Hallucinations & the Mental Health Act

 

I’ve recently read Oliver Sacks’ excellent book Hallucinations. It contains a wide range of accounts of different medical conditions that can produce hallucinations or hallucinatory experiences. As Sacks says: “In the popular imagination hallucinatory voices are almost synonymous with schizophrenia – a great misconception, for most people who do hear voices are not schizophrenic.”

In fact, most of the conditions he writes about do not amount to mental illness at all. One such example is Charles Bonnet Syndrome, where sufferers can experience very vivid visual hallucinations.

For them, the condition is a result of sight impairment, and Sacks discusses a range of conditions or situations that produce hallucinations of various types as a result of sensory deprivation of various kinds, ranging from physical states such as blindness to self imposed states of sensory deprivation such as immersion in tanks of warm salt water, where one can lie in a state of suspension and with the entire absence of external stimuli.

It appears that when the conscious brain has nothing to do, it can create often complex and elaborate, but completely unreal, visual and auditory environments.

One of the crucial distinctions between hallucinations arising from physical causes and those experienced by people with psychosis is that the people experiencing these phenomena have insight and recognise them not to be real, and don’tt have any accompanying delusions.

One of Sacks’ conclusions appears to be that hallucinations can be experienced by anyone, as a normal part of life experience, whether as a result of some physical process, such as migraine or epilepsy, or as an entirely normal part of the functioning of the brain, such as hypnogogic hallucinations (hearing or seeing something when about to fall asleep) or sleep paralysis, which can occur when someone is waking up from sleep, during which time the person can believe themselves to be awake when in fact they are still asleep.

The fact that experiencing hallucinations does not invariably mean that someone is mentally ill is an important factor to consider when assessing people’s mental health, whether under the Mental Health Act, or as a standard mental health assessment, and it’s important to keep an open mind and to look for alternative explanations.

When I worked in a community mental health team, we conducted standard assessments which included the question “Have you ever heard a voice when there has been no-one around?” Probably around 15% of those I asked answered that they did, but hardly any of them appeared to be psychotic.

One woman told me that every day, as she walked with her child to school, she would hear a voice calling her name at a particular point on the journey. I asked her what she did about it.

“Oh,” she said, “I decided to take a different route to school, and I never heard the voice again.”

I always tried to be open minded when I was listening to patients telling me about their experiences. Sometimes what someone says may seem so unlikely as to be a sign of mental disorder, but which later turns out to be true.

One example was Edna, a lady in her late 80’s who lived in an old semi-detached flint cottage in the town where I worked. She complained to her doctor that she kept hearing strange noises in her house and feared that the house was haunted. Concerned that she was experiencing auditory hallucinations, the doctor arranged for an older people’s mental health nurse to visit her.

Edna was insistent that she was indeed hearing strange noises. She knew they were in the house, but could not identify where they were coming from. However, as no untoward sounds were apparent while the nurse was there, the nurse became convinced that the only explanation was that Edna had dementia. He persuaded her to be admitted to hospital for further assessment.

A few days later, the nurse went to her house to collect some personal effects for her. While there, he was startled to hear inexplicable noises emanating from somewhere within the cottage, when he knew there was no-one else in the property.

It eventually transpired that the two cottages both had cellars, although Edna’s cellar was not accessible from her house. The next door neighbour had knocked his own cellar through into the lady’s cellar and had been converting it into additional accommodation for himself.

Edna had been hearing her neighbour’s d-i-y activities directly beneath her feet.

Is Diogenes Syndrome a Mental Disorder? A case study

 

Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.

He likes cats and encourages strays to enter his home, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.

The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.

Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.

The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission and gives a graphic description of what will happen to anyone who tries to make him go to hospital.

I am asked to assess Harry. I speak to the psychogeriatrician, who has visited Harry a couple of times. She is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate and provides me with a medical recommendation.

I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has always been a difficult man, who was physically abusive to him as a child and made his mother’s life a misery. He rings him at least once a week and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to do.

I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. Based on the evidence, I am already leaning towards a decision to detain for assessment.

The house is exactly as described. We enter his living room, where he spends nearly all his time. Cats rummage through the heaps of rubbish.

Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I discussed in more detail the purpose of our visit, he becomes more hostile, and asks us to leave.

The GP the social worker and I huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The GP agrees with me. On this basis, I can’t justify detention in hospital.

Harry is not happy we are talking about him. He insists that we leave, shouting and repeating this in my face. He won’t let me tell him what our conclusions are and bundles us out of his house.

Some sixth sense tells me his social worker isn’t happy with the outcome. On the pavement outside, I discuss the reasons for my decision with him.

Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have lifestyles others find unacceptable or repugnant. It’s often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.

Harry may or may not have Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself. Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.

Things continue to deteriorate. The carers continue to complain about the rats. The social worker arranges for a visit with an environmental health officer.

Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.

The psychiatrist, the social worker and the GP gather on the pavement outside Harry’s house. The social worker visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as searching the overgrown garden. He could find no evidence of rats – no rat runs, no droppings, no urine, no evidence of chewing – nothing.

This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to some changes to his medication to see if this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.

The weirdest mental health law you’ve never heard of

 

(Here's the text, but it's worth watching the video for pictures of puffins)

The Mental Health Act has been evolving over many decades. Indeed, the Victorian Lunacy Acts in the 1800’s contained recognisable germs of the current MHA.

The Mental Treatment Act 1930 first introduced the idea of treatment for people with mental disorder, while the 1959 Act introduced the concept of the Mental Welfare Officer, whose role provided an independent check on doctors having complete control of the detention process.

The 1983 Act further refined this process of legal protection for people being detained against their will in psychiatric hospitals, and the 2007 Act enshrined subsequent changes in human rights legislation into mental health law. The 2022 Draft Mental Health Act will make further changes, if it ever reaches the statute books.

These Acts, and accompanying regulations and statutory instruments, tended to amend, consolidate or even abolish previous legislation. Sometimes, however, anomalies survived.

The smaller islands of the British Isles are a case in point. The Isle of Man, for instance, with a population of around 81,000, has its own Mental Health Act, which still has Approved Social Workers rather than AMHPs, and Jersey in the Channel Islands has a Mental Health Law going back to 1969.

What is almost unknown, however, is the existence of regulations relating to mentally disordered persons in the Farne Islands. This piece of legislation appears to have been forgotten by legislators, with the result that The Farne Islands (Removal of Lunatics to England & Wales) Regulations 1927 was never repealed.

The Farne Islands are a group of small islands off the coast of Northumberland in Northern England. They are now owned by the National Trust.

Mainly inhabited by a vast range of seabirds, including puffins, as well as a large colony of seals, in the early part of the century there was still a community of people living permanently on the islands.

This small but tight-knitted group, known disparagingly as “Fannies” by the mainlanders, eked a precarious living by farming seaweed, milking seals to make seal cheese, and taking eggs and any seabirds they could catch using finely woven nets thrown off the top of the guano covered cliffs.

The Farne Island regulations were created as a result of a notorious incident in 1927 known in the press of the time as the Wellington King.

An aristocrat known as the Honourable Petrus Wimple-Burgoyne developed the delusion that the Farne Islands were the remains of the lost continent of Atlantis, and that as his family originated from Atlantis, he was the rightful king. He started to petition King George VI, challenging him to the throne of the Farne Islands, and demanding that he be invested in Westminster Abbey.

He became such a nuisance that he was eventually committed to a lunatic asylum under the Lunacy Act 1890. However, he got wind of this, and before the ambulance arrived, he fled to the Northumberland coast, where he hired a boat at Seahouses and just after dawn on 1^st April 1927 he reached the Farne Islands.

He was able to convince the rather credulous and inbred “Fannies” that he was their rightful king, and in a ceremony involving the smearing of the rather oily seal cheese over his entire upper body, an India rubber wellington boot was forced over his head, crowning him the “Wellington King” of the Farne Islands.

When it was discovered where he was, efforts were immediately commenced to recover him to the mainland. It was at this point that it was realised that there was no legal instrument that could be invoked to lawfully remove him.

An emergency session of Parliament was convened, and so was born the Farne Islands (Removal of Lunatics to England & Wales) Regulations.

