Sunday, 28 October 2012

Social Work with the Dead

Perhaps it’s the dismal weather we’ve had recently, perhaps it’s the shortening days. Whatever the reason, I’ve been thinking quite a bit about the dead. In particular, my first hand encounters with death.
Thankfully, I’ve seldom come face to face with a dead body during my career as a social worker. However, on four occasions I have been in the unfortunate position of being directly involved in the discovery of a recently deceased person.
I have already written about two of these on this blog. One was many years ago, but still sticks vividly in my mind. I wrote recently about this sorry tale only last month in Origins 5: Death in Charwood. The other was the case of Lenny, who I wrote about back in July 2011 (Lenny: A Life and Death in the Mental Health System; you can read it here and here).
Because encountering a corpse in social work is so rare, when it does happen, it’s not something you tend to forget. So here, then, are accounts of the other two.
George was in his 50’s and was a  longstanding patient of the Community Mental Health Team. He had a very long history of chronic paranoid schizophrenia, and was on a range of antipsychotic medication, including a fortnightly depot injection. Although I was not his care coordinator, I had had to detain him under the Mental Health Act on a couple of occasions.
One day, Jim, his community nurse, went round to his house, where he lived alone, to give him his fortnightly injection. He had been unable to get a reply. Jim returned to the CMHT and discussed this with me.
It was not like George to be out on the day his injection was due, or not to answer the door. We decided to go out together to investigate further.
We rang the bell and knocked on the door, but there was no reply. The curtains were drawn, but we could hear the television. Jim knelt down and peered though his letter box.
“Oh, God,” I heard him say, as he backed away.
“What is it?”
“I can see him. He’s sitting in his chair in the living room at the end of the corridor. He’s not moving. I think he’s dead.”
I had a look myself. His profile could be seen clearly through the open door of his living room. His head lolled to one side, supported by the wings of the armchair. I called, but there was no movement. I feared the worst.

We decided to call the police.
When they arrived, we explained the situation to them. They too had a look through the letterbox, then tried to find an open window or unlocked door, without success.
One of the police then revealed an arcane piece of knowledge. The windows on this estate all slid within a groove in order to open them. There was a way to jiggle the window so that it could be slid back a little way, even though there was a window lock, and then it was possible to reach through and release the lock so that the window could be opened enough for a person to climb through. He didn’t tell me how he knew about this.
The police officer climbed into George’s house and opened the front door. We all entered and went into the living room. His eyes gazed sightlessly at the morning TV programme. He appeared to have been dead for at least a day or so.
Once we had formally identified the body, we returned to the CMHT.
Jim was pale. He was badly shaken. He was looking at something far away.
“So lonely,” he said. “So alone. Looking down that long corridor through the letter box, there he was. He died on his own. He was so alone.” He began to cry quietly. There was nothing I could do for him.
One morning I had a call from one of my service users. Beth was a middle aged woman with whom I had been working for several years.
Not long before I first started to see her, she had finally escaped a long, abusive marriage to Gordon. Gordon was an alcoholic. Throughout the marriage he had terrorised her, undermined her, hit her, and sponged off her.
I had helped her through the aftermath of this, including aiding her resolve not to return to him, affirming her decision, and assisting her to go ahead with a divorce. Over time, she had adjusted to being a single parent, and her confidence in her own ability to be a parent for her children slowly increased.
In recent months, after a long time with no contact, she had started to see him again – not because there was any prospect she would return to him but through pity. Because of his drinking, he was in very poor physical shape. For the sake of the children, who still had contact with him, she wanted him to get help for his drinking and also tried to persuade him to see his doctor, as he had lost weight and was physically quite frail, even though he was only in his early 50’s.
“Masked AMHP,” she said, “I’ve been round to Gordon’s flat, but I can’t get any reply. I was going to do his shopping for him. I’m sure he’s dead. I’m convinced of it.” She began to cry.
I arranged to pick her up and go round to the flat again. Sure enough, there was no reply. She has last seen him a couple of days previously, when she had done some shopping for him. He never left the flat. So I called the police.
The police managed to get a key from the housing association, and I arranged to meet them at the flat. I persuaded Beth not to come. I didn’t want her to be in the position of having to identify the body, if our worst suspicions were realised. She didn’t want to, anyway.
I went into the flat with the police officer. We found Gordon huddled on a sofa. He was dead. He looked tiny, emaciated, desiccated, almost mummified; there was hardly any weight to him. He didn’t look as if he could ever have been alive, somehow. Although I had never met Gordon in life, I had no doubt it was him. His skin was a deep yellow, almost mahogany. I had never seen anything quite like it.  He had clearly been in the last stages of liver failure.
Beside him on the floor, still in a carrier bag, was the last shopping that Beth had done for him. Still in the bag was a 3 litre bottle of white cider.
I went to see Beth at her home. She was crying profusely. I told her roughly what had happened. I didn’t give her the details of his appearance.
“I killed him, you know,” she said in between gulps of air.
“What do you mean, Beth?” I asked her.
“I didn’t want to. He made me.”
“What do you mean?” I asked again.
“He made me buy him some alcohol, that last time,” she wailed. “I knew I shouldn’t have. I killed him.”
“Beth, he never opened the bottle. He didn’t have a drink before he died. It was drink that killed him. But not that particular drink.”
Over the months following this incident, I had to spend many sessions helping her to work through her bereavement and guilt issues. But the fact that I had gone in that day, and had found that bottle, and had seen that it hadn’t been touched, and could tell her this, certainly helped to absolve her of at least some of her guilt.

