat” him with a combination of street diazepam and cannabis. When this was unsuccessful, they had dropped him off at his mother’s house. His mother, who worked in the mental health field, immediately recognised that he was unwell, arranged for him to be assessed by mental health services, and he was admitted informally to Bluebell Ward.

He somehow managed to leave the ward unobserved, and a few hours later turned up at his mother’s again. She called the GP, who came out and examined him, gave him a dose of antipsychotic medication, and made a request for an assessment under the Mental Health Act.

Having established that he was still officially an informal patient on Bluebell Ward, I developed a cunning plan. I would visit him at home, and if he was still agreeable, I would simply return him to the ward where he was nominally still an inpatient. No need for forms and doctors at all.

When I arrived and explained this to his mother, she was very happy with this plan. Because of her own professional involvement with mental health services, she was reluctant for him to be detained under the Mental Health Act if it could be avoided, and as she was the nearest relative I necessarily had to take her wishes into account.

Francis appeared vague and confused on interview. He could not remember being admitted to Bluebell Ward, and neither could he remember leaving. He appeared thought disordered. Sometimes he replied to questions with meaningless disconnected strings of words. There was evidence of pressure of speech. He admitted to hearing voices on direct questioning, but could not give any concrete examples. He eventually accounted for his present condition as due to “walking into a microwave” while at work in Ibiza. He got up frequently and wandered around during the interview.

In the absence of any previous history of psychosis and knowing that he was an habitual cannabis user and may also have taken other drugs, it appeared that Francis might have taken something while in Ibiza that had precipitated a drug-induced psychosis. However, he was unable to say whether or not he had taken any suspect substances.

He had earlier taken one of the tablets the doctor had prescribed, and readily took another when his mother offered it to him. I suggested that it would be a good idea for him to return to hospital. He appeared amenable to this suggestion, promptly getting into the back seat of my car and putting on his seatbelt. His mother offered to come with me and we set off on the 10 mile journey to the hospital.

This is when things started to unravel. As we drove, the medication appeared to start wearing off and he became increasingly restless. He tried the door handle, which did not open as I had placed the safety lock on, and then wound down the window. I thought he just wanted air, until I saw in my rear view mirror that he was trying to climb out of the window, with his mother who was sitting next to him trying to pull him back in.

What should I do? Attempt to drive on, while his mother hung onto his legs? That did not imply consent, did it? And was patently dangerous. Take him back home so that he could be reassessed? The same problems of risk applied. Drop him off at the side of the road, as that seemed to be his wish? But that would put him in unnecessary danger.

In the end, I pulled over and spoke to him about the dangers of trying to get out of a moving car and reminded him that we would soon be back at the hospital. He grunted and nodded his head, putting his seatbelt back on. Somewhat reassured, I set off again, and for the next few minutes prayed that he would behave. If this had been an informal admission, rather than a return to hospital of an inpatient, then this might be evidence of a refusal to accept an admission. Did he have capacity to make a decision anyway? And why hadn’t I gone out in the first place with the GP and a psychiatrist and done it by the book? Was this a good time to hand in my warrant?

Once we had arrived at the ward, I allowed myself to feel a little relief. However, Francis’s behaviour became even more erratic. Although clearly under the influence of the medication, he seemed to be restless and fighting the sedative effects. While waiting to be seen by an admitting doctor, he climbed out of the window of the side room on two occasions, although both times did accept being guided back into the ward. I realised that he was in no state to remain as an informal patient, and would need to be detained so that he could be properly assessed. And of course I did not have any medical recommendations. I was a bad, bad AMHP. I prayed for a hole to open up beneath my feet so that I could be cast into the fiery pits of Hell. Anything was preferable to carrying the knowledge that because of my mishandling of the case events were now completely out of my control.

Just as Francis set off the fire alarm in the process of trying to get out of the fire door, causing the entire ward to be evacuated, the duty doctor arrived and placed him on a Sec 5(2) (this can be used by a single doctor as a holding power until he can be assessed in the usual way). At last there was a legal basis for his detention in hospital!

While all the available male staff were fully occupied in restraining him, I used the diversion to slink off and arrange for a proper Mental Health Act assessment.

Monday, 23 August 2010

The Science Bit

A Brief Statistical Analysis of Outcomes of my Assessments under the Mental Health Act

A reader of this blog (hi, La-reve) recently asked how often in my experience admission to hospital was deemed necessary, and of those, how many resulted in formal detention under the Mental Health Act.

I thought this was an interesting question, so I had a trawl through my records. (Throughout my professional career I have kept meticulous records of assessments and outcomes. This is not [just] because I am obsessive-compulsive, but because AMHP’s have to be able to provide evidence of active practice in order to gain reapproval every 5 years.)

The total number of MHA assessments I have undertaken during my career so far that have resulted in either: no admission; informal admission; Sec.2; Sec.3; or Sec.4, is approaching 600. From these figures I have extracted the following statistics:

No admission: 35.8%
Informal admission: 15.6%
Sec.2: 18.5%

From this you will see that over a third of assessments did not result in an admission at all. Just under half of the assessments (48.6%) resulted in detention under Sections 2, 3 or 4.

There are a number of reasons why a formal assessment under the MHA may not result in an admission.

• The request may have been inappropriate or misguided.

• Detention under Sec.136 (when a police officer removes someone from a public place who appears to be mentally disordered) nearly always triggers a statutory duty for an AMHP and a doctor to assess under the MHA. However, many of these assessments do not result in a hospital admission. This is often because the person may have been under the influence of drugs or alcohol at the time of their initial detention, or because the detaining police officer misinterpreted the person’s behaviour (police have little formal training in mental disorder).

