I’ve
been reading a lot recently about how artificial intelligence is going to
change the world, for better or worse. But could it make the role of the AMHP
obsolete?
So,
I asked Copilot, my phone’s AI companion, to write a comedy stand up routine as
if performed by the Masked AMHP. This is word for word what it gave me.
I'm really, very, very sorry. At least it's not very long.
1
The Great Clipboard Caper:
Our
hero walks into a chaotic ward, clipboard in hand. Their mission? To assess a
patient's mental state. But wait! The patient has vanished. Poof! Like a
magician's rabbit. The Masked AMHP scours the ward, peeking behind curtains,
under beds, and even in the laundry hamper. Alas, no patient. Turns out, they
were just in the bathroom. Crisis averted!
2.
The Case of the Disappearing Section136 Suite:
The
Masked AMHP arrives at the designated Section 136 suite, ready to assess
someone in crisis. But - plot twist - the suite has vanished! It's like
Platform 9 3/4. but for mental health. Our hero searches high and low, only to
find the suite relocated to the basement. Apparently, it needed a change of
scenery.
3.
The Epic Battle with the Acronyms:
AMHPs
deal with more acronyms than a teenager's text messages. MHA, MCA, CTO, CPA - you
name it. The Masked AMHP faces off against the evil forces of bureaucratic
jargon. Armed with a highlighter and a strong cup of coffee, they decipher the codes
and save the day. Bonus points if they can explain them to anyone else.
4
The Midnight MHA Assessment:
Picture
this: It's 2 AM. and the Masked AMHP receives a call. A person needs an urgent
Mental Health Act assessment. Our hero dons their mask (and pyjamas) and rushes
to the scene. They navigate dimly lit streets, dodge nocturnal creatures, and
arrive at the doorstep. The patient? Asleep. The Masked AMHP whispers,
"I'm here to assess your sanity. Sweet dreams."
5.
The Unmasking:
In a dramatic twist, the Masked AMHP reveals their
true identity: a mild-mannered social worker by day, AMHP by night. Their
colleagues gasp, "You're the Masked AMHP?" The hero shrugs,
"Well, yeah. It's in the job description." They unmask, revealing a
tired but determined face. And the crowd goes wild (or at least nods politely).
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.
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.
(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
1st 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.
