Wednesday, 28 December 2011

Calling All AMHP's! Assistance Needed for Survey

Janine Hudson, who is a recent member of The Masked AMHP's Face book Group (see how much fun it is? Join today!) would like your help on a research project she is undertaking into stress and burnout in AMHP's.

Here are the details in her own words:

Fellow AMHPs we need your help:

We’re looking for Approved Mental Health Professionals practising in England to complete a survey about stress and burnout. The survey aims to determine whether there is a difference in experiences of stress and burnout between the professional groups that perform the AMHP role.

The study has been approved by King’s College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (REC reference number PNM/11/12-23). It is the first survey of its kind since the AMHP role was introduced and with your help we hope it will yield some useful and valuable data.

It is important that AMHP’s from all professional backgrounds complete the study. However we would particularly like to encourage those from a non-social work background to take part as they are still relatively small in number. An information sheet containing further details about the study is displayed on the first page of the online questionnaire. If you would like to read more about and or complete the survey please click on the link below:

We would also be grateful if you would forward this link to any AMHP’s you know that might be interested in taking part.

Thank you in advance for your time and support.

Janine Hudson
Approved Mental Health Professional
Student, MSC Mental Health Social Work with Children and Adults'

I've already taken the survey. It doesn't take too long!

Sunday, 18 December 2011

The Masked AMHP’s™ Essential Christmas Merchandise!

Now's your chance to stock up with the Masked AMHP’s™ Essential Merchandise!

Your AMHP colleagues will be delighted to find one (or more) of these essential items in their stocking this Christmas!

The Masked AMHP™ MHA Tee Shirts

Never go out on a Mental Health Act assessment without wearing one of The Masked AMHP’s ™ MHA Tee Shirts! They are designed to save valuable time explaining the reasons for two doctors and an AMHP turning up at the patient’s door!

There are two stylish and useful versions:
The Politically Correct MHA Tee Shirt
The Politically Incorrect MHA Tee Shirt

For when you’re in a real hurry!

The Masked AMHP™ Magic Wand

No more long waits for a hospital bed, the police or an ambulance! Simply wave The Masked AMHP™ Magic Wand, make a wish, and whatever you require will magically materialise! (Warning: if an ambulance is still in use after midnight, it is likely to turn into a pumpkin.)

The Masked AMHP™ Telepathic Section Papers

With The Masked AMHP™ Telepathic Section Papers you no longer need to worry about filling in the details correctly! When you give the papers in to the MHA Administrator, they will see exactly what they want to see!
The Masked AMHP™ Inflatable Sec.12 Doctor
Ever found yourself going down your list with increasing desperation trying to find a Sec.12 doctor for your Mental Health Act assessment? With the Masked AMHP™ Inflatable Section 12 Doctor, such worries will be a thing of the past! Comes with realistic looking stethoscope and white coat for added authenticity! The Deluxe version speaks 3 useful phrases: “Tell me, how long have you been hearing voices?”, “I think you ought to go into hospital,” and “Have you got an expenses form?” – just like the real thing! When not in use, stows easily in your glove compartment!

Buy one and get a second for exactly the same price!
Anatomically correct! (Contains small parts)

Thursday, 8 December 2011

More on Section 117 Aftercare: Clash of the Titans

Masked AMHP: Hi, Blog Reader. Nice of you to drop by.

Blog Reader: Clash of the Titans, eh? What’s that all about then?

MA: I’m glad you asked me that. This post is all about when S117 Aftercare Goes Bad.

BR: Ooer! Tell me more…

MA: Don’t worry, I will. This is essentially all about Local Authorities and their efforts to avoid their financial responsibilities to provide aftercare under S117. But don’t go away, it’s fascinating. Honest. Just to briefly recap on my last post about S117, the MHA 1983 established the duty of PCT’s and Local Authorities to provide aftercare to people who had been detained under Sec.3 and certain other sections imposed by the Criminal Courts. From then on, many local authorities challenged the implication that they could not charge for aftercare services under S117. As far back as 1994, the Department of Health had to issue guidance stating clearly: “Services provided under section 117 of the Mental Health Act 1983 are not subject to charging”. In 1998, a Parliamentary written answer stated: “"Charges cannot be levied for services, residential or non-residential, which are provided as part of the programme of after care for a patient . . . under section 117" (Hansard Written Answers, 28 July 1998, col. 172).

BR: I’ve think I’ve got that. Carry on.

MA: If only local authorities were as astute as you! A number of local authorities over the years have sought to either challenge this statement or find ways around it. A good example is Regina v. Manchester City Council Ex P Stennett and Two Other Actions [2002] UKHL 34. This involved consideration by the Court of Appeal of 3 cases of people with mental illness who had been detained under Sec.3, discharged into residential care and then charged for their accommodation. These cases were appealed by the individuals, and their appeals were upheld. The 3 local authorities involved then took the cases to the House of Lords. They argued that S117 merely operated as a gateway section to trigger provisions under other statutory provisions, for example, Sec.21 National Assistance Act 1948, under which services can be charged. The Court of Appeal dismissed this argument and the appeals.

BR: Quite right, too. Justice prevails.

MA: But then another tack is to simply try to avoid providing appropriate aftercare at all. AK v Central and North West London Mental Health NHS Trust and The Royal Borough of Kensington and Chelsea, Queen’s Bench Division, 30th May 2008 concerned the case of a man with schizophrenia who made an apparent suicide attempt by jumping from the second floor window of bed and breakfast accommodation whilst he was under the care of a Mental Health NHS Trust and the local authority. He was seriously injured. He brought a case of negligence against them for failure to provide appropriate aftercare under S117, as he had previously been detained under Sec.3, specifically, for “failing to provide or arrange for the provision of a competent social worker or care-coordinator to address the Claimant’s need for high to medium supported accommodation, and to ensure his safety by securing such a placement”. The original case was dismissed, but there was a further appeal to the Court of Appeal, which found that both the NHS Trust and the Local Authority, as well as acting negligently, had breached Articles 3 & 8 of the European Court of Human Rights, and the appeal was allowed.

BR: The European Court of Human Rights, eh? This goes right to the top, doesn’t it? By the way, just remind me what Articles 3 & 8 are?

MA: I do like your questions. It’s almost as if I wrote them myself. Article 3 prohibits torture and inhuman and degrading treatment or punishment, and Article 8 concerns the right to respect for private and family life.

BR: Do you think that’s why the present Government has been talking about getting rid of the Human Rights Act?

MA: I couldn’t possibly comment.

BR: Do local authorities always get a hammering?

MA: Mmmm, let me think – not always, there’s the case commonly known as “Mwanza” (R v Greenwich London Borough Council and Bromley London Borough Council, ex parte Michael Mwanza (2010) [2010] EWHC 1462 (Admin) QBD (Admin) (Hickinbottom J) 15th June 2010). This case involved a Zambian national who was in this country on the basis that his wife had a student visa. He was subsequently detained under Sec.3. He and his wife stayed in this country for several years, during which time his wife’s student visa ran out and they were then considered to be residing in this country unlawfully, so they were unable to work or claim benefits. He applied for accommodation and financial support. When this was refused, he applied for judicial review on the basis that S117 aftercare covered both eventualities, as they could be considered to be necessary in order to prevent a deterioration in his mental health. The Court found that a local authority’s duty to provide aftercare was limited to the services necessary to meet a need arising from a person’s mental disorder. As his mental disorder had not been the cause of his homelessness or destitution, then there was no requirement on the local authority to meet this need.

BR: That must have been a relief.

MA: You’re right, it does put clear limits on what can be considered to be aftercare, ie services only need to be provided under S117 in order to meet an assessed mental health need.

BR: Any other problems around provision of S117 aftercare?

MA: This is where it gets really dirty. Local authorities mud wrestling with each other over which one is responsible for providing aftercare! Figuratively speaking, of course. I’m not suggesting that representatives of local authorities literally get into a pool of mud and resolve disagreements over funding by wrestling with each other.

BR: I didn’t think you were.

MA: Although, come to think of it, it could be a good way of sorting out disputes…

BR: So, what sort of disagreements do they have? Are they fighting over the opportunity to pay for aftercare?

MA: Hardly. I’ll give you a theoretical, but not unusual, scenario. Mr X lives in the area covered by Authority A. He has paranoid schizophrenia, becomes unwell, and is detained under Sec.3 MHA. The S117 aftercare planning meeting concludes that he needs specialist long term care that can only provided in a care home. They find an appropriate home in the area covered by Authority B and he is placed there. A year or so later, his mental state deteriorates and he is again detained under Sec.3. So who is responsible for his aftercare when he recovers?

BR: Well, if Authority A placed him there, then surely they are still responsible for his aftercare?

MA: Wrong. You see, he has changed the place of his residence. He no longer resides in Authority A, but Authority B. Therefore Authority B has to pick up the tab for aftercare.

BR: Let me think about this – so Authority A might be quite happy for Mr X to become unwell and need detaining again, because they would no longer have any responsibility for providing aftercare?