• An alternative to admission has been identified. This may be that the patient agrees to take medication, or that the Home Treatment team takes them on, or it is identified that a crisis is resolved, or an admission to a care home or respite has been arranged as an alternative.

• Increasingly I am getting requests for assessments under the MHA for older people with dementia who lack mental capacity who do not actually need admission to hospital but do need to be removed from a risky environment. In those cases, the powers under the Mental Capacity Act can, and should, be used.

There are of course quite a few people who find themselves being assessed on multiple occasions. I have written about some of them. There are several reasons for this.

• Some people with severe and enduring mental illness such as bipolar affective disorder or schizophrenia may have little insight into their illness and therefore can be prone to discontinuing medication and withdrawing from mental health services. This can then lead to an acute relapse. These people may require repeated admissions under Sections of the MHA.

• Some people, especially those with borderline or emotionally unstable personality disorders, may from time to time display alarming or disturbing behaviour that others may identify as “illness” and which may lead to formal assessments. Behaviours may include impulsive overdoses, self harming behaviour such as cutting or burning themselves, or making threats to harm themselves. However, it is generally recognised that admission to hospital for these people rarely achieves anything, and alternative strategies are usually preferable. I know that in my CMHT we try and work with people with personality disorder to reduce their risk behaviours as a response to stress or distress by helping them to devise alternative coping strategies.

The relationship you may have with an individual patient may also influence outcomes.

• It is more likely that someone with a history of mental health problems who is assessed by an AMHP and doctors who do not know the patient will be detained under the MHA, especially if the assessment is occurring outside normal working hours. Having worked in the past in an out of hours emergency social work service, I know that professionals are often less inclined to take risks when assessing in the middle of the night; they are also less likely to have access to information that may help them with their decision making, and may also have less access to support services and alternatives.

• If I know a person and have worked with them over a period of time (and possibly been in a situation in the past with them where I have had to undertake a formal assessment), it is sometimes possible to use the trust the patient may have to persuade them to take medication or to accept an informal admission.

Saturday, 14 August 2010

Anatomy of a Mental Health Act Assessment

(This account has been edited to correct some minor inaccuracies. 08.10.15.)

Even though every formal assessment under the Mental Health Act is different, the actual procedure tends to follow a typical pattern.

Assessments have a similar structure, or series of steps, which have a logical sequence, and need to be followed if the assessment is to meet legal and professional standards. I will illustrate this with a real assessment: Robina, a woman in her early 80’s living alone, with steadily worsening dementia.

 • The Referral
1400 hrs
The referral came from the GP in the early afternoon. He spoke to the Social Services customer services, and they took down the basic details and then passed it to me for action as the duty AMHP. The GP had visited that morning with Robina’s social worker and the manager of a care home to try to arrange for an urgent admission to the home. However, she had been angry and aggressive, and had refused to consider this. They therefore decided to refer her for a formal MHA assessment.

• Gathering Information
I needed more information. I needed to know more about her personal circumstances. I needed to know what had led to this. Did she really need a formal assessment? Were there alternatives? I had several possible sources: the GP, Robina’s social worker, and any case notes that might be available through the Social Services computer system.

I rang the GP surgery, but the GP had finished his surgery and had gone home. He wasn’t available. This also unfortunately meant that he would not be available to provide a medical recommendation, if that turned out to be necessary.

I tracked down the mobile number of the social worker and rang her. However, her phone was sent to voicemail. I left a message for her to contact me urgently.

As it happened, there had been a request for a MHA assessment a week previously. I had a look at the assessment report. Robina had been known to services for several months. She was a widow who lived alone, and had home care, as well as considerable support from her daughter who lived a few miles away. Robina’s dementia had worsened considerably in the last few weeks. She had started to wander. Although she lived in a village a few miles outside the main city, she had been found in a garden centre several miles from home. She had become reluctant to accept the home care. The AMHP had assessed her with a psychiatrist, but had concluded that as Robina clearly lacked mental capacity, the powers to act in a person’s best interests under the Mental Capacity Act should be used, as she needed residential care rather than a hospital admission.

While I was reading this report, Robina’s social worker returned my call. She was able to fill me in on events since the previous assessment. The social worker had managed to find a bed in a care home and had organised an emergency admission. In the meantime, during the last week, things had got even worse. The police had had to rescue her from a large roundabout in the middle of a major interchange, and on another occasion had located her late at night walking down the central reservation of a dual carriageway 4 miles from her home. Her daughter was so concerned for her safety that she had spent the last couple of nights with her. Unfortunately, Robina was so hostile this morning that the care home were not prepared to offer her a bed, even if she could have been persuaded to go.

It was certainly looking as if all alternatives had been tried. There was no option but to arrange for an assessment.

• Organising the Assessment
1500 hours
The next step was to arrange to attend with two doctors. Robina’s own GP was not available. Since it is highly desirable to have at least one doctor who knows the patient (the AMHP has to explain on the section papers why they could not find a doctor who knew the patient if this is the case), I rang the surgery to see if they had another GP who had had contact with her and knew her. Unfortunately, there was only one GP now in the surgery, with a waiting room full of patients needing to be seen. And in any case, they had never seen her. I tried to contact Robina’s own consultant but he was on holiday.

This meant that I was going to have to get two Sec.12 approved doctors. These are doctors who may or may not be psychiatrists but who have particular knowledge of mental disorder and are therefore “approved” under Sec.12 of the Mental Health Act to act in this capacity. This is not always easy. AMHP’s have a list of Sec.12 doctors. They also have a list of Sec.12 doctors who are prepared and willing to come out to an assessment at the drop of a hat. This list is not so long, although there are always a number of doctors who are very keen to oblige and undertake these assessments, as they receive a fee in the region of £180 for each assessment they undertake.

