Wednesday, 24 April 2013

When Service Users Seek To Deceive Part IV

The Masked AMHP assessing "nature or degree" in the hit Edinburgh Fringe play "How to Survive a Mental Health Tribunal -- Missus"

The following account may contain triggers for self harm.

It’s nearly 10 years since I last had any contact with Eunice, but I still think about her from time to time.

Eunice was, and still is a mystery. I don’t think I ever really did get to the bottom of what was happening with her. I don’t suppose I ever will.

Eunice was in her 50’s. She was married to a man somewhat older than her. He was a bank manager. When he retired, they moved to Charwood, and bought a large house on an upmarket estate.

Her consultant psychiatrist from the area where she had lived wrote a letter of referral to the CMHT. It described her as a “pleasant, polite and deferential lady” with a long history of depression. More unusually, she had consistently recounted a long history of having been physically and emotionally abused by her husband. More than that, she also described a history of having been the victim of systematic physical and sexual abuse by a group of men, including her husband, who would come to her house and abuse her in various unspeakable ritualistic ways. The psychiatrist had never been able to corroborate these stories. He had once invited her husband to come to an appointment, but the husband had not attended.

I conducted an initial assessment with a female member of the team. Eunice was a tiny, birdlike woman who had very poor eye contact. She frequently trembled during the assessment, and often appeared to be in great distress. She recounted a history of childhood emotional and sexual abuse at the hands of her father. She was an intelligent woman who went to university and obtained a degree in English Literature, then met and married her husband and became a housewife and mother to her son and only child.

It was noticeable that her arms were covered with a silvery criss-cross of scarring consistent with many years of self harming with a sharp object. However, when I asked her about the scarring, she denied that she had ever deliberately self harmed, claiming instead that these were inflicted by her husband and others during their abuse of her.

When I came to write up my assessment, I concluded that “Eunice's overall presentation is consistent with a history of chronic sexual, physical and emotional abuse as a child, and her accounts of this abuse, and her beliefs and reactions revealed when discussing it, ring entirely true. However, her accounts of the sadistic abuse over many years by what appears to be an organised ring is necessarily very hard to believe. This is not a description of conventional, if that is the word, "satanic" or "ritual" abuse.”

Despite my reservations, my approach with people who reported childhood abuse has always been to believe them unless I had evidence to the contrary.

I worked with Eunice for over 5 years in total. Initially, I attempted on a number of occasions to persuade her to allow me to report her allegations to the police and the Adult Protection Team. She would never allow me to do that. I explored with her as gently as possible the nature of the abuse. Some of it involved reports of her husband deliberately inflicting pain on her, an example being when he allegedly burned her with an electric iron. She showed me the burn on that occasion.

There were in fact several times when I saw injuries on her, including what appeared to be rope burns on her wrists and ankles. On one occasion she told me that she had been taken by car, with a hood on her head, to somewhere in the countryside, where she had been tied up and then subjected to a range of appalling ordeals. But she would never let me intervene.

I continued to persevere with her, trying to improve her self esteem and assertiveness to the extent that she would permit me to take action over this apparent abuse.

In one review I noted:

The injuries I have seen on Eunice are consistent with systematic and organised abuse. However, these injuries could as easily have been self inflicted as caused by others. There are three possible explanations for the reported abuse:
1. She is the victim of an organised ring of sadists of whom her husband is a member.
2. She has a longstanding and consistent, but untrue delusion that she is the victim of this abuse, caused by a psychotic state.
3. The accounts of the abuse as an adult are hysterical inventions and all the injuries are self inflicted and consistent with Munchausen's Syndrome, possibly arising as expressions of genuine childhood abuse.
She will not give me permission to speak to her husband, and has refused offers to help her leave him and go to a safe place, saying she is afraid not so much of what they might do to her, but that they might harm her adult son.

After a couple of years of working with Eunice, her husband unexpectedly and suddenly died of a heart attack.

