Wednesday, 16 March 2011

When Detained Patients Appeal – Part II

Although many detained patients may find this difficult to believe, psychiatrists and care coordinators do not want to keep people detained under the MHA if it is not clinically justified. People will tend to have their sections removed as soon as the clinical team feels that their mental state has improved enough that they can either be discharged, or will remain as informal patients. Many detained patients will come to recognise the necessity for medication once they have received treatment for a period of time.

Care Coordinators and psychiatrists will also not want to have to write a report for a Tribunal or Managers Hearing, or appear at a Tribunal or Managers Hearing, unless it appears absolutely necessary. If a patient gets as far as the date of the hearing, it is likely to be because they are not yet well enough to recognise the need for treatment.

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 promptly leave hospital and stop 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 non payment of the mortgage and was living in a caravan on a residential caravan 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 in order 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 by the out of hours AMHP.

On admission to Bluebell Ward, he refused all medication and promptly appealed. I was asked to write the social circumstances report.

When I interviewed him for the report, he was exceptionally 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 I did think showed that he was likely to be mentally ill.

I concluded that “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 does appear to be abnormally fixated on the 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, at present 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, without considerable further assessment, a process which Norman is unlikely to allow voluntarily.”

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, since they were all about his custody battle, but which he attempted to quote from at length. After a few minutes, the chairman had clearly become 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 haughtily.

The Chairman, who might possibly have been a barrister, 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 and conscientious man with a real interest in mental disorder, whom I had seen representing many patients in Tribunals and Managers Hearings.

His solicitor attempted 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 Chairman became increasingly irritated. Norman’s solicitor looked increasingly desperate as he saw any chance of his client being discharged evaporating.

Eventually, the Chairman 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 George Orwell’s estimable book 1984.”

This was enough for the Chairman. 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 he was detained under Sec.3 and treatment for bipolar affective disorder was commenced.

He inevitably appealed again, but within a few weeks, as a result of 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.


  1. Great post - thanks for sharing some of your experiences of tribunals.

  2. Very interesting, what happened next??!

  3. Very interesting.
    I agree with Norman's 1984 comment. There is so much evidence all around that most people don't see, but people like me do. Apparently I am delusional, but I just know the truth and the truth seeks me out to give me knowledge and rips through this existence to show me through visual, auditory and tactile sensory processes.

  4. great post - and describes well my dilemmas when working with people :
    'However, at present 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'
    thanks masked amhp

  5. Really interesting posts on MHRT's - thank you. Would love to hear about Guardianship if you ever get the time!

  6. I'd been thinking NPD until you mentioned he responded to treatment for bipolar. I'm glad he did. Is he okay now?

  7. He definitely does have bipolar affective disorder. Sadly, he is not okay now. The insight and concordance with medication went out of the window...