Thursday, 27 December 2012

When Service Users Seek to Deceive, Part I

Reconstruction by actors. The Masked AMHP is being played by the woman at the back

(Before reading this cautionary tale, I want to make clear to readers that this post is in no way intended to imply that people on benefits are scroungers. Quite the contrary – most mental health service users that I know who are reliant on benefits would dearly love to be able to do a meaningful and adequately paid job, but are prevented from doing so by their mental health problems. Many feel deeply ashamed that they are no longer able to work and are forced to rely on benefits. Cutting the benefits of people with disabilities will not spur them on to work; it will only serve to exacerbate their problems.)

As a social worker, it has always been my basic approach with service users to believe what they tell me, unless and until I have evidence to the contrary. Having worked with many people over the years with a history of childhood sexual abuse, many of whom were doubted when they disclosed as children, I know that it is of vital importance to them to be believed.

That does not mean I am gullible, but I am prepared to keep an open mind and apply the Evidence Test. The Evidence Test is simple and straightforward – is there any evidence which contradicts what a person is telling you?

I remember visiting an old lady who told me that her living room had been full of girls singing and dancing the previous evening. She said that they had then all disappeared into a hole in the wall – directly behind her TV. Before coming to the conclusion that the lady was suffering from dementia, and was no longer able to differentiate reality from television, I had a look behind the TV just in case there was, indeed, however unlikely it may seem, a hole. There wasn’t.

There was another unfortunate old lady who lived in Charwood, who was detained under the MHA and admitted to hospital after repeatedly reporting the existence of strange noises in her old terraced cottage. Following her admission, her community nurse arranged to collect some personal effects from her home. She entered the cottage and was disconcerted to hear loud noises emanating from somewhere within the building. It was eventually traced to her next door neighbour, who had decided to convert his cellar into accommodation, and in the process had extended his own cellar by knocking into the space beneath the old lady’s home.

So I initially had no reason to disbelieve Brenda.

Brenda was referred to Charwood CMHT by her GP. The letter catalogued the terrible experiences she had had at the hands of her abusive husband who, even after she had left him, had continued to stalk and harass her and had even broken into her house and raped her on one occasion.

The consequence of this was that Brenda was afraid to leave her house. She had difficulty sleeping, and reported frequent flashbacks to her ordeal. She was afraid of being alone, and only slept with the light on. She reported a full house of symptoms of post traumatic stress disorder.

I worked with her for several months. One of the first things I did was to help her make a claim for Disability Living Allowance. I was surprised when she was turned down for this, and helped her to appeal.

I put quite lot of work into this. She had a neighbour, who was often at her house when I visited, who had told me the extent of the help she had had to provide Brenda, as she lived alone, and had no supportive relatives. I typed up a detailed account of the daily assistance she provided Brenda, which included encouraging her to eat properly, taking her to appointments, and even going round to her house in the night when Brenda was too frightened to sleep. I sent this statement off with the appeal documents, and arranged to take Brenda and the neighbour to the appeal and to act as her advocate.

The members of the Appeal Tribunal were sympathetic, and awarded Brenda DLA at the lower rate of care and mobility. It was backdated 9 months. I was as delighted as Brenda, and felt I had done a good job.

A few months later, Brenda had more problems with benefits. This time, she told me, she had had her housing benefit suspended because of an anonymous tip off that she was fraudulently claiming. Someone had told the district council that she was working. She suspected that it was her ex-husband.

I again offered to write a supporting letter for her.

A week or so later, she told me that she had been summoned to an interview, under caution, at the local council offices, in connection with these allegations. I offered to attend with her as an appropriate adult.

We went into the interview room and the investigating council officers began the formal interview.

The basic charge was that she had fraudulently claimed housing benefit for a number of years while working full time, and that she had not disclosed her earnings, or the existence of bank accounts into which these earnings had gone, to the council.

Brenda denied these charges.

The interviewers listened patiently.

Then the main interviewer opened up a large dossier and began to show Brenda some documents. Was this her bank account? Yes. How did she account for regular sums of money going in on a monthly basis, of around £1000 per month? She didn’t know what the money was for.

The interviewer showed Brenda the payrolls of several different employers. Was this her name and address? Yes, it was. Was this her National Insurance number? Yes, it was. Was this her signature on the forms? It looked like her signature. Was the employee therefore Brenda herself? No it wasn’t. It must have been someone who had used her name and address. Was it same person who had then arranged for her monthly pay to be deposited in Brenda’s bank account? It must have been. And this person was not, in fact, Brenda? No, it wasn’t.

It was becoming blindingly clear to me that Brenda had, indeed, been systematically claiming housing benefits and other benefits fraudulently for several years, and that I had been an unwitting accomplice in this.

In the car on the way home, Brenda continued to maintain, in the face of overwhelming evidence to the contrary, that she was entirely innocent. I couldn’t look at her. I dropped her off at home and advised her to consult with a solicitor. I said I would be in touch.

