Sunday, 31 January 2010

The Section 2 That Wasn’t

Perdita had suffered horribly for most of her life. She had been abused physically, sexually and emotionally as a child, and as an adult had gone from one abusive relationship to another. Along the way she had developed a wide range of coping strategies, including cutting, overdosing, denial of food, dependence on alcohol and drugs, and a range of alternate personalities, some of whom coped well and appeared “normal”, and some of whom you would not like to meet on a dark night. Or even in broad daylight.

Her alternate personalities all had names. There was Perdita of course, whom her community nurse encouraged to be in control. But there was also Grendl. Grendl was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone. And there was also Mavis, a very ordinary, impeccably behaved woman who appeared when she had to in order to rather resignedly clear up the mess left by Grendl.

Not surprisingly, Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, including Dissociative Identity Disorder, Anorexia Nervosa, and of course Borderline Personality Disorder.

Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia (Perdita liked flowery names). Perdita had always done her best to protect her daughter from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.

Her community nurse was a patient and very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendl was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia. After a couple of weeks of escalating out of control behaviour, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendl answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.

That was when the Masked AMHP was asked to get involved.

The consultant gave me a recommendation for an admission under Section 2 MHA for assessment, and I went out to see Perdita in the company of another Sec.12 approved doctor and Perdita’s community nurse. I figured we’d probably be a lot safer if we went with someone who had a good rapport with her.

I wasn’t sure whether it was an angry Perdita or a subdued Grendl who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.

She was not amused when I told her the purpose of our visit. She became almost instantly hostile, asked us to leave and shared with us an impressive selection of insults and swear words. I tried to continue to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to speak to her.

We sat patiently for a few minutes, and after a while she turned down the TV to a reasonable level. This gave me an opportunity to speak.

“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”

I had by now concluded that Perdita was so out of control that there was no alternative but to detain her in hospital for assessment. The doctor and I left the house and retreated to my car to complete the paperwork.

I went back into the house to break the news to her. Perdita had switched. The aggression and hostility had evaporated. In its place was a melodramatic level of contrition.

“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!” She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.” This level of apology and contrition was actually much worse to bear than her anger, insults and aggression.

I had made a decision. I had completed my application. She was now officially detained under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.


Grendl did seem to have gone for the time being. The threat of admission did seem to have brought Perdita back in control again. She was making reasonable plans for the future (at least the immediate future). And what would be the effect on Ophelia of being separated from her mother?

So in the end I decided to use the discretion given in Sec.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially Sec.2, an admission follows as quickly as suitable transport to hospital can be arranged.

I did a deal with Perdita. She would cooperate with us. She would allow us to help her to keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her tomorrow to review the situation. She readily agreed to all of this and was embarrassingly grateful. And when I visited the following morning, she was calm, collected, polite and cooperative, although still clearly feeling low and sad.

I continued to monitor her on a more or less daily basis for the next week. Things continued to improve. The crisis was over. I shredded the papers.

Tuesday, 26 January 2010

“You’ll Have a Cup of Tea...”

I was on night duty and received the call from the GP early in the evening. Keith was a patient of his in his 50’s. He was a divorced man who lived alone in his own bungalow. He worked as an engineer. He had no previous history of mental illness, but had this evening turned up at the surgery complaining of sleep problems. The sleep problems seemed to relate to Keith spending every night working on a special project in his garage. He was adapting a Reliant Robin.

(For the benefit of those who have never encountered this form of vehicle, the Reliant Robin was a rather flimsy and unstable three wheeled car made of fibreglass, which is now thankfully no longer in production. Their cornering ability was notoriously bad. I once witnessed a Reliant Robin attempting to turn rather faster than it should. The car rolled over onto its side. The driver climbed out, shook his head, pushed it back onto its three wheels, and drove on.)

After a few minutes Keith confided to the GP that the special adaptation he was fitting to this Reliant Robin was an antigravity drive. At this point the doctor gently suggested that it might be a good idea if he were to see a psychiatrist. Keith did not take kindly to this, was uncharacteristically rude to the doctor, and abruptly left the surgery.

