Ricky No Wonder: The perils of persuading someone with bipolar affective disorder to go into hospital.

 The perils of persuading someone with bipolar affective disorder to go into hospital.

Ricky was an electrician. He also had bipolar affective disorder. The two things did not necessarily go well together.

Another assessment from the early years of the Mental Health Act 1983. 

You wouldn’t do it like that nowadays.

When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.

Bipolar Affective Disorder and Mel – Happy Ending Alert

Bipolar Affective Disorder affects about 1 per cent of the population. It is characterised by marked mood fluctuations – someone may feel very elated or “high”. They can display a range of typical symptoms, including pressure of speech – talking very fast and with little opportunity to interrupt; grandiose delusions – thinking they have special powers or are very important; and spending money they do not have on irrational things. They may find difficulty sleeping, mainly because their minds are too full of plans to sleep, and may at times be sexually disinhibited.

They may also have periods of low mood or profound depression. These cycles can often be plotted over time (there are some useful mood diaries around which can reveal these patterns). Many people with Bipolar Affective Disorder will only tend to go “high”. The onset of this disorder is typically in the mid twenties through to early thirties.

It also seems to be a disorder that some people actually seem to want to have – our CMHT often has referrals from GP’s which go along the following lines:

“Dear Team, Florence came into my surgery today convinced she has Bipolar Affective Disorder. She describes rapid mood swings, one minute laughing and cheerful, the next minute tearful and feeling suicidal. She has been researching on the Internet, and thinks the symptoms match those of Bipolar Affective Disorder. Could you assess her?”

Almost invariably, these people do not have Bipolar Affective Disorder – they are more likely to have Emotionally Unstable Personality Disorder – or just be adjusting to some adverse life event. However, they are often unhappy to be told this. Some demand mood stabilising medication, which people who really do have Bipolar Affective Disorder are often very reluctant to take.

I have often written in this blog about my experiences of assessing people with this disorder under the Mental Health Act, but this doesn’t mean that people with Bipolar Affective Disorder will inevitably require detention under the MHA or even a hospital admission.

A diagnosis of Bipolar Affective Disorder also does not mean that they will always be disabled; indeed, I have written about people who have successfully managed to work in positions of responsibility despite this diagnosis. I have even known Consultant Psychiatrists with Bipolar Affective Disorder.

Mel
Mel is a very good example of someone with this disorder who, despite at first encountering serious problems controlling her condition, went on to achieve success and happiness. Yes, this is a story with a happy ending. I’m in a good mood today.

