The last post looked at s.135(1). This one is looking at
s.135(2).
The Code of Practice states that the purpose of a s.135(2) warrant is to
provide police officers with a power of entry to private premises for the
purposes of removing a patient who is liable to be taken or returned to
hospital or any other place or into custody under the Act.
Unlike s.135(1), almost anyone can apply to a magistrate
for a s.135(2) warrant. It could be an AMHP, but it can also be a police
officer, a clinical member of the community mental health time, or a nurse from
the hospital.
The warrant applies to anyone who is liable to be detained,
for example:
Someone who has been assessed and an application made under
s.2 or s.3
Someone already detained in hospital but who has absconded
or who has failed to return from s.17 leave
Someone subject to a Community Treatment Order who has been
recalled to hospital
It should be established that the patient is refusing to be
admitted or to return to hospital and that they’re refusing entry to their
home.
Although it only requires a police officer to attend, in
practice an AMHP or a member of a community team or hospital would also
accompany the police officer. An ambulance should be arranged to transport the
patient. Normally, the police officer’s role would end once entry has been made
and the patient located.
As with s.135(1), the application has to be made to a
magistrate.
It is commonly thought that, as in the case of s.135(1),
only an AMHP can make this application.
But it is not the case. Almost anyone else can make the
application, although an AMHP service may kindly advise someone from a hospital
or community mental health team on the local procedures for applying for a
warrant.
When it comes to s.135 of the Mental Health Act, there is
the law, and then there is the reality.
I’ll look at the law first, then I’ll look at how it all pans
out in the real world.
If there are grounds to believe that someone with a mental
disorder has been or is being, ill-treated, neglected or kept otherwise than
under proper control, or is living alone and unable to care for themselves, an
AMHP can apply to a magistrate for a warrant under s.135(1).
The Code of Practice states that the purpose of a warrant
is to “provide police officers with a power of entry to private premises, for
the purposes of removing the person to a place of safety for a mental health
assessment or for other arrangements to be made for their treatment or care.”
Only an AMHP can apply for a s.135(1) warrant.
The police officer must be accompanied by an AMHP and at
least one s.12 approved doctor.
The police officer can use force if necessary to get into
the premises, and once in can remain and search the premises. The AMHP and the
doctor can decide whether to conduct an assessment then and there, or have the
patient taken to a place of safety for assessment.
Detention can last for a maximum of 72 hours. Wherever it
takes place, once the assessment has been completed, the power to detain under
the warrant ceases.
Sounds all quite straightforward, doesn’t it?
But this is the reality.
Before any decision is made to apply for a s.135(1)
warrant, an AMHP should conduct a normal assessment. This means turning up at
the patient’s house with two doctors and attempting to gain entry in order to
interview the patient in their home.
Sometimes, the patient may allow entry, but then refuse to
cooperate with the assessment, or insist the AMHP and doctors leave before an
assessment can be completed. Sometimes, the patient may simply refuse to let
the assessing team in at all.
In itself that may not be sufficient to apply for a
warrant. There also needs to be evidence to support the contention that the
patient is unable to look after themselves, or is a danger to themselves or
others, for example.
Applying for a warrant can be complicated. It used to be
that the only way an AMHP could get one was by contacting the clerk of the
local magistrate’s court and asking to see a magistrate. The AMHP would then
have to attend the court and have to wait for a break in normal proceedings to actually
see a magistrate.
In my experience, some magistrates would simply read the
application, ask a couple of questions and then provide the warrant. Sometimes,
however, they might grill the AMHP extensively before being satisfied, and
could refuse. In which case, more evidence would have to be obtained, such as
making further attempts to conduct an assessment.
In the AMHP hub where I used to work, the region was
covered by a virtual magistrate’s court. If it was necessary to apply for a
warrant, the AMHP who had assessed would complete the application for the
warrant, and then the senior practitioner on duty, who was also an AMHP, would
then book a slot online and the application with supporting evidence would then
be sent by secure email to the court.
