Wednesday, 9 January 2019

When is it appropriate to use the MHA when someone is causing a public nuisance?


When I was working in a community mental health team, I was once asked to attend a public meeting regarding a Housing Association tenant. The meeting was arranged following a large number of complaints from tenants of one of the Charwood social housing estates.

It was to be chaired by the Housing Association, with representation from the local District Council and the police. They also wanted someone from the CMHT, as it was thought that the tenant who was the subject of the meeting might have mental health problems.

So I somewhat reluctantly attended as a representative of the CMHT. I was reluctant, because I was not sure what would be expected of me. Having checked the name of the person, who I will call John, on our records, I knew that he had no previous involvement with mental health services.

The hall in the local community centre where the meeting was to be held was packed. I was one of the panel members situated at the front. The others were the local chief inspector and a senior housing officer from the district council. Being faced by several dozen hostile tenants felt quite intimidating, to say the least.

John had not been invited to attend, and was not aware that the meeting was taking place. I only knew that John was male, single, and in his 30’s.

The chairman, the chief officer of the housing association, summarised the reason for the meeting. They had received many complaints about the conduct and behaviour of John in public areas of the estate.

Almost immediately, people started making allegations about him. It appeared that he was often to be seen naked to the waist, swaggering around near the estate shops, brandishing a pair of martial arts nunchuks, and that he often verbally threatened passers by.

Allegations started to be made that he was a paedophile. The chief inspector intervened.

“Could you tell me on what basis you are making these allegations?” he asked.

“Just a few weeks ago he was chasing a 15 year old girl down the street. It’s good job she got away from him. We told the police, but nothing happened,” one of the tenants said.

“Let me put this straight,” the chief inspector said. “I am aware of the incident you are referring to. The person in question was actually running away from the police, who were trying to arrest him. The girl just happened to be in front of him.”

The tenant who had made the allegation looked momentarily deflated. “Yeah, but he’s a menace. He needs to be sorted.”

A woman in the audience, whom I recognised as being a patient of the CMHT, looked at me.

“What’s he doing here?” she demanded. “He must be a nutter. What are you doing about it?”

Both the audience and the other panel members looked expectantly at me.

I was not actually anticipating having to say anything. I was suddenly concerned about breaching confidentiality. But was it a breach to say that someone was not a patient?

“I am just here as a representative of Charwood CMHT,” I said. “I can tell you that he is not one of our patients. I know nothing at all about him, other than what I’ve heard today.”

“Well why don’t you know about him? He obviously needs sectioning,” another of the tenants said.

“Look, we honestly don’t go round looking for people to admit to hospital under the Mental Health Act. In order to be seen by the CMHT, their GP has to make a referral. And that has to be with the consent of the person. We’ve never had a referral for John.”

While the tenants were clearly not satisfied by my response, the chairman steered the discussion to what the housing association could legally do about John in response to the concerns expressed by the tenants, and I was not asked to comment again.

After the meeting, the panel members had a private discussion. I discussed with the chief inspector the potential use of S.136 if John appeared to be mentally disordered and in a public place, which would facilitate a formal MHA assessment.

I was struck in this meeting by two things. One was how people can make assumptions based on misinformation and prejudice. The other was the assumption that someone behaving in an unusual or antisocial manner must by definition be mentally ill.

What happened next?

I’d like to be able to say that John was never heard of by mental health services again.

However.

A few months later John was arrested in a public place in Charwood during the evening. He was armed with a large knife, was stripped to the waist, and was threatening to kill anyone who came near him.

He was taken to Charwood police station and assessed under the MHA by the out of hours AMHP. He was reported to be floridly psychotic and too unwell to give any coherent account of himself. As a consequence of his dangerousness, he was detained under S.2 and admitted to a psychiatric intensive care unit (PICU).

I assessed him again a month later and detained him under S.3.

He remained a patient of the CMHT with a diagnosis of paranoid schizophrenia, and was detained under the MHA several times over the next few years, always after stopping his medication. On the last occasion, he was discharged on a Community Treatment Order.

After being made subject to a CTO, he remained well and did not require any further acute admissions. In fact, when the time came to consider extension of the CTO on two subsequent occasions, he made it clear to me that he liked the security of the CTO and wished to remain on it.

There’s no clear moral to this story. Even though John may have been mentally ill at the time of that public meeting, the anger of the local people did not in itself justify taking action to detain him under the MHA.

It’s often the role of the AMHP to unpick what’s really happening when complaints from members of the public are received. 

But people are allowed to be unusual or eccentric, or even mentally ill, as long as their behaviour is not putting themselves or others in danger.

It was only once John stepped over that line, from being a nuisance to posing a real danger, by possessing an offensive weapon in a public place, that it became appropriate to consider use of the MHA to protect John and the public from the consequences of his actions.

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