My initial plan was to locate at least one Sec.12 doctor who specialised in old age psychiatry. I rang around other old age psychiatrists on my list; none of them were available. It took me over 30 minutes to obtain two doctors willing to come out; neither could attend before 1700 hrs.

I rang Robina’s daughter, who was with her mother in her mother’s home, introduced myself, explained what was going to happen, and outlined the legal process, including identifying her as Robina’s nearest relative (this is an important legal requirement, as nearest relatives have certain rights and powers under the Mental Health Act). I also asked her to tell me more about her mother. Her daughter was clearly very distressed by her mother’s deterioration. Robina’s outburst and hostility to the social worker, GP and care home manager that morning had clearly taken her by surprise and had shocked and upset her. Her mother was normally a very polite lady.

All of this was further useful information which I needed in order to conduct a proper assessment.

• The Interview
1700 hrs
I met with the doctors outside Robina’s house. I knew both of them. We often met in these circumstances.

We knocked on the door, and Robina’s daughter answered and welcomed us in. She seemed pleased to see us, but was obviously distressed by what was happening. Her husband was also there.

Robina was sitting in a conservatory at the back of the house. She showed no surprise or curiosity at our presence in her house, and at first was civil and polite. Her daughter sat in on the assessment. Robina had earlier taken some medication, but showed no signs of sedation. It very quickly became clear that her dementia was very advanced. She was unable to say what year, month or season it was, and seemed unclear whether her husband was deceased or not. She denied having had to be brought back by the police, said she did not have any home care and did not need it, and said that there was nothing wrong with her. She had only the vaguest memory of the visit she had had that morning, but when we broached the idea of going into a care home or being admitted to hospital, she became very hostile and refused to cooperate with the rest of the assessment, ordering us out of the conservatory.

• The Decision
1800 hrs
The two doctors and I went into the kitchen (this is often the place for these discussions – unless we have been thrown out of the house, in which case it will be around the wheelie bin or in my car, if wet). The decision this time was comparatively easy – there were patently serious risk issues, which appeared to be escalating. Her daughter was at the end of her tether, and was now afraid to let her out of her sight. It was not currently an option to explore residential care, and Robina was even denying the need to have home care. There had been significant changes in her mental state in recent weeks, and it therefore appeared reasonable to consider an admission for further assessment, as that assessment could not take place in her own home.

The two doctors completed a joint medical recommendation for admission under Sec.2 for assessment. Their role in the process having been discharged, they then left.

• Completing the application
1830 hrs
My job, however, was still very far from over. I could not legally detain Robina until I had established that there was a hospital willing to take her. I could not complete my application without the address of a hospital.
I needed a hospital bed. I rang the bed manager of the local psychogeriatric hospital. He informed me there were no beds. However, it was his task to find a bed, so he went off to do so.
In the meantime, I needed to manage the situation. I kept a low profile with Robina, but talked to her daughter about what was happening.
1915 hrs
The bed manager rang me back. He had at last found a bed for Robina. It was in a unit on the other side of the county, 50 miles away. But at least I had the address of the hospital. I completed my application, and from that moment the legal framework for detention under Sec.2 was complete.

 • Arranging for an admission
I needed to inform Robina of the decision and of her rights. Even though I knew she would be unlikely to understand this, I still needed to do it. I went back into the conservatory. She did not recognise me, even though I had only been out of her sight for a few minutes. I explained to her that she was going to have to go to hospital, and offered her two options: she could go with me in the company of her daughter and son-in-law, or she could go in an ambulance. She listened to me, then chose option three: to stay at home, thank you very much. I tried to explain to her that this option was not available, but as there was nothing wrong with her, she did not need to go to hospital, and would therefore stay at home.

I realised that I was going to need an ambulance and called Ambulance Control. They gave me an expected time of arrival: up to two hours from now. This is by no means unusual. Sometimes I have had to wait for up to 6 hours for an ambulance.

From time to time, I approached Robina to try to persuade her to go to hospital. She wasn’t having any of it and told me so in an extremely terse way. This distressed her daughter, and I had to spend time with her, trying to reassure her.

2000 hrs
In view of her consistent antagonism, I decided that it was fairly likely that I would need police assistance to get her into the ambulance. I rang Police control and explained the situation and my need for assistance.

• The Admission
I was still on the phone to the police when the ambulance arrived, somewhat earlier than anticipated. The police officer asked me to keep the line open so that he could monitor what was going on and organise attendance if necessary.

I explained the situation to the ambulance crew, and followed behind as they entered Robina’s house.

It’s amazing what a uniform can achieve. Robina started to flirt with one of the paramedics, and within a few minutes walked out of the house arm in arm with him, a broad smile on her face, and entered the ambulance without fuss. Robina’s daughter accompanied her. I stood the police down.

2015 hrs
The ambulance departed, with Robina and her daughter on board. The detention papers, as well as an authorisation by me for the ambulance crew to transport her (all legal requirements) went with the ambulance.

Since the duties of the AMHP are not discharged until the patient is formally accepted by the admitting hospital, and also because Robina’s daughter would need a lift back home, I followed the ambulance in my car, with Robina’s son-in-law.

Often this trip is a chance for the AMHP to relax a bit – it’s actually an incredibly stressful process being responsible for the safety and wellbeing of not only the patient but also the relatives – but this time, with a stressed and anxious relative on board, it was necessary to answer his questions, to explain exactly what was happening and also what was likely to happen in the future and reassure him that everything was for the best.