Within days, a Naval Frigate sailed to the Farne Islands and a dozen sailors alighted on the island of Inner Farne to apprehend him. Despite the sailors being pelted mercilessly with puffin eggs and foul-smelling lumps of seal cheese by the loyal “Fannies”, the so-called “Wellington King” was seized, and returned to England, where he was placed in St Bernard’s Hospital in Southall, Middlesex.

To this day, the Honourable Petrus Wimple-Burgoyne is the only person for whom this regulation has been used.

Is being a vexatious litigant a mental disorder? A case study

 

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 stop any 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 defaulting on his mortgage and was living in a caravan on a residential 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 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.

On admission to the psychiatric ward, he promptly appealed. I was asked to write the social circumstances report.

When I interviewed him for the report, he was 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 in my view showed that he was likely to be mentally ill. He had refused medication.

In my report I concluded: “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 is abnormally fixated on 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, without considerable further assessment, 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.”

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, but which he attempted to quote from at length. After a few minutes, the chair, who is a judge, was clearly getting 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

The judge 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 man, whom I had seen representing many patients in Tribunals and Managers Hearings.

His solicitor began 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 judge became increasingly irritated. Norman’s solicitor was looking desperate as he saw any chance of his client being discharged evaporating.

Eventually, the judge 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 Orwell’s book 1984.”

This was enough for the judge. 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 we detained him under Sec.3 and treatment for bipolar affective disorder was commenced.

He inevitably appealed again, but within a few weeks, after finally receiving a period of appropriate 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.

How to get off your section

 

So, you’ve been detained under the MHA, and you want to get out of hospital. Based on my decades of first-hand experience here a few hints and tips that might make your stay a little shorter.

1. Appeal against your detention

When you are detained under a section of the MHA, it is the duty of the AMHP who detained you, and of the hospital staff, to inform you of your rights to appeal. Staff have a duty to help you if you want to appeal. Your case will then be heard by an independent Tribunal which is part of the judicial system. Around 15% of appeals to Tribunals are successful.

A formal appeal to a Tribunal will also concentrate the mind of your psychiatrist. If you are making a good recovery, they may well decide to discharge you from detention prior to the actual date of the appeal.

2. Get a solicitor

Patients detained under the MHA have the right to free legal aid regardless of their incomes. There are solicitors with special training who will take on this work. The hospital staff will put you in touch with an approved solicitor. Although a patient can use almost anyone to help them present their case in a Tribunal, your chances will be improved by having a qualified legal representative.

3. Allow the solicitor to present your case

Although Tribunals try to appear as informal as possible, it is nevertheless essentially a court of law. The chair of the Tribunal is a judge, and will not appreciate the patient making constant interruptions or challenging the testimonies of the psychiatrist or AMHP. You can ask your solicitor to point out inaccuracies or discrepancies in written and verbal reports. Your solicitor will frequently pick up on these issues without prompting.

4. Be wary of opportunities to speak to the Tribunal

I’ve seen many cases appear to go well in the Tribunal right up until the moment when the patient is asked by the medical member or the chairman to tell them more about how they are or if they have anything they wish to say to the Tribunal. Many a paranoid or psychotic patient has then gone into great detail about their delusions or hallucinations, thereby proving that they have a mental illness “of a nature or degree which warrants detention in hospital” for assessment or treatment, and which would then make it very difficult for the Tribunal to discharge them.

I remember one Tribunal I attended. The patient had sat there quietly throughout, allowing his solicitor to question the psychiatrist and his care coordinator. It had been going quite well for him. The solicitor had certainly made the psychiatrist look uncomfortable at times. The medical member then said to him: “Is there anything you would like to tell us?”

“Yes,” he replied. “I don’t need any medication or anything like that. I’d be perfectly all right if it wasn’t for these voices. They never leave me alone. They’re always going on at me to do bad things. I think it’s my psychiatrist, he projects them into my head from a transmitter on his desk. I had a brain implant inserted into my head many years ago which has made me half robot and half human. The implant picks up the signals and then I hear them. Those voices, they drive me mad, I tell you.”

Strangely enough, he didn’t get off his section.

5. Don’t threaten or assault the psychiatrist or other staff

This doesn’t look good in a report to the Tribunal. It will also tend to stay with you in every future risk assessment.