Although Eunice expressed considerable grief, I also saw this as a possible new start for her. Now her husband was dead, she might be able to forge a new life for herself, free of abuse.

I enlisted the help of a female support worker from the team, and together we helped her to clear her house of her husband’s effects. I had secretly hoped to find some corroborating evidence relating to her husband’s double life, but there was none.

The support worker began to work with Eunice, and over several months Eunice’s mood appeared to improve. I even caught her smiling occasionally during my sessions with her.

Then she began to tell us that she was again receiving visits from the men.

She reported to us that one of them had left an obscene message on her answering machine. Unfortunately, she had erased it.

On another occasion, she told us that a video had been posted through her letter box containing compromising scenes involving her husband and herself, and a threat to send it to her son. However, the “visitors” then took it back.

Still working on the basis that what she told us was true, in spite of some misgivings (why did she always dispose of the objective evidence), I encouraged her to increase her security, including having a spyhole installed in her front door, installing a chain, and also ensuring that her other doors and windows were secure. I even suggested that we have a CCTV camera installed, but she would not agree to this.

Then one day, when I visited her, I found her in a state of intense distress. She said that the previous afternoon there had been a ring on her doorbell. She said that when she opened the door, one of the men was there. She eventually revealed, over a long period interspersed with tears and trembling, that he had forced his way in, and had then dragged her upstairs where he had tied her up and abused her.

She showed me what looked like fresh rope marks on her wrists and ankles.

I told her that this could not be allowed to continue, and that I would have to report it to the police.

I arranged for a female police officer to interview Eunice in the presence of the support worker. She was told that, for a formal investigation to take place, she would have to make a formal complaint and have a medical examination. She said that she could not tolerate submitting to a physical examination, as it would remind her too much of her abuse.


Eunice continued to give periodic reports of visits from the men, and accounts of their continuing abuse of her. Sometimes she would show us injuries – rope burns, bruises.

After a few more months of this, I discussed the case with a female officer from the local Adult Protection Unit without telling Eunice. She said she would make some discreet enquiries prior to any further action. I assumed she meant that she would do some background police checks on Eunice’s husband. She came back to me, saying that they would not be able to do anything further without interviewing her.

Eunice reluctantly agreed to this.

I was pleased about this – the Adult Protection Officer was extremely experienced and might just be able to get somewhere with Eunice.

She interviewed Eunice on her own, at her home, coincidentally the day after Eunice had reported yet another “visit” and with accompanying rope marks on her wrists.

The Officer reported back to me afterwards. She did not consider that Eunice was being abused in the way she described. This was on the basis of the content of Eunice’s account, her body language during the interview, and exaggerated and incongruous reactions to touch, etc. She also based her conclusions on her experience of interviewing rape victims as well as people known to have made false allegations.

I decided that I should change focus with Eunice. I reviewed her Care Plan with her, pointing out that it appeared she would prefer me to sit and listen rather than try to impose change on her that she feels unable to achieve. She gave me a list of concerns which I tried to address, some practical, some emotional. One thing was her car wing mirror, which was hanging off. I looked at it for her, and was able to fix it easily and quickly. Eunice appeared delighted in a childlike way by this, even smiling spontaneously.

For the next few sessions, I became a handyman, replacing light bulbs that she could not reach, fixing a latch on her back gate, fixing a leaking tap. While I did this, she sat and talked to me about her mixed feelings of grief and relief over the death of her husband. I did not mention the “visitors” and neither did she.

Then one day she abruptly announced that she was moving. Her son, who lived in another county, was arranging for her to live in a bungalow nearby to where he lived. He was taking over her house and was going to let it out.

Within a month, she was packed and gone.

I confess to a sense of relief. She was no longer my problem.

A few months later, however, I received a letter from her. She said that she did not know what to do, as the “visitors” appeared to have tracked her down, and were again entering her house at will and abusing her in various terrible ways.

I wrote back, telling her that she had to report it to the police, and should also let her son know.