Friday, 19 October 2012

The Masked AMHP Profiled in Guardian Select

You can read the fascinating things The Masked AMHP has to say to the Guardian about himself and his blog here.

Monday, 15 October 2012

On Assessing People Who Conceal Their Symptoms

Over the years, I have frequently found myself in a position where I have had to assess someone under the Mental Health Act where their presentation on assessment is directly at odds with the reports from relatives and other professionals of their behaviour and symptoms.

What is the AMHP supposed to do in these situations? While it is important for the AMHP to “interview in a suitable manner” and reach their own conclusions about the need or otherwise for admission to hospital, it is not sufficient to take the patient’s reports at face value; the AMHP also has to be satisfied “in all the circumstances of the case” that the patient needs to be admitted, whether formally or informally. It is therefore essential for the AMHP to obtain information from relatives and carers, as well as other professionals who have had involvement with the person.

One has to be very careful in weighing up this evidence. On the one hand, people who may be depressed and suicidal, or seriously and dangerously psychotic, may be fully aware that if they are truthful about their symptoms, they are likely to be admitted to hospital against their will. After all, if your intent is to take your own life, you won’t want an AMHP interfering with your plans by detaining you in hospital.

Equally, if you know beyond doubt that there is a global conspiracy initiated by alien invaders from the Dog Star designed to prevent you from achieving your potential as the saviour of the world, you are likely to believe that the nosy AMHP asking you probing questions is simply part of the nefarious plot.

On the other hand, someone may have unusual but not necessarily psychotic beliefs; while you personally may have difficulty in believing that Jesus visited the American continent and left the evidence on gold plaques which later mysteriously disappeared, many people do believe this, and most are probably not thought disordered.

It is also not unknown for people to make malicious and false allegations about the mental health of their relative. I have had a number of demands from estranged husbands to assess their partner under the MHA because they are clearly unreasonable and deluded in objecting to their applications for custody of the children.

A good illustration of these difficulties is the case of Siobhan. Siobhan was a single woman with a school age daughter who lived in a local authority house in Charwood. Her mother, who was originally from the Republic of Ireland, also lived in Charwood. Over a period of more than 10 years, I received a number of requests from her mother to assess Siobhan under the MHA.

On the first occasion, Siobhan’s mother reported a range of behaviours and incidents that anecdotally seemed to indicate that she may be psychotic. However, when I formally assessed her, Siobhan presented at entirely free of any symptoms of mental illness, presenting as warm and appropriate. We took no further action.

A few months later, however, we received a letter from the GP saying that Siobhan had been taken by her mother to the Republic of Ireland and had been admitted to a psychiatric hospital there. She had been diagnosed with paranoid schizophrenia and started on depot injections of antipsychotic medication. She was now back in Charwood and needed the CMHT to give her injections.

I was bemused. Did she or did she not have a psychotic illness? The nurse who gave her her injections found Siobhan to be much as I had, warm, appropriate and without symptoms. But then that could be due to the medication. After a year, Siobhan decided she did not want her depot any more. She disengaged from mental health services. We were not unduly concerned, as we only had anecdotal evidence that she had a mental illness.

A year later, Siobhan’s mother again contacted the CMHT. Siobhan had a partner, and was pregnant. She and the partner were both concerned about Siobhan’s mental health. Both her mother and her partner came to the CMHT to see me. They reported that Siobhan believed that she was not giving birth to a human baby, but to an alien. She had told her partner that she was preparing to be transported to another planet when her alien baby was born. She was neglecting herself and her daughter, and keeping her daughter off school for no good reason.

These were very disturbing reports. I arranged to assess her at home with the CMHT psychiatrist and her GP.