The doctor thought that Keith might be showing symptoms of bipolar affective disorder: in particular, grandiose delusions, as well as boundless energy, poor sleep, irritability, and pressure of speech.

I arranged to meet him with a psychiatrist at Keith’s house. It was mid evening by the time we got there, and dark. Keith answered the door, I explained who we were, and he rather reluctantly let us in.

When we were in his living room, I asked him, “Tell me more about your project.”

Despite his reticence, this was clearly a topic close to his heart, and he could not resist telling us about it, the sentences flooding out almost faster than he could move his lips.

“I received a vision about a week ago,” he said. “It was a plan for an antigravity device. It came from the Dog Star. Incidentally, the inhabitants of the Dog Star aren’t at all like dogs, you know, they’re more like furry slugs, and they all fly around on antigravity platforms. They chose me because of my engineering know how. I’ve managed to get most of the parts, and I’m making the ones I can’t buy myself.”

“Why a Reliant Robin?” I asked. “It’s somehow seems an unlikely car to fit an antigravity drive into.”

“Ah,” he said. “You might think that, but you’d be wrong. It’s exactly the right vehicle. You see, it’s made of fibreglass. That means it won’t interfere with the antigravity rays.”

I thought about this. I could see that this made a kind of sense. But not enough.

“I think it might be a good idea if you went into hospital for a while,” I said to him.

“What on earth for?”

“I think you may be mentally unwell at the moment.”

“They said people would think that. Well, you can all just get out of my house. Go on, get out!”

We retreated rapidly, especially as he had picked up a golf club and was waving it about in a threatening way, and heard him locking his front door as soon as we were outside.

It was strange that Keith had suddenly appeared to develop full blown symptoms of bipolar disorder in his 50’s with no previous history of any mental illness. We wondered if there was some organic cause. Whatever the reason, in view of his unpredictability and irritability, we decided that he needed to be in hospital, and was clearly not going to agree to this. We completed an application under Sec.2 MHA, for assessment. Then I called the police.

Four police officers in two police cars turned up a few minutes later. They knocked on his door, but he would not open it. We could see him peering out of his window at us. It looked as if I might have to get a magistrate’s warrant under Sec.135, but I decided to have one last try. I made my way to the front of the melee of police standing at his front door, and knocked again. I could see him through the glass on the other side of the door, and knelt down at his letter box.

“Please let us in, Keith, you have been detained under Sec.2 of the Mental Health Act. You’re going to have to go to hospital. If you won’t let us in now, I’ll have to come back later with a warrant.”

There was a pause. Then I heard him unlocking the door. As he opened it I smartly stepped forward and entered, expecting the police to be right behind me. However, as soon as I was in, Keith quickly shut the door and locked it behind us.

The police were on the other side of the door. On the wrong side. I was locked in a house with an unpredictable and irritable detained patient. Who had threatened us with a golf club. And the police were outside.

“You’ll have a cup of tea,” Keith said.

It was important not to panic. It was important to show Keith that I was in control of the situation.

“Actually, Keith, I don’t want a cup of tea. I’m actually feeling quite anxious about this. I’d feel a lot better if you unlocked the door.”

“Feeling anxious are you? Well, you’ll have a cup of tea then.”

I tried to find another way out of the house. I went through room after room. But all the windows and external doors were sealed unit double glazed units, all fitted with locks that could only be opened with a key. And Keith had the key.

“What are you doing?” he asked me ingenuously, as he followed me round the house.

“I’m trying to get out. I don’t like the fact that you’ve locked me in.” I could see the police milling about outside, trying windows and doors, but basically looking powerless and ineffectual.

“You’ll have a cup of tea,” he repeated, putting the kettle on.

“I really don’t want a cup of tea right now, Keith. We need to take you to hospital.”