After consultation with my manager, I wrote to Brenda to say that Charwood CMHT would be discharging her from the service, as we could only work with people with mental health problems. I never saw her again.

Wednesday, 12 December 2012

Get the Masked AMHP™ App This Christmas!

Just in time for Christmas, the Masked AMHP™’s extensive team of Tech guys have completed the brand new, shiny and indispensable Masked AMHP™ App!

One of the Masked AMHP's Tech guys

Crammed with useful tools for the busy Approved Mental Health Professional, you won’t know how you ever lived without it!

The Masked AMHP™ App comes preloaded with a fully searchable database consisting of the Mental Health Act 1983, the Code of Practice and the Reference Guide, as well as all the associated Statutory Instruments! Wahey!

The Masked AMHP™ App also has a fully searchable database of ALL the relevant case law associated with the MHA and the Human Rights Act! Woohoo!

But that’s only the beginning!

Once you’ve downloaded The Masked AMHP™ App onto your mobile device it will solve ALL your AMHP problems!

Section 2 or Section 3?
You’ll never be stumped by this conundrum again! Just point your mobile device at the patient, and it’ll automatically identify which section you need to use. The Masked AMHP™ App will then autocomplete the Section forms and wirelessly transfer them to the nearest printer!

Never fear making an error in discerning whether or not the Mental Capacity Act might be preferable! The Masked AMHP™ App will make the decision for you!

Is the patient Mad or not?
Simply point your mobile device at the patient, and The Masked AMHP™ App will automatically identify whether or not the patient is mentally disordered! (Warning: Still in Beta stage)



Who is the Nearest Relative?
Simply input a list of suspects into your mobile device, and The Masked AMHP™ App will instantly identify who the nearest relative is, and will then autocomplete the section form with a cast iron reason why it was impracticable to consult them! Guaranteed to stand up in Court!

Where’s the nearest hospital bed?
Using advanced GPS technology, The Masked AMHP™ App can instantly locate a vacant bed anywhere in England or Wales! Even the ones the bed managers are hiding!

Problems getting a Section 12 Approved Doctor?
The Masked AMHP™ App can not only identify which local Sec.12 doctors are available, but will also text them with an irresistible reason why they need to attend! Even when they’re on holiday, or simply can’t be arsed!

Tormented by ambulance delays?
The Masked AMHP™ App can hack into your local Ambulance Trust’s system and place your request at the top of their priority list! Simply input an address and postcode and an ambulance is guaranteed to turn up within 15 minutes!

All this and even more!
  • Nurse AMHP’s, OT AMHP’s, Social Worker AMHP’s – who’s the best?
  • X Factor or Strictly Come Dancing?
You won’t know how you ever lived without The Masked AMHP™ App!

 What people have said about The Masked AMHP™ App:

“Now why didn’t I think of that?” Mark Zuckerberg

“Now why didn’t I think of that?” Bill Gates

“Now why didn’t I think of that?” Richard Jones

Tuesday, 4 December 2012

On Being Observed While Doing Your Job

The Masked AMHP (in a suit) attempting to interview in a suitable manner -- with hilarious results. Publicity shot from the stage production of "Ooer, Missus, It Shouldn't Happen to an AMHP!" 

Every five years, AMHP’s have to provide evidence to their local authority of their competence to continuing practicing. One of my local authority’s recent mandatory requirements for being reapproved in the role of Approved Mental Health Professional is to be critically observed and assessed while actually undertaking a live Mental Health Act assessment. Scary or what?

Although there are many professions who are often in the public eye while doing their jobs (teachers,  police officers and nurses to name just three), AMHP’s are possibly more closely scrutinised while performing their duties than most.

A typical MHA assessment in someone’s home, as well as the patient, of course, can easily include two doctors, two or more police officers, a couple of ambulance crew, the nearest relative, and the patient’s care coordinator. There can also be an AMHP trainee shadowing the AMHP, and possibly even students from other professions. That’s a possible total of 11 or even more. And some of them may be fairly hostile to the AMHP’s role, especially if they’ve formed their own lay assessment of the situation.

While Mental Health Cop on his blog is valiantly attempting to educate his colleagues on the law relating to people with mental disorders, police officers nevertheless often find it difficult to understand the factors that AMHP’s legally have to take into account when assessing a patient for possible compulsory hospital admission. And ambulance drivers and paramedics often have alarmingly little knowledge which they are then very keen to exercise.

The nearest relative or other carers will frequently be experiencing a range of distressing emotions, and whatever decision you make may be a source of additional distress to them. They may be reluctant to recognise that their relative needs to be admitted to hospital. They may be upset by a decision to admit, as it means acknowledging that they can’t cope with the behaviour of their loved one any more any longer. Equally, they may be upset by a decision not to admit.

All of this means that AMHP’s often have to explicitly articulate the process of assessment to others, almost in the way that a surgeon may narrate a procedure to medical students and other junior staff in the operating theatre.

This is, of course, no bad thing. A vital part of the AMHP role is to know at all times what one’s legal powers and responsibilities are, and to be able to explain this to all others involved in the assessment in such a way that it can be clearly understood.