I never heard from her again.

Saturday, 6 April 2013

Are CTO’s Any Good? Observations on the OCTET Trial

I recently read the abstract of the OCTET research into the use of Community Treatment Orders for patients with psychosis published in the Lancet on 26th March 2013. I’ve only read the abstract because, despite the research being funded from public money via the National Institute of Health Research, the full report is only available behind a paywall. So I apologise now if I’ve missed something important.
The burgeoning use of CTO’s since 2008 to manage mentally disordered people in the community is something I have written about on a number of occasions, if only because it has become an increasingly large part of an AMHP’s work – the AMHP has to endorse an application for a CTO, an extension of a CTO and the revocation of a CTO. All these require assessments, reports on the assessments, and these actions also often precipitate a Managers Hearing or a Mental Health Tribunal, both of which require the writing of a report and attendance at the hearing.
The trial selected detained patients with a diagnosis of psychosis. The total sample consisted of 333. Half the sample (166) were discharged on a CTO and the other half (167) were made subject to extended Sec.17 leave. Sec.17 leave is a process whereby a patient is not formally discharged from detention under Sec.3 Mental Health Act, but allowed out of the hospital on leave. They can be recalled at any time, with little formality.
The object of the research was to see if CTO’s reduced readmission. They monitored the samples for 12 months. Their conclusion was that “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.”
The message from this research seems to be unequivocal: CTO’s don’t work, and therefore shouldn’t be used.
AMHP’s and Psychiatrists clearly do not want to be engaging in practices which could be regarded as oppressive and/or counter productive: we’d all much prefer that patients should stay out of hospital and to use the least restrictive means to achieve that. The initial response to these conclusions would therefore appear to be a reluctance to subject anyone else to a CTO.
But how much credence can we give to this research?
A number of things strike me as making the results not as unequivocal as they at first seem.
The first is the size of the sample. They looked at 166 patients who were subject to Supervised Community Treatment. However, since 2008, when CTO’s were introduced, until March 2012, which is the most recent date for which figures are available, a total of 14,295 people have been placed on CTO’s. This means that their sample accounts for less than 1.2% of the total up to March 2012. This, to me, seems to be a very small sample on which to be base such serious and potentially far reaching conclusions.
The second is the selection of only people with a diagnosis of psychosis, which according to the abstract were those with schizophrenia. In my experience, CTO’s are not only used for people with schizophrenia, but are also often used for people with bipolar affective disorder, eating disorders, and other diagnoses. Would outcomes have been different if bipolar affective disorder had been selected, or if there had not been a restriction on diagnosis at all? We can’t possibly know without further research.
The third is the comparisons used. The two samples were people on CTO’s versus people subject to Sec.17 leave.
The Code of Practice does not exactly encourage the use of extended Sec.17 leave. In fact, the CoP (21.9-10) states:
“When considering whether to grant leave of absence for more than seven consecutive days, or extending leave so that the total period is more than seven consecutive days, responsible clinicians must first consider whether the patient should go onto supervised community treatment (SCT) instead… The requirement to consider SCT does not mean that the responsible clinician cannot use longer-term leave if that is the more suitable option, but the responsible clinician will need to be able to show that both options have been duly considered."
In practice, extended Sec.17 leave should only be used sparingly, and only for very good reasons. Yet, it appears that for the purposes of the study, patients “were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients)”. Is this within the spirit of the MHA and the Code of Practice?
In the real day to day world of working within the MHA, Sec.17 leave is not an alternative to discharge on a CTO. It does not therefore seem to be a valid comparison. It might have been more useful to compare outcomes for patients discharged on a CTO with patients discharged with no CTO at all. What would the figures have shown with these two samples? We can’t possibly know without further research, but they may have shown a more positive result for CTO’s.
I have been working with people on CTO’s for several years now. These have been people with diagnoses of psychosis, bipolar affective disorder, and anorexia. While my own sample is tiny, and I would not want to draw any firm conclusions from my experience, I would say that overall, CTO’s have helped to keep patients out of hospital who otherwise would have been “revolving-door” patients.
I recently looked for research into the numbers and efficacy of the use of CTO’s for people with eating disorders. There was hardly anything to be found. In fact, this trial appears to be the first significant piece of research into CTO’s in this country.
That is why I would like to see much more research into the use of CTO’s, on much larger samples, using more realistic comparators, and looking at other diagnostic groups, before making a blanket decision to stop endorsing new CTO’s.