The senior practitioner would then receive a phone call at
an allotted time and answer any questions the magistrate might have. The
warrant would then be sent by secure email to the AMHP hub. All that can take
several days.
But then, in order to execute the warrant you first have to
get all your ducks in a row.
The AMHP needs to get two s.12 doctors. The AMHP needs the
police to attend at the same time as the AMHP and the doctors.
The AMHP has to make sure that a place of safety, normally
the s.136 suite at the local psychiatric hospital, is available, if it is
decided to remove the patient from their home for the assessment.
And the AMHP also needs to have identified that a bed is
available if it is decided to detain the patient for assessment or treatment.
Oh, and let’s not forget the ambulance, which would be
required if the patient was being taken to a place of safety or being admitted
directly to hospital from their home.
A warrant normally lasts for 28 days. And you might need
that length of time.
I’ve even known warrants to run out before they can be
used.
"About
to take a massive overdose. See me now or see me in hell."
I
knew she wasn’t messing about. Grendel was in charge.
I
went straight out to see her, taking a female colleague with me. I know when
not to go alone.
When
we arrived at her house, her front door was ajar. I had a horrible feeling of
déjà vu.
We
went inside and called, but there was no answer. In the kitchen, we found a
pile of bubble packs of tablets. They were all empty.
We found Perdita in the living room. She was staring blankly ahead of her.
“Perdita,”
I said, “What’s going on?”
“Perdita,”
she repeated, her thousand yard stare unwavering. “What’s going on?”
“Perdita,
how many tablets have you taken?”
“Perdita,
how many tablets have you taken?”
She
seemed to be in a dissociative state again. It was clear that it was not going
to be possible to reason with her.
I
rang 999 and asked for an ambulance to attend because of the likely overdose.
Perdita
started to put on her boots, and fearing she was intending to leave I asked for
the police to attend as well.
As
she leaned forward to put her boots on, I could see that she had a knife tucked
into her back pocket.
I
was worried about her self harming, so I reached out and quickly removed the
knife.
Perdita
objected to this. She stood up and spun round, lunging at me. I saw she had
another knife in her hand. I leapt backwards and I was aware that the point of
the knife penetrated my arm, drawing blood.
I
couldn’t get to the front door, so I told my colleague to run upstairs. I
followed her.
In
the process, I dropped the other knife. Pausing briefly to retrieve it, Perdita
came after us.
My
colleague ran into one of the bedrooms and barricaded the door. I went into another
bedroom and slammed the door behind me, keeping hold of the handle.
Perdita
tried to open the door, then started to pound the other side with the knives. The
blades started to penetrate and the flimsy door began to bow inwards. I put a
foot up against the edge of the door, and fished my phone out of my pocket.
I
realised that I had not hung up and the operator was still on the line.
“Are
you all right, sir?” she was saying, presumably having heard a commotion.
“No
I’m not,” I said as calmly as possible. “Could you send assistance as soon as
you can, Perdita has knives and is attacking me.”
“And
what is the address of the incident?”
I
gave the address.
“Do
you have the postcode?”
No,
I didn’t have the postcode to hand.
“Is
the address Acacia Road or Acacia Close, sir?”
“It’s
Acacia Close. Could you send someone as soon as possible, because I’m trapped
in a bedroom and I don’t think the door is going to hold for much longer.”
By
now, I had gone into some sort of dissociative state myself. I found myself
observing the entire scene as if I were watching a TV programme. This is
remarkably like the “Here’s Johnny!” scene in The Shining, I remember thinking
dispassionately. How interesting.
The
operator was speaking again. “We can’t seem to find Acacia Close on our
system,” she was saying.
“I
assure you I’m in Acacia Close, and I need a police presence here as soon as
possible! Just tell the police to come to Perdita’s house. They all know where
she lives!”
The
pounding on the door stopped. I heard Perdita go to the other bedroom door and
try to get in there, but fortunately without success. Then I heard her go
downstairs, and it all went quiet.
