Leroy

The phone rang.

“Hi there, it’s Shirley Adams. I’m ringing about Leroy. I think we may need to section him.”

I knew Shirley. She was the consultant psychiatrist with the Assertive Outreach Team. I also knew Leroy. In fact, I first met Leroy in the 1970’s when he was only 14 years old and I was a very young social worker working at the time with young offenders. They called it Intermediate Treatment back then (I never did understand what “Intermediate Treatment” meant).

Leroy came from just about the only black family living at that time in the small rural town where I work. He and his brothers had consequently suffered a degree of prejudice, especially from the police. For example, while a white 14 year old in the 1970’s would probably have been ignored or just given a verbal warning when caught riding a bicycle without lights, Leroy was taken to juvenile court. He was one of 5 brothers, three of whom in adulthood developed bipolar affective disorder. In fact, I had detained one of his brothers under the Mental Health Act in the past. I had also detained Leroy under the Mental Health Act on two previous occasions, the first time 18 years ago, and more recently three years ago. He was now in his mid forties.

I still vividly remembered the last time I had been involved with him. He was in the habit of disengaging from the community psychiatric team, and would then stop his medication, take lots of amphetamine, and end up with an acute admission, frequently from the police station. This time he had been an informal patient, but had decided to pop home to his flat without bothering to tell anyone, and had not returned. The ward rang to ask if we could get him back. I had gone out with Pam, our criminal justice liaison nurse, and had tentatively knocked on his door, expecting no answer, or at best a distinct lack of cooperation with our plan.

Instead, he immediately opened the door, welcomed us as if we had come to confirm his jackpot win on the National Lottery, and said: “Thank God you’ve come. Please, please take me back to the hospital. It’s terrible here – the TV’s talking to me!” We decided to oblige, but then wished we hadn’t – he became increasingly bizarre during the journey to the hospital, at one point telling me that I was an alien from Alpha Centuri, and then telling me that, although he was not gay, he nevertheless wanted to kiss me – “on the lips”. Once returned to hospital, I detained him under Sec.3. Unfortunately, I then became the focus of some of his paranoid beliefs, and at one stage during his hospitalisation he announced that he wanted to kill me. Even when he had recovered, he remained hostile towards me. That was when he was taken over by the Assertive Outreach Team.

So when Shirley rang me and mentioned Leroy’s name, I felt a degree of trepidation. This feeling increased when she told me that his mental state had been deteriorating over the last few weeks, they believed he was taking amphetamine again, and thought he might have also stopped his medication. His relatives had reported that he had broken his mother’s window the previous week and appeared to be very agitated. Shirley therefore wanted to pay him a visit with an AMHP and another doctor to conduct a formal assessment under the MHA.

Since there was no other AMHP available (there are only two of us in my team), I had no choice.

The following morning Shirley, another Sec.12 doctor and I called at the time he normally expected the Assertive Outreach Team to visit him. He opened the door and to our surprise readily invited us into his flat. Although he eyed me up a little suspiciously, he remained civil and calm, even when we told him the purpose of our visit.

He told us that he had given up “puff and speed” a week ago, and that he had doubled his medication, including his olanzapine and lithium (this did worry his consultant, because he had been known to become lithium toxic in the past). There was some evidence of elevated mood and disinhibited behaviour, eg he lifted up his teeshirt to display his stomach to show us he had lost weight, and talked to us in detail at one point about the colour of his “poo”, but there was no evidence of delusions or hallucinations. He admitted that he had had a disagreement with his mother last week and had “bricked” her window, but said that he had seen his mother yesterday and offered to pay for the repair. He did tell us that he had noticed that car registration numbers looked “phonetical” – twisted and reversed, but this was the only real evidence of abnormal thought processes. We were in his flat for over 45 minutes, and throughout that time he remained amiable and composed. At one stage he agreed to an informal admission if that was considered necessary. He agreed to maintain engagement with the Assertive Outreach Team and said he would cooperate with any community treatment plan.

We slipped into his kitchen to discuss our decision. We were unanimous in feeling that a detention under the MHA could not be justified on the basis of this interview, even taking into account the reports of his relatives. We told him the news, Shirley warned him not to tamper with his prescribed doses of medication and arranged with him for further visits from team members, and then we left.

Two weeks later he was admitted to Bluebell Ward in the middle of the night in the company of the police, and was quickly detained under Sec.3.

Moral: AMHP’s and psychiatrists are not infallible.

Is it OK to use the word “section” as a verb?

AMHP’s and other mental health professionals use the word “section” all the time when referring to someone being detained under the Mental Health Act. Even patients often use the word as a verb: “You’re not going to section me, are you?”

For those who don’t work in the mental health field, I will give a more detailed explanation. The MHA gives powers to apply for the detention in hospital of people with mental disorder. Specific sections of the MHA lay down these powers, for example, Section 2 allows someone to be detained for assessment for up to 28 days, and Section 3 allows detention for treatment for up to 6 months. Normally two doctors make recommendations that someone should be detained, and the AMHP then makes the final decision and completes the application. Once all the paperwork has been completed and the AMHP has signed his or her application, that person is then formally detained under the MHA, even if they are not yet in hospital. The formal detention gives the AMHP powers to arrange for the patient to be taken to hospital against their will, by whatever means necessary. This will usually involve an ambulance, and may also involve the police.

To talk about “sectioning” someone is therefore a form of shorthand: “Fred’s going hypomanic again. I think we’re going to have to section him.” (Instead of: “I think we’re going to have to assess him under the Mental Health Act to see if he needs to be detained.”) “Adele took an overdose and was sectioned last night.”(Instead of: “Adele was assessed under the Mental Health Act and detained in hospital.”)

Although I confess to using this term when talking to other professionals, I don’t necessarily feel entirely comfortable about it. Is it jargon? Does it demean or depersonalise people with mental disorder? I would never use the term with a patient, and always explain exactly what is happening when an assessment is taking place. This is not only good basic practice, it is a legal requirement. That is why I try to avoid using the word in this blog or in the written reports I have to provide when sectioning (sorry, detaining) someone.