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.