I
gingerly opened the door and peered out. There was no sign of Perdita. I crept
along the landing to the other bedroom. My colleague let me in. She was
absolutely terrified.
“I’ve
called the police,” I told her. “They should be here any minute.”
I
went warily down the stairs. I could see Perdita sitting motionlessly in the
living room, rocking slightly. I went outside into the street.
At
that point, several police cars arrived, followed by an ambulance. They had at
last found Acacia Close, having presumably first been to Acacia Road, Acacia
Drive and maybe even Acacia Avenue.
I
stood at a discrete distance while several police officers went into the house.
I heard a brief scuffle, and then they led Perdita out in handcuffs. She lifted
her head and saw me.
“Oh
hello, Steve”, she said, as the police led her away, “you took your bloody time
getting here!”
A change of
staff at the CMHT meant that I became Perdita’s care coordinator. Perhaps
surprisingly, in view of my attempt to section her, she didn’t object to this.
In fact, she told me that because of the way I had handled that event, she felt
she could trust me.
I got to know
Perdita quite well. Splitting her self into several discrete personalities was
her way of managing the intolerable emotions which arose as a result of her
severe childhood abuse. There were certain triggers to her “checking out”, as
she described this process of extreme dissociation, during which one or more of
her other “parts” manifest themselves. These usually involve certain stressful
situations which she is unable to cope with, as they touch raw nerves relating
to betrayal.
The DSMIV
defines Dissociative Identity Disorder as “the presence of two or more distinct
identities or personality states”. These identities or personality states must
recurrently take control of the person's behaviour. The patient must also
experience an “inability to recall important personal information that is too
extensive to be explained by ordinary forgetfulness”. In my professional career
I have only encountered three people with this diagnosis.
Having seen
Perdita manifesting these different personalities, I was convinced that she was
not putting on these episodes, and genuinely had no conscious control over what
happened when the other parts took over.
I have met
Mavis, who is charming and polite, and a pleasure to work with. I have also met
Mary, who is a small child, who can be mischievous and playful. I had heard all
about Grendel, the really angry and destructive one, but had not yet met her.
I worked with
Perdita on the basis of damage limitation. I tried to help her to manage her
mood swings. We worked together to identify and avoid triggers for her
dissociative episodes. We especially tried to keep Grendel under control.
But things
don’t always work out.
One morning, I
had a call from Perdita.
“I’ve been let
down big time by someone.” She told me the details. “I can feel myself going.
I’m afraid I’m going to check out. I’m afraid Grendel’s going to take over.”
We talked this
through for a few minutes. I suggested a range of risk management strategies
that we had put into her care plan. But I had the feeling that “checking out”
was going to be unavoidable.
A few minutes
later, I got another call. This call consisted entirely of maniacal laughter. I
guessed that it must be Perdita. I tried to get through to her, but the
chilling laughter went on and on and on. After a while, I realised I was not
going to get any sense out of her, and put the phone down.
The phone rang
again. More scary laughter.
“It’s Grendel
here,” she said. “I’m having a great laugh! I’ve really cut the bitch to pieces
this time!” Then she hung up.
I felt I had
to respond quickly. I rang the emergency services, asking for an ambulance and
police to attend, then went to see her, taking one of my colleagues with me. It
was going to be necessary to concentrate on limiting potential damage – damage
to Perdita, damage to her house, damage to her daughter, damage to other
professionals…
We could hear
the laughter from outside the house. The front door was ajar. I went straight
in, and we cautiously entered the living room.
Perdita was
sitting on the sofa, rocking backwards and forwards as she whooped with
laughter. She had an open pair of scissors in one hand, and her other arm was
covered in lacerations. There was a fair amount of blood, so it was hard to see
how serious the cuts were.
“Give me the
scissors, please, Grendel,” I said as calmly as I could.
“You’ll have
to give me three good reasons!” Grendel replied, and slashed several more times
at her arm.
“Give me the
scissors, Grendel,” I repeated as calmly as I could.