6. Take the prescribed medication

As a rule, psychiatrists really do want their patients to get better. Nowadays there is intense pressure on hospital beds, and psychiatrists don’t generally want patients to remain in hospital longer than absolutely necessary. There is a wide range of medication that really can help people with depression, psychosis or mania manage their symptoms. Cooperating with the inpatient treatment plan and with plans for your aftercare after discharge will definitely make your stay shorter.

An important note: If you are detained under S.3 (for treatment) you will inevitably be subject to s.117 of the MHA. This refers to the duty of the NHS and the local authority to provide aftercare when you are discharged. The cost of any aftercare provided (including residential or nursing care, as well as provision of community support services) will have to be met by the local authority or the local NHS Trust.

What's the worst day to be sectioned? A Christmas Day MHA Assessment

 

Back in the1980’s, when I used to do out of hours on call duties, Christmas Day was generally considered a good shift to have – you got double pay for the bank holiday, and no-one ever called Social Services on Christmas Day – Boxing Day, yes, New Year’s Day, yes, but never Christmas Day.

Unless someone had chosen that day to go mad.

It was a snowy evening, very festive, when I got a call from a GP. Robert was a 30 year old man who lived alone. He had only a minimal history of mental illness. He had been referred to the local CMHT a few months before after having had an odd transient psychotic episode following general anaesthetic for minor surgery. I had actually seen him on one occasion, and although I had found him a little odd, he had not displayed any overt symptoms of mental illness and there was no follow up.

His father, who lived in a village some miles from Robert, had decided to invite him for Christmas dinner. Since Robert did not have any transport, his father had picked him up and brought him to his house. His father had found him rather quiet and subdued, but Robert had been like this for some months, so he thought nothing of it.

But as the day progressed, Robert’s father became increasingly worried about him. He appeared very stiff, as if his muscles were seizing up, and had to be helped to the dining table. His father would try to engage him in conversation, and got the impression that Robert was trying to reply, but no words would emerge. Robert had sat motionless throughout the meal, staring at his plate, but had eaten nothing. After the meal, his father had been unable to persuade him to leave the table. He called the duty doctor, who gave him a physical examination and found nothing wrong with him, but was equally unable to persuade him to talk or move. He came to the conclusion that mental illness was the only explanation, and called us.

I managed to locate the duty psychiatrist, who was surprisingly easy to persuade to attend – perhaps he had had a fraught day with his family – and we arranged to meet the GP at the house.

Robert was still seated in the chair at the table. The table had been cleared, and he seemed to be staring intently at the tablecloth.

“Hi, Robert,” I began, sitting down at the table with him. “Do you remember me?”

His eyes flickered, as if he were straining to move them in my direction, and eventually they moved enough so that he could see me. However, his neck and body stayed absolutely still. I could see his throat quivering, as if he were trying to speak, but the only sound that came out of his slightly open mouth was a low gurgle.

We asked him a number of questions, but during the 20 minutes or so of the interview the only words he managed to utter, and clearly with much effort, were: “My heart.”

It was impossible to make a further assessment. Our impression was that it was a classic case of catatonic schizophrenia, which can be characterised by a complete inability to move or speak. He clearly needed further assessment, was unable to give any indication of consent, and we concluded that he needed to be detained in hospital under Section 2 for assessment.

When the ambulance arrived, the crew had to physically lift him, still in a seated position, into the ambulance, and he remained in that position all the way to the hospital.

He did indeed have catatonic schizophrenia, and in fact I was called on a number of occasions in subsequent years to assess him, frequently with the same presentation. But never again on Christmas Day.

In a final twist, as I was collating the paperwork and writing up my assessment at the hospital, I noticed his date of birth. It was the 25^th December.

Green Lycra and Fairy Wings: Arrested for attempted murder, is Stella mad, bad – or completely innocent?

 

I was at the CMHT when I got a call from the Criminal Justice Liaison Nurse. He had been asked to see Stella, a 62 year old woman in the local Police Station, who was under arrest on suspicion of attempted murder.

 “I’ve just seen her,” he said. “She gives long rambling answers to even the simplest questions. I asked her about her next of kin, and she said: ‘I usually I do everything in 12’s and 24’s because I used to be a Playboy Bunny’. She isn’t making any sense. She’s not fit to be interviewed. She needs an assessment under the Mental Health Act.”