Monday, 1 April 2013

How to Displace the Nearest Relative, as Told to Sooty

What’s that, Sooty? You want to know what to do if a patient’s Nearest Relative unreasonably objects to making an application for admission under Sec.3 Mental Health Act?

Well, Sooty, that’s an interesting question. Let’s just put the question in context for our readers, shall we?

Let’s say that Sweep became mentally ill and needed to go into hospital for treatment. But Sweep doesn’t want to go into hospital, so an AMHP has to section him.

What’s that, Sooty? Sweep’s completely mental anyway? That’s not a nice thing to say, is it, boys and girls?

Anyway, let’s get back to our example. The AMHP has to consult with Sweep’s Nearest Relative if he wants to detain him under Sec.3 for treatment. But the Nearest Relative can object to this. If that is the case, then the AMHP cannot proceed with the Sec.3.

What’s that, Sooty? Is Harry Sweep’s Nearest Relative?

That’s a good question, Sooty. Sooty’s full of good questions today, isn’t he, readers? Well, Harry can’t be Sweep’s Nearest Relative because Harry is a human being and Sweep is a glove puppet.

No, Sooty, Richard can’t be Sweep’s NR for the same reason. No, it doesn’t matter how often he puts his hand up Sweep’s backside, he will never be his NR within the meaning of the Act.

Remember, the Nearest Relative is the Nearest Relative is the Nearest Relative.

Anyway, this is just a hypothetical situation, Sooty.

What’s that, Sooty? What does hypothetical mean? Well, it means that it’s not real, it’s made up.

What’s that, Sooty? Am I made up? No, Sooty, The Masked AMHP is a real person, but he’s got a pretend name.

Anyway, this is where displacement comes in. You see, Sooty, if the AMHP thought that Sweep’s NR was being unreasonable in not allowing the AMHP to section him, the AMHP can apply for the NR to be displaced.

There are lots of different things in the Mental Health Act, Sooty. It’s a bit like the ingredients in a cake. When you mix them all up and cook them, then a nice big Act comes out at the end.

What’s that, Sooty? You’d like to make a nice lemon meringue pie? Well, you can get on with that while I carry on explaining to all the boys and girls about displacing the NR.

I’ll tell, you what, I’ll hold the bowl while you put the ingredients in and mix them all together.

So, the AMHP has to go to court and see the Judge in order to get the NR displaced. The AMHP should ask the patient if they have any preferences, otherwise the AMHP can nominate someone, such as the local AMHP lead, or the Director of Adult Services, to act as the patient’s NR.

Now careful squeezing that lemon, Sooty – ouch, it’s gone right in my eye!

Now where was I? Oh yes, the court can then appoint that person if they are satisfied that the NR has acted unreasonably. They can even appoint someone else, anyone they like, in fact.

What are you doing with that whisk, Sooty? You’ve got egg white on my tie!

So, has that answered your question, Sooty?

Now careful, Sooty, try and keep the whipped egg white and the icing sugar in the bowl.

My, that’s nice and light, isn’t it, Sooty?

What’s that, Sooty, it’s so light you can lift the whole bowl over my head?

Watch out, Sooty, you’re going to spill it...

Ooooooh! Sooty, look what you’ve done now! You’ve emptied the bowl all over my head! It’s dripping off my ears!

Oh, Sooty! You are a naughty bear! I’m going to have to get cleaned up now!

Bye bye, readers. Bye bye!