MA: I’m sure that no local authority would be so unscrupulous as to permit that to happen. But there are some local authorities in the country that have a lot of care homes compared to other places, and therefore other local authorities frequently make placements out of area. Those local authorities can therefore end up with a disproportionate number of complex cases for whom they become responsible for the duty to provide S117 aftercare. And they’re often not terribly happy about it. Consequently, they go to law from time to time. There have been a couple of very recent court cases in which the Courts have been asked to make judgments about which local authority is responsible: R (Hertfordshire County Council) v LB Hammersmith and Fulham (JM as Interested Party) Court of Appeal, Carnwath, Rimer and Sullivan LJJ, [2011] EWCA Civ 77, 15th February 2011, and R (on the application of Sunderland City Council v South Tyneside Council [2011] EWHC 2355 (Admin) QBD (Admin) (Langstaff J) 15th July 2011. The first case looks at the concept of “ordinary residence” as defined by Sec.21 National Assistance Act 1948, and dismisses it for the purposes of S117 aftercare. During the court case, the argument was explicitly advanced that there was a need to reduce the temptation for local authorities to place people for whom provision was made under Sec.21 out of their area so that the authority in which they were placed became responsible if Sec.3 of the MHA was invoked. This argument, however, was dismissed. In the second case, one of the conclusions was that there was no material difference between “resident”, “ordinarily resident” and “normally resident”, and also that a hospital could not be considered to be a place of residence for these purposes. That would be a relief to local authorities who have hospitals where people from out of area may frequently be admitted.

BR: Well, thanks again, Masked AMHP, for yet another enlightening post. I will in particular be left with an indelible image of Directors of Adult Services slugging it out together in a pool of mud over who’s going to pay for Mr X’s aftercare.

MA: It’s my pleasure.

Tuesday, 6 December 2011

Section 117 Aftercare: What You Didn’t Know You Didn’t Know

Blog Reader: I say, Masked AMHP, are you there?

Masked AMHP: Who’s that? Oh, hello there, Blog Reader. How can I be of service?

BR: I’d like to ask you a few questions about Sec.117 Aftercare, if you don’t mind.

MA: Oh dear… Actually, I’m really rather busy preparing my special Christmas post. Can you come back another time?

BR: But it’s stuff I really need to know… This friend of mine, you see, has been detained under Sec.3 and they’re having a meeting to discuss aftercare… They’re talking about putting him in some sort of a care home…

MA: (Sighs) OK, then, fire away.

BR: Let’s begin with basics, then. What exactly is Sec.117 of the Mental Health Act 1983?

MA: Sec.117 applies to anyone who has been detained under Sec.3 or Sec.37. There are a couple of other forensic sections, but they’re pretty rare, so I won’t confuse you with them. Sec.117(2) states: “It shall be the duty of the Primary Care Trust… and of the local social services authority to provide, in co-operation with relevant voluntary agencies, after-care services for any person to whom this section applies.” It’s a pretty significant section, in that it introduced a legal requirement for Mental Health services and local authorities to make sure that people who had been detained under the MHA for treatment were given the help they needed on discharge to keep them out of hospital, rather than just being dumped back into the community with no support.

BR: So, what are these meetings all about, then?

MA: The Code of Practice says: “After-care is a vital component in patients’ overall treatment and care. As well as meeting their immediate needs for health and social care, after-care should aim to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital. (27.5)” Before anyone detained under the relevant sections is discharged from hospital, there has to be a meeting involving any relevant professionals or others, including the patient, relatives, and carers. There’s an extensive list in the Code of Practice as to what should be considered (27.13). These include: the psychological needs of the patient, as well as their family and carers; their physical healthcare; daytime activities or employment; appropriate accommodation; identified risks and safety issues; social, cultural or spiritual needs; assistance in welfare rights and managing finances; contingency plans and crisis contact details. There are many other things to be considered as well. Once the patient is discharged, there have to be regular reviews in the community.

BR: And what exactly is an aftercare need?

MA: Aftercare itself is not defined in the MHA. It’s very broad. However, some case law has given guidance as to what should be included (Clunis v Camden and Islington Health Authority (1994)). It would certainly include social care provision, support in helping with employment, accommodation or family relationships, the provision of domiciliary services and day centre and residential facilities.

BR: Is there a time limit, like with other sections?

MA: No, there isn’t. The requirement to provide S117 aftercare will continue indefinitely, in practice until the Consultant Psychiatrist and a representative of the local authority, eg a social worker, “are satisfied that the person concerned is no longer in need of such services”. The Code of Practice helpfully states: “The most clear-cut circumstance in which after-care will end is where the person’s mental health has improved to a point where they no longer need services because of their mental disorder. But if these services include, for example, care in a specialist residential setting, the arrangements for their move to more appropriate accommodation will need to be in place before support under section 117 is finally withdrawn” (27.19) However: “Even when the provision of after-care has been successful in that the patient is now well settled in the community, the patient may still continue to need after-care services, for example to prevent a relapse or further deterioration in their condition.”( 27.21)

BR: Mmmm. And what’s this all going to cost?

MA: Aah! I’m glad you asked me that. The MHA Reference Guide observes: “Because the Act provides no power to charge anyone for after-care services provided under section 117, they must be provided free of charge.” (24.18)

BR: So if something is part of the S117 aftercare plan, the patient gets it entirely free? My friend wouldn’t have to pay anything for this home they’re thinking about?

MA: That’s exactly right! And that’s where it all begins to get a bit complicated and messy.

BR: What do you mean?

MA: Aftercare can be very expensive, especially if someone is in a residential or nursing care home. Some of these places can literally cost thousands of pounds a week! And regardless of the personal income of the patient, the local authority can’t get back a penny! So some local authorities have tried to wriggle out of their responsibilities under S117.

BR: Local authorities wouldn’t try to do that, surely?

MA: Are you really that naïve?

BR: No, actually, I’m being sarcastic.

MA: That’s all right, then. Local authorities have tried a number of cunning ruses over the years. But they’ve often come a cropper. There have been a number of cases referred to the Ombudsman over the years in which local authorities have been hammered.

BR: Local authorities getting hammered? Please tell me more!

MA: Well, let’s see… York City Council was found guilty of maladministration after it persuaded an elderly lady detained under Sec.3 to make her own residential care arrangements at her own expense by threatening that if she went through the normal procedure for getting a residential placement she’d have to languish in hospital for a year. She therefore agreed to waive her entitlement to the funding of her aftercare under S117.

BR: What happened to the council?

MA: They had to pay her for the costs she had incurred for her care. Then there was Bath and North East Somerset Council. This was another old lady with dementia, detained under Sec.3. She was placed in a residential care home as part of her aftercare pan, which was paid for by the Council under S117. After about 2½ years they tried to discharge her from S117 aftercare on the basis that she no longer needed residential care, was settled in her care home, and was not at risk of being readmitted to hospital. The Ombudsman again found maladministration, on the basis that whether a person was settled in a residential placement or not was an “irrelevant consideration”. It was stated that “these defective criteria fatally flawed the decision that Mrs Fletcher was no longer at risk of readmission to hospital.”

BR: Any more dirt to dish?

MA: Why, yes! Poole Borough Council were found guilty of maladministration for failing to carry out a proper assessment of a woman’s mental health needs to establish that section 117 aftercare was no longer required. It also failed to hold a multi-disciplinary meeting with the relevant professionals, the patient and her carer or nearest relative to review the care plan. In all these cases the local authority had to reimburse the patient or their families tens of thousands of pounds. And there have been others, generally around the local authority spuriously deciding to discharge someone from S117 when in fact they are still receiving aftercare.

BR: Phew! So local authorities must be much more conscientious about keeping to the rules now.

MA: I think you’re having a little laugh, aren’t you? Some local authorities are trying a new tack. They’re trying to distinguish between chargeable services, under Sec.21 of the National Assistance Act 1948, and S117 aftercare services, which they can’t charge for.

BR: And what exactly is Sec.21 of the National Assistance Act 1948?

MA: That’s where residential care is provided outside of the MHA for such things as frailty or physical disability. I’ll give you a little scenario. Edna Wilby is 85. She has lived in a care home for 3 years, having been admitted there after she had a fall at home and broke her hip, and was no longer able to manage in her own home. She has been contributing to the cost of her care based on her personal retirement income and savings. Over time, she becomes increasingly demented, and is eventually assessed under the MHA after she assaults a member of the care staff. She is detained under Sec.2 MHA for assessment and admitted to a psychogeriatric ward. She is subsequently detained under Sec.3. She improves with treatment and they hold a S117 aftercare planning meeting at which it is decided that she is able to return to the care home in which she had been living for the last 3 years. She will be followed up by the psychogeriatrician in Outpatients, and a psychiatric nurse from the community team will advise the home on management of her dementia. So, does she have to pay or not?

BR: Well, if the plan to return to the care home is part of the aftercare plan, she shouldn’t have to pay, should she?