2115 hrs
We finally arrived at the hospital. Nurses took Robina and her relatives into a side room and gave them a cup of tea while I went into the nursing office to organise the formal acceptance of the paperwork by the hospital. I was offered a cup of coffee – the first refreshment since I had set off for Robina’s house nearly five hours ago. Unfortunately there was no-one on duty who was able to receive the paperwork, and I couldn’t leave until this had been officially completed. An authorised person had to come from another unit a couple of miles down the road.

While I waited for this, I set to work writing my AMHP assessment report – another requirement is that a formal report should be left on the ward before departure. I had already started to write this earlier, and had it stored on a memory stick, so this did not take too long to complete.

• The Aftermath
2145 hrs
At last the papers had been formally checked and accepted. It was time to take Robina’s relatives back to Robina’s house 50 miles away.

Extricating them was tricky. Robina was quite happy to be sitting with them drinking tea, but when she realised they were leaving and not planning to take her with them, she understandably objected. Although the nursing staff were experienced at handling this situation, it was still extremely distressing for Robina’s daughter, who started to cry once we were in my car. I spent the journey back attempting to reassure her that the decision was correct, that there was the prospect of improving or stabilising Robina’s condition, and that the likely outcome would be that she would be transferred to a care home in the near future.

2245 hrs
We finally get back to Robina’s house and I drop her daughter and son-in-law off. That is officially the end of the assessment.

2315 hrs
I get home. At last, after over 9 hours, I can actually relax, and maybe even get something to eat. And then I’ll have to be back at work by 0900 hrs tomorrow.

Tuesday, 3 August 2010

Vanessa – A Postscript

In my last post I talked about my experiences nearly 20 years ago with Vanessa, a woman with bipolar affective disorder. There’s a little more to the story.

Following her detention under Sec.3 Vanessa made a very good recovery – although she continued to harbour paranoid and delusional thoughts focused on me. Because of this, I made sure I kept a low profile. She remained a patient of the CMHT for a few years, was detained on one more occasion, but then, as she remained stable, she was eventually discharged.

Mental Health Services had nothing more to do with Vanessa for another 17 years. Then out of the blue the GP referred her to the CMHT again. He was concerned about her, as in the previous 7 days her presentation had changed markedly: she was becoming increasingly irritable, suspicious and paranoid, was experiencing poor sleep, was not eating, had lost weight, and was reported to be exhibiting pressure of speech.

I had not forgotten her. I continued with my policy of being invisible as far as Vanessa was concerned, and made sure another member of the Team saw her. As she was so unstable, the Crisis Team became involved, but she refused to cooperate with them. One evening over the weekend the police were called after she made threats to kill one of her neighbours, and she was detained under Sec.136 and taken to a place of safety for assessment. However, when assessed (and without access to any background knowledge) she presented as calm and rational, and was allowed to go home, with her assurance that she would engage with the Crisis Team in home treatment.

When they visited, however, she was again uncooperative, and appeared hypomanic and irritable, still expressing paranoid ideas about her neighbour, and waving a rolling pin around in a threatening way. Eventually, she forcefully told the Crisis Team to leave, although not in those words (I do try to avoid the use of the word “fuck” in this blog if I can help it). Her sons, who were now in their 20’s but still living with her, were also expressing anxieties about her behaviour, and were saying that they could not cope with her any longer. An assessment under the Mental Health Act was becoming inevitable.

Unfortunately, when the request came, I was the only AMHP in the team available.

Not without a degree of trepidation, I went to her house with her Community Nurse and two psychiatrists, both of whom fortunately knew her.

17 years on, here I was again at her door. I determined to take a back seat and be as invisible as possible. If I went in behind the others, she might not even notice I was there.

Yeah, sure.

“What the fuck are you doing here?” she said to me, glaring venomously past the others and fixing her eyes on me.

Determined to avoid confrontation, I said, “Look, I’m here because I have no choice. I will respect your wishes if you don’t want me to stay. I’m happy to leave right now.”

I moved towards the living room door.

“You’re not going anywhere,” she said. “Stay here where I can see you.”

I perched on the arm of a sofa, as near the door as possible, ready to make a quick – very quick – exit if required.

“I didn’t tell you you could sit down,” she said, so I stood up again.

“I hit him once,” she said to the nurse and the psychiatrists. “Didn’t I?” she glared at me again.

“You certainly did,” I replied meekly.

“Are you being fucking sarcastic?” she growled.

“Honestly, I’m not.”

“Perhaps I should hit you again. I’ve a good mind to hit you again. It’d teach you a fucking lesson about not being sarcastic when you’re sectioning someone.”

Vanessa looked around at the others. “Do you know what happened the last time he came round here?” she began. “He told a joke. Do you know what he said? He certainly wasn’t very fucking professional. He said: ‘What’s the difference between a social worker and a Rottweiler? You get your kids back from a Rottweiler.’ What sort of a joke is that for a social worker to tell a single parent with kids? It’s fucking outrageous! He should have got the sack!””

I began to feel offended. She had misremembered. She had forgotten that it had been her who had told the joke, not me! Over all those intervening years, whenever she had thought about that particular day she had it fixed in her mind that it had been me who had told the joke. If she had ever told a friend about that day, she would have told them her account of the story.

I didn’t want the other professionals to think I might have been so unprofessional as to tell jokes during a Mental Health Act assessment. But I knew that if I disagreed with her it would inflame her still more.

I felt that my presence in the room would only make things worse. She might be more reasonable if I were absent. Without saying any more to her, and without waiting for her permission, I left the room.

One of her sons was in the hallway, keeping out of the way. He indicated to me to come into the kitchen with him.

This worried me too. What would be his memory of my last visit to this house? Would he blame me for what had happened?

“I really didn’t tell that joke,” I said to him. “It was your mother who told that joke to me.”

