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.