MA: You’d think so, wouldn’t you? But some local authorities would argue that the care she is receiving in the care home is not for her mental disorder, but for her physical frailty, which she has been receiving, and paying for, under Sec.21 of the National Assistance Act 1948. They would say that the aftercare covered by S117 was only the outpatient appointments and involvement of a community psychiatric nurse.

BR: Very cunning. Do you think they’d get away with it?

MA: We’ll have to see what the Ombudsman thinks about it, if it’s ever challenged.

BR: Thank you, Masked AMHP. You’ve been very helpful. I’ll be off now.

MA: Wouldn’t you like to hear about the ructions that occur when local authorities can’t agree about who should pay for aftercare?

BR: Er, another time, Masked AMHP, another time.

Monday, 21 November 2011

Origins of the Masked AMHP 3: Social Work in the 1970’s

Social work was very different in the 1970’s -- even the concept of “social work” as a single profession was novel. The social work task certainly seemed more straightforward back then – generic social work implied that you could be equally competent to practise with all service users, whatever their problems.

Some processes were certainly much simpler than they are now. If you visited an elderly or disabled person and thought that they needed home care, all you had to do was talk to the “Home Help Organiser” in the team. She would then undertake her own assessment of need, decide how many hours and what sort of care was required, then arrange for an in-house “Home Help” to go in. The service user paid for this service, if necessary, by buying stamps from the local post office.

Is that really less cost effective than conducting an assessment for a personal budget (our local authority has 140 steps in the process of assessing and setting up personal budgets), then arranging for an account to be set up for an individual so that they could then hire their own carer – with the assistance of the (separate) independent living team?

There was undoubtedly a sense of optimism, especially among the hordes of new social workers who were appointed then (as well as a naivety that would be quickly dispelled). There was quite a lot of money going into social work – local authorities then, far from having to cut back year on year, were actually going through a period of immense budgetary growth.

New services were being created: “Intermediate Treatment” was being mooted as a way of tackling juvenile crime, social workers were getting involved in dealing with young offenders; family centres were being set up in their dozens, based on the philosophy of tackling the problem of teenage alienation by targeting early deprivation and working with families where children were considered to be at risk of future offending.

Some social problems were really rather rare, particularly out in the rural parts of the Charwood area; far from there being the extensive drug and alcohol problems, and associated services, that there are now, I can remember that in Charwood back then, the numbers of registered heroin addicts could be counted on the fingers of one hand.

Other problems, however, especially in Charwood and its surrounding area, were very common. Isolation and difficulties accessing services were serious issues for the people in the outlying villages. Having said that, even the smallest hamlet had a post office; this was extremely important when trying to find “Dingley Cottage, Golden Corner, Hempland St Giles”, as comparatively few people had telephones and the local sub post master or mistress could always give you directions (“Oh, you’ll be wanting Edna Boggis – her arthritis has been playing her up terrible, you know.”)

Charwood itself contrasted markedly with the surrounding countryside, having a bizarre preponderance of inner city type problems. This was because of its status as a London Overspill town. People moving up from London brought their London problems with them as well as finding new problems when they arrived. It never ceased to amaze me how many Charwood people had been associates of the Krays; some of them, I suspected, were laying low in the town to avoid possible “unpleasantness”, and might even have had assumed names.

Many of those who moved to Charwood from London found it very difficult to adjust. While I was delighted that I could walk out of the back gate of my house on a GLC estate and immediately find myself walking down a path beside a river teeming with fish into the middle of a wood full of deer, woodpeckers, and edible fungi, many of the people I started to see could not get over the lack of any significant night life, the dearth of takeaways, and the absence of any leisure activities at all apart from bingo at the local cinema, not to mention the difficulty of finding public transport that would take you anywhere more cosmopolitan.

Our threshold for services was rather different then, and some of our social work tasks would seem completely alien now. One example was the arrangement we had with the public utilities companies (water, gas, electricity). If they were planning to disconnect someone and had reason to believe they were vulnerable, for example, if they had young children or a disability, they would write to us to give us notice. We would then go out to visit them, and if necessary would loan them a calor gas heater or cooker. We had a store room at the office full of such equipment.

We also used to get sent out on trivial errands – I can remember driving 10 or more miles simply to deliver a bendy straw or a non slip placemat to someone with a physical disability!

In those days one of the perks of being a social worker was that you were designated an “essential user” and therefore entitled to quick installation of a telephone. You have to remember that British Telecom back then hadn’t been privatised and had a monopoly for provision of phone lines and equipment. They were in short supply, and ordinary members of the public often had to wait 6 months to have a phone connected. As well as jumping the queue, you had your quarterly standing charge paid for.

There was no countywide out of hours emergency service; emergencies outside normal working hours were dealt with by the local area. This meant being on a duty rota for evenings and weekends. Your home phone number was put on the answer-phone message at the office, and police, doctors, or members of the public could ring you directly at home. Being on duty over the weekend meant that you could not be out of ear shot of your phone at any time over the entire 48 hour period.

Our filing system consisted of huge cabinets full of paper files, into which all our visits and contacts were recorded. We had a large typing pool whose job it was to type up our handwritten notes and insert them in the files.

It must have been an onerous job, although the typists never complained. Some social workers were into “process recording” – this entailed not just writing down the bare facts of a visit, but also including your thoughts and opinions, and even your speculation as to what the service user might be thinking.

I was particularly struck by the notes I found in one child’s file by the previous social worker.

“Little Lorna was nervous about meeting her new foster parents. She gazed up at me, her lip trembling, an apprehensive tear in her eye, and held my hand tightly as we walked up the flower bordered path towards the Jones’ front door. The green painted door opened as we approached, and Sally Jones knelt down on the doorstep, her arms held wide in welcome. Lorna looked up at me again, spotted the doll in Sally’s hand, and gingerly reached out to it... As I drove away, I looked into my rear view mirror, and saw Lorna waving with one hand, the doll clutched firmly under her arm. She will settle in well, here, I thought, and felt a lump in my throat.”

I decided that I would attempt to be more concise in my own recording.

Wednesday, 9 November 2011

How to Interview in a Suitable Manner

One of the primary duties of an AMHP is to interview someone who is being assessed for admission under the Mental Health Act “in a suitable manner”.

The Act states: “Before making an application for the admission of a patient to hospital an approved mental health professional shall interview the patient in a suitable manner and satisfy himself that detention in a hospital is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need.” (Sec.13(2)

The Code of Practice does not have a great deal to say about exactly how an AMHP should interview “in a suitable manner”. It does recommend that the patient should have an opportunity to see the AMHP alone, or in the company of someone with whom the patient feels comfortable, if possible. It also suggests that “it is not desirable for patients to be interviewed through a closed door or window” (5.54), stating that this would be acceptable only where “other people are at serious risk.” It is not clear whether this includes the AMHP.

The Reference Guide to the Act offers some additional guidance as to what interviewing “in a suitable manner” entails, stating that this should take into account "the patient’s age and understanding and any hearing or linguistic difficulties the patient may have” (2.31).

Some Case Law has further elucidated what constitutes interviewing “in a suitable manner”. One of these is R (on the application of M) v The Managers, Queen Mary’s Hospital [2008]. The judge concluded in this case that the purpose of the interview is achieved where the AMHP “attempts to communicate with the patient, but she fails to respond, or responds inappropriately, in a manner suggesting that she does indeed require treatment.”

Another case is M v South West London & St. George’s Mental Health NHS Trust, Court of Appeal (Civ Div) 7th August 2008. This case concerned a woman with a diagnosis of bipolar affective disorder who had been detained under Sec.2. She was then going to be assessed under Sec.3, but she attempted to avoid this by telling her solicitor that she was not well enough to be assessed (she was in A&E with pancreatitis). Nevertheless, she was interviewed by the doctors and ASW (at the time) and was detained. She objected to this on the grounds that the interview had not been conducted properly and the detention was therefore illegal. The Judge, however, concluded that even a short interview could be considered as sufficient, and also that the cooperation or otherwise of the patient being interviewed was not required.

This Case Law should provide comfort to AMHP’s who not unusually encounter people who are less than enthusiastic about being assessed under the MHA. I have certainly had situations in which I have had to follow a patient around the house, attempting to interview him, or where they have refused to answer questions or cooperate in any way with the process. Some of them have abruptly left the interview when they have cottoned on to what is happening.

Here are some basic guidelines, then, about how to interview "in a suitable manner".

The interview should take place in the least threatening or least restrictive way possible.

Unless the patient has been demonstrated to be dangerous, they should not be interviewed in a police cell, but should be seen in an interview room if at all possible. There are now many specially designed S136 suites around the country, so interviewing at the police station is now less likely than in the past.

(Having said that, I recall on one occasion interviewing a patient through the flap in the cell door. He was a fly weight boxer with bipolar disorder who was manic. He was naked from the waist up, was flexing his muscles in a distinctly intimidating manner, and I knew he had already assaulted several police officers. Despite being in handcuffs, I was not taking any chances. When he was eventually admitted to hospital, he managed to do a back flip out of one of the windows and successfully escaped.)

If the patient is being interviewed in hospital, this should ideally take place in an interview room rather than the patient’s room, and certainly in private and out of earshot of other patients.