“You’ll have a cup of tea,” he said again, very firmly, putting some teabags into a pot and pouring in the hot water. “You’ll have a cup of tea. Then we’ll go to the hospital.” He got out some cups.

I began to see what was happening. He too was attempting to retain a measure of control over the situation. It was a stalemate.

“All right,” I said eventually. “We’ll have a cup of tea. Then we’ll go to the hospital.”

“Milk?” he said, smiling. “Sugar?”

So we had a cup of tea. He chatted about this and that, while I drank the tea and tried to hide my panic. Then he unlocked the door, stepped out into the night and calmly got into one of the police cars.

Thursday, 21 January 2010

The Problem with Relatives

Relatives and carers of people with mental illness need to be heard and respected. They are frequently good informants, and often bear the considerable burden of caring for a mentally ill relative without complaint, and for far longer than they necessarily ought.

However, relatives are not always good informants. Sometimes they can be actively malicious – I have had several nearest relative requests for assessments (to which, under Sec.13(4) MHA, we have to respond) from ex-partners complaining that their wives/husbands are behaving in an irrational and unbalanced way, when the only “irrational” behaviour is that they no longer wish to live with an abusive partner. And sometimes they become just too sensitised to the relative and interpret innocuous or normal behaviour as signs of mental illness.

Ivan’s GP phoned me one afternoon. He had had a call from Ivan’s mother saying that he was becoming unwell again. She reported that he was threatening her and neighbours, and that the police had been called on one occasion. Although the GP had not recently seen Ivan, he was nevertheless requesting a formal assessment under the Mental Health Act. He had noticed that Ivan had not ordered a repeat prescription for his antipsychotic medication for about 6 months. On the basis of this information, I agreed that I would undertake an initial assessment with the GP, and the GP arranged for Ivan to visit the surgery the next day.

I did know Ivan. He was a man in his 40’s who lived alone. I had assessed him under the Mental Health Act about 7 years previously, again on the information of his mother. In fact, she had often reported that he was displaying gross symptoms of mental illness, but when assessed had been found to be largely asymptomatic. On the previous assessment, he had admitted to an unusual somatic hallucination or delusion, which was the feeling that someone was pressing down on his head. He admitted that the only way he could find of relieving this symptom was to bang his head on the wall, and indeed he had a few contusions and abrasions as a result of this practice. He had also lost a lot of weight and complained of having no appetite.

That assessment had been inconclusive, and the psychiatrist and I had not felt he was detainable under the MHA. However, he did agree to an informal admission, and he was checked out medically to exclude any physical causes for these symptoms. He was discharged on a small dose of antipsychotic medication, had remained very well for several years and had eventually been completely discharged from the Community Mental Health Team.

In view of this previous history, and despite the reported concerns, I somehow doubted that the assessment would result in an admission to hospital.

I was right.

I saw Ivan on his own initially, as the GP had had to see another patient. Ivan remembered me from my previous contacts with him, and was friendly and appropriate throughout the conversation. He told me that for the last few years he had been doing a part time Open University course leading to a degree in Astrophysics. He had attended short courses and summer schools, and had even spent a week working at an astronomical observatory on Majorca.

All this was true. Since cosmology is something I am quite interested in, while we waited for the GP to join us, we had an illuminating and interesting discussion about String Theory, the Large Hadron Collider, and the nature of black holes, and even got into an argument about whether or not the Higgs Boson existed.

He showed not the slightest evidence of psychosis or any other signs of mental illness. He said that he was still taking his medication, and had not collected any recently because he was on such a small dose he still had a supply. This was plausible. He had insight into his disorder, recognising the ill effects of not taking the medication on the occasions when he forgot it. He denied any problems with the neighbours, although agreed that he had fallen out with his mother a couple of months previously because she had been trying to convince him that he was unwell. He had not seen her recently. There was no evidence of head banging, and he had even put on weight since I had last seen him.

He shook my hand as he left, and I wished him luck with his degree.