“Yes I know that,” he replied reassuringly. “I do remember how ill mum was back then. But I haven’t seen her like this for years and years.” He was clearly upset by it all

We talked things over. Since I was still the AMHP in this assessment, I obtained more information from him about her mental state over the last week or so and possible precipitants or triggers, and discussed with him the possibility that she may be detained again. He was completely happy with this.

I slipped out to my car, and waited for the others. I was satisfied that she needed to be admitted to hospital. Her presentation was exactly the same as it had been all those years ago.

But in the end, it was all a bit of an anticlimax. Once I had left, she became much calmer. After further discussion with the psychiatrists, she agreed to an informal admission. Detention under the Mental Health Act wasn’t necessary after all. She even agreed to the nurse taking her to the hospital. And that’s what happened.

Tuesday, 27 July 2010

Assault and Battery – and Arrows

Vanessa was a woman in her late 20’s, who lived on an estate in Charwood with her two sons, aged 6 and 8. Vanessa had bipolar affective disorder. About 20 years ago, over a two year period, I had to assess her under the Mental Health Act on 8 separate occasions, invariably during a hypomanic episode.

Most of the time I liked Vanessa. Most of the time she liked me. I felt I knew her. And that was my mistake.

Her default state was to be vivacious and amusing. When she was high, her vivaciousness increased exponentially. She could be deliberately (and also unintentionally) funny.

I remember one evening assessing her in her home. She had taken a liking to the GP. A great liking. She started to flirt with him. Ignoring the psychiatrist and me, she concentrated all her powers on attempting to seduce him with her feminine wiles. She did this by the device of lighting a match, fixing her eyes on his, then pretending to blow the match out. Her lips quivered seductively, on the point, the very cusp, of extinguishing the flame. Her breath would cause the flame to tremble and gutter. But then, teasingly, she would desist, allowing it to burn a little longer, narrowing her eyes a little as she gazed into the GP’s own perplexed and startled eyes. She repeated this with increasing levels of salaciousness. And finally, at the moment when the flame was about to reach her fingers, she delivered the coup de grace.

We were all entranced by this display. But it didn’t stop us detaining her.

It also didn’t seem to interfere with my ability to work with her. Usually, when she recovered, she would recognise that, if on occasion I had had to exert my authority under the Mental Health Act, it was done in the interests of herself and her sons, and did not hold it against me. But over time, an edge of irritability and maliciousness crept into her character, especially when she was high.

The last assessment I undertook (at least in that two year period – there was one more, but that will remain for another post) was also the most spectacular. We knew Vanessa was going to become unwell again because she was refusing her medication. It was only a matter of time. One day, her community nurse reported that she was becoming high again. I contacted the Consultant Psychiatrist and the GP, and in the meantime, we went out to see her to see if she might agree to an informal admission.

“Hi there, Vanessa,” I said as she opened the door. “You can probably guess why I’ve been asked to come to see you.”

Her face was sour. “You’d better come in, I suppose,” she said, ungraciously.

It was the middle of summer. Her two boys were at home. She sent them to play upstairs. The three of us sat in her kitchen. She made herself and the nurse a cup of coffee, but pointedly did not ask me. As I asked her questions about how she had been and whether or not she was taking her medication, she just stared at me with increasing animosity. Finally, she looked at the nurse and said to him, “Is he always this much of an arsehole? Shall I throw this coffee over him?”

“Actually, Vanessa, I wouldn’t do that,” the nurse said supportively.

She suddenly stood up and started to shout at me. I backed off.

“You always come here smarming your way in, then you put me in hospital when there’s nothing whatever the matter with me. I know your fucking game, mate – you’re trying to get my kids aren’t you?”

I tried to reassure her, but she wasn’t having any of it. She left the kitchen and went into her living room. I followed her.

“I’m going out for some fresh air,” she shouted. “I can’t stand the stink in here!” She went out of the patio doors into her back garden. The nurse and I cautiously followed her.

She continued to shout to no-one in particular. “The arsehole’s here to steal my kids!”

The neighbours could certainly hear her. They knew her when she was well, and they knew her when she was unwell. They knew something interesting was going to happen. Down the terrace in either direction, I could see people bringing out their deckchairs or leaning out of upstairs windows in order to get the best vantage point of the spectacle to come.

I didn’t particularly like conducting a Mental Health Act assessment with such a large audience.

“Let’s go inside, shall we?” I said. "You don’t want everyone watching, do you?”

Vanessa did not like this suggestion at all. She suddenly launched herself towards me, arms flailing. She proceeded to box my ears, hitting me hard on either side of the head and knocking my glasses into the grass.

I backed off, while the nurse grabbed her from behind and pinned her arms to her sides, giving me a chance to find my glasses.

“Leave my kids alone!” she shouted, her arms moving uselessly as the nurse attempted to restrain her.

“Leave our mum alone!” her boys shouted at me from the upstairs window.

Before I knew what was happening, they started firing down a rain of toy arrows, which, although the suckers were not actually painful, were certainly humiliating, especially as the observing neighbours were making appreciative comments.

Vanessa broke free from the nurse and ran back through the house and out of the front door.

I followed her, keeping a safe distance, grateful to get away from the arrows.

“Have you heard a joke?” she shouted at the top of her voice to the entire street. “It’s a fucking funny joke. It goes like this.”

She started to walk down the street, shouting as she went. As she passed each car, she deftly snapped off its radio aerial.

“What’s the difference between a Rottweiler and a Social Worker?” she shouted. “You’ll like this, it’s a fucking funny joke. You get your kids back from a Rottweiler! There, that’s a funny fucking joke isn’t it?”

She continued in this vein until she reached the end of the street and went off through the estate.

A police car came round the corner and stopped. The lone police officer wound down his window as the nurse and I approached.

“We’ve had a complaint,” he said. “A report of shouting.”