The patient needs to know why you are there and what you are doing; the nearest relative needs to understand their specific role as the NR within the meaning of the MHA; and you may need explain to ambulance crews and police officers what their legal powers and obligations are in assisting the AMHP to manage the overall process.

And when the assessment has been completed, the AMHP has to write a formal report on the assessment in which they will need to justify their actions and decisions in case of future challenge.

After a while, stage fright can be overcome, and the AMHP can perform their functions with quiet competence. Being a still point of confidence and calm in the midst of chaos and fear can be of enormous importance.

Nevertheless, there are few professions who are subject to a formal assessment of their competence in such a live situation. Teachers are one such profession, as they have to teach a class in front of OFSTED inspectors when required, with hardly any notice.

Being shadowed by a student or trainee AMHP is something I actually rather enjoy. It keeps me on my toes, it makes me think very carefully and explicitly about why I do what I do and why I make the decisions I do. Trainee AMHP’s in particular are good at asking awkward questions during the subsequent debriefing (Why did you do that? Why did you say that? Wouldn’t it have been better if you’d done so and so?)

So the day came when it was planned that one of my AMHP colleagues would shadow me while doing a MHA assessment. We sat together in the AMHP office, where the day’s duty AMHP’s sit and wait for referrals to come through. And a referral did indeed come.

Aaron was a 19 year old young man who lived with his parents. He was a patient of the Early Intervention in Psychosis Team, as he had presented a few months ago with the first symptoms of psychosis. But he also had marked autistic spectrum traits. He had been fairly well controlled with an oral antipsychotic, but because of side effects, the dose had been reduced, and his behaviour had become more disruptive and difficult for his parents to manage.

His mother had taken him to see his GP, but he had become anxious and agitated and had run out into the street, ignoring traffic and potentially putting himself at risk. The police had been called, who quickly apprehended him, and because of his continuing behaviour in the police car, during which he almost succeeded in climbing out of the window and onto the roof of the moving vehicle, he was taken to the S.136 suite.

And that was where he was on referral.

From the moment of taking the call, I was being observed and assessed. My actions and decisions were being constantly monitored – arranging for a Sec.12 doctor to attend, speaking to the patient’s mother and establishing which of the parents was the NR for the purposes of the MHA, consulting with the Early Intervention Team to get background information, and scanning the patient’s electronic notes.

My AMHP observer, the Sec.12 psychiatrist and I went together to the S.136 suite, where two police officers and his mother were with the patient.

I explained to Aaron what my role was and what tasks I had to undertake. He stared at me fixedly, then as soon as I had finished said, “Can I go home now?”

This was a frequent response to questions I asked him throughout the assessment. He appeared to have only limited understanding of the reasons for his detention and the purpose of the assessment, despite my attempts to explain this to him. Throughout the assessment he maintained fixed eye contact and displayed no facial expression or emotion, although there was implicit evidence of agitation and anxiety. However, he was unable to verbally acknowledge or express this.

He was very guarded during the assessment and was reluctant to discuss any possible psychotic phenomena. He often only answered questions with yes or no answers, and had difficulties with open questions. He eventually said that he had left the doctor’s surgery because he had been disturbed by the doctor’s use of the computer, but refused to enlarge on this. He said that he was willing to take medication and willing to engage with the EIT or the CRHTT if considered necessary. His preference was to return home.

So what would my decision be? I needed to use the information I had obtained, combined with the consultation with the patient, and with his mother.

The Early Intervention Team told me that Aaron had been considered a few weeks ago for compulsory detention, but they had concluded that he could be managed by them in the community. They had also concluded that in view of his autistic spectrum traits, admission to an acute psychiatric ward would be likely to make him worse, and increase his anxiety and agitation. They told me that they would be happy to continue with this plan.

His mother, on the other hand, was concerned about her ability to stand up to Aaron’s demands on her, and worried about how to respond if for example he went off on his bike. However, she did concede that he was capable of cycling from their village into Charwood, where he would go into shops or go to the library. Although she was not prepared to say it openly, I could tell that she would rather he was admitted to hospital.

The psychiatrist was doubtful that compulsory admission was indicated. The discussion with him was helpful. In conjunction with the psychiatrist, the Early Intervention Team, and Aaron and his mother, a short term plan was constructed.

Aaron would not be admitted to hospital. The psychiatrist recommended a change to his medication, and he was also given some diazepam that his GP had prescribed. The Early Intervention Team would increase their input in the short term. The psychiatrist spoke to the GP on the phone in the S.136 suite and faxed his assessment and recommendations to the surgery.

This plan would be open to constant review, and it was made clear to Aaron that if his mother felt unable to manage his behaviour, then a further assessment would become necessary.

Aaron and his mother went home. The police officers vacated the S.136 suite. My observer and I returned to the AMHP office for an in depth debrief. And of course, I had my assessment report to write.
At the end of it all, it felt quite satisfying. I had quite enjoyed the experience of being formally assessed. It was all part of the job.