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.
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.
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.
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 25th December.
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
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.
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.
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.
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.