I explained to him what was happening, and suggested that she be detained under Sec.136 so that she could be taken to a place of safety to be assessed (with less risk to the assessors).

“I think you’ll need more than one officer to detain her,” I said. “She’s wild.” I explained what had happened to me. He did not seem impressed.

“I’ve got a colleague in another car on the way,” he said. “I’m sure we can handle her.”

As he was talking to us, we heard his colleague over the police radio.

“I’ve located the suspect,” we heard him say. “I’m about to apprehend her.” Then we heard a lot of shouting and screaming. “Assistance requested – aah!” we heard the other officer say.

“You get your fucking kids back from a Rottweiler!” we heard Vanessa shout in the background.

The officer drove off at full speed to assist his colleague.

I went to the police station. By the time I was ushered into the custody office, I knew Vanessa was there. I could hear her shouting at the top of her voice from one of the cells. She was saying something about Social Workers and Rottweilers.

Thursday, 1 July 2010

Assault and Battery: Beware Little Old Ladies

During my years practising first as a Mental Welfare Officer, then as an Approved Social Worker and now as an AMHP, I’ve been in a few tight spots (being chased round a bungalow by an old man with dementia brandishing a shotgun being one that springs to mind). However, I have only rarely been actually physically assaulted. I like to think that’s because I know how to keep myself safe and de-escalate potentially violent situations, but perhaps luck also has something to do with it. When I look at the situations in which I was assaulted, generally I can recognise that I’ve made mistakes of judgment (although sometimes they are completely unpredictable).

I’ve already mentioned Derek in my August 2009 post, The Mental Health Act Assessment of Fear. I would certainly count what happened there as a physical assault. In fact, there’s something uniquely repulsive and invasive about someone spitting into your face. Over the next couple of posts I’ll write about some other memorable incidents.


Violet was 93 years old. She lived alone, with no other living relatives. She was suffering from dementia. Although she was remarkably physically fit for her age, she was forgetting to eat, was going out at night and forgetting where she lived, and was generally putting herself in danger. She had also become quite paranoid, and although she had initially accepted home care from social services, she had begun to accuse them of stealing things from her house, and had stopped letting them in. Her social worker was becoming increasingly worried about her, as it was only the home carers who were ensuring she was eating adequately.

When her GP, the old age consultant psychiatrist, her social worker and I arrived at her house early in the evening and knocked on her door, at first there was no reply. We could see her peering round the curtains, but she wouldn’t come to the door. However, while we discussed what to do next, her curiosity clearly got the better of her, because she opened the door. Recognising her GP (GP’s often seem to have a supernatural ability to persuade reluctant patients to cooperate with assessments), Violet decided to let us in.

At first, Violet listened politely to us as we asked her questions and tried to reason with her. She made an effort to answer us, but her answers made little sense. She wanted to defer a decision until her husband came home from work (he had died 20 years previously); she didn’t need home care because her daughter did all her shopping for her (she had never had children); she never went out after dark (the police had had to bring her home in the early hours on several occasions). It was clear that her dementia was quite advanced.

Once we had completed the interview, we withdrew into her kitchen to discuss our conclusions, and then completed the forms for detention under Sec.2. Then it was my job to tell her what was going to happen next.

Violet again appeared to listen politely to me. However, when she realised that our intention was to admit her to hospital, she became quite irate, insisting that she was as fit as a fiddle and that there was nothing at all wrong with her. The doctors made their excuses and left, leaving her social worker and me to manage her while waiting for the ambulance.

I continued to try to negotiate with her and prepare her for the arrival of the ambulance. She ran to the top of the stairs, then rather impressively high stepped down the flight of stairs, saying, “Look, look! There’s nothing wrong with me, is there young man?”

She then ran straight upstairs again and went into a bedroom. I followed, rather more slowly. When I went into the room, she was standing behind the door and was holding a full roll of wallpaper in her hand. While I tried to work out what was happening, without warning she swung the roll at me like a baseball bat, and hit me with surprising force on the side of the head.

For a moment, I reeled sideways and nearly fell over, completely disoriented. Full rolls of wallpaper pack quite a punch, and although I was not significantly injured, I was certainly in pain.

I staggered down the stairs just as the ambulance crew arrived.

“So we’ve got a 93 year old lady, have we?” the ambulance man asked, looking at his paperwork.

“Yes,” I replied, rubbing the side of my head, which now had a noticeable contusion. “But you need to be careful, she’s quite aggressive. She’s just hit me.”

The ambulance man looked at Violet, who was again high stepping on the stairs, and then looked rather pityingly at me.

“I don’t think we’ll have too much trouble managing her,” he said slightly condescendingly, and proceeded towards her up the stairs.

“Hello, Violet,” he said, smiling insincerely as he approached her, holding his hands out. “We’ve come to take you to hospital.”

“Oh no, you’re not,” she said, and punched him on the nose.

The ambulance man fell backwards, bumping down the stairs and clutching his nose, which was bleeding. His colleague rushed up the stairs, getting past her, and then grabbed her from behind, clutching her round the waist and pinning her arms against her sides.

“Quick, grab her legs!” he shouted at me.

I was a bit taken aback. I don’t normally make any physical contact with patients in my role as an AMHP (or as a social worker, come to that), but instinctively did as I was told, gripping her ankles, and between the two of us we managed to carry her downstairs, despite her objections and struggles. The ambulance men then strapped her into a chair and wheeled her into the ambulance.

“And let that be a lesson to you, you ruffian,” I heard Violet say triumphantly to the injured ambulance man as they closed the doors.

Moral: Never underestimate the capacity of a 93 year old lady to inflict significant harm.

