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.