Sunday, 31 January 2010

The Section 2 That Wasn’t

Perdita had suffered horribly for most of her life. She had been abused physically, sexually and emotionally as a child, and as an adult had gone from one abusive relationship to another. Along the way she had developed a wide range of coping strategies, including cutting, overdosing, denial of food, dependence on alcohol and drugs, and a range of alternate personalities, some of whom coped well and appeared “normal”, and some of whom you would not like to meet on a dark night. Or even in broad daylight.

Her alternate personalities all had names. There was Perdita of course, whom her community nurse encouraged to be in control. But there was also Grendl. Grendl was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone. And there was also Mavis, a very ordinary, impeccably behaved woman who appeared when she had to in order to rather resignedly clear up the mess left by Grendl.

Not surprisingly, Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, including Dissociative Identity Disorder, Anorexia Nervosa, and of course Borderline Personality Disorder.

Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia (Perdita liked flowery names). Perdita had always done her best to protect her daughter from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.

Her community nurse was a patient and very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendl was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia. After a couple of weeks of escalating out of control behaviour, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendl answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.

That was when the Masked AMHP was asked to get involved.

The consultant gave me a recommendation for an admission under Section 2 MHA for assessment, and I went out to see Perdita in the company of another Sec.12 approved doctor and Perdita’s community nurse. I figured we’d probably be a lot safer if we went with someone who had a good rapport with her.

I wasn’t sure whether it was an angry Perdita or a subdued Grendl who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.

She was not amused when I told her the purpose of our visit. She became almost instantly hostile, asked us to leave and shared with us an impressive selection of insults and swear words. I tried to continue to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to speak to her.

We sat patiently for a few minutes, and after a while she turned down the TV to a reasonable level. This gave me an opportunity to speak.

“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”

I had by now concluded that Perdita was so out of control that there was no alternative but to detain her in hospital for assessment. The doctor and I left the house and retreated to my car to complete the paperwork.

I went back into the house to break the news to her. Perdita had switched. The aggression and hostility had evaporated. In its place was a melodramatic level of contrition.

“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!” She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.” This level of apology and contrition was actually much worse to bear than her anger, insults and aggression.

I had made a decision. I had completed my application. She was now officially detained under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.


Grendl did seem to have gone for the time being. The threat of admission did seem to have brought Perdita back in control again. She was making reasonable plans for the future (at least the immediate future). And what would be the effect on Ophelia of being separated from her mother?

So in the end I decided to use the discretion given in Sec.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially Sec.2, an admission follows as quickly as suitable transport to hospital can be arranged.

I did a deal with Perdita. She would cooperate with us. She would allow us to help her to keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her tomorrow to review the situation. She readily agreed to all of this and was embarrassingly grateful. And when I visited the following morning, she was calm, collected, polite and cooperative, although still clearly feeling low and sad.

I continued to monitor her on a more or less daily basis for the next week. Things continued to improve. The crisis was over. I shredded the papers.


  1. I always feel rather satisfied if an alternative can be found to admission although to be honest, by the time referrals are made, it is often the case that everything else has been tried. I think it indicates the need for discretion and the importance of the AMHP's role.

  2. That must have been a really tough call to make, especially as there was a child involved. How did you know that things wouldn't go totally tits up after you had left? That she wasn't just saying those things to get rid of you (is it obvious how my mind works?!)? Obviously it was fine and all worked out, but it must be so hard to make that kind of decision - I do have respect for you guys for doing that.

    Oh, and when I think of Ophelia, I don't think of flowery - I think of crazy girl in Hamlet who kills herself... Must be bloody hard to be well adjusted with a name like that!

  3. Oh, and I forgot to mention. The title of this post sounds like an Enid Blyton book, love it!

  4. brilliant i hope i can be as competent as you when i am an AMHP.

  5. Good call. Nice bit of AMHP'ing.

  6. As a 2nd year SW student hoping to go in to mental health SW practice I was heartened to read this thoughtful, thought provoking person centred account. Sounds like this AMHP is in the right job. I hope I encounter more like minded workers.