Stella had called for an ambulance late the previous evening. When it arrived they found her husband with a kitchen knife sticking out of his ribs. The police were called and arrested her. Her husband was now in intensive care.

I went with our local psychiatrist and a s.12 doctor. Stella had no psychiatric history, so we had very little information to go on. The only thing I’d been able to find out was that her husband had spent a brief time in a psychiatric unit over ten years ago being treated for “alcoholic hallucinosis” – vivid and often frightening hallucinations resulting from acute alcohol withdrawal.

The custody officer told us that when the police had attended, they found a man with a knife embedded in his chest, and with only one other person in the house they reached the conclusion that the uninjured person had inflicted the wound on the injured person, and had therefore arrested Stella. The police do have suspicious minds.

“The reports we’ve had from the hospital so far suggest that the husband is mentally ill himself. He says there are people hiding under his bed who want to kill him. He says he stuck the knife into himself. They think he’s psychotic. They’re arranging for him to have a mental health assessment as well,” the custody officer told us. “And we’ve had reports from the officers investigating the incident that indicate Stella’s known in the area for being ‘different’ to say the least.”

Stella was a slight woman, conservatively and appropriately dressed, with evidence of good self care. She seemed intelligent and articulate. She maintained good eye contact with us throughout and cooperated with the interview.

I began by explaining to her why we were there, then I asked her to tell us what had happened the previous evening.

She proceeded to tell us at great length everything she had done, giving us a minute by minute account of the entire evening. We were quite keen for her to tell us how her husband had come to have a knife in his abdomen, but she could not be diverted from answering the question in as much detail as possible.

She’d gone out on her bike to the supermarket and had then visited a friend. She gave us more details than we wanted of what they had said to each other and how many cups of tea she had drunk. She’d eventually returned to the house at 10.00 pm. She said she felt there was something wrong, as her husband seemed to be staring at something in the corner of the room and was mumbling as if talking to someone. To snap him out of it, she suggested they have a cup of tea, and he had then gone into the kitchen.

When here husband hadn’t returned, she went into the kitchen. She saw blood on the floor and found her husband collapsed in the corner with a knife in his chest. She then rang for an ambulance.

Throughout our interview, Stella appeared lucid and coherent. There was no evidence of being under the influence of alcohol or drugs. She was fully orientated. There was no evidence of dementia, or emotional lability or abnormal mood. In fact, there was no evidence at all of any mental disorder.

The only thing of note was that she seemed somewhat detached, with little evidence of emotional distress at either the situation she was currently in, or of the events that had led up to her arrest for attempted murder. But this was not sufficient to cause us undue concern.

“The person who spoke to you earlier said something about you ‘thinking in 12’s and 24’s’. Could you tell us a bit more about that?” I asked her. On the face of it, this seemed at the very least an unusual, if not irrational, comment to make.

She explained that when she was in her 20’s she had trained as a Playboy bunny. This mainly entailed learning how to work in a casino, including operating the blackjack and roulette tables. This, she told me, required an ability to calculate quickly in multiples of 12. A rational enough explanation.

The two doctors and I had a discussion. We concluded that, whatever may have occurred that night, Stella was not suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital under the Mental Health Act.

I told the custody officer it was our view that Stella was fit to be interviewed. The custody officer gave us a look.

“You’re sure about that, are you?” he said. “Perhaps you’d better have a word with the officer dealing with the case.”

He called in the detective sergeant.

“We’ve spoken to the neighbours,” she told us. “Stella’s known locally as ‘Psychedelic Stella’. One of the neighbours told me she’d known her for 10 years and had ‘never had a sensible conversation with her’. They told us she was ‘not on the planet’. They’ve said she often rides round on her bike wearing ‘green lycra and fairy wings’. You should see the house and front garden. There’s rubbish and junk everywhere. You can hardly get to the front door.”

Even if Stella did indeed ride her bike dressed in green lycra and fairy wings, it still didn’t justify detaining her under the Mental Health Act. I saw no reason why this should influence our decision.

“But what if we have to bail her?” the detective sergeant asked.