Many assessments, of course, take place in the patient’s own home. In these situations, the patient often has more control over the process. However, the AMHP not only has the legal duty to conduct an interview, but also the legal power to ensure that this takes place, even if the patient does not wish to cooperate.

Ultimately, you may not have much choice over location. On one occasion I had to interview someone in a churchyard in the middle of the night, when the police had been called after someone walking their dog had found a man lying prostrate on a grave stone, stripped to the waist, with his chest covered in blood from self inflicted wounds.

On at least two occasions, I have had no choice but to interview the patient through a closed door. The alternatives I assessed as being disproportionate or counterproductive.

Inappropriate Circumstances
There are specific circumstances in which it is not possible to attempt to interview at all: if the patient is unconscious, for example, or too heavily sedated to be able communicate, or if they are clearly intoxicated with alcohol or under the influence of drugs. However, that is not to say that the AMHP should refuse to assess if even a whiff of alcohol is detected – it has to be a matter of judgment of the specific circumstances – chronic alcoholics may never be sober, but still be capable of being interviewed and assessed.

Other people
The AMHP will generally be with at least one doctor, and it does make sense for them to interview the patient together. This can also serve to prevent duplication which the patient could find irritating or distressing. However, there may be circumstances in which the fact of the AMHP not being a medical person could put the patient more at ease, so consideration should be given to offering to interview alone, if it is safe to do so.

Assessments at home can involve large numbers of people: I have certainly regularly had situations in which, as well as the patient, their relatives, two doctors and an AMHP being present, there have also been several police officers, an ambulance crew, and an assortment of student professionals of various types. This can be very intimidating, and the AMHP should seek to minimise the pressure this may place on the person being interviewed.

Facilitate communication
It is vital to take into account any specific communication needs the patient may have. This would include obtaining an interpreter if the patient does not have English as their first language, or using someone who knows sign language if the patient is hearing impaired. The use of a Makaton interpreter may be required with someone with a severe mental impairment. I wrote at length about one particularly unusual situation, with a young woman who was Portuguese and hearing impaired, and who had her own unique way of communicating with her mother, who also did not speak English (Lost in Translation).

Explain the purpose of the interview
The AMHP is required to introduce themselves and explain the purpose of the interview. My typical introduction would go along the following lines:

“Hello, my name is The Masked AMHP. I am an Approved Mental Health Professional. I have been asked to assess you to see if you need to be detained in hospital under the Mental Health Act.”

The AMHP is required to display identification when acting as an AMHP.

Obtain necessary information
The AMHP should already have obtained as much background information as possible from relatives and carers, medical records, and other involved professionals such as the GP, a community nurse, a social worker, or the police, but obtaining corroboration (or contradiction) from the patient is just as important.

The AMHP should find out as much as possible about the patient’s past and present circumstances, and their medical and psychiatric history, including information about risk behaviour (suicide attempts, assaults, etc.). The implications for the carers of the patient’s behaviour is also very important.

Although the AMHP will have had an account of the specific symptoms being displayed that have precipitated the assessment, it is important to try and elicit these symptoms from the patient at first hand. Sometimes this is easy – the patient may have so little control over their symptoms that they are displaying clear signs such as pressure of speech or grandiose delusions. They may be very controlled but willing to cooperate, therefore revealing frank evidence of the existence of suicidal intent and plans, or so distressed by their symptoms that they want to tell you what is happening to them. On one occasion I knocked on the door of someone I was visiting to assess. As soon as he answered the door, the patient cried out: “Thank God, you’ve come! I’m begging you to take me to hospital! The TV’s talking to me! It’s awful!”

At other times, the patient may be very guarded, and unwilling to acknowledge that they have any symptoms at all. In such situations, it may be necessary to explore their thought processes at considerable length in order to be satisfied that they are indeed experiencing signs of severe mental illness.

Be sensitive
In all circumstances, the AMHP needs to behave with sensitivity to the needs of the patient. Being subject to a formal assessment can be a terrifying ordeal, and the AMHP needs to be acutely aware of the power imbalance inherent in the role and act accordingly.

This is a summary of factors that an AMHP should take into account when conducting an assessment under the MHA. Ultimately, the situations in which an AMHP finds themselves are unique to each case, and it has to be a matter for the professional judgment of the AMHP as to what constitutes interviewing “in a suitable manner”. As long as the AMHP can show that they have acted in good faith and with due professional diligence, and records any difficulties they have encountered and steps taken to try to overcome them, then they will have discharged their legal duties.

So what unusual situations have readers of the blog found themselves in (either as AMHP’s or interviewees) – and how did you deal with it?

Tuesday, 1 November 2011

Bipolar Affective Disorder and Mel – Happy Ending Alert

Bipolar Affective Disorder affects about 1 per cent of the population. It is characterised by marked mood fluctuations – someone may feel very elated or “high”. They can display a range of typical symptoms, including pressure of speech – talking very fast and with little opportunity to interrupt; grandiose delusions – thinking they have special powers or are very important; and spending money they do not have on irrational things. They may find difficulty sleeping, mainly because their minds are too full of plans to sleep, and may at times be sexually disinhibited.

They may also have periods of low mood or profound depression. These cycles can often be plotted over time (there are some useful mood diaries around which can reveal these patterns). Many people with Bipolar Affective Disorder will only tend to go “high”. The onset of this disorder is typically in the mid twenties through to early thirties.

It also seems to be a disorder that some people actually seem to want to have – our CMHT often has referrals from GP’s which go along the following lines:

“Dear Team, Florence came into my surgery today convinced she has Bipolar Affective Disorder. She describes rapid mood swings, one minute laughing and cheerful, the next minute tearful and feeling suicidal. She has been researching on the Internet, and thinks the symptoms match those of Bipolar Affective Disorder. Could you assess her?”

Almost invariably, these people do not have Bipolar Affective Disorder – they are more likely to have Emotionally Unstable Personality Disorder – or just be adjusting to some adverse life event. However, they are often unhappy to be told this. Some demand mood stabilising medication, which people who really do have Bipolar Affective Disorder are often very reluctant to take.

I have often written in this blog about my experiences of assessing people with this disorder under the Mental Health Act, but this doesn’t mean that people with Bipolar Affective Disorder will inevitably require detention under the MHA or even a hospital admission.

A diagnosis of Bipolar Affective Disorder also does not mean that they will always be disabled; indeed, I have written about people who have successfully managed to work in positions of responsibility despite this diagnosis. I have even known Consultant Psychiatrists with Bipolar Affective Disorder.

Mel is a very good example of someone with this disorder who, despite at first encountering serious problems controlling her condition, went on to achieve success and happiness. Yes, this is a story with a happy ending. I’m in a good mood today.

Mel was in her early 30’s when I first started working with her. She was an exceptionally intelligent and charming woman, who had been halfway through a PhD in Parasitology, studying the reproductive processes of deer ticks (more interesting than it sounds), when she had started to develop manic symptoms. Her behaviour became increasingly erratic over a period of a few months until she could no longer continue with her fieldwork. She was diagnosed with Bipolar Affective Disorder and started on mood stabilising medication.

By the time I became her care co-ordinator, she had had to abandon her studies, and was working as a pharmacy assistant in the local general hospital. She lived alone in a small flat, and was struggling.

Mel generally had very good insight into her disorder. We developed a shorthand for describing her mood fluctuations. On a scale of 1 to 10, 5 was normal mood. Below 5 was low, above 5 was high. She also kept a mood chart, and over time we were able to construct an elegant model of her mood changes over time. She seemed to have a two month cycle, where she would gradually become high, then return to normal, before sliding into depression and then gradually recovering.

I was usually able to give her a score on our scale within a couple of minutes of coming to an appointment. Sometimes she would be confused, lethargic and tearful. At other times, she would be vivacious and giggly. Sometimes she could identify when she was high, but sometimes I had to point this out to her, one such example being when she had told me on entering the room that she had just had her navel pierced and then proceeded to show me!

Mel, her psychiatrist and I worked hard to try and even out these mood fluctuations. We tried a whole range of mood stabilising drugs, with varying degrees of success. Over time, her control over her mood seemed to decrease. She went on long term sick leave, as she was no longer able to manage her job, and eventually gave it up completely. She could no longer afford her car, and got rid of it. She made a successful claim for Disability Living Allowance. The condition was beginning to disable her, and she was acutely aware of this.

The length of time Mel spent at either extreme of her mood cycles seemed to grow longer, especially the depressive periods. During these times, she would isolate herself in her flat, spending up to 18 hours asleep. She put on weight, some of this unfortunately precipitated by medication (Olanzapine, while being a very effective anti-psychotic and mood stabiliser, has the notorious side effect of excessive and often unacceptable weight gain). She even had a brief, informal hospital admission.

We worked with her to try and end this decline. Cheryl, our support worker, got involved with her to increase her motivation and work on plans to reduce her weight. We provided her with funds to pay for membership of the local gym. Our psychiatrist found a mood stabiliser that worked for her, and seemed to both stabilise her and lift her mood. Over a period of months the mood charts she kept religiously began to show a levelling out of her fluctuations.

