Tuesday, 20 August 2013

Trying to work but living below subsistence level

I’m currently working with a couple who typify the unintended consequences of recent changes to welfare benefits arising from the recession. Despite their best efforts, the recession has made it impossible to earn a living wage, and they have then been further victimised by the current system, that should be designed to protect the most vulnerable.

Mr and Mrs Jones live in a Housing Association 3 bedroom house. They have lived there for over 30 years, raising 5 children, and maintaining the property immaculately.

Mr Jones works as a self employed landscape gardener. While not making a huge amount from this work, he has nevertheless managed to support himself and his family for many years without recourse to public funds, but when the recession started to bite in 2008, gardening work became scarcer as people tried to find ways of cutting back, and he began to fall into debt.

He started to get depressed. However, he tried to fight this, and in an attempt to meet his ongoing commitments and to service his debts, he took a part time job delivering parcels for a national company. But, already depressed, he found the struggle to keep up with the schedule impossible to manage. He ended up working hours longer than he was paid to in order to meet the delivery targets.

After a few months of this, and still unable to meet his financial commitments, one morning he woke up and was simply unable to get out of bed. He felt terrified to even leave the house, and would have panic attacks at the very thought of going shopping.

He went off sick, and started to receive statutory sick pay. He also made a claim for housing benefit and council tax benefit. But this is where it became even more complicated.

Mrs Jones has a zero hours contract with a local commercial cleaning company. This means that she fills in for the sickness or absence of cleaning staff. Sometimes she works 6 hours a week, sometimes she works 20 hours a week. Some weeks she is not called on at all.

The consequence of her erratic income is to make claiming means tested benefits very haphazard. Each week Mr Jones has  to notify the local authority how much she has earned, and benefits are then paid accordingly. Of course, there is always a delay in calculating and paying these benefits, which means that there is little guaranteed money coming into the house to pay essential bills. Mr Jones is having difficulty trying to pay the prescription charges for the antidepressant and other medication he has been prescribed to try to help him recover.

To add to Mr & Mrs Jones’ woes, because their children are all adult and have left home, they have two unused bedrooms, so are penalised further by the “bedroom tax”. For the first time in their lives, they are falling into arrears with their rent.

Their current predicament is unsustainable. But what should they do?

 Mr Jones has lost 3 stone in weight because of his depression and anxiety. He considers that leaving the house to walk to the post box on the corner on his own without having a panic attack at the moment is a major achievement. If he went back to work, the stress of his delivery job would precipitate a major relapse. In his current state of mind, there is no way he should return to that job, but his job as a gardener is also unsustainable.

Should Mrs Jones continue doing her job? Her irregular income creates havoc with their finances, and it would surely be better for them as a couple if she stopped work altogether, so that they would at least be able to count on a regular income from benefits, inadequate though it is, especially with the additional penalty of the bedroom tax.

Should they attempt to move to smaller accommodation to reduce their rent and stop being penalised? The problem with that is that hundreds of others in social housing in the area are also trying to do the same thing, and as a consequence, one bedroom properties are in very short supply. And is it really just that a couple who have been exemplary tenants, and who have put their lives into maintaining their house as a much loved home, should have to leave it?

As a mental health worker, whose job it is to aid recovery from mental illness, I would have to advise Mr & Mrs Jones to stop working completely, and be reliant on benefits. That way, their income would be regular and stable, they would be entitled to help with prescription and dental treatment, and they might be able to at least pay essential bills, even if they would not be able to service their debts.

What a shame it is that the welfare system is not designed to facilitate those people who want to work, even if only part time, but instead makes it impossible for them to work. And of course, if Mr Jones remained without work, he would start to be subject to capability for work assessments, whether there was work for him or not. Would that harassment hasten his recovery? I think not.

Saturday, 10 August 2013

What You Need to Know If You’re Sectioned

So, you’ve been detained under the Mental Health Act 1983, and you’re in hospital. It’s most likely you’ve been detained under either Section 2 or Section 3.

Section 2

A Sec.2 lasts for up to 28 days. The purpose of detention under Sec.2 is to assess you to decide if you have a mental disorder.
There are two grounds for a Sec.2:
“(a) he is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period; and
(b) he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons.”

Two doctors will have assessed you and will have decided that, in their opinion, you have a mental disorder. An Approved Mental Health Professional will have “interviewed you in a suitable manner” and would have had to satisfy themselves 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”.

