Tuesday, 27 November 2012

On Inappropriate Mental Health Act Requests

All AMHP’s will be familiar with being asked to do assessments under the Mental Health Act when it is not appropriate, but is motivated by the desire on the part of the caller to pass the buck. They might, for example, receive a request to assess an elderly person who actually just needs residential care, not a hospital admission, or to assess someone who is in emotional distress, where the professional involved with them is uneasy about leaving them over the weekend and just wants to relieve themselves of the responsibility.

Sometimes, it is possible to avoid a formal assessment. But at other times, you soon realise that, whatever the likely outcome, you’re going to have to go out and do a face to face assessment.

Back in the days when I did out of hours social work sessions, I was on duty one Saturday evening when I received a rather agitated call from the police.

They had a “situation”. They were asking for a MHA assessment to deal with it. They had earlier taken a call from Mike, the partner of Bella, because Bella had threatened to cut her wrists if he left the house. Mike was on police bail having assaulted Bella, but had been to see their six week old baby. The problem was that he would be in breach of his bail conditions if he did not leave, and stayed overnight.

When the police attended, they became embroiled in a domestic situation which did not seem to have an immediate solution. Mike wanted to leave, but Bella wouldn’t let him.

The police could not arrest Mike, as he had so far done nothing warranting arrest, and neither could they arrest Bella.

Bella had a considerable history of involvement with mental health services with depression, having had a couple of inpatient spells following suicide attempts, and had been receiving considerable support from mental health services, which in the past had included periods of 24 hour domiciliary care. She currently had regular visits from a domiciliary support worker in connection with the baby.

However, they could not detain Bella under Sec.136, as she was not in a public place. So they requested a formal assessment under the MHA.

It was further complicated by the presence in the house of a three year old child as well as the six week old baby. Removing the mother would raise considerable difficulties about who was to care for the children, especially the baby. In the circumstances, Mike was not an appropriate person to care for the baby, and the three year old was not in any case his child.

It became apparent that the only appropriate response as an on call social worker was to attend to make my own assessment.

The police were relieved to see me. So relieved, that they left almost immediately, despite me asking them to stay while I attempted to find a solution to the problem.

I decided to try to interview the two of them separately, but Bella was very reluctant to do this.

“He’ll leave the house if I let him out of my sight,” she said. “And then I’ll kill myself.”

“But I’ve got to go, or I’ll get arrested,” Mike pleaded.

“But you can’t leave me. I can’t live without you.”

Bella threw herself at Mike, who pushed her away and raised his fist. Bella seemed to be provoking him to hit her, but to his credit, he turned away, obviously distressed.

“I have to make a proper assessment,” I said. “I need to speak to both of you, but not together. Otherwise, we’ll just go round and round in circles and get nowhere. I have to be sure that both you and the children are going to be safe.”

“Leave the children out of this!” she screamed. “You’ll take them over my dead body!”

“I’m not proposing to take your children away, that’s the last thing I want to do, but I do need to make a proper assessment.”

I did eventually get them to agree to go into different rooms, and Mike promised he wouldn’t leave until I had completed my assessment.

With Mike out of the room, Bella slowly began to calmed down. She told me something of her mental health history, and talked about her fears that she would lose Mike because she had not been feeling like sex since her depression. I saw that she had cut her forearm, although it was only superficial.

She spoke to me of her feelings of inadequacy with looking after her new baby, feeling that she wasn’t a good enough mother. It became clear that this was at the root of her unwillingness to let Mike go, despite his violence towards her. I tried to reassure her, and gradually she relaxed and became less anxious.

I then talked to Mike on his own. He was in turmoil. He wanted to leave, but feared that Bella would harm herself. She had cut herself in front of him, and he had never encountered anyone deliberately self harming before. He couldn’t understand it, and that made him afraid – both for Bella and for his baby.

“Look, Mike,” I said. “Bella’s much calmer now, I suggest you leave now, while you’ve got the chance. I’ll see to Bella.”

I saw him out of the house, and heard him drive away.

Bella also heard him, but by the time she came out of the room she was in, he had gone. I persuaded her to make a cup of tea, and as we talked together, her anxiety subsided again. It became clear that she had a good relationship with her baby and older child, who were both blissfully asleep upstairs, and oblivious to the drama going on downstairs.

As we talked, Bella recovered some of her own confidence in herself, and began to make plans for both the immediate and the longer term future. I encouraged her to do this, and her mood began to brighten. She even managed a couple of smiles when talking about her children.

I was feeling increasingly confident that not only did Bella not require hospital admission, but that she was capable of caring for her children. Additionally, I was aware she was having a visit from a domiciliary care worker the following day, which would provide monitoring until normal office hours on the Monday.

I began to inwardly congratulate myself on having averted not only a detention to hospital under the MHA, but also the prospect of having to find a foster placement for a three year old toddler and a six week old baby late on a Saturday evening.

Then I heard a car pull up outside. Was it the police, coming back to check how things were going?

I went outside to investigate, and to my horror saw that Mike had returned. As he got out of the car, I asked him incredulously, “Why have you come back?”

“I wanted to make sure Bella and the kids were OK,” he said.

I found this hard to believe. I could only think he was somehow trying to stir things up some more. Perhaps he did not like feeling that Bella wasn’t, after all, entirely reliant on him.

At this point, Bella came out of the house. All her insecurities became reactivated.

“Don’t go, Mike, stay with me. I need you,” she pleaded.

“No, I can’t stay, I’ve got to go,” Mike replied, making a move to get back into the car.

Bella flung herself onto the bonnet of the car as he revved the engine.

“Don’t go, don’t go,” she repeated.

“I’ve got to go, I’ve got to go,” he yelled out of his window.

This was rapidly turning from pathos to bathos. I had to take control of the situation. Desperate measures were required

“Right,” I said, “It’s becoming apparent to me that you’re both clearly unable to look after your children. I’m going to have to get the police back, and they can make a Police Protection Order and take them to a place of safety.”

Bella was horror struck. She removed herself from the car bonnet and came towards me, pleading with me not to get the police. This gave Mike an opportunity to leave again, which thankfully he did.

 “Come on, Bella,” I said firmly but gently, “Let’s get back inside and check that the children are OK.”

 I stayed another half hour or so, mainly to make sure Mike did not decide to “check up” on Bella again, and when I was convinced that Bella was again calm and composed, I left.

Neither Bella nor the children came to any harm.

1 comment:

  1. I've read this three times:

    Notwithstanding the probability that the officers wouldn't actually appreciate the distinction between a mental health assessment, a Mental Health Act assessment and generic mental health support from a mental health social worker - I'm struggling to see how officers attending a non-criminal domestic incident like this, involving self-harm in private place by a person with a history of mental health problems, is "inappropriate" when they call for MH professional's support.

    If there was a linguistic distinction about officers asking for what they thought was a MHA assessment when in fact what they needed was needed was a generic MH response to identify need, support or whatever - it is probably no more grave a failing than the error of thinking the officers might remove the children under s46 of the Children Act 1989 to a "place of safety". Section 46 makes no reference to a 'place of safety', but to suitable accommodation.

    They don't know the full details of your job and vice versa; but one of the first things I'd expect an officer to do with the above scenario, is contact a MH worker connected to the woman's case to become in some way, shape or form, involved in it all. Even if just to advise or provide some information to better inform a decision.

    I understand it's cheeky when they leave ... an AMHP did that to us in custody they other day, arguably whilst in breach of s13 MHA. We've all got these stories, including paramedics of AMHPs and of the police.

    Does that make sense, as written?