Mel managed to lose weight, and became much fitter. Her confidence increased, to the extent that one day she confided in Cheryl about her interest in a man who worked in the Charwood art gallery. She would like to meet him, but didn’t know how to go about it. Cheryl offered to go in with her on the premise of being interested in purchasing one of the pictures. I wasn’t sure that match-making was a function of a support worker, but decided that it was worth a try.

One day, Cheryl and Mel went into the art gallery. Cheryl engaged the art dealer in conversation, and gave Mel openings to join in. The man seemed to show a genuine interest in Mel, and actually said to her: “We must go and have a coffee sometime.”

Mel was delighted. So was Cheryl. The cunning plan seemed to have shown promise. But no invitation from the man materialised.

“Well, Mel,” I said to her one day, “it’s up to you now. Why don’t you go in there, and say to him, ‘Hi, I was just passing, and thought I’d take you up on that offer of a coffee’ – and see what happens.”

She decided, with some trepidation, to try it. Cheryl and I waited, with some trepidation, to find out what came of it.

I saw Mel a week later. Her eyes were sparkling.

“I did as you suggested,” she said, “—and it worked! We had a coffee. Then he invited me out to the cinema. And next week he’s taking me out to dinner!”

Things just continued to get better from there on. Despite having been unemployed for 2-3 years, Mel applied for a job doing administrative work in the Zoology department at the local University. And got the job. The relationship with the art dealer continued to grow. After a few months they decided to move in together.

One day, Mel confided that she had stopped taking her medication several months previously. This alarmed me, but there had been no recurrence of her mood swings, so we decided to just see what happened.

Despite my fears, Mel’s mood remained stable. She and her partner bought a house together, out of the Charwood CMHT catchment area. On the last appointment before she moved, I asked her if she wanted a transfer of care to the new area. She said she didn’t but promised she would go to her GP if she was concerned about her mental state.

Three years down the line (I have my spies) everything still seems to be absolutely fine.

There can be happy endings in mental health, after all.

Wednesday, 19 October 2011

Are Community Treatment Orders Taking Over the Mental Health Act?

There have been a couple of interesting publications released in the last month relating to Community Treatment Orders. One was the annual Government statistics for the use of the Mental Health Act, which includes detentions and discharge under Supervised Community Treatment (In-patients formally detained in hospitals under the Mental Health Act, 1983 – and patients subject to supervised community treatment, Annual figures, England 2010/11). This relates to the second full year’s activity for CTO’s.

What a clear and easy to follow publication this is! It even begins with a concise and easy to understand analysis of the figures. And what these figures show is the full impact that the introduction of Supervised Community Treatment (Sec.17A) in 2007 has been having on general uses of the MHA.

I can’t paraphrase the summary any better than the report itself, so I will quote directly:

“Although the total number of formal admissions to hospital and the number of new Community Treatment Orders (CTOs) decreased between the 2010/11 reporting period and the previous one, the overall number of people subject to the Mental Health Act [this includes formal detention in hospital as well as CTO’s] at 31st March increased by 5.0%, from 19,947 in 2009/10 to 20,938 in 2010/11. This increase can be attributed to a rise by nearly a third in the number of people on a CTO at 31st March.”

On the face of it, the figures seem contradictory; for example, the total number of formal admissions decreased by 2.2 per cent, and yet the number of people detained in hospital at 31 March increased by 0.2 per cent. This, however, can be attributable to a rise in the number of CTO recalls, two thirds of which were then revoked. The underlying Sec.3 then comes back into force.

The report also observes that “the number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The report states that admissions for treatment under Section 3 fell by 14.4 per cent. This can also be attributed to the rise in the use of CTO’s, as they mask the true use of Sec.3, since in essence the detention under Sec.3 is merely suspended by the CTO, and can be reinstated when a CTO is revoked without a fresh formal assessment.

What is clear is that, after only two full years of its use, CTO’s are beginning to seriously impact on the overall use of the MHA. There appears to be an inexorable rise in the number of people in the community subject to CTO’s, as once made, CTO’s can be extended indefinitely.

At least part of the reason for this can be found in a study recently published in The Psychiatrist, which looked at the views of psychiatrists relating to CTO’s (Community treatment orders in England and Wales: national survey of clinicians’ views and use, Manning et al, The Psychiatrist (2011), 35, 328-333).

This study found a considerable popularity for the use of CTO’s among psychiatrists, despite an initial reticence before the new powers came in. The research found that “clinical reasons were rated as being more important in decision-making than ethical or bureaucratic concerns. For example, the most important factors in initiating an order were considered to be promoting adherence to medication, protecting individuals from the consequences of relapse, and ensuring contact with health professionals.”

AMHP’s may find this more than a little alarming, as an AMHP must consider the ethical implications, and must also necessarily ensure adherence to due legal procedure. However, the study does conclude that:

“There remains considerable disagreement and uncertainty regarding the clinical usefulness of CTOs. It is important that clinicians are mindful of this. They should seek multidisciplinary input when making such fundamental treatment decisions in the face of enabling legislation, a lack of evidence, and (perhaps more challengingly) a lack of professional consensus or guidance. Multidisciplinary discussion and decision-making should reduce variability in the use of compulsion.”

In my post back in January this year (Community Treatment Orders and the Role of the AMHP) I looked at the previous years’ figures and concluded “since CTO’s are often being kept in place for a year or more, this could mean a growing accumulation of patients in the community on CTO’s.”

Both the new figures, and my own personal experience of CTO’s, bear this out. Back in January, I had only been professionally involved with CTO’s on two occasions. However, in the last 12 months, I have endorsed 5 CTO’s, 3 extensions (Sec.20A) and 2 revocations (Sec.17F(4)). Additionally, I have frequently been involved in multidisciplinary discussions of patients detained under Sec.3 in which discharge under SCT has been mooted, where it seems likely that more people currently detained under Sec.3 will be discharged on Community Treatment Orders in the future.

As I have said before, the AMHP role can be very quick and easy to discharge legally – you do not actually have had to interview the patient or Nearest Relative, and it is not even a formal requirement to provide a report, although at least the CQC are now promoting this as best practice. I would say that that is all the more reason to exercise diligence and best AMHP practice when a request is being made for a CTO, or an extension or revocation.

Of course, a consequence of that is for assessments for CTO’s to become drawn out processes occupying a lot of AMHP time. One recent example of this was when I received a request to endorse a CTO for a patient with learning difficulties who was detained under Sec.37 MHA (by the courts), following the commission of a serious sexual offence. He had been detained in a secure hospital for several years, during which time he had been provided with an extensive sex offenders’ treatment programme. It was now felt that he could be managed out of hospital, and a bed in care home had been identified.

Since I knew nothing about this patient other than the bare bones, and in view of his serious forensic history, I felt that it was necessary to make a thorough examination of his medical and nursing notes. This entailed a visit to the hospital, and an afternoon closeted away in a side room working through his very extensive files. In particular, I wanted to know precisely what the nature and degree of his mental disorder was, as well as the treatment he had received, the progress he had made, and the plans for his aftercare on discharge.

I then attended the hospital again to interview him and for a CPA/Sec.117 review meeting. This was a useful, although gruelling, meeting, as the prospective community Responsible Clinician was present, as well as the clinical psychologist, hospital psychiatrist and nursing staff who had been treating him, and the Nearest Relative of the patient. We concluded that it was appropriate for him to be discharged on a CTO, and the hospital RC and I then completed the paperwork together.

The entire process had taken me around 10 hours, including two visits to the hospital and a written report, but I felt that professionally it was necessary.

Another consequence of the increase in the use of CTO’s is the additional and unavoidable burden of work on the AMHP, or the patient’s care coordinator. Although I have not yet come across a patient who has appealed against their CTO, what I have been discovering is that imposing a CTO (which lasts for 6 months), and extending a CTO (which would initially be for another 6 months), can lead to automatic referrals to the hospital managers, the Tribunal, or both. This of course then entails the necessity to interview the patient, to consult with the Nearest Relative, and to write a report, followed by mandatory attendance at a Managers Hearing or Mental Health Tribunal.

These Hearings and Tribunals themselves can be rather surreal. What I am finding is that patients who are offered the chance to leave hospital and return home, as long as they accept being on a CTO, are unlikely to object to this. Once they are have been discharged home, they are also fairly unlikely to want to return to the hospital in order to attend a hearing.

One patient I was involved with explicitly stated that she wanted nothing to do with the hearings that had been arranged for her, and neither did she want a legal representative. This resulted in attending a Managers Hearing where only the 3 hospital managers, the hospital Psychiatrist and I were present. The hearing lasted all of 15 minutes.

The subsequent Tribunal consisted of the community Responsible Clinician, the three Tribunal members, and I. This lasted for a full 30 minutes, at the end of which the Tribunal members looked at each other, then at us, and gave their decision without an adjournment. Considering that the average length of a Tribunal for an appeal against Sec.2 or Sec.3 is well over 2 hours, the RC and I were somewhat taken aback.

