Perdita: Encounters with a woman with dissociative identity disorder. Part 1: I'm asked to assess Perdita under the Mental Health Act – but is it the best way forward?

 

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, and dependence on alcohol and drugs.

She had also acquired 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, come to that.

These personalities all had names. There was Perdita of course, with all her problems. But there was also Grendel. Grendel 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 then there was Mavis, a very sensible, impeccably behaved woman who appeared when she had to in order to clear up the mess left by Grendel.

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

Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, most notably Dissociative Identity Disorder.

Her community nurse was a 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 Grendel 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, during which things continued to worsen, 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, Grendel answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.

That was when I was asked to get involved.

Armed with a S.2 recommendation from Perdita’s psychiatrist, I went out to see Perdita with another S.12 doctor and her community nurse.

I wasn’t sure whether it was an angry Perdita or a subdued Grendel 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 why we were there. She became instantly hostile, telling us to leave with an impressive selection of insults and swear words. I continued to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to continue.

We sat patiently for a few minutes, and after a while she turned it down. 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 chaotic that there was no alternative but to detain her in hospital. The doctor and I left the house and retreated to my car to complete the paperwork.

I went back in to tell her. But Perdita had switched. The aggression and hostility had evaporated. In its place was a spectacularly 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 worse to handle than her insults and aggression.

But I had made a decision. I had completed my application. She was now officially liable for detention 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.

But then again...

It seemed Grendel had gone for the time being. The threat of admission seemed to have brought Perdita back in control. She was making reasonable plans for 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 S.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 S.2, an admission follows as quickly as a hospital bed can be arranged.

I did a deal with Perdita. She would cooperate with us. She would allow us to help her 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 the next day to see how she was doing. She agreed to all this and was embarrassingly grateful. And when I visited the following morning, despite still feeling low and sad, she was calm, collected, polite and cooperative.

I continued to monitor her closely over the next week. Things continued to improve. The crisis was over.

I shredded the papers.

S.13(4): The Right of the Nearest Relative to request a Mental Health Act Assessment

 

Relatives are often unaware of their right under s.13(4) MHA to request an assessment of their relative under the Mental Health Act.

Those who are aware, are often under the mistaken belief that this will inevitably trigger a visit to their relative by an AMHP and two doctors.

S.13(4) states:

(4) It shall be the duty of a local social services authority, if so required by the nearest relative…, to make arrangements … for an AMHP to consider the patient’s case with a view to making an application for his admission to hospital; and if in any such case that professional decides not to make an application he shall inform the nearest relative of his reasons in writing.

The Reference Guide has very little to say to enlarge upon this, except to state that “the nearest relative can require the local authority (verbally or in writing)…to arrange for an AMHP to ‘consider the patient’s case’ including whether there is a need for compulsory admission to hospital.”

The only thing the Code of Practice adds is to state that the local authority must respond not only to a direct request from the NR, but also to a request “on behalf of” the NR.

So what does all this mean to the nearest relative and to the AMHP receiving such a request?

The NR doesn’t need to put the request in writing, but can make a request by phone. They can also ask someone else to make a request, such as another relative, or their GP, and this must be considered as if it were a direct request from the NR.

The local authority AMHP service has to respond to this request. But this does not necessarily mean that they will conduct a formal assessment. An AMHP only has to “consider the patient’s case”. If, having done this, they do not think that an assessment is merited, there is no requirement to assess.

From the AMHP point of view, there may be many reasons why it is not appropriate to assess the patient under the MHA. A typical reason may be that other arrangements are being, or have been made. This might include a GP referring the patient to the local crisis team for assessment. It would therefore be wrong to pre-empt this assessment, under the principle of the least restrictive option.

Another reason might be that the patient is already involved with a community mental health team, who are managing the patient’s condition and would not welcome an AMHP’s intervention, or do not consider that a formal assessment is necessary.

It may be that, while the relative is concerned about the patient, the patient has not actually seen a doctor recently. In which case, I would always advise the relative that they should arrange for the patient to see a doctor first.

In some cases, the request may be “mischievous”; in other words, the relative may have made frequent or recent requests for their relative to be assessed, and unless there has been any significant changes in the patient’s condition, it would be oppressive to keep making fresh assessments.

I recall one such case, where the mother of the patient, a pregnant single parent with a young child, reported that she was expressing a range of alarming paranoid delusions, especially around her unborn baby. The ex-partner of the patient also corroborated this.

I went out with the GP and a psychiatrist, to find her preparing tea for her daughter and a school friend. Everything appeared completely normal, and she spoke politely and rationally to us for about an hour. We were unable to elicit any symptoms of mental illness, but based on the reports of the relatives, with heavy hearts we decided to detain her, and she was detained under s.2 for 28 days.

During that time she was not given any medication, and did not provide any evidence to ward staff of any mental illness.

On another occasion, I received a request from the husband of a woman. They were recently separated. His concerns seemed to boil down to the view that since his wife did not want to talk to him, and would not agree to what he wanted to happen to the property and children, then she must be mentally ill. I did not respond to this request.

Once an AMHP has considered the case, and has either decided not to undertake a formal assessment, or has assessed and has decided not to detain, they have a legal requirement to write to the referring relative. These letters have to be very carefully written. The Code of Practice states: “Such a letter should contain, as far as possible, sufficient details to enable the nearest relative to understand the decision while at the same time preserving the patient’s right to confidentiality.”

