Wednesday 15 May 2024

An Interview with a Murderer


Back in the 1980’s and 90’s, under the Police and Criminal Evidence Act 1984 (PACE), social workers were often called upon by the police to attend interviews of children and vulnerable adults if a parent or other suitable person was not available. When I worked out-of-hours it was common to spend many hours at night sitting with a child or young person while they were interviewed for a suspected offence.

From time to time, we were asked to attend interviews with adults with mental disorders or learning difficulties. These were usually for the most serious offences.

Sean had been arrested for murder. He had a history of drug misuse and petty crime and was working in a local poultry processing plant gutting chickens.

The basic facts are these. After work, he had gone to the house of a woman he had had a brief relationship with some time previously, even though she had taken out an injunction. Her current boyfriend was there, and Sean was unhappy about this. The boyfriend told him to leave, but Sean insisted that he wanted to speak to the woman and began to approach her.

The boyfriend persisted, standing in front of the woman. Sean told him to get out of the way. The man refused. Sean took out his chicken gutting knife and again said he wanted to speak to the woman.

The man did not move, so Sean told him that he would stab him if he continued to interfere.

The man stood his ground, and Sean stabbed him.

Sean had earlier been interviewed in the presence of a solicitor, who happened to have a special interest in mental disorder.

She spoke to me privately when I arrived and was keen on my opinion as a mental health social worker as to whether Sean’s actions were the result of mental illness. She understood that Sean had involvement with the local forensic psychiatric service and had seen a psychiatrist within the last month.

Sean told us he wanted to make a statement on record, so I sat in the interview room with a police officer and his solicitor. What followed was quite chilling.

Sean began by telling us that there had all been a terrible mistake.

You see, he only wanted to talk to his ex girlfriend, because he was sure that if she knew how he felt about her, they could get back together again, but the other man kept telling him to get out and threatened to call the police.

Sean had told him to get out of the way and had told him that he would stab him if he didn’t, but as he wouldn’t do what he asked, he really had no choice but to carry out his threat.

You see, it was not his fault that the man had been stabbed. After all, he had warned him, so it was his own fault, you see.

It was clear that Sean genuinely believed that once he had explained it all to the police, they would say, “Ah, right, we understand now. Well, on your way, Sean, sorry we had to arrest you.”

This was one of the few occasions when I came face to face with a psychopath, someone who was unwilling to take any responsibility for his actions, however extreme, and was convinced that everyone else was to blame. Sean really did not, and could not, understand why the police should not simply let him go.

Sean was not released, but was remanded in custody, was tried and found guilty of murder, and was detained under s.37/41 Mental Health Act to a special hospital.

Monday 29 April 2024

I asked AI to write a comedy stand up routine for the Masked AMHP – and this is what I got

 I’ve been reading a lot recently about how artificial intelligence is going to change the world, for better or worse. But could it make the role of the AMHP obsolete?

So, I asked Copilot, my phone’s AI companion, to write a comedy stand up routine as if performed by the Masked AMHP. This is word for word what it gave me.

I'm really, very, very sorry. At least it's not very long.

1 The Great Clipboard Caper:

Our hero walks into a chaotic ward, clipboard in hand. Their mission? To assess a patient's mental state. But wait! The patient has vanished. Poof! Like a magician's rabbit. The Masked AMHP scours the ward, peeking behind curtains, under beds, and even in the laundry hamper. Alas, no patient. Turns out, they were just in the bathroom. Crisis averted!

2. The Case of the Disappearing Section136 Suite:

The Masked AMHP arrives at the designated Section 136 suite, ready to assess someone in crisis. But - plot twist - the suite has vanished! It's like Platform 9 3/4. but for mental health. Our hero searches high and low, only to find the suite relocated to the basement. Apparently, it needed a change of scenery.    

3. The Epic Battle with the Acronyms:

AMHPs deal with more acronyms than a teenager's text messages. MHA, MCA, CTO, CPA - you name it. The Masked AMHP faces off against the evil forces of bureaucratic jargon. Armed with a highlighter and a strong cup of coffee, they decipher the codes and save the day. Bonus points if they can explain them to anyone else.

4 The Midnight MHA Assessment:

Picture this: It's 2 AM. and the Masked AMHP receives a call. A person needs an urgent Mental Health Act assessment. Our hero dons their mask (and pyjamas) and rushes to the scene. They navigate dimly lit streets, dodge nocturnal creatures, and arrive at the doorstep. The patient? Asleep. The Masked AMHP whispers, "I'm here to assess your sanity. Sweet dreams."