The primary purpose of detention under Sec.2 is to assess you to see if you do, in fact, have a mental disorder or not. Although the detention is for assessment, you can be given treatment as well.

Section 3

A Sec.3 lasts for up to 6 months, although it is fairly unusual for someone to be detained as long as this. The purpose of detaining under Sec.3 is in order to give you the treatment it is thought you need for a mental disorder.

There are three grounds for a Sec.3:
“(a) he is suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital; and
(b) it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section; and
(c) appropriate medical treatment is available for him.”

Again, you will have been assessed by an Approved Mental Health Professional and two doctors.

The sort of treatment you will receive is primarily at the discretion of the hospital psychiatrist. However, Electro Convulsive Therapy (ECT) cannot be given to a detained patient unless they consent and are deemed to have the capacity to consent. See this post for more details about ECT.

A Sec.2 cannot be extended beyond 28 days. However, a Sec.3 can be extended for another 6 months. It can be extended beyond that, in which case the renewal would then last for 1 year.

“Mental disorder”

Both sections depend on establishing whether or not you have a mental disorder. The definition of “mental disorder” in the Act is very wide, being “any disorder or disability of the mind”.

The Code of Practice does however suggest a range of conditions which could be considered to be mental disorders. These include the following, although this is not an exhaustive list:

  • affective disorders, such as depression and bipolar disorder
  • schizophrenia and delusional disorders
  • neurotic, stress-related and somatoform disorders, such as anxiety, phobic disorders, obsessive compulsive disorders, post-traumatic stress disorder and hypochondriacal disorders
  • organic mental disorders such as dementia and delirium
  • personality and behavioural changes caused by brain injury or damage
  • personality disorders
  • mental and behavioural disorders caused by psychoactive substance use
  • eating disorders, non-organic sleep disorders and non-organic sexual disorders
  • autistic spectrum disorders (including Asperger’s syndrome)
  • behavioural and emotional disorders of children and adolescents     
As a rule, you cannot be detained under the Mental Health Act purely on the grounds that you have a learning disability, unless it is associated with “abnormally aggressive or seriously irresponsible conduct”.

Dependence of alcohol or drugs is not in itself considered to be a mental disorder.

What you can do

Everyone detained under Sec.2 and Sec.3 has the right to appeal.

If you’re appealing against a Sec.2, you will have to do this within the first 14 days of your detention. An independent Tribunal will then hear your appeal within a week.

If you’re appealing against a Sec.3, you can appeal at any time during the 6 months of the detention, and after that during any renewal.

An appeal against a Sec.3 can be considered by a panel of hospital managers. These are not staff of the hospital, but lay people who have an interest in mental health issues and who also have the time to devote to these duties. They would hear your appeal within a couple of weeks. If they do not discharge you from the section, then a Tribunal would hear your appeal within a month or two.

A Tribunal consists of a panel of three – the judge, who is a lawyer, the medical member, who is a psychiatrist, and specialist lay member, who is generally a lay person with a particular interest and experience in working with people with mental health problems, such as an AMHP, a nurse, or someone with extensive experience in the voluntary sector. Tribunals are part of the Judiciary, and are in effect a court of law, although they are much more informal than a normal court hearing.

For both a Managers’ Hearing and a Tribunal you are entitled to have a legal representative to present your case. These are solicitors with particular training and knowledge of mental disorder. You will not have to pay for this representative. Alternatively, you can appoint any other person to represent you, apart from people who are themselves detained under the MHA or who are inpatients in the hospital.

You will be allowed to attend the hearing, and will also be allowed to take part and have your say. The other people present at these hearings will be your representative, your Consultant Psychiatrist or one of his junior doctors, a hospital nurse involved with your care, and someone from the community mental health team, who could be a social worker, a community mental health nurse or an occupational therapist. Your nearest relative can also attend if you want them to. There will also be a clerk.

Both a Managers Hearing and a Tribunal Hearing will have access to three reports: a medical report compiled by the patient’s psychiatrist, a nursing report, and a social circumstances report written by someone from the community team.

Both Tribunals and Managers have to be satisfied that you are “suffering from mental disorder of a nature or degree which makes it appropriate for the patient to be liable to be detained in hospital” for either assessment or treatment. For a Sec.2 they also have to be satisfied that the patient’s detention “is justified in the interests of the patient’s own health or safety or with a view to the protection of others”, while for a Sec.3 they also have to be convinced that “it is necessary for the health or safety of the patient or for the protection of others that the patient should receive such treatment”. For Sec.3 they also have to be satisfied that the appropriate medical treatment is available.