Displacing the Nearest Relative

 

The Mental Health Act 1959 first introduced the concept, role and statutory rights and duties of the Nearest Relative applying to patients subject to the Act.

The 1983 Act and the 2007 Act hardly made any changes. In certain circumstances, the NR under the Mental Health Act can be displaced, and replaced with an acting NR.

The Code of Practice states: “An acting nearest relative can be appointed by the county court on the grounds that: the nearest relative is incapable of acting as such because of illness or mental disorder; has objected unreasonably to an application for admission for treatment or a guardianship application; has exercised the power to discharge a patient without due regard to the patient’s health or wellbeing or the safety of the public; is otherwise not a suitable person to act as such; or the patient has no nearest relative within the meaning of the Act, or it is not reasonably practicable to ascertain whether the patient has a nearest relative or who that nearest relative is.”

So - is there any guidance to the practicalities of executing the role of acting nearest relative for professionals?

While displacing a patient’s NR and appointing an acting NR is not a very common procedure, it happens often enough that all local authorities have detailed written procedures for how AMHP’s may displace nearest relatives. However, none of them appear to give written guidance on exactly how an individual appointed to take on that role should discharge that duty.

Neither the Code of Practice nor the Reference Guide have anything say about how someone appointed to act as a nearest relative should act. The MHA itself makes the only reference to specific duties, in Sec.116. Sec.116(1) states: “Where a patient to whom this section applies is admitted to a hospital ... the authority shall arrange for visits to be made to him on behalf of the authority, and shall take such other steps in relation to the patient while in the hospital as would be expected to be taken by his parents.”

Sec.116(2) defines to whom this section applies. It predominantly applies to children and young people, but it also includes “(c) a person the functions of whose nearest relative under this Act are for the time being transferred to a local social services authority.”

Richard Jones in the Mental Health Act Manual has little to add to the bare words of the MHA. However, David Hewitt, the author of The Nearest Relative Handbook, says that the acting nearest relative “must be treated as if they were the substantive nearest relative”. He interprets this to mean that they should exercise all the nearest relative rights, interestingly including the right to delegate nearest relative status. He points out that to act as a patient’s representative is not the identified role of the NR.

This means that the local authority appointed acting NR is a distinct role from that of the Independent Mental Health Advocate (IMHA). He acknowledges that the role of the acting NR is ill-defined, but points out that this is also the case for a normal NR.

The NR has some wide ranging powers and duties. These include the right to be consulted regarding decisions being made by professionals concerning the patient, the right to make an application in their own right under Sec.2, 3, 4 or 7, and the right to request that an AMHP assess the patient under Sec.13(4) MHA.

If the acting NR is an AMHP employed by either the local authority or the local MH Trust, it is actually quite difficult to see how they might comfortably exercise some of these powers and functions.

Indeed, David Hewitt points out that there is considerable scope for conflicts to arise with the role of the AMHP, the role of the IMHA, the wider advocacy role, and with the role of the Director of Adult Services. He has suggested that possible solutions to these conflicts could be by neighbouring local authorities having reciprocal arrangements to provide this role, or even to use some sort of external independent provider.

How to survive in social work

 

One day, while I was still working in a Community Mental Health Team, one of our nurses returned to base in tears. She had been visiting one of her patients, a woman with bipolar affective disorder. She knew she was relapsing and had been trying to support her and her relatives and had been striving to avoid a hospital admission for several days.

The patient had shouted at her. She hurled very personal insults at her. She berated her for failing in her job, for letting her down, for not being a good enough nurse. It hit a nerve with my colleague. It triggered her deepest fears. Was she a bad nurse? Was she incompetent? Could she have done more to prevent this crisis? Was she so useless? Should she hand her notice in right away?

The team did their best to support and comfort her. She was a good enough nurse. She had done her best. She had seen a relapse coming, and she had done everything she professionally could to avert it.

This incident made me think about how mental health and other care professionals survive the job. It made me think about how I had managed to continue to function as a (hopefully) effective social worker for four decades.

In my first few months as a social worker, I was allocated Gwen. She and her children were very well known to services and had had many social workers over the years. I was the latest.

I knocked a little nervously on her front door, and when she opened it I introduced myself.

She looked me up and down and did not seem very impressed.

“Well, you’d better come in I suppose, she said, scowling.

I followed her into her front room. She closed the door behind me, took a deep breath and then proceeded to treat me to a tirade of complaints and insults which continued for at least 30 minutes. Throughout this deluge of vituperation, I stood silently and listened diligently.

I stood there mortified. Judging by her comments, I was the very worst and most totally useless social worker in the entire world.

While this destruction of my character continued, it suddenly occurred to me that this had nothing to do with me at all. She was ventilating. She was expressing her anger and despair at the system, and at the world in general. I just happened to be conveniently there. It wasn't personal. It wasn't about me at all.

I learned right then that if I were to survive as a social worker, I had to separate the professional persona and my professional functions from the personal, from the individual me. As I realised this, I suddenly felt a lot better. I waited patiently for her to finish, then got on with the job in hand. She never shouted at me again.

It's a simple lesson, but not necessarily easy to learn. But it helped me to deal with the often hostile and verbally aggressive people who I have had to assess under the Mental Health Act.

It has even helped me to remain mentally intact and sufficiently detached to manage the few occasions when I have been physically assaulted during the course of my work.

It's not actually about you.