5. The Unmasking:

In a dramatic twist, the Masked AMHP reveals their true identity: a mild-mannered social worker by day, AMHP by night. Their colleagues gasp, "You're the Masked AMHP?" The hero shrugs, "Well, yeah. It's in the job description." They unmask, revealing a tired but determined face. And the crowd goes wild (or at least nods politely).

Monday 22 April 2024

Hallucinations & the Mental Health Act


I’ve recently read Oliver Sacks’ excellent book Hallucinations. It contains a wide range of accounts of different medical conditions that can produce hallucinations or hallucinatory experiences. As Sacks says: “In the popular imagination hallucinatory voices are almost synonymous with schizophrenia – a great misconception, for most people who do hear voices are not schizophrenic.”

In fact, most of the conditions he writes about do not amount to mental illness at all. One such example is Charles Bonnet Syndrome, where sufferers can experience very vivid visual hallucinations.

For them, the condition is a result of sight impairment, and Sacks discusses a range of conditions or situations that produce hallucinations of various types as a result of sensory deprivation of various kinds, ranging from physical states such as blindness to self imposed states of sensory deprivation such as immersion in tanks of warm salt water, where one can lie in a state of suspension and with the entire absence of external stimuli.

It appears that when the conscious brain has nothing to do, it can create often complex and elaborate, but completely unreal, visual and auditory environments.

One of the crucial distinctions between hallucinations arising from physical causes and those experienced by people with psychosis is that the people experiencing these phenomena have insight and recognise them not to be real, and don’tt have any accompanying delusions.

One of Sacks’ conclusions appears to be that hallucinations can be experienced by anyone, as a normal part of life experience, whether as a result of some physical process, such as migraine or epilepsy, or as an entirely normal part of the functioning of the brain, such as hypnogogic hallucinations (hearing or seeing something when about to fall asleep) or sleep paralysis, which can occur when someone is waking up from sleep, during which time the person can believe themselves to be awake when in fact they are still asleep.

The fact that experiencing hallucinations does not invariably mean that someone is mentally ill is an important factor to consider when assessing people’s mental health, whether under the Mental Health Act, or as a standard mental health assessment, and it’s important to keep an open mind and to look for alternative explanations.

When I worked in a community mental health team, we conducted standard assessments which included the question “Have you ever heard a voice when there has been no-one around?” Probably around 15% of those I asked answered that they did, but hardly any of them appeared to be psychotic.

One woman told me that every day, as she walked with her child to school, she would hear a voice calling her name at a particular point on the journey. I asked her what she did about it.

“Oh,” she said, “I decided to take a different route to school, and I never heard the voice again.”

I always tried to be open minded when I was listening to patients telling me about their experiences. Sometimes what someone says may seem so unlikely as to be a sign of mental disorder, but which later turns out to be true.

One example was Edna, a lady in her late 80’s who lived in an old semi-detached flint cottage in the town where I worked. She complained to her doctor that she kept hearing strange noises in her house and feared that the house was haunted. Concerned that she was experiencing auditory hallucinations, the doctor arranged for an older people’s mental health nurse to visit her.

Edna was insistent that she was indeed hearing strange noises. She knew they were in the house, but could not identify where they were coming from. However, as no untoward sounds were apparent while the nurse was there, the nurse became convinced that the only explanation was that Edna had dementia. He persuaded her to be admitted to hospital for further assessment.

A few days later, the nurse went to her house to collect some personal effects for her. While there, he was startled to hear inexplicable noises emanating from somewhere within the cottage, when he knew there was no-one else in the property.

It eventually transpired that the two cottages both had cellars, although Edna’s cellar was not accessible from her house. The next door neighbour had knocked his own cellar through into the lady’s cellar and had been converting it into additional accommodation for himself.

Edna had been hearing her neighbour’s d-i-y activities directly beneath her feet.

Monday 8 April 2024

Is Diogenes Syndrome a Mental Disorder? A case study


Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.

He likes cats and encourages strays to enter his home, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.

The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.

Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.

The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission and gives a graphic description of what will happen to anyone who tries to make him go to hospital.