Sunday, 20 June 2010

Ricky, No Wonder

Ricky was an electrician. He also had bipolar affective disorder. The two things did not necessarily go well together.

Back in the mists of time (well, in the very early years of the 1983 Mental Health Act at any rate) I was called on to assess Ricky on two separate occasions.

You’ve read my advice to AMHP’s in the previous two posts. Now see how many rules were broken during these assessments.

The First Assessment

I was called by Dr Grundy, an old style country GP, an amiable but slightly idiosyncratic man, as most country GP’s seemed to be back then.

“Ricky’s gone completely bonkers, old chap,” he said. “He was doing some electrical work at my house, but this morning didn’t turn up. He eventually rang me to say that he had run out of electricity and had been delayed because he was generating some more to bring over to replenish my supply. I think he might need sectioning.”

I arranged to meet with Dr Grundy at Ricky’s house, which was in a small village. Ricky answered the front door, and it was immediately apparent that he was as high as the proverbial kite.

“Come in, come in,” he said expansively, without enquiring as to who I was (he recognised Dr Grundy) or the purpose of our visit. “Let me take your hats. No hats? Well let me give you some hats!” He himself was wearing a deerstalker at a jaunty angle, and he rummaged in a chest of drawers in the hallway, muttering, “Everyone must have hats, everyone must have hats”, until he finally produced a straw hat and a motor cycle helmet which he gave to us. Dr Grundy put on the straw hat, but I put the motorcycle helmet down (There are some things I draw the line at.)

“Dr Grundy thinks you may not be well at the moment,” I began. “He thinks maybe you need to be in hospital.”

“Does he, does he? Hospital, eh? Hospital. Lots of different hats in hospital, aren’t there?”

“You can have as many hats as you like, if you go to hospital,” Dr Grundy said. I rather wished he hadn’t. You shouldn’t lie to patients.

Somewhat to my surprise, Ricky agreed. I think he was dazzled by the thought of all the hats he would be able to wear.

“Let’s go then,” he said. “No time to waste. No time at all.” He strode out of the house and climbed into the doctor’s Volvo estate, which Dr Grundy had left unlocked. (Rule 47: Never leave your car unlocked when conducting a Mental Health Act Assessment.) He then locked all the doors from the inside.

Dr Grundy knocked on the car window. Ricky beamed out at him. Dr Grundy mimed winding down the window. Ricky also mimed winding down the window. Dr Grundy found this amusing. So, it must be said, did I. But then, Ricky hadn’t locked himself in my car.

Eventually, after a great deal of furious miming on the part of Dr Grundy, Ricky cottoned on and wound the window down a little way.

“Can I help you, Dr Grundy?” he asked in a serious voice.

Dr Grundy choked a little on his laughter, then said, “Would you be a very good chap and get out of my car? You’ll be going in the other car.”

Ricky leaned out of the window and looked at my car dubiously. “That looks like a German car. I don’t like German cars.”

“It’s not a German car,” I assured him.

“I like this car better,” he said, and wound the window up again. He started to move the steering wheel round as if he were driving.

Dr Grundy was trying so hard to control his mirth that I began to fear he might have an aneurysm. But he had a cunning plan. The tailgate was unlocked, so he opened it and crawled into the boot, then climbed over the back seat until he could unlock one of the doors. It was the first time I had seen a GP get so hands on during a Mental Health Act Assessment.

Ricky eventually agreed to get into my car. I had him sit in the back seat. But as I was alone, and the doctor needed to get back to his surgery, I did not have an escort.

However, Ricky seemed more than happy about going to hospital, and we set off on the 15 mile journey.

He laughed and chuckled and fidgeted in the back seat. I wondered what he was up to, and tried to keep an eye on him in my rear view mirror. At one point he said, “Are you sure this isn’t a German car?”

“No it definitely isn’t a German car. It’s a Fiat. A Fiat 127.”

“Only I don’t like the Germans. They fought us in the War, you know. Who makes Fiats?”

“The Italians,” I replied, without thinking.

“Weren’t the Italians in the War too, on the German side?” he asked, a little threateningly I thought.

“Er, no, I’m sure there weren’t,” I lied.

“Well, that’s all right then,” he said, and went back to his chuckling and fidgeting.

Eventually we arrived at the hospital. I pulled my seat forward to let him out.

That was when I discovered that Ricky had taken a screwdriver with him. And throughout the journey, he had been systematically removing all the screws he could find in the back of the car. The screws were in a tidy heap on the back seat. The component parts of the interior of the rear of my car were in another tidy heap.

The Second Assessment

I received another request from Dr Grundy to assess Ricky a year or so later. Deciding that it was likely that Ricky would agree to an informal admission if required, I went out initially without Dr Grundy this time.

The front door was ajar. I knocked, but there was no reply. The garage door was open, so I had a look. Ricky’s nearly new Rover was parked inside. However, there was something badly wrong with it. The words: “Brooom! Broooom!” were written down the side of it in large letters in matt black emulsion. The driver’s door was open. Ricky had obviously been busy with his screwdriver again, because most of the dashboard had been dismantled, and dials and wires and various other components were scattered all over the front seats.

I went into the house, calling Ricky’s name. There was no reply. I went into his living room. There was again something very wrong about the room. It was dark, for one thing, although it was the middle of the day, so I turned on the light. That was when I realised that Ricky had painted the glass of the windows with matt black paint. The TV was on in the corner, but he had obscured the screen with matt black paint.

I continued on my journey through the house, into the kitchen, where I saw that the central heating thermostat had been dismantled and was hanging from the wall. The lid of the chest freezer was up, and inside was a dismantled toaster.

But there was still no sign of Ricky.