  7. Excellent piece of writing, I couldn't wait to get to the end to see what happened but was pleased to read all remained calm. It's a tough job you have and risky if things go wrong.

  8. Wow ...a very tough decision that thankfully worked out on this occasion. Easy to see just how quickly the situation could have gone wrong. Left me wondering what the other professionals involved felt about the decision (specifically in relation to the child's welfare). Not a criticism as it was a tough call but personally; I wouldn't have been able to sleep that 1st night.

  9. With regards to the masked AMPH that was a good judgement in the same vein it could go belly up. I work as an emmergency duty social worker (EDT) last night whilst on duty had to assess a patient brought into hospital on a s136. She was brought in by police due to an overdose which could not be determined how many paracetamols tabs she had taken. In the ambulance she was obstructive and physically agressive towards crew and police were called in. I interviewd her with the doctor, she presented with low mood,and depressive symptoms very co-operative and agreed to informal admission to enable a review in the morning. Whilst arranging a bed she flipped and became very volatile and refused admission within few minutes had calmed down and bvecame apologetic. It was very difficult to admit her as an informal patient even though she had calmed again and became co-operative. My heart agreed to informal however i had to weigh the risk of her mood flunctuating, where she would become a risk to herself and others. Decide to walk out at 3am in the morning putting herself at risk. I had to maintain her on a s136 not discharge as I could not complete an application due to lack of information and was unknown to the service.

  10. I'm gobsmacked at the response this post has had. Thank you all for your comments. The bottom line is, when you're making an assessment under the MHA you're often flying by the seat of your pants. There are many occasions when I've not made the "safe" decision and have had a sleepless night as a result. Usually, they turn out OK -- but not always -- subject of future blog, perhaps. I do believe, however, that the more experience you have, the more you are able to balance risk and that allows you to take an (informed) chance. The role of the AMHP is a serious one, and should never be underestimated.
    To those future AMHP's who read my blog: it's a demanding job but valuable and rewarding -- although there are times when it doesn't feel like it.
    End of ramble. Thank you all again for reading.

  11. I agree with MHLH

  12. Wow powerful. Makes me wish you were the AMHP that reviewed my case. At least then i might have got a fair hearing rather than a punishment.

  13. A tutor of mine once said you should consider every move you make professionally as if you'll have to explain it to an inquiry.

    Then you get those cases.

  14. Trying to understand19 February 2010 at 17:40


    This might be the perfect place to ask this question if not sorry

    Currently writing a essay on comtemporary mental health practice anyone able to steer me to key legislation/policy/theory pertinent in practice now. Heard a bit about personalistion CTO's, and recovery but Im sure there is more.

    Also do you know where might be a could place to start interms of research. Cheers

  15. Personalisation is more of a reform to the NHS community care act and wont affect MHA. Also i dont think CTO's have come into force. Deprivation of liberty safeguards and the mental capacity act the pros and cons would be a good starting point. Try making a comparison of rights and liberties of above with the deprivation of liberty under MHA. That shouls make an interesting essay!

  16. correction... CTO's are now in place under MHA 2007, under s3 or 37.

  17. Only just came across this... Hmmm... I'd certainly endorse the judgment and the principles, but unfortunately I think the decision is wrong. When you sign the application, you're saying that the person ought to be admitted to hospital. The 14 days isn't to allow second thoughts about the decision - it's to allow for delays in getting the person in. If you're not sure whether to make the application, S6(1)(c) gives you 14 days from the date of the last medical examination to detain the patient (who isn't in fact 'officially detained' until they're admitted to hospital). If something bad had happened while you were sitting on a signed application, so to speak, you would have had to explain why you decided the patient ought to be admitted, but then didn't do anything to make it happen.

    Sorry... as I said, I fully agree with the principle, but there was a better (and legal) way to achieve the same ends....

  18. Very interesting and a very tough call. I wonder why this would have been a 2 as opposed to a 3 for treatment as there was a diagnosis and I assume treatment plans?
    Very skilled intervention, inspiring. Thankyou