I am asked to assess Harry. I speak to the psychogeriatrician, who has visited Harry a couple of times. She is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate and provides me with a medical recommendation.

I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has always been a difficult man, who was physically abusive to him as a child and made his mother’s life a misery. He rings him at least once a week and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to do.

I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. Based on the evidence, I am already leaning towards a decision to detain for assessment.

The house is exactly as described. We enter his living room, where he spends nearly all his time. Cats rummage through the heaps of rubbish.

Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I discussed in more detail the purpose of our visit, he becomes more hostile, and asks us to leave.

The GP the social worker and I huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The GP agrees with me. On this basis, I can’t justify detention in hospital.

Harry is not happy we are talking about him. He insists that we leave, shouting and repeating this in my face. He won’t let me tell him what our conclusions are and bundles us out of his house.

Some sixth sense tells me his social worker isn’t happy with the outcome. On the pavement outside, I discuss the reasons for my decision with him.

Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have lifestyles others find unacceptable or repugnant. It’s often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.

Harry may or may not have Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself. Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.

Things continue to deteriorate. The carers continue to complain about the rats. The social worker arranges for a visit with an environmental health officer.

Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.

The psychiatrist, the social worker and the GP gather on the pavement outside Harry’s house. The social worker visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as searching the overgrown garden. He could find no evidence of rats – no rat runs, no droppings, no urine, no evidence of chewing – nothing.

This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to some changes to his medication to see if this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.

Monday 1 April 2024

The weirdest mental health law you’ve never heard of


(Here's the text, but it's worth watching the video for pictures of puffins)

The Mental Health Act has been evolving over many decades. Indeed, the Victorian Lunacy Acts in the 1800’s contained recognisable germs of the current MHA.

The Mental Treatment Act 1930 first introduced the idea of treatment for people with mental disorder, while the 1959 Act introduced the concept of the Mental Welfare Officer, whose role provided an independent check on doctors having complete control of the detention process.

The 1983 Act further refined this process of legal protection for people being detained against their will in psychiatric hospitals, and the 2007 Act enshrined subsequent changes in human rights legislation into mental health law. The 2022 Draft Mental Health Act will make further changes, if it ever reaches the statute books.

These Acts, and accompanying regulations and statutory instruments, tended to amend, consolidate or even abolish previous legislation. Sometimes, however, anomalies survived.

The smaller islands of the British Isles are a case in point. The Isle of Man, for instance, with a population of around 81,000, has its own Mental Health Act, which still has Approved Social Workers rather than AMHPs, and Jersey in the Channel Islands has a Mental Health Law going back to 1969.

What is almost unknown, however, is the existence of regulations relating to mentally disordered persons in the Farne Islands. This piece of legislation appears to have been forgotten by legislators, with the result that The Farne Islands (Removal of Lunatics to England & Wales) Regulations 1927 was never repealed.

The Farne Islands are a group of small islands off the coast of Northumberland in Northern England. They are now owned by the National Trust.

Mainly inhabited by a vast range of seabirds, including puffins, as well as a large colony of seals, in the early part of the century there was still a community of people living permanently on the islands.

This small but tight-knitted group, known disparagingly as “Fannies” by the mainlanders, eked a precarious living by farming seaweed, milking seals to make seal cheese, and taking eggs and any seabirds they could catch using finely woven nets thrown off the top of the guano covered cliffs.

The Farne Island regulations were created as a result of a notorious incident in 1927 known in the press of the time as the Wellington King.

An aristocrat known as the Honourable Petrus Wimple-Burgoyne developed the delusion that the Farne Islands were the remains of the lost continent of Atlantis, and that as his family originated from Atlantis, he was the rightful king. He started to petition King George VI, challenging him to the throne of the Farne Islands, and demanding that he be invested in Westminster Abbey.

He became such a nuisance that he was eventually committed to a lunatic asylum under the Lunacy Act 1890. However, he got wind of this, and before the ambulance arrived, he fled to the Northumberland coast, where he hired a boat at Seahouses and just after dawn on 1st April 1927 he reached the Farne Islands.

He was able to convince the rather credulous and inbred “Fannies” that he was their rightful king, and in a ceremony involving the smearing of the rather oily seal cheese over his entire upper body, an India rubber wellington boot was forced over his head, crowning him the “Wellington King” of the Farne Islands.

When it was discovered where he was, efforts were immediately commenced to recover him to the mainland. It was at this point that it was realised that there was no legal instrument that could be invoked to lawfully remove him.