“Then she’ll go home,” I answered. “At the present time both her account and that of her husband seem to corroborate each other. Of course, if there is evidence that she was the perpetrator and he was just covering up for her, then a further psychiatric assessment might be appropriate.”

The custody officer and the detective sergeant didn’t seem that impressed with our conclusion. But that was no reason to change our minds.

The next day I contacted the medical ward where Stella’s husband was being treated. He had been fortunate. He had missed damaging any internal organs. He had had a psychiatric assessment and had been given medication to help with acute alcohol withdrawal; he had had alcoholic hallucinosis again.

I spoke to the detective sergeant who was satisfied the injury had been self inflicted.

I rang Stella to talk to her about the assessment and to see how she was. But she wasn’t terribly happy with me, and told me politely but firmly that she wanted nothing more to do with me

I couldn’t blame her, really.

MHA assessments can sometimes get seriously out of control!

 

During the 1980’s and ‘90’s, as well as my day job as a social worker, I also did shifts on the out of hours service.

I was on duty one evening when I got a call from the police. They had detained a man under s.136 – this is when a police officer who finds someone in a public place who “appears to him to be suffering from mental disorder and to be in immediate need of care or control” can “remove that person to a place of safety”. Nowadays there are specially designated places of safety on hospital sites where people can be taken, but back then a police station was the usual “place of safety”.

There was nothing at all known about Andrew except for his name, age (30) and address. The police had been called to an incident in the street outside his house. He had resisted all attempts to calm him down, and then became violent to the police who had attended. The police had found his house in a squalid condition, floors covered with dog faeces and rotting food in the kitchen. His electricity had been disconnected long ago. He had a rather neglected looking dog which was taken to a boarding kennel. There was no record of any previous psychiatric involvement, and he did not even seem to be registered with a GP.

I assessed him with two doctors. As we approached his cell, he could be heard talking to himself and making odd noises. He abruptly stopped as we entered and looked at us with some hostility.

Andrew was unable to concentrate on what we were saying and would not give us any information about his home circumstances, relatives or friends. He stared straight ahead most of the time, and after a while he began pacing the cell and breathing increasingly heavily, forcing the breath in and out through his clenched teeth until he began to foam at the mouth. This was disturbing.

We reached a tentative conclusion that he was experiencing a hypomanic episode. The state of his house seemed to indicate that his mental health had been deteriorating for some time. It was possible that this was a drug induced psychosis, but he had vehemently denied illegal drug use when asked. Either way, he needed further assessment and was in no state to give informed consent to this, so we completed an application under s.2.

I informed Andrew of the decision and explained to him that he would be taken to hospital by ambulance. His demeanour changed, he seemed quite happy about this, and followed us out of the cell and strolled down the corridor flanked by two police officers.

That’s when it all started to unravel.

I left the police station to get to my car, which was parked outside the police compound. I watched as an ambulance backed up to the rear entrance, from where Andrew and the two officers were emerging. I watched as one of the ambulance crew got out and opened the ambulance doors, and then stood there under the harsh sodium lights, waiting for the group to approach.

Then things suddenly seemed to go into slow motion. Andrew suddenly broke free from the police officers and lunged forward. The ambulance man folded up as Andrew’s head connected with his stomach and the two disappeared into the ambulance. The police officers dived into the ambulance after them. The ambulance began to shake violently and two other police officers dived in. Then the ambulance doors were suddenly closed from inside, the blue lights started to flash, and the ambulance sped off to the hospital.

This broke me out of my stunned state. I quickly got into my car and followed the ambulance to the hospital, where it parked right outside the admission ward. One of the police officers opened the ambulance doors and went to the ward. He returned with two male nurses and the duty doctor. Even though Andrew was being restrained by three police officers, he was still struggling, causing the ambulance to shake constantly. The nurses restrained him some more, while the doctor administered an injection of IM Haloperidol, of a dose designed to rapidly sedate him.

Andrew continued to struggle, hissing and panting through his teeth all the while, flecks of foam landing on the arm of the officer closest to his head. I saw that somewhere along the way he had incurred a head injury, and blood was oozing down his face. The officer nearest him also had a cut over his eye, which was also bleeding. There seemed to be quite a bit of blood in the ambulance.