Monday, 11 January 2010

Update - Jenny

I wrote about Jenny in my blog in July 2009 (“God told me not to answer the door!”) Jenny had the dubious distinction of being the person I have assessed under the MHA more than any other, a total of 11 assessments over a 7 year period. She has now extended her record, which is becoming unassailable.

Assessment 12: After 18 months without hearing anything about her (she was being managed by the Assertive Outreach team – a specialist mental health team who work with patients who have problems with disengagement from services or non compliance with medication), I had a call from their consultant. There was growing evidence that she was becoming unwell again. Workers were reporting that Jenny believed that her brother-in-law was a hacker working with MI5 and was watching her internet activities. She has also said that she had been freaked out by a Whitney Houston video where Whitney was singing a song about her. She had subsequently refused to let workers in to see her.

Jenny was told we would be visiting her to assess her under the Mental health Act yet again, and somewhat surprisingly she agreed to this. So the following day her consultant, another psychiatrist and I turned up at her door.

Sue answered the door and let us in. Jenny was cooperative and pleasant throughout the interview. There was little evidence of active psychosis during the interview – the only matter of possible concern was her freely disclosing that she engaged in sexually explicit activities on a webcam. There was evidence that she had been taking her medication. She appeared sedated and said that she had taken a double dose the previous evening. She agreed to continue to engage with the Assertive Outreach Team and agreed to an increase in medication. She said that she had not had any cannabis for about a month, but this was more through lack of supply than lack of desire. She did admit to having used speed recently. We were there for about 45 minutes, during which she remained friendly and cooperative and did not display any of her usual symptoms indicating relapse. We could not justify detaining her on the basis of this interview.

Assessment 13: However, things were somewhat different a month later. Her consultant reported that since Assessment 12 her relatives were reporting increasing concerns about her mental state. She was engaging less with the Team, there was evidence that she was not taking her medication, she was reported to be drinking alcohol, which is unusual for Jenny, and most worryingly she now had a supply of skunk again, which usually makes her worse. There had been more damage to her house – breaking a window and smashing belongings – again this was a typical part of her relapse signature.

She was contacted and told we would be conducting another formal assessment, and the next day we were standing in the snow again knocking on her door. She let us in, but, unlike the previous occasion, she was immediately hostile. There was evidence in the house of damage, including the kitchen door hanging off, holes in the kitchen wall, a broken window in her living room and a broken mirror. She sat in the kitchen rolling a joint from a large bag of herbal cannabis and then proceeded to smoke it while we were attempting to interview her. As the kitchen filled with the aromatic smoke she told us that she was no longer mentally ill and did not need medication or further involvement with mental health services. Cannabis was all she needed to keep her well. She was very preoccupied with people she knew who might be paedophiles, and made several loud and explicit allegations which seemed unlikely to be true. She identified me as the principle villain on this occasion, shouting and swearing at me and making an inventive threat – she told me darkly that she had a copy of my death certificate, signed and dated. After about 20 minutes, Jenny ordered us out of the house. We had had enough, and were glad to leave.

We retreated to the warmth of my car to discuss our assessment, and within a few minutes we had completed the paperwork. I went back to her to tell her what was happening. She refused to open the door and swore at me through the letterbox.

I called the police for assistance, fearing that I might have to get a magistrate’s warrant (Sec.135) in order to enter her house and take her to hospital. The doctors having made their excuses and left, I sat in my car and watched from a discrete distance as the police knocked on her door. To my relief she let them in.

I followed inside after a few minutes and explained to Jenny that she was now detained and would have to go to hospital. By now she was somewhat calmer – the spliff she was smoking freely in front of the police when I entered may have helped – and was becoming resigned to the inevitability of her admission. She would not come with me (I had an escort with me), but said she would allow the police to take her. However, she wanted everyone out of the room while she packed a bag. I realised that this was so that she could find some way of concealing her stash and smuggle it onto the ward (she had managed this in classic drug mule fashion in the past) and alerted the police, who persuasively offered to look after it at the police station for her.

I think I am now becoming as resigned as Jenny to another knock on her door sooner or later in the future.