“Give me three
good reasons!”
“I’m not
getting into any games. Just give me the scissors.”
I waited
nervously, keeping at a safe distance, until the ambulance arrived, and two
paramedics came into the room. The police arrived almost at the same time, and
the room was soon full of people in uniform.
Grendel loved
it. “You’re very tall, aren’t you?" she said seductively to one of the
paramedics, who was indeed exceptionally tall.
He asked to
look at her arm, but instead, she slashed away at it again, occasionally
holding the blade against her throat, as if she were holding Perdita hostage.
“Give me the
scissors,” I said again, in as gentle and unthreatening a way as I could
manage. The police and paramedics kept quiet, waiting to see what would happen.
“You’ll have
to give me three good reasons!” she said again.
I was going to
have to play her game after all.
“OK, Grendel.
First, you’re hurting Perdita. Second, Ophelia will be upset if she finds you
like this.” (Ophelia, by now 14, was still at school.)
“That’s only
two reasons!” Grendel cried, giving her arm a few more slashes.
“And third,
you’re scaring the hell out of me!”
I have found
that being entirely honest can work well in these situations.
She thought
about this for a moment.
“Okay, fair
enough,” she replied, and threw the scissors onto the floor. I kicked them
away, and one of the police picked them up.
“Grendel, I
really need to speak to Perdita.”
“Perdita’s
gone away. You’ve got me!”
“I need
Perdita. We need to get your arm sorted out. And Ophelia will be home from
school soon, and I don’t want her to find all this.”
There was a
pause. Perdita’s face sagged and went blank. She slumped forward. Then her head
snapped up and the eyes of a small lost child stared into mine, tears running
down her cheeks. She looked absolutely terrified, staring with fear at the room
full of people.
“Hello there,”
I said gently. “Can I see Perdita. Or Mavis. Either of them would be good.”
Her face went
blank again and her eyes closed for a moment. Then her face changed. She opened
her eyes.
“Oh, hello, Steve,”
she said, a little surprised, looking around and taking stock of things. She
looked at her arm. “Is it Grendel? Has she been out?”
I recognised
Mavis. She would do. She would be able to sort things out. She rolled herself a
cigarette and then smoked it while she allowed the paramedic to examine her
wounds, and clean and dress them. “My, you’re tall, aren’t you?” she observed.
After all, Mavis had not seen him before.
“Steve,” she
said. “It’s so nice to see you again.” It was uncanny, but Perdita’s face,
mannerisms, and even accent, were quite different when Mavis was in charge.
I negotiated
with her. I asked her to stay in charge for the time being. I told her that I
would come back later in the afternoon when her daughter was due home, to see
Ophelia and explain what had been happening (she was, sadly, used to these
episodes), and to check that Perdita/Mavis was safe and in control. Mavis
listened to me obediently, making meticulous notes from time to time.
My analysis of
the situation went something like this. Once Perdita or "Mavis", the
sensible one, can be induced to return, the crisis is usually over.
"Mavis" herself was confident that she could remain in control. Her
wounds did not require hospital treatment.
I had from the
beginning worked with Perdita explicitly on the basis that hospital admission
was best avoided during these crises, and the Crisis Team also had little role
to play in these situations, once the immediate crisis had passed. This was
written into her care plan.
It would also
generally not be appropriate to use the Mental Health Act, and would undermine
any trust Perdita had in me.
So we worked
out an immediate plan. The police would notify Children's Services of the
incident, who could be mindful of Ophelia’s needs. Ophelia could stay with her
father if required, but would invariably prefer to stay with her mother, and
would be under less distress if she was with her. It would not be in the
immediate interests of Ophelia to separate her from her mother.
The police and
ambulance crew withdrew. I said goodbye to Mavis and reminded her I would be
back later to check up on the situation.
As Mavis
pulled deeply on another cigarette, she said to me: “Steve, when you see
Perdita next, could you try and persuade her to give up smoking? It is such a disgusting habit.”