After 15 minutes, the doctor decided that the injection should have taken effect and they attempted to try and transfer him into the ward. But as they momentarily adjusted their grip on him, he took the opportunity to make a break for it, and very nearly got away.

It took another injection and another 20 minutes of relentless restraint before he was sufficiently sedated to be transferred safely into the ward.

The little girl with the rat on her shoulder: a case study of Lewy Body Dementia

 

Certain forms of dementia, such as Lewy Body Dementia, can produce the most vivid and outlandish of hallucinations in older people. One man I had to assess was troubled because “there are 3,474,263 people in my room, and they won’t go away.” 

Another elderly man I assessed had pulled up his fitted carpet and piled all his furniture in the corner of the room. When I asked him why he had done this he told me: “there’s lots of calves coming out of the floor and I’m trying to find out where they’re coming from.” He also told me there were a pair of dogs with a litter of pups in the corner, and he would not go into his bedroom because “the ceiling’s covered with thousands of spiders.”

Ethel was a lady in her 80’s with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He lives in the garden now – I can’t sleep because I don’t know what he’ll be up to next.”

When I first assessed her under the Mental Health Act, she was unshakeable in her belief that this man existed. She could see him with her own eyes. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under s.2, and on discharge agreed to take medication and accept a package of home care -- although she was still convinced that there was a man living in her garden.

A few months after discharge I was again asked to assess her. The man in the garden was causing her more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.

I went round with Ethel’s psychiatrist, her GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder.  The man was “getting on her nerves.”

Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.

In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state.

The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect.

It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.

In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment. In view of her recent history, knowing her diagnosis and need for treatment, this time we decided to go for a s.3 for admission for treatment.

“I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.

She complained of chest pains on the way to hospital. I began to feel uneasy – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.

“But I haven’t had anything to eat today,” she said.

ECT and the Mental Health Act

Electroconvulsive Therapy was first introduced as a treatment for mental illness in 1938. Today, its main use is in severe treatment resistant depression, as well as in catatonia and the depressive phases of bipolar affective disorder.

The most recent statistics for the UK indicate that over 1,800 patients received courses of ECT during the year 2021. The average number of treatments per course was around 10.

The perception of ECT as a treatment was not helped by its depiction in the Jack Nicholson film One Flew Over The Cuckoo’s Nest, but in reality it is a lot safer than most antidepressant medication.

The mortality rate for ECT treatment is 0.002% that is, the chances of dying as a direct result of receiving ECT are only 1 in 100,000. When compared to the suicide risk for people with severe depression, that seems like good odds, if it works. ECT even compares well to mortality rates for antidepressant medication.

In the past, patients were given vast amounts of ECT. I once worked with a woman with a very long history of bipolar affective disorder, who was incarcerated in an old-style asylum for 10 years during the 1960’s. She reports that she received several hundred ECT treatments, and I have no reason to doubt her. However, according to the most recent figures, the average number of treatments per course is only 10.

Because of its controversial nature, the whole issue of ECT has a special place in the Mental Health Act. One of the amendments to the Act in 2007 was the addition of s.58A. This section applies to detained patients and to all patients aged under 18, whether or not they are detained. ECT cannot be given to a detained patient unless they consent and are deemed to have the capacity to consent. Equally importantly, ECT cannot be given to a patient lacking in capacity who has made a valid advance decision to refuse ECT.

There are, however, still circumstances in which patients can receive ECT even though they lack the capacity to consent, or when they do have capacity and have refused. This is where a SOAD (a Second Opinion Approved Doctor)  certifies that the patient lacks capacity to consent and  considers that the treatment is appropriate, there is no advance decision refusing treatment, no one with power of attorney objects, and there is no conflict with any Court of Protection decisions.

This means that ECT can only be given if an independent, specially approved psychiatrist has looked at the individual’s case and has authorised it.

In the case of a person who does have capacity, but has refused to have this treatment, the only circumstances in which ECT can still be given are when treatment with ECT is immediately necessary to save the patient’s life, or will prevent a serious deterioration of their condition or will alleviate serious suffering by the patient”, or will prevent the patient from behaving violently or being a danger to himself or to others.