I went out of the open back door and into the back garden. I finally found him in the greenhouse, sitting on a deck chair and wearing his deerstalker hat and sunglasses. He beamed up at me, lifted up his sunglasses, winked at me broadly, and then gave me a piece of paper. On it he had written: “Jul Aug Sep Oct No Wonder!” I puzzled over this for a few moments, then suddenly realised that this was a list of abbreviations for months of the year, but he had then gone off on a tangent: classic flight of ideas.

“I think it’s time you went to hospital again,” I said to him. Ricky nodded and stood up.

But this time I made sure he didn’t have a screwdriver with him.

Monday, 14 June 2010

This Much I Know Part 2

Be aware of your body language and general demeanour
• It is usually best to maintain good, although not too intense, eye contact. However, people who are plainly paranoid may find this threatening, in which case, avoid too much eye contact when talking to them.
• Appear to be relaxed – even if you aren’t. Sit down if possible, although it is generally better to perch than to be enveloped in a saggy armchair, in case you need to make a quick exit.
• Do not get into the personal space of the patient.
• Maintain an even tone when talking, even if the patient is shouting.
• Do not show that you are frightened or intimidated by a patient.

A foot in the door can be a lot quicker than a Sec.135 warrant
• Remember that under Sec.115(1) of the MHA: “An approved mental health professional may at all reasonable times enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.”
• This is one of the powers of the AMHP, and does give a degree of authority to enter a patient’s house. It may be worth pointing this out to an uncooperative patient before going off to the magistrate.
• It is also worth remembering Sec.129 MHA relating to obstruction:
“(1) Any person who without reasonable cause
(a) refuses to allow the inspection of any premises; or
(b) refuses to allow the visiting, interviewing or examination of any person by a person authorised in that behalf by or under this Act or to give access to any person to a person so authorised; or…
(d) otherwise obstructs any such person in the exercise of his functions,
shall be guilty of an offence.”
• I have to say, however, that I have never had to make use of that particular section, and I am not aware of anyone actually being arrested in connection with this offence. But there’s always a first time.

Try to give the patient choices
• Always show respect for the patient.
• Depending on the degree of capacity of the patient, it is reasonable to explain the choices available to them. You will of course explain the purpose of the assessment. This can include explanation of the options available, such as home treatment, informal admission to hospital, or admission under the MHA.
• Once a decision has been made to admit, offering a choice of admission by ambulance or car, for example, can often result in the patient feeling they have some control over the process and they are then more likely to make a positive choice to go to hospital and can be less likely to object when the time comes to be admitted.

Know when to use the police
• Don’t expose yourself to an unacceptable degree of risk.
• If you have evidence of violence or aggression, arrange for the police to accompany you.
• The police may not actually be required, but it is good to at least alert the police to the possibility that they may be required and to get an incident number, or ideally to have them nearby.
• In my experience, a police uniform, rather than provoking a patient, can be very calming to an agitated or hostile patient.
• Patients will often be more amenable to cooperating with the assessment in the presence of the police.
• Police can be good intermediaries when the AMHP is being seen as the villain of the piece.
• The Police are often very good at explaining to the patient the necessity of cooperating with the admission process.
• In my experience it is rare for the police to actually have to use physical restraint to facilitate an admission.

Never be alone
• Once the assessment has been concluded, and the papers have been signed, doctors are usually very keen to be off. Make sure they don’t leave you on your own with a patient. At the very least, make sure there are relatives or other professionals with you (students can be useful in these circumstances!). Involve the police if you need to.

A Mental Health Act assessment, especially when it takes place at the patient’s home, can be very distressing for the relatives as well as the patient
• Don’t forget the likely distress the relative already has, or the additional distress the relative may have witnessing the actual process.
• Try to spend time explaining to the relative what is happening, the reasoning behind any decisions, and what will happen next.
• It may be appropriate to give the relative the option of accompanying the patient to hospital: this can also assist in reassuring the patient.
• Make sure the relative knows where the patient is going, and other information, such as the phone number of the ward, visiting times, etc.

When dealing with situations of high risk, at times I ask myself the following question:
• “Would I rather justify my decisions to an Appeal Tribunal or to an Inquest?”
• This does not necessarily mean you should always take the “safe” course, but this question can concentrate your mind.
• There are occasions when it’s definitely in the interests of the patient to return control to them (even if you do have a sleepless night!). It may even restore their faith in Mental Health Services.

You’re always an AMHP
• Once you become an AMHP, it begins to pervade your day to day practise.
• You may be sitting chatting to a service user. Something they say sets alarm bells ringing, and suddenly the interview takes a different course. Suddenly you have your AMHP hat on. But equally suddenly, (and undetectably) you can take it off again.
• If you work in a Mental Health Team, it soon becomes second nature to see case discussions in the light of duties and powers under the Mental Health Act (and the Mental Capacity Act). You may not even say anything differently; but you are thinking differently.
• You find yourself contributing to discussions in ward rounds or team case reviews in the context of possibilities under the MHA.
• Do these discussions and interviews constitute Mental Health Act assessments? In a way, yes. But they can also remove the need to go down the MHA route. It can save a lot of time when a quick chat with a Consultant removes the need for a full blown assessment.

Occasionally, I entertain a little fantasy
• I am in a theatre, watching a play.
• One of the actors begins to behave erratically. They fluff or change their lines, they interrupt other actors when they’re not supposed to, they laugh inappropriately, they don’t respond to cues, they move round the set knocking things over. They start fighting with other members of the cast. Eventually, the curtain falls prematurely.
• A murmur rises from the audience, wondering what has gone wrong, wondering what is happening.
• After a few minutes, the director parts the curtains and stands at the front of the stage.
• “Excuse me,” he announces, his voice rising over the audience. “But is there an Approved Mental Health Professional in the house?”