We arrived late afternoon. She answered the door and welcomed us warmly in, even though she was not expecting us. Her daughter and a friend from school were there, playing a game in the living room. Siobhan was preparing a meal for them in the kitchen.

Throughout the assessment, Siobhan again presented as rational, calm, warm and cooperative. The house was in good order, and her daughter appeared well and relaxed. Siobhan denied having said any of the things reported, but said that she and her partner had been having problems and she was unsure if she wanted the relationship to continue.

The psychiatrist, the GP and I retreated to my car to have a discussion. The contrast between Siobhan’s presentation and the reports of the relatives simply did not fit together. I was inclined to go with my impression of Siobhan as she was today, except – this time it was not only her mother reporting psychotic symptoms, but her partner as well. She was pregnant – what if she really did think her unborn child was an alien? What risks to the child might arise from that?

We all felt deeply uncomfortable with the decision, but eventually we decided to believe the mother and partner, and with heavy heart I made an application for Siobhan to be detained under Sec.2 for assessment.

Siobhan took it all with calm resignation. We made arrangements for her mother to look after Siobhan’s daughter and take the friend home, and Siobhan packed a bag and came with me to hospital.

For a fortnight, Siobhan was observed and assessed on Bluebell Ward. During that time she was not given any medication. Also during that time, she did not display any symptoms of mental illness. After 14 days, the section was discharged and she went home.

Despite having displayed no symptoms of mental illness, she did agree to seeing a nurse from the CMHT. She gave birth uneventfully to another daughter, and there appeared to be no problems.

Four years later, Siobhan’s mother again came to the CMHT in a state of agitation. She told us that Siobhan had assaulted a number of people and had also broken her own window. She was insisting that she was mentally ill and needed to be in hospital. While she was telling us this, the police arrived. They had gone out to see Siobhan at mother’s request, and she was not prepared to let the police into the house. The police were expressing concern, as Siobhan’s two children were also in the house.

I decided to go out with her nurse and the police. When we arrived at the house, the police had gained entry. We found Siobhan in the sitting room.

Throughout the interview Siobhan presented as understandably stressed, but nevertheless calm and collected. Her manner and affect were entirely appropriate for the situation, and she did not reveal any symptoms of thought disorder. She said that she had been pressured by her mother and had broken the window as a response to this. She readily admitted that there had been times in the past when she had been unwell, and was aware of her early warning signs. She also said that she wished to continue taking her present medication.

I saw both of Siobhan’s daughters. They both appeared unperturbed by the situation. They were clean, well dressed, and well nourished. They happily reported to me what they had had for breakfast and lunch (cereals, and meatballs with rice respectively). There was no evidence that the children were neglected or in danger. The house was untidy but not dirty, and appeared to be in good decorative order. Again, there was no evidence of significant neglect in the house. I concluded that there were no grounds to consider admission to hospital either formally or informally.

I suggested to Siobhan that we could arrange a meeting with herself, her mother, her nurse, her psychiatrist, and me, to try to reach some agreement about a course of action. Siobhan readily agreed to this idea. I arranged to call in to see her the next morning.

We returned to the CMHT and saw Siobhan’s mother in the presence of two police officers. She was very agitated, and was reluctant to listen to what we had to say about our assessment. She became quite abusive. The police officers were clearly irritated by her. They told her not to harass her daughter, and they wanted Siobhan to be told to inform the police if her mother harassed her further.

The next morning I visited Siobhan as arranged. There was no reply, but the lights were on upstairs and I saw that a venetian blind was momentarily opened.

I phoned her from my car.

“Hello,” I said. “This is The Masked AMHP. Can I come in and see you?” I knocked again, but again there was no reply. However, I heard noises from inside and heard her tell the children to stay in a room.

I phoned her again.

“Do you know who I am?” she screamed down the phone at me.

“You’re Siobhan,” I replied calmly.

“No I’m not,” she shrieked, “I’m her Royal Highness, the Queen of the World!”

“Siobhan, can you let me in?” I asked her, approaching the door again. I heard her thump the inside of the door and then she turned up the stereo to full volume.

I returned to the car to phone her one more time.

“I’m the fucking princess!” she bawled at me when she answered.

It was clear that she was not going to let me in, so I retreated back to the CMHT.

I called the police and explained what had happened. They agreed to go out straight away, especially as the children were inside the house with her.

I returned rather quickly with Siobhan’s GP. There wasn’t time to get a Sec.12 doctor.

The police had managed to gain entry. I found Siobhan curled up in a foetal ball under the stairs. She looked up at me as I knelt down beside her.

“Are you my daddy?” she asked me.

 I detained her under Sec.4.