Important Note: If you are a service user (or potential service user) who objects to the idea of ECT, but thinks it’s possible you might be given ECT at some future time, it is important to make an advance decision now (under the Mental Capacity Act) stating clearly what your wishes for treatment are. Ideally, you should get a solicitor to draw up this document to ensure that it is legally sound.

There are two main situations in which the issue of ECT is likely to arise in a professional context for AMHP’s.

The first is when an AMHP is asked to make an application under Sec.3 for treatment for the specific purpose of giving them emergency ECT. This can present an AMHP with a dilemma: should the MHA be used to compel a treatment which the Act itself regards as being of a different order from other treatments for mental illness, to the extent that it was amended specifically to reflect the unease with which many people regard ECT?

Whatever the personal view of an AMHP regarding the use of ECT, an AMHP must remember that their role is only to make a decision regarding whether, in all the circumstances of the case, a person needs to be detained under the Act in order to receive treatment; it is not their role to decide what form that treatment should take.

The other occasion in which an AMHP may become involved is for consultation under Sec.58A(6). The SOAD, before certifying that a patient should have ECT but is lacking in capacity, must consult with two other professionals who have been involved with the patient’s treatment; while one of these has to be a nurse, the other must be “neither a nurse nor a registered medical practitioner”. An AMHP who has assessed the person could therefore be the second consultee.

For more information on ECT statistics, take a look at this excellent blog, the title of which says it all.

For a positive account of ECT, take a look at this Guardian article.

Section 7: Guardianship

For a guardianship application to be made, a person has to be suffering from a mental disorder, and it is necessary for the welfare of the person, or to protect other people.

A guardianship order gives the guardian three powers: to require the person to reside at a specific place, to require the person to attend for medical treatment, occupation, education or training, and to require access to be given to a doctor, an AMHP or other specified person.

The guardian may be the local social services authority, or an individual, such as a relative.

The application has to be made by an AMHP, with two medical recommendations.

Unlike detention under sections 2, 3, or 4, a guardianship order does not have any effect until the local authority accepts the person into guardianship.

This means that an AMHP and two doctors can’t just decide that someone needs to be under guardianship. In practice, there’s an extended process whereby a panel set up by the local authority look at the circumstances of someone being considered for guardianship, and an application will only go ahead if it is accepted that it is appropriate.

There are a number of problems with guardianship. One is that it can be used to restrict someone’s liberty, but it can’t be used to deprive them of their liberty. So, for example, if someone on a guardianship order decided to leave the care home where they were living, they could not be physically prevented from leaving, but could be returned once they have left.

Another snag is that although guardians have powers to require people to attend for medical treatment, they don’t have any power to make them accept that treatment.

In practice, guardianship tends mainly to be used for people lacking capacity, either because of dementia or learning disability.

The Code of Practice suggests that guardianship is most likely to be appropriate for someone who is likely to respond well to the authority and attention of a guardian and therefore would be more willing to comply with necessary treatment and care for their mental disorder. The clear implication of this is that the patient should essentially be in agreement with the proposed Order.

So guardianship doesn’t have the powers of compulsion of a community treatment order, although unlike with a CTO the person does not have to be detained under s.3 before a guardianship order can be considered.

However, guidance suggests that If the person lacks capacity and is objecting, then the powers under the Mental Capacity Act would have to be used to authorise a deprivation of liberty. And with a non-objecting, non capacitous person, it might be better just to go down the Mental Capacity Act route, rather than consider guardianship at all.

I was practicing under the Mental Health Act 1983 for a total of 37 years, and I only once made an application for guardianship. That was in 1985, not that long after the 198 Act came into force. I won’t go into detail here, but it did not work out well.

According to the most recent statistics for England, which go up to 2021, perhaps because of the factors I have mentioned, local authorities are not keen on guardianship either.

These statistics go back as far as 2003. In the year 2003-4 there were 460 new cases of guardianship, and 900 continuing cases. However, in the year 2020-21, there were only 55 new cases, and only 155 ongoing cases. This represents a nearly 90% fall in the rate of new cases, and a 94% fall in ongoing cases.

I fully expected that the draft Mental Health Bill in 2022 would either end the use of guardianship orders completely, or at the least drastically revise the rules, but it makes no changes.

I suspect that within a few years guardianship will essentially cease to exist.