What’s in the major parties’ Manifestos for mental health?

 

So here we are with another General Election. And not before time. Since the Conservatives, who had been promising a revised Mental Health Act since the last General Election, finally ditched the published Mental Health Bill before it could be passed into law, it looks like a good time to see what the major national parties have to say about mental health in their manifestos.

Surprise, surprise. They say that they will “pass a new law to provide better treatment and support for severe mental health needs in the first session of the next Parliament”, although it is unclear what resemblance this may have to the oven ready Mental Health Bill.

They encouragingly say “mental health should have parity of esteem with physical health” but there is little detail regarding how they will do this.

They concentrate on plans to support children and young people with mental health needs, including expansion of mental health support teams in schools and providing early support hubs for 11-25 year olds. They also optimistically say they will “extend patients’ right to choose to more NHS community services over time, including diagnostics, talking therapies and other mental health services.”

Then somewhat ominously they tell us that “we will improve PIP assessments to provide a more objective consideration of people’s needs and stop the number of claims from rising unsustainably. While people suffering with mental health conditions face significant challenges, it is not clear that they always face the same additional living costs as people with physical disabilities.” They appear to think that the best way to improve the mental health of people unable to work is by making them even poorer.

Like the Conservatives, Labour is keen to give parity of esteem to mental health: “we will reform the NHS to ensure we give mental health the same attention and focus as physical health.”

They also have a little more to say about revising the Mental Health Act. “Mental health legislation is… woefully out of date. The treatment of people with autism and learning difficulties is a disgrace. The operation of the Mental Health Act discriminates against Black people who are much more likely to be detained than others. Labour will modernise legislation to give patients greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment.” It will be interesting to see how much of the Mental Health Act review will inform this proposed legislation.

Again, as with the conservatives, Labour recognise the mental health needs of young people, offering to “provide access to specialist mental health professionals in every school” and creating “Young Futures Hubs, which will make sure every community has an open-access hub for children and young people with drop-in mental health support.”

The Liberal Democrats outline a detailed package of reforms targeted at improving mental health services, many of them wholly laudable.

They plan to end “out-of-area mental health placements by increasing capacity and coordination between services, so that no one is treated far from home”, they will extend “young people’s mental health services up to the age of 25 to end the drop-off experienced by young people transitioning to adult services”, and they will take “an evidence-led approach to preventing and treating eating disorders”.

They also propose to introduce changes to the way the police respond to mental health crises by “introducing a target of one hour for handover of people suffering from mental health crisis from police to mental health services, ensuring that all forces have a mental health professional in the control room at all times and supporting the police to achieve adequate levels of training in mental health response.”

The Lib Dems, too, intend to introduce new legislation, promising to modernise “the Mental Health Act to strengthen people’s rights, give them more choice and control over their treatment and prevent inappropriate detentions.”

The Green Manifesto is distinctly sketchy on how they will tackle the crisis in mental health care. They say that they would introduce “a legal framework that supports the rights of those struggling with their mental health to be respected and to live fulfilling lives” and will also increase “funding for mental health care, putting it on an equal footing with physical health care and enabling people to access evidence-based mental health therapies within 28 days.”

And then we come to the Reform Party’s Contract with the UK.

There are precisely two references to mental health in their Contract. This is what Reform have to say about mental health in its entirety:

“Employment is critical to improving mental health. Britain’s young people are in the grip of a mental health crisis. Work is a cure not a cause.”

Yes, I’m sure that’ll work out just fine.

An interview with an attempted 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 fulfil the role of appropriate adult when interviewing children or vulnerable adults.

Requests to attend interviews with adults with mental disorders or learning difficulties were usually for the most serious offences.

So, one day I had a call from the local police station. That morning, a woman in her 60’s had literally crawled into the police station, covered in blood. She had twenty or more stab wounds. She was able to tell the police that her husband, George, had attempted to kill her by stabbing her repeatedly with a pair of scissors.

She was taken to hospital by ambulance. In the meantime, the police had attended her home, which was just round the corner from the police station. George answered to door and did not seem surprised to see them.

“Hello,” he had said. “I’ve just tried to kill my wife. I expect that’s why you’re here.”

I did some background checks. I discovered that George, who was 64, had been a patient of the mental health service for over 40 years.

I got hold of his community psychiatric nurse, who told me that George had a diagnosis of paranoid schizophrenia. He had last had a psychiatric admission over 40 years previously. While in hospital, he had met his future wife, who at the time was a psychiatric nurse.

Since then, he had been maintained in the community through regular outpatient appointments and a fortnightly depot injection.

However, three months previously the community nurse had visited him for his depot, but George had politely refused. The nurse visited once more, and George had again politely but firmly refused.

His psychiatrist made an outpatient appointment, but George didn’t attend.

This is where things got a bit unusual. Because he had missed the appointment, the psychiatrist, rather than exploring other avenues, had discharged George from psychiatric services.

Prior to the formal police interview, I saw George in a side room. He smiled at me as I entered.

“George”, I began, “can you tell me what happened today?”

“I was arrested,” he said.

“Yes.”

“I was arrested for attempting to kill my wife.”

“Yes.”

“I stabbed her with a pair of scissors.”

“Why did you do that?”

“We’ve been married a long time, and I just thought it seemed like a good thing to do. They were the nearest thing to hand.”

“Did you have an argument?”

“No, I just thought it was about time.”

“Why did you stop having your depot injection?”

“I’ve been having one for decades. I haven’t complained. I just decided I didn’t want it anymore.”

“Did your wife know?”

“I told her the nurse had said I didn’t need it any more after all these years.”

I was unable to elicit any obvious paranoid delusions, and he was not obviously presenting with evidence of thought disorder.

He had not had any medication for several months, so maybe his mental illness was reasserting itself.

Whatever was going on with him, I knew he would not be being released any time soon.

After interview and charging, he would appear in court and would be detained in hospital under s.35 MHA for assessment.

And his psychiatrist would have some questions to answer.

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.

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).

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.

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.

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 1^st 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.