In order to satisfy themselves of these factors, they will use the reports supplied, but will also hear verbal evidence presented by those present. This gives a chance for you and your representative to cross examine the other people present and to give your side. They can then decide one of three things: not to discharge you, to discharge you with immediate effect, or to direct that you be discharged at a future date.

It’s worth appealing, because often a psychiatrist will decide to discharge you from your section before the appeal is heard, and even if they don’t, about 15% of people who appeal are discharged by the Tribunal.

Monday, 5 August 2013

What Do You Call a Person Who Receives Mental Health Services?

A description or a label?

There are people who have had bad experiences of mental health services – you only have to look in the comments sections of my posts on this blog to find people who have nothing good to say about mental health services  -- who would answer “victim”. (I just thought I’d get that in first).

But this is actually a serious question. When I started out as a social worker in the late 1970’s, social workers, and probation officers come to that, had “clients”. I didn’t then, and still don’t, think there is anything innately wrong with this term. After all, solicitors have clients. Architects have clients. Advertising companies have clients.

There is nothing pejorative or demeaning about the word “client”. It simply indicates that there is some form of consultative partnership going on. There is no hint there of any sort of power differential.

But “client” no longer appears to be a satisfactory term. Nurses and doctors have “patients”, but social workers clearly cannot have patients. The Oxford Dictionary definition of the word “patient” is: “a person receiving or registered to receive medical treatment”. Since social workers (or occupational therapists or clinical psychologists) do not actually give medical treatment, the term “patient” does not really apply.

However, I must say that, working in a multidisciplinary team with doctors and nurses, it is easy to refer to “patients”. I try to resist this, not always successfully. This is made a little more difficult by the Mental Health Act referring to people subject to the Act as being “patients”. So there are times when I have to use that term in a professional context when acting as an AMHP.

There has recently been what in my view is a wholly deplorable move, to use the term “customer”. “Customer” does not describe the relationship between a mental health service and someone who receives that service.

The Oxford Dictionary defines “customer” as: “a person who buys goods or services from a shop or business” while the Merriam-Webster Dictionary gives the definition: “one that purchases a commodity or service”. Since someone who sees a mental health professional, either voluntarily or because they have been detained in hospital or are subject to a Community Treatment Order is in no way “buying” or “purchasing” that service.

This is the problem I have with attempts to apply a business model to a public service. Under the new GP led NHS system, the “customer” is not the person in receipt of the service, the customers are actually the Community Care Groups (CCG’s) who are in reality purchasing services from the Mental Health Trusts. It is therefore the CCG’s that the Trusts have to satisfy, not the people who actually receive their services.

If shops treated their customers in the way that mental health services treated the recipients of their services, it might go something like this.

Customer: Have you got this blouse in stripes and size 14, please?
Shop Assistant: We’ve got that in stock, but I’m not going to give it to you. You need a pair of leggings in size 16. Here they are. No need to try them on.

So, I think we’re all clear now that “customer” should never be used when referring to people who use mental health, or indeed and public service.

So what have we got left? The popular term currently appears to be “service user”. Even service users refer to themselves as “service users”.

It’s possibly the least worst, but I’m still not convinced that it accurately reflects the role. It still implies that the “service user” has a choice over whether or not to use the service. This is not always the case, especially where the Mental Health Act comes in. Is someone detained against their will under the Mental Health Act “using” that service? Is it indeed a “service” at all?

Is a prisoner serving a sentence in a prison a “service user”? Not if they have no choice over whether or not they want to receive that particular “service”.

The other problem is whether what a social worker, or a nurse, or a psychiatrist, or a psychiatric hospital can be described as a “service”.

A waiter is providing a service. They are quite literally your servant. The customer is always right. It is the job of the waiter to give you what you want, not what the waiter wants to give you. Contrast that with a psychiatrist, for example.

Patient: I’d like 10mg Olanzapine, as well 20mg Citalopram. Oh, and I think I’ll have some 5mg Diazepam prn, just in case I get a bit anxious.

Psychiatrist: No.

So do I have any alternative suggestion? My only alternative is “service recipient”. That is, someone who is in receipt of a service. Or  at a pinch, “client”.