Saturday, 17 March 2012

How Do You Section a Dolphin? An AMHP Perspective on Cetacean Sentience

“There’s no way I’m getting in that ambulance."

A recent article on the BBC news website suggests that dolphins should be given the same rights as humans. “Dolphins should be treated as non-human "persons", with their rights to life and liberty respected, scientists meeting in Canada have been told... They believe dolphins and whales are sufficiently intelligent to justify the same ethical considerations as humans.”

The article goes on to say: “It is based on years of research that has shown dolphins and whales have large, complex brains and a human-like level of self-awareness. This has led the experts to conclude that although non-human, dolphins and whales are "people" in a philosophical sense, which has far-reaching implications.”

Were this idea to be taken seriously by Government, there would indeed be far-reaching implications. Many laws would have to be amended: for example the Human Rights Act would have to be renamed the “Sentient Beings Rights Act” in order to afford cetaceans the full rights which human beings currently uniquely enjoy among the animal kingdom.

However, a close reading of the Mental Health Act reveals that there is nowhere a definition of what constitutes a “patient” or a “person”, so the MHA could as equally apply to dolphins as to people.

This would pose all sorts of difficulties for AMHP’s discharging their legal duties. For a start, how do you establish whether or not a dolphin has “a mental disorder of a nature or degree which warrants the detention of the patient in a hospital” for assessment or treatment?

Do dolphins suffer from depression, or psychosis? It’s quite possible that dolphins and other cetaceans exhibit suicidal ideation. There have been many examples of dolphins and others deliberately beaching themselves, often with tragic consequences. One recent example occurred on 5th March 2012 in Brazil, when 30 dolphins were beached. In this instance, humans took matters literally in their own hands and dragged them back into the sea.

But perhaps they should instead have waited for an AMHP and two doctors (one of whom should ideally have specialised in dolphin psychiatry) to conduct a formal assessment under the MHA before taking any other action. After all, they may have been deemed to have capacity to make “unwise decisions”.

All sorts of other dilemmas present themselves. How do you interview a dolphin “in a suitable manner”? It would be essential to have dolphin interpreters. But would you then want a dolphin who could speak English, or a human who could speak Dolphin? Which is the least oppressive option?

And would you expect the dolphin to come onto dry land to be interviewed, or should the AMHP don a wet suit, snorkel and flippers and interview in the dolphin’s natural environment?

Then there’s the matter of putting the right name of the patient on the section papers. We don’t currently have any phonetic system for transcribing dolphin’s natural names. Would we therefore have to use the names imposed on them by humans, for example, “Flipper” or “Bubbles”? And would that be considered oppressive? I don’t suppose it matters legally, as long as the same name is on all the paperwork.

Having made the decision to detain a dolphin under the MHA, how would you transport it to hospital? We would need special ambulances with a water tank in the back. But what about when the ambulance has to take a sharp turn?

And what if the dolphin objected to being taken to a dolphin psychiatric unit (and what would one of those look like?) and became aggressive? How do you handcuff a dolphin? Actually, that wouldn’t be necessary – a couple of Velcro restraint belts with carrying handles should do the trick.

And then there’s the whole issue of treatment…

My brain hurts…

Saturday, 10 March 2012

Conversations with Monica: Are People with Mental Disorder Responsible for their Actions?

I always welcome comments on my blog, even if they are critical (readers, please take note!), and frequently take the time to answer points seriously. It shows that people do actually read what I write, and are sufficiently stimulated, in whatever way, by what they have read to leave a comment. I like knowing that.

Lately, I’ve been engaging in some interesting dialogue with a blog reader called Monica. Most recently, Monica has been posting some comments in response to my last post (A Young Person’s Guide to the Mental Health Act) which pose some interesting issues.

Readers of this particular post will have noticed that I made a somewhat flippant reference to a hypothetical patient who believed that they were related to the Queen, in order to illustrate an example of someone being deluded and possibly having a mental illness.

Monica made the point: “I realize that if someone said that s/he is, for example, a sibling of the Queen, you would be able to know that this is not the case… But how can you tell true delusion from being indeed "related" to the Queen through some common ancestors or by being, for example, a distant relative of someone who married into the family?” After a fascinating riff on the subject of relatedness to the Royal Family, she concluded: “Still, I can imagine that, under the wrong circumstances, if told that I have such relatives, a psychiatrist would be more likely to send me to the loony bin then to check my ancestry.”

I realised from previous comments that Monica was asking for a serious reply, so I posted the comment: “Just being deluded should not in itself constitute grounds for detention under the MHA. There has to be substantial additional risk to the person or others as a consequence of that belief -- for example, one person I detained thought her central heating boiler was talking to her. That it itself did not justify detention, but she then trashed the boiler, causing a gas leak in the process, which would have endangered her and her neighbours.”

Monica responded at some length to this comment, but somewhat to my surprise concluded by saying: “By the way, what happened to the woman with the boiler? Did she lose her apartment? Was she criminally charged or asked to pay for the damages? Was anything done to prevent her from having access to boilers in the future, at least not in her own apartment building and to a boiler that is not safely locked inside a separate room or solid enclosure?”

