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.