We are now 6 months on from these latest figures, and so far I have not seen enthusiasm in the use of CTO’s waning. I await the figures for 2011/12 with interest.

Friday, 7 October 2011

Origins of the Masked AMHP Ep. 2: Seebohm, London Overspill – and Quaint Country Pubs

Part Two of an occasional series

One Monday morning in the early autumn of 1976 I turned up for work at Charwood Social Services Department, along with 3 other people who had also succeeded in getting jobs as unqualified social workers in Charwood.

This post may turn into something of a history lesson for my younger readers, as social services provision was very different 35 years ago. In 1974, only two years before I started work as a social worker, there had been a huge national reorganisation of social care provision, precipitated by the Local Authority Social Services Act 1970. This in turn had been inspired by the Seebohm Report, published in July 1968, which had proposed the integration of disparate social care services into single, generic departments overseen by local authority social services departments.

Until then, social care had been administered in a range of guises. For example, mental health had Mental Welfare Officers, defined by the Mental Health Act 1959. Services for children and families had Children’s Officers. Hospital social work was done by Hospital Almoners. In 1974, all these people were moved into these generic departments, and all became known as “social workers”.

Most of the people already working in Charwood area office had come from these areas. Most of them either had no formal qualifications, or had qualifications in their specialist areas. When I started there were only one or two staff in the entire team of more than 20 who had actually formally trained and qualified as social workers.

The area office dealt with everybody in the community who had a social care need: children and families, the mentally ill, people with learning difficulties (who were then known as “mentally handicapped”), people with physical disabilities, the elderly, and people with sensory impairment (although they were then formally known as blind, partially sighted or deaf).

As a generic social worker, I was expected to have a caseload with a mixture of all these people.

We had comparatively little to do in the first couple of days: we had a brief induction process, to explain administrative procedures: the filing system, methods of recording, and so on. The expectation was that all contacts with service users would be written by hand and then given to the large team of typists, who would then type it onto contact sheets, which would then be filed.

Within a couple of days, however, I was sitting in with the duty officer, whose job it was to take any calls relating to enquiries or requests for services from any source, and to see and interview anyone who walked into the department requesting help. After a morning of this, during which I sat in on several interviews, ranging from a request to have a home help for an elderly relative, to a young mother saying that she couldn’t cope any more and wanted her children “taken into care”, the social worker decided I had accumulated enough experience to field a call, and the next time the phone rang she told me to answer it.

My bowels immediately turned to water. I broke into a sweat as my shaking hand reached for the ringing phone. Everything suddenly seemed to go into slow motion.

“Hello, can I help you?” I asked with a quavering voice.

Thankfully, it wasn’t a service user. It was a doctor, asking for one of his elderly patients to be assessed for Part III accommodation. I had picked up in the previous couple of days that “Part III accommodation” meant a local authority old people’s home, so that didn’t phase me. I took down the details of the person and told the doctor we would arrange to see her. I had successfully managed my first duty call!

Charwood social services catchment was very varied. It covered a geographical area about 20 miles in diameter, which included Charwood, as well as a couple of small market towns and a lot of villages. About half the population lived in the villages and small towns, and the rest lived in Charwood. The main problems for people outside Charwood related to age and infirmity. Charwood itself, however, was quite different.

In the 1960’s through until the late 1970’s, the Greater London Council embarked on a massive social housing building programme in existing towns outside London, as well as encouraging the creation of new towns such as Milton Keynes. Businesses were encouraged to relocate to these towns, taking their employees with them. Charwood was one of these London Overspill towns.

It meant that Charwood had a very unusual demography for the county in which it lay. Charwood had increased in size from a population of about 4,000 in the 1950’s, to approaching 20,000 by the mid 1970’s. Most of this increase consisted of families with children, who had all moved from the London area, and who all had jobs in the relocated light industries, since the requirements for obtaining one of the new GLC houses was that you had to live in a London borough, and you had to have a job in Charwood.

Since I met these requirements, I was entitled to one of these houses, and for the first year I lived on one of the largest of the new GLC housing estates. As Charwood Social Services Department was in the old site office of that estate, I did not have far to go to get to work.

We four rooky social workers were sent on a three day residential induction course. The course took place in a convent in a very rural area of the county, where the nuns provided home grown and home cooked food, a venue and sleeping quarters. There were around 40 on the course, as the county had been engaging in a massive recruitment programme.

(Back in those days training departments had reasonable budgets, and courses were frequently regarded as a perk of the job. Residential courses, often in very pleasant country hotels, were not unusual. Nowadays, you’re lucky if a course provides free coffee.)

During the course we learned about the organisation in which we were employed, the nature and philosophy relating to generic social work, and the basics of the different client groups we would be serving.

However, the main thing about the course that I remember now was the vast difference between life in the London Borough I had moved from and life in the rural county in which I now lived. This was exemplified by the pub a group of us found in the nearby village one evening.

The village itself was charming, consisting mainly of thatched cottages around a large village green. We had been told there was a pub in the village, but we could not immediately identify where it was. There was no inn sign to be seen anywhere. We trooped past one charming cottage after another, none of which looked remotely like pubs, until we came to a double fronted detached farmhouse. We noticed above its unremarkable 30’s style front door that there was a statement saying that Miss Enid Abbs and Miss Hilda Abbs were licensed to sell alcoholic beverages for consumption on or off the premises.

We tried the door, and it opened onto a narrow corridor, lit by dim ceiling lights covered by ancient lampshades, at the end of which was a half door with a small counter attached to it. There were doors on either side down the corridor. We looked in one, and found an entire extended family, ranging from elderly grandparents to small infants, all sitting round a large table containing several glasses containing alcoholic beverages which took up most of the room, watching a TV perched high up in the corner on top of a cabinet. Another door opened into a room where several men were playing a range of pub games, including dominoes, darts and shove ha'penny. They all stopped what they were doing and stared at us in silence until we closed the door again.

We eventually reached the half door at the end and realised that this was what passed for the bar. Beyond was basically a kitchen, with a stone sink in one corner, a row of beer and cider barrels ranged along the back wall, and a counter in another corner containing a range of bottles of spirits. An elderly lady, who must have been one of the Miss Abbs, smiled at us and asked us what we would like to drink.

Once our orders had been taken, she told us to go through another door, and that she would bring us our drinks. The small room was unoccupied. Ancient bench seats were ranged around the walls, and the middle of the room was again occupied by a large table. A small coal fire burned in a grate. Once we were seated, she brought through our glasses, along with several large jugs of beer freshly drawn from the barrel.

We got a kitty going in the middle of the table, and then set to work on transferring the contents of the jugs into our glasses. The old lady periodically checked the jugs, removed the empty ones and replaced them with brimming ones, taking the appropriate amount of money from our kitty as she did so. What a splendid arrangement.

I decided that I was going to enjoy working at Charwood.

Next time: Learning the ropes as a generic social worker: my first home visit. I get a caseload!

Saturday, 1 October 2011

The Masked AMHP makes it into the Guardian!

The Masked AMHP has had a short piece published on the Guardian website in their new Social Care Network. Based on my recent post about my pre social work career, you can find it here.

Wednesday, 28 September 2011

The Dark Side of Love 2: De Clerambault’s Syndrome and other disorders

Afflicted by love's madness all are blind. Sextus Propertius

Psychotic or delusional disorders
These can manifest in two basic ways:

Morbid jealousy (also known as Othello Syndrome) is when a person holds a strong delusional belief that that their spouse or sexual partner is being unfaithful in the absence of any actual evidence.

Jealousy is a very common emotion, but when jealousy is entirely baseless then it can become pathological in nature. This can range along a spectrum between essentially normal feelings of jealousy, perhaps arising from an individual’s basic sense of insecurity or personal inadequacy, through to full blown psychotic illness.

Morbid jealousy is likely to take the form of constantly checking what the person’s partner is doing at any time of the day. The person may look on their partner’s mobile phone to see who they’ve been ringing or texting. They may interrogate them during the evening about what they’ve been doing, who they’ve been talking to.

This can be obsessional, but essentially non-psychotic in nature and therefore amenable to treatment, in which case, a talking therapy such as Cognitive Behavioural Therapy, can be effective in tackling and addressing the individual’s personal insecurities and anxieties. However, if it is truly delusional in nature, then it can be much more difficult to treat. It can also extend into stalking behaviour.

De Clerambault’s Syndrome (also known as erotomania) is a delusional belief that the person is in love with another, and that that love is reciprocated. This seems to occur most commonly in women. Usually, the subject of the person’s attention is only a casual acquaintance, and the affection is entirely unreciprocated. This belief can also lead to stalking behaviour.

(Isn’t it curious how so many syndromes and disorders are named after people with unusual or glamorous names? Gaetan Gatian De Clerambaut was a French psychiatrist practising in the early years of the 20th century who specialised in hallucinations and delusions and first described the syndrome in the 1920’s. “De Clerambaut’s Syndrome” almost onomatopoeically seems to describe the symptoms. What if Stanley Boggis had discovered it? Or John Woodcock?)