I mistakenly assumed that these were largely rhetorical questions, until a few days later Monica reminded me that I had not replied:

“Can you answer my questions about the boiler, though? Did the woman pay for the damages, or get charged with any crimes, or lose her housing? I really hope she did. You see, only because I tend to question psychiatric and police interventions, that does not mean that I don't believe in individual responsibility. On the contrary! I'm pretty much for leaving people alone but then whoever damages a boiler should pay for it and for any other damages to property, and get criminal charges, too, if the damage was intentional. And get kicked out of the building, too.”

This does raise significant issues relating to issues of personal responsibility for the consequences of actions which I felt deserved to be aired in the context of a full post rather than a comment.

The crucial point here is to do with mental capacity. In the words of the Department of Health’s Summary, the Mental Capacity Act 2005 was designed to provide “a statutory framework to empower and protect people who may lack capacity to make some decisions for themselves, for example, people with dementia, learning disabilities, mental health problems, stroke or head injuries who may lack capacity to make certain decisions. “

The Act is underpinned by 5 key principles. The first and most important is: “A person must be assumed to have capacity unless it is established that they lack capacity.” The protective or restrictive elements of the Act therefore would only apply to people who had been formally assessed as lacking capacity. The logical consequence of this is contained in the third principle: “A person is not to be treated as unable to make a decision merely because he makes an unwise decision.”

This means that adults can do whatever they like as long as they have capacity, however unwise others might consider it. This might include, for example, bungee jumping, driving too fast in poor driving conditions, smoking, taking illegal drugs, pot holing, mountain climbing, eating too much, not taking enough exercise, or sending money to someone purporting to be a bank manager in a foreign country who wants to send them millions of dollars.

Of course, this also means that people with capacity have to take responsibility for the consequences of their actions. If you persist in smoking, you may get lung cancer. If you drive too fast in the wet, you may crash and harm yourself or others, and then be arrested and taken to court. If you send money to someone who has emailed you out of the blue, then you may never see that money again.

This brings us to the patient I mentioned earlier who attacked her boiler because she thought it was talking to her.

If you work in the field of mental health you find yourself working with people with a wide range of mental disorders. Some of these people have capacity, some lack capacity, and some have fluctuating capacity.

You cannot make any blanket judgments according to diagnosis, along the lines of “someone with a diagnosis of schizophrenia lacks capacity”, or “someone with an emotionally unstable personality disorder has capacity.”

Making an assessment of an individual’s capacity at any particular time will inform decision making relating to how you respond to their presenting behaviour and whether or not you consider it necessary to invoke the Mental Health Act (or Mental Capacity Act) to limit their freedom to take certain actions and make certain decisions. Someone may indeed have schizophrenia, but they may be well controlled on medication and their symptoms may be so much in remission that they are working and otherwise lead a normal life. Their underlying condition would not justify an assumption that they lack capacity.

Let’s look at the woman who damaged her boiler again. She has a diagnosis of paranoid schizophrenia. She has stopped taking her medication. She has been exhibiting a range of symptoms which constitute her known relapse signature: hearing voices, believing that God is in communication with her, believing that the Royal Family are conspiring to kill her. (It’s remarkable how many people do have delusions about the Royal Family.)

She had damaged her central heating boiler because God was talking to her out of it, and she had to stop it happening. In other words, the actions she took were a direct consequence of her mental illness. She would not have done this if she had not been actively psychotic.

In these particular circumstances, at this particular point in time, her mental illness had rendered her incapable of making rational decisions, and she therefore lacked capacity to manage her day to day life or to make decisions about going into hospital or taking medication. She was therefore in need of protection from the consequences of her actions.

In answer to Monica: this patient did not pay for the damage to the boiler, she did not get charged for criminal damage, and she did not lose her housing. In my view, this is quite right: it would not have been fair for her to be penalised in that way when she was mentally incapacitated.

That is not to say, of course, that people committing serious criminal offences while incapacitated through mental illness or disorder should not have to face any charges. But Part III of the Mental Health Act is designed to deal with these situations, for example, by giving the courts powers to arrange for the assessment of a mentally disordered offender (Sec.35), or to order them to be detained in hospital for treatment (Sec.37).

However, those with mental disorder who are deemed to have capacity would have to take responsibility for their actions. I am currently working with a woman with an emotionally unstable personality disorder. She frequently expresses anger inappropriately, for instance, by being verbally hostile to professionals trying to help her, or by cutting or hitting herself. At times she has carried a knife and self harmed in front of professionals.

These behaviours may be unwise, but her disorder does not deprive her of capacity. She can reason through her actions, and understand the dynamics that drive them, and therefore can choose or not to behave in the way that she does.

I would try to avoid the use of the Mental Health Act with this woman (I have formally assessed her on one occasion, and did not detain her), and although I am working with her to find alternative ways of expressing and releasing her anger, ultimately, only she can decide to modify her behaviour, and in the meantime must take the consequences. These have included a number of professional agencies withdrawing support to her, and occasionally police involvement.