An emergency session of Parliament was convened, and so was born the Farne Islands (Removal of Lunatics to England & Wales) Regulations.

Within days, a Naval Frigate sailed to the Farne Islands and a dozen sailors alighted on the island of Inner Farne to apprehend him. Despite the sailors being pelted mercilessly with puffin eggs and foul-smelling lumps of seal cheese by the loyal “Fannies”, the so-called “Wellington King” was seized, and returned to England, where he was placed in St Bernard’s Hospital in Southall, Middlesex.

To this day, the Honourable Petrus Wimple-Burgoyne is the only person for whom this regulation has been used.

Wednesday 20 March 2024

Is being a vexatious litigant a mental disorder? A case study


Norman was a man in his early 50’s. He came from a fairly wealthy middle class family, was educated in a public school, obtained a degree in Chemistry and had a high profile job in a pharmaceutical company for some years before setting up his own consultancy company.

He married and had one son. The couple divorced after 4 years.

He was dissatisfied that custody of his son was given to his wife, and embarked on a series of legal challenges which went all the way to the House of Lords. He insisted on conducting his own cases. He continued to challenge court decisions for over 20 years. He had a reputation as a “vexatious litigant”.

In the previous 10-15 years he had been detained under Sec.2 MHA on several occasions. A tentative diagnosis of bipolar affective disorder was made, but he never spent more than a couple of weeks in hospital. He invariably appealed against detention and represented himself in the Tribunal. He was invariably discharged from detention, would stop any medication.

By the time I became involved with him, Norman had lost all contact with his son, his consultancy had gone into liquidation, he had been evicted from his home for defaulting on his mortgage and was living in a caravan on a residential site paid for by his long suffering mother, as he refused to claim benefits.

One day he went to his bank to request a loan to continue with his endless appeals over custody of his son (who by now was 30 years old). When the bank manager refused, he attempted to remove the computer from the manager’s desk in lieu of a loan. He was arrested and detained under Sec.2 MHA.

On admission to the psychiatric ward, he promptly appealed. I was asked to write the social circumstances report.

When I interviewed him for the report, he was arrogant and dismissive. That was not in itself evidence of mental illness, but his grandiose delusions about his life, and his denial of the dire consequences of his futile litigation over the years in my view showed that he was likely to be mentally ill. He had refused medication.

In my report I concluded: “it appears likely that Norman has a mental disorder that could be amenable to treatment. However, he has only ever been detained in hospital for short periods of time for assessment, and as far as I can see has never had any treatment which could have a significant impact on mental illness. He is abnormally fixated on past perceived injustices relating to custody of the child of the marriage, to the extent that after all this time he is unable to lead anything approaching a normal life. However, without considerable further assessment, it is impossible to say whether this obsession is delusional and amounts to a treatable mental illness or is merely an extreme manifestation of despair arising from real injustice.”

As usual, Norman represented himself at the Tribunal. He treated the Tribunal as an adversarial court of law, and had huge quantities of documents, none of which had relevance to his appeal, but which he attempted to quote from at length. After a few minutes, the chair, who is a judge, was clearly getting irritated, and ordered him to stop talking. He asked Norman if he would consider having legal representation.

“I think, with all respect, your honour, that I have more knowledge of legal process than most of the jumped up barristers that inhabit the Inns of Court,” he replied

The judge adjourned the Tribunal, insisting that Norman appoint a legal representative.

A week later, the Tribunal reconvened. This time Norman had a solicitor representing him, an eminently reasonable man, whom I had seen representing many patients in Tribunals and Managers Hearings.

His solicitor began to present Norman’s case for discharge from detention. But Norman was not prepared to sit silently, and instead continually interrupted him, correcting him constantly on minor and irrelevant factual points. The judge became increasingly irritated. Norman’s solicitor was looking desperate as he saw any chance of his client being discharged evaporating.

Eventually, the judge ordered Norman to be quiet, otherwise he would be asked to leave the Tribunal. Norman reluctantly agreed to this, but had to be reminded several times, as he found the impulse to challenge every minor point almost too much to suppress.

“I put it to you, Doctor,” he interrupted at one point while the psychiatrist was being interviewed, “that your entire psychiatric edifice is a farrago of nonsense which is designed only to control the minds of those few remaining independent thinkers in this country in which we find ourselves having to live, in an ever increasing verisimilitude to the terrifying world described in Orwell’s book 1984.”