I’ve known Sian for nearly 10 years now. She provides an interesting illustration of both these disorders. Sian was in her late 20’s when she first came to the attention of psychiatric services. She has first assessed in the court cells about 12 years ago, having been arrested for harassment of her ex-husband and his partner. Although this assessment was inconclusive, there were approaching a dozen further incidents of harassment over the next 6 months.

Things finally came to a head when she was arrested after being found hiding in the wardrobe of her ex-husband’s bedroom, having broken into his house. She was arrested on suspicion of burglary, and assessed by a psychiatrist in police cells, who recommended an assessment under Sec.35 MHA. Following this assessment, she was detained in hospital from the Magistrates Court under Sec.37.

I first became involved with Sian when she appealed to the Hospital Managers against her detention. It is a comparatively little known aspect of the Mental Health Act that, although a patient cannot appeal to a Tribunal against Sec.37 in the first 6 months of detention, they do have the right to appeal to the Managers of the hospital, who can, if they wish, discharge the patient.

I had to provide a social circumstances report and appear at the Hearing. This is when I discovered her story.

Sian had led a completely normal life until her late 20’s. She was married and they had one daughter. After a few years of marriage she became more and more suspicious of her husband, coming to believe that he was having an affair. She began to check his whereabouts, ringing him up constantly to find out what he was doing and where he was, and searching through his clothes and belongings. This behaviour began to put increasing strain on their marriage. In an effort to make him jealous and win back his affection, Sian had a brief affair with a friend of her husband. This only succeeded in finally ending the marriage.

On an impulse, Sian left the matrimonial home, leaving her daughter in the care of her husband. Her husband applied for residence, which was granted. After a year or so, her husband obtained a divorce and his new partner moved in. This provoked the increasingly abusive and violent attacks by sian which eventually resulted in her being arrested, and spending a week or so on remand in prison until she was admitted to hospital.

When I interviewed Sian, she was still wearing her wedding ring, even though they had been divorced for a year and her ex-husband was now engaged to his new partner. She denied that it was possible that their relationship was over, and could not believe that her ex-husband could be having an intimate relationship. They were just friends, and Sian was certain that if she could cause a rift between him and his fiancée, then he would return to her. These beliefs were completely unshakeable.

Sian was not discharged by the Managers, and remained in hospital for about 4 months, during which time she was treated with antipsychotic medication and appeared to make a reasonable recovery, gradually realising that it was futile to believe that she and her ex-husband could ever get back together again. She was discharged from hospital with the rather vague diagnosis of “delusional disorder”.

Over the next few years Sian seemed to manage fairly well, getting a flat, and a job as a shop assistant, although she had a tendency to avoid contact with her care coordinator, and at times stopped taking her medication. At such times, she would become delusional again, invariably believing that someone she had served once or twice in the shop was in fact in love with her. She would then start stalking him, finding out where he lived and staking out his house. It was usually possible to persuade her to restart her medication, and these beliefs would then evaporate.

Sian’s most recent admission to hospital came out of the blue. She had been engaging well with the CMHT, was clearly taking her medication, and I had begun to explore with her some of the issues from her past. She had enduring guilt about abandoning her daughter, as she saw it, and I began to analyse her history and the breakdown of her relationship with her husband, in the context of the insidious onset of a psychotic illness over which she had no control. She seemed to have good insight into this, and it appeared to be reassuring her.

Then suddenly, over the course of two weeks, Sian began to behave increasingly bizarrely. She threw out all her clothes, resigned from her job, destroyed all her identity documents, and declared to her daughter, who was now an adult, that a man she had met in a pub a few days previously was her sole mate and one true love. She presented as highly distressed, agitated and tearful, with pressure of speech. Her daughter called out the Crisis Team, as it was at the weekend, and they assessed her and admitted her informally.

It took several months for her to return to normality. It took many weeks before she was able to recognise that this wonderful, perfect relationship was entirely delusional (I had checked it out and knew for a fact that she had only met this man twice, and only in the company of others, and that he had no romantic interest in her). However, antipsychotic medication, combined with an antidepressant, eventually restored her mental health, and to date, over a year on from that relapse, Sian remains stable and content. And has no irrational beliefs about any of her male acquaintances.

Friday, 16 September 2011

The Dark Side of Love 1: Adjustment Disorders

When Neitzsche said: “There is always some madness in love. But there is also always some reason in madness” he wasn’t referring to the British 70’s/80’s pop/ska band.

It is certainly true that love and relationships can at times give rise to bizarre and irrational behaviour. Indeed, it has been argued that since the definition of a delusion “is a sustained belief that cannot be justified by reason”, then being “in love” with someone could itself be regarded as a delusional state. But I’m not going to plumb those murky depths today.

There are a number of well defined psychiatric conditions that could be said to arise from, or are manifested as, love and issues with relationships. Some of them are sudden and intense but fleeting, while others may be persistent, insidious and difficult to resolve. Either way, they can present as acute psychiatric emergencies requiring formal assessment under the Mental Health Act.

I would divide these disorders roughly into two types: adjustment disorders, and delusional or psychotic states.

Adjustment Disorders
A good definition of an adjustment disorder is “an emotional and behavioural reaction that develops within 3 months of a life stress, and which is stronger or greater than what would be expected for the type of event that occurred”. This can frequently be precipitated by the ending of a relationship, and in my experience, seems to occur more commonly among men.

Everybody can feel upset, bereft, or even suicidal when a loved one wants to end their relationship. Most people can fairly quickly accommodate and adjust to it, but some people have extreme and bizarre reactions, or develop a complete refusal to accept the reality of the situation. Here are a few examples from my personal experience.

Carl worked on a pig farm. One day he presented himself at Charwood police station in a state of agitation and distress, saying that he had killed his wife. The body could be found on the farm, buried in a heap of pig slurry. He confessed that he had been clearing the slurry when his wife’s body had emerged. Although he had no memory of it, he concluded that he must have killed her.

The police immediately investigated, searching through tons of pig manure, but did not find the body of Carl’s wife, or indeed anyone else.

They eventually did manage to locate her. She was safe and well, having left Carl a few weeks previously and gone to live somewhere else in the country. Nothing untoward had happened between them.

It was as if Carl found the idea of his wife being dead more bearable than the fact that she did not love him any more. When Carl was confronted with this, he began to recall what had actually happened, and his distress gradually abated over the next couple of days.

Colin had been married for 15 years. One day, his wife unexpectedly told him that she did not love him any more and wanted to leave. He went off to work as usual, but when he returned home in the evening, he was shocked to find teenage children in the house whom he did not recognise. He also did not recognise his wife. He demanded to know what they had done with his young wife and infant children.

His wife called the on call GP and he was sedated.

I saw Colin with his wife the following morning. The crisis was over by then. It appeared that his brain’s response to the news of the end of their relationship had been to develop a form of hysterical amnesia, where he had “lost” the previous 10 or so years, taking him back to a golden past in which he and his wife had young children and a happy marriage.

Overnight, the amnesia had worn off, and he was reluctantly beginning to accept the reality of the situation.

Christopher presented to the Accident & Emergency department one day with global amnesia. He did not know his name, or where he lived. He had no memory of his past. He was unable to give any information about himself.

He was examined for head trauma, but he had no injuries of any sort, and was admitted to Charwood psychiatric hospital.

After a cpouple of days a police trawl of missing persons revealed who he actually was, and his mother visited him on the ward. He did not recognise her.

Over a period of about two weeks, his memory gradually returned, and the story of what had actually happened emerged. And guess what? It was all about the ending of a relationship. His girlfriend had told him she wanted to finish with him. His immediate reaction was one of rage, and he literally picked his girlfriend up off the ground and hurled her across the room. Fortunately, she was shaken, but not otherwise physically harmed. He then stormed off – and promptly wiped everything from his mind, including his entire life history.

These three cases featured forms of amnesia as a way of coping with intolerable news. Other people will simply refuse to accept that anything has changed, and will attempt to carry on despite all evidence to the contrary.

I was asked to assess Charles by his GP. Charles was a man in his 40’s who had been married for about 20 years. The couple had two teenage sons. 3 or 4 months previously his wife had told him that she wanted a divorce. She asked him to leave, but he refused. Since then, he had been living in the dining room. He had put locks on the inside of the door and only left the room in the middle of the night when the rest of the family were in bed. Then he would creep out and use the kitchen to prepare food for himself.

His wife had initiated formal divorce proceedings and had decided to put the house on the market. When she told him about this, he vacated the dining room one night and moved into the garage.

I went out to try and see him. His wife let me in and showed me photographs of the dining room that she had taken after he had vacated it. He had constructed a network of tunnels using cardboard boxes and blankets that had filled the room.

I went out to the garage, which had an up and over door which was closed. A car was in the garage, and he appeared to be living in that. There then followed one of my more unusual attempts to interview “in a suitable manner”. I could not induce him to open the door so that I could talk with him face to face, and had to make do with talking to him through the door.