However, there may be a situation in which she is in so much mental distress, that she ceases to be able to make rational decisions, and can be deemed to lack capacity. Then, it is justifiable to make decisions on her behalf that are considered to be in her best interests. On one occasion she took a very serious overdose that nearly killed her: she was admitted to a medical ward for life saving treatment, even though at that time she genuinely wanted to die.

So the brief answer to the question posed at the beginning of this post: are people with mental disorder responsible for their actions?

It all depends…

Friday, 2 March 2012

A Young Person’s Guide to the Mental Health Act

It's March. The days are getting longer. Spring is just around the corner. A young man's thoughts turn to -- the Mental Health Act...

Son: Daddy, what do you do for a job?

Dad: I’m an AMHP, son.

Son: A lamp? Do you light up?

Dad: No, son, I’m an AMHP. An Approved Mental Health Professional.

Son: An Aluminium Metal Shelf Partition?

Dad: No, an Approved Mental Health Professional. I have the power to detain people in hospital under the Mental Health Act.

Son: Is that a special power?

Dad: I suppose it is.

Son: Like Spiderman – he can climb up the side of buildings and squirt spider webs out of his wrists! Are you like Spiderman?

Dad: I must say, being able to squirt spider webs out of my wrists would be useful sometimes, but no, I can’t do that.

Son: So can you climb up the side of buildings?

Dad: No, but I can get police officers to force open someone’s door with the right warrant. Which is nearly as awesome.

Son: I don’t think so, Daddy. You’re not really like Spiderman at all, are you?

Dad: No, I’m not, son. I only have the powers given me under the Mental Health Act by being approved. I haven’t been bitten by a radioactive spider.

Son: What is the Mental Health Sack, Daddy?

Dad: (Takes deep breath) The Mental Health Act was written by the Government to provide a legal framework for the treatment of people with a mental disorder.

Son: What is a mental disorder, Daddy?

Dad: A mental disorder is when there’s something wrong with your head.

Son: Like a bump, Daddy?

Dad: Not exactly – although a bad bump on the head could give you a mental disorder. It’s more like feeling very, very sad, or having funny thoughts.

Son: Funny thoughts, Daddy? Like jokes? Knock knock!

Dad: Who’s there?

Son: Peter!

Dad: Peter who?

Son: Peter Bananas!

Dad: Peter Bananas? Peter Bananas?

Son: It’s funny, daddy. It’s a joke.

Dad: No, not like jokes. It’s more like having beliefs that other people find strange.

Son: Like wanting to eat broccoli? Ech! I hate broccoli!

Dad: No, not like that. Like thinking that you’re related to the Queen.

Son: But if you’re Prince Harry, you are related to the Queen. Is Prince Harry mentally disordered?

Dad: Not as far as I know. Like thinking you’re related to the Queen when you aren’t. Or thinking that God is controlling your breathing.

Son: But God does control everything. He’s everywhere and knows everything. Even when you put a bogie on Susan’s back at school.

Dad: Did you do that?

Son: No, no, Daddy. That’s just an example. So what do you do for your job, Daddy?

Dad: Well, let’s see. Here’s a little story.

Son: I like stories, Daddy!

Dad: Once upon a time there was a man called Derek. His doctor was very worried about him, because Derek had been doing strange things.

Son: What sort of strange things, Daddy?

Dad: Erm, well he has been spending lots of money. He has been buying hundreds of plastic ducks and keeps them in his living room, all around the walls. He has told the doctor that the Duck Man wants to take him to Duck Land, where he will have to float around on a lake all day and night.

Son: He’s a funny man, isn’t he?

Dad: Well, the doctor thinks that Derek is mentally disordered and needs to be in hospital. So he asks Daddy to see Derek and arrange for him to go into hospital.

Son: I see! You’re like an ambulance driver! You take people to hospital!

Dad: No, no, son. I’m not like an ambulance driver. Although I do use ambulances sometimes. My job is to go and see people like Derek to see if they’re mentally disordered and to decide whether or not they need to go into hospital. After all, Derek might have a good reason for buying lots of plastic ducks.

Son: He might have a big bath, mightn’t he, Daddy?

Dad: Yes, he might. But he might be mentally disordered. If Derek wants to go to hospital, then there’s no problem. But if I think he needs to go, but Derek doesn’t, then I can section him and make them go into hospital, even if he doesn’t want to.

Son: Do you make people do things they don’t want to do? Like when I don’t want to eat my broccoli? Are you a bad person, Daddy?

Dad: No, I’m not a bad person. Not really. I try not to be. I try to do what is the best for somebody like Derek. Although they don’t always like it.

Son: When they go into hospital, do they make them better?

Dad: They try to. They give them tablets to make the funny thoughts go away.

Son: Do the tablets always work?

Dad: Usually. Often. Sometimes. Look, why don’t I read you a story from one of your story books?

Son: All right. Derek wasn’t a very good story. Can I have Numpty the Sloth Gets Sectioned?

Dad: Not tonight. That’s a bit too much like Derek. How about The Famous Five Appear to be Mentally Disordered in a Public Place?

Son: All right, then.