This was enough for the judge. He asked for Norman to be removed from the room, and the rest of the hearing was conducted in his absence.

He was not discharged from his section, and indeed, following a ward discussion in which it was forcefully argued that, if it was considered that Norman had a serious mental disorder, then he should be treated for it, a week later we detained him under Sec.3 and treatment for bipolar affective disorder was commenced.

He inevitably appealed again, but within a few weeks, after finally receiving a period of appropriate treatment, he began to emerge, as a butterfly emerges from a chrysalis, as a civil, polite and thoughtful man, who could at last see that his behaviour for the last 20 years had been irrational and pointless. He was discharged from detention before his appeal was heard, remained for a further period as an informal patient, and then was discharged to more appropriate accommodation.

Monday 11 March 2024

How to get off your section


So, you’ve been detained under the MHA, and you want to get out of hospital. Based on my decades of first-hand experience here a few hints and tips that might make your stay a little shorter.

1. Appeal against your detention

When you are detained under a section of the MHA, it is the duty of the AMHP who detained you, and of the hospital staff, to inform you of your rights to appeal. Staff have a duty to help you if you want to appeal. Your case will then be heard by an independent Tribunal which is part of the judicial system. Around 15% of appeals to Tribunals are successful.

A formal appeal to a Tribunal will also concentrate the mind of your psychiatrist. If you are making a good recovery, they may well decide to discharge you from detention prior to the actual date of the appeal.

2. Get a solicitor

Patients detained under the MHA have the right to free legal aid regardless of their incomes. There are solicitors with special training who will take on this work. The hospital staff will put you in touch with an approved solicitor. Although a patient can use almost anyone to help them present their case in a Tribunal, your chances will be improved by having a qualified legal representative.

3. Allow the solicitor to present your case

Although Tribunals try to appear as informal as possible, it is nevertheless essentially a court of law. The chair of the Tribunal is a judge, and will not appreciate the patient making constant interruptions or challenging the testimonies of the psychiatrist or AMHP. You can ask your solicitor to point out inaccuracies or discrepancies in written and verbal reports. Your solicitor will frequently pick up on these issues without prompting.

4. Be wary of opportunities to speak to the Tribunal

I’ve seen many cases appear to go well in the Tribunal right up until the moment when the patient is asked by the medical member or the chairman to tell them more about how they are or if they have anything they wish to say to the Tribunal. Many a paranoid or psychotic patient has then gone into great detail about their delusions or hallucinations, thereby proving that they have a mental illness “of a nature or degree which warrants detention in hospital” for assessment or treatment, and which would then make it very difficult for the Tribunal to discharge them.

I remember one Tribunal I attended. The patient had sat there quietly throughout, allowing his solicitor to question the psychiatrist and his care coordinator. It had been going quite well for him. The solicitor had certainly made the psychiatrist look uncomfortable at times. The medical member then said to him: “Is there anything you would like to tell us?”

“Yes,” he replied. “I don’t need any medication or anything like that. I’d be perfectly all right if it wasn’t for these voices. They never leave me alone. They’re always going on at me to do bad things. I think it’s my psychiatrist, he projects them into my head from a transmitter on his desk. I had a brain implant inserted into my head many years ago which has made me half robot and half human. The implant picks up the signals and then I hear them. Those voices, they drive me mad, I tell you.”

Strangely enough, he didn’t get off his section.

5. Don’t threaten or assault the psychiatrist or other staff

This doesn’t look good in a report to the Tribunal. It will also tend to stay with you in every future risk assessment.

6. Take the prescribed medication

As a rule, psychiatrists really do want their patients to get better. Nowadays there is intense pressure on hospital beds, and psychiatrists don’t generally want patients to remain in hospital longer than absolutely necessary. There is a wide range of medication that really can help people with depression, psychosis or mania manage their symptoms. Cooperating with the inpatient treatment plan and with plans for your aftercare after discharge will definitely make your stay shorter.

An important note: If you are detained under S.3 (for treatment) you will inevitably be subject to s.117 of the MHA. This refers to the duty of the NHS and the local authority to provide aftercare when you are discharged. The cost of any aftercare provided (including residential or nursing care, as well as provision of community support services) will have to be met by the local authority or the local NHS Trust.