During the interview I was unable to elicit any overt signs of psychosis, and he generally answered questions rationally, although avoided any discussion of the impending divorce. I concluded that despite the unusual circumstances, there was no evidence of risk that would merit obtaining a magistrate’s warrant under Sec.135. He was simply in denial, and unprepared to accept reality.

I advised his wife to get legal advice about evicting him from the property, and subsequently heard that after a few weeks he left of his own volition.

None of the above were actually detained under the MHA. In other cases, precipitated by rejection and the end of a relationship, people can self harm or become suicidal and present with high levels of risk. But do they actually have a mental disorder that makes them liable to be detained?

One such example was the man I wrote about in a previous post (Should People Be Stopped From Committing Suicide?) who eventually successfully committed suicide, more through petulance than mental illness. In practice, in the case of most adjustment disorders, the presenting aberrant behaviour will either quickly resolve, therefore not requiring the use of the MHA, or it is sufficiently difficult to establish the existence of a mental disorder sufficient to warrant detention that the MHA cannot be used.

Next time: Psychotic or delusional disorders named after people: Othello Syndrome and De Clerambault’s Syndrome

Thursday, 1 September 2011

Origins of the Masked AMHP: Episode 1

An occasional series

The Beginning
I think no-one has ever asked a child or even a teenager what they’d like to be when they grew up and the answer has been: “social worker”. A fireman. An engine driver. An astronaut. Maybe even a nurse. But never a social worker.

I was no exception. When I was a teenager I wanted to be either a poet or a professional actor. Preferably both. Consequently, I wrote vast quantities of incredibly bad and embarrassing poetry, and was a member of various drama groups.

In the very early ‘70’s, when I was 16, I attended a careers evening at secondary school. I went straight for the desk where the local authority’s head of drama education was sitting to ask about pursuing a career as a professional actor. He knew me, as I had been involved in various drama activities both in and out of school, some of which he had organised. He gave me the following advice:

“The best thing to do is to enrol on a teacher training course and specialise in Drama. That way, you will always have teaching to fall back on if you have difficulty finding employment as a professional actor.”

I could see the sense behind this advice. I was not so naïve as to be unaware that it was very difficult to make a living in the theatre, and the rate of unemployment among actors was very high. So I took his advice, and applied for several teacher training colleges that offered Drama as a main subject. In particular, I decided to go for courses that offered a combined option of Drama and English Literature, so that I could combine my love of the Theatre with my love of poetry.

It really wasn’t very difficult. The course I opted for, which was in the London area, only required 1 A Level (in those days the standard qualification was a Certificate in Education, which wasn’t actually a graduate qualification, so you didn’t even need 3 A Levels). Knowing I didn’t have to work too hard, I frittered away the rest of my 6th form acting in amateur productions and writing terrible poetry. I consequently only managed to get 2 A Levels.

But that was enough to get me on the course, and at the age of 18 I left home and went to college.

The course mainly succeeded in extinguishing any desire or ambition I may have had to be a professional actor. With hindsight, I suspect that the drama adviser knew I had no real talent to make a go at acting. I think if he had thought I had any real dramatic spark he would have advised me to go to Drama School.

I wouldn’t say that going on the course was a total waste of time. I did at least learn how to live independently on a small budget (my grant – yes, students had grants in those days – was £13 per week). However, the main thing I learned was that I didn’t want to be a teacher, or at least, not in any conventional sense.

So I looked around for a job I might like to do. Being an inveterate Guardian reader even back then, I fancied the idea of a career in journalism, so I wrote letters to all the local papers in the Greater London area asking to be considered for a post as a trainee journalist. I figured my training in English and Drama would stand me in good stead.

I did not even get a single interview. So I set my sights lower and started applying for jobs as a trainee building society manager, which seemed incredibly sensible, especially as I’d just got married, even though my heart sank at the prospect.

Then I saw a job advertised in the local paper for a “junior houseparent” in a children’s home. This involved looking after children in a 24 bed children’s “reception and observation centre”. I liked the sound of it. I would get to work with children, one of the few things I had enjoyed about the teacher training course, and I would be involved in managing and supporting their care and development. I got an interview, for once my Certificate in Education and experience of working with children was relevant, and I was given the job.

The home, being a “reception and observation centre”, took children, usually in emergency, anywhere between the ages of 4 and 16, although the oldest we had there was a young man of 18 with learning difficulties, whose social worker could not find anywhere else for him.

Children would arrive at the home at any time of the day or night, usually with the minimum of information. I remember one morning arriving at the start of an early shift (which started at 7.30 a.m.) to find a family of three young children asleep under a pile of blankets in a space under the stairs. Aged between 4 and 9, they had been brought in on a Place of Safety Order (as Child Protection Orders were then called) in the early hours of the morning, and the night staff, not wanting to disturb the other children, who slept in dormitories, had put them there.

One of my first tasks, within a week of starting there with no previous experience, was to take a group of children to the local fireworks display. This entailed walking with a dozen children, the youngest of whom was 6, and the oldest of whom was 15, along a busy road, in the dark, until we reached the park where the firework display was being held. It was terrifying – being entirely responsible for the safety of 12 children in the care of the local authority, all of whom were erratic or unreliable in some way, in a park full of hundreds of people, in the dark, with a large pile of explosives separated from the crowd by nothing more than a rope.

I found myself being led by the excited children, who pushed through the crowd in order to get as close as they could to the firework display. I ignored the fact that all the older children (that is, aged 12 or over) were taking the opportunity of being in a large crowd in the dark to smoke, and concentrated on the 3 children under 10, who were beside themselves with excitement. I tried to hold the hands of all of them at once, but it was futile. One of the young children was so entranced by a Catherine wheel that he pulled away from me and dodged under the rope, heading straight for it. I found myself diving after him, and managed to manhandle him to the ground just before he reached out to grab the conflagration with both outstretched hands.

“Can’t you keep your children under control?” the organiser shouted at me. No, I couldn’t.

I learned a lot, fast. I learned never to enter the girls’ dormitories without a female member of staff; I was told that a previous male member of staff had once been enticed into a compromising situation by responding to a request from a teenage girl to help her in her room. I learned to be careful how you admonished a pugilistic teenage boy, when he punched me in the face, breaking one of my front teeth. I learned to avoid distressed children when they were close to the cutlery box in the dining room, when I was showered with knives by a provoked and desperate young boy who had realised that his parents didn’t love him.

We took in abused children, young offenders, children whose foster placements had broken down, children in emergencies. The average stay was about 3 months before their social workers managed to find them a more appropriate placement. This was my first contact with social workers. On the social care career ladder I was the lowest of the low. I was not even a “residential social worker”, I wasn’t even a “house parent” (some of the younger children would actually call us “uncle” or “aunty”), I was just a “junior” house parent.

The children’s social workers would turn up from time to time, have a brief chat with their child and a brief chat with the officer in charge, and then leave again, maybe not visiting again for a month or two. They would never bother to talk to the junior house parent, the one who had spent many bedtimes telling stories to a sad and abandoned little boy, but who probably knew more about him than anyone else in the home.

Nevertheless, they were in charge of each child’s care and destiny, they made the plans that could affect a child for the rest of their life. And they only worked a five day, 9-5 week. And they were paid a lot more than a junior house parent.

I began to be drawn to the idea of becoming a social worker – not just because of the pay and conditions, but because you had more of a chance of influencing a child’s fate for the good, because you could also follow through and see a child growing up and hopefully begin to heal.

However, the Summer of 1976 made up my mind to apply for a post as a field social worker.

Those of my readers who are old enough to have lived through the British Summer of 1976 will not need reminding how extraordinary it was. For months it didn’t rain. Drought was declared. Some people were reduced to getting water from standpipes. And it was hot. I remember spending that whole summer wearing nothing more than a pair of flared jeans (come on, it was the 70’s), a T-shirt and sandals.
It was too hot for the children in the home. They couldn’t settle in the evening. As it got hotter and hotter, the children became more and more restless. One evening, at 10.30 pm, when all the children, of whatever age, should have been tucked up in bed, half of our residents had been officially reported missing, and the other half were running around in the grounds of the home throwing stones at the windows.

I arrived at work one afternoon for a late shift to find the morning staff barricaded in the office, waiting for the police to arrive, as there had been a riot during breakfast over an inadequate supply of Sugar Puffs.

My wife and I decided that it was no fun living in a London borough. I decided to apply for social worker jobs in the surrounding shire counties, in particular, the ones where it was possible to afford to buy a house.

I was offered an interview at Charwood area social services office. It was a blisteringly hot day. I drove up wearing jeans and T-shirt, then stopped in a quiet woodland area a few miles outside Charwood and changed into my only suit. Nevertheless, by the time I reached the office for the interview, I was drenched in sweat. I was then ushered into a waiting room with the 16 other applicants, who would be competing for 4 posts. We were all unqualified. In those days it was not a condition of employment, and few social workers were qualified.

The area officer was a kind man. He allowed the male applicants to take off their jackets for the interview, and even tolerated us loosening our ties.

I must have done fairly well in the interview (by this time I was beginning to have a reasonable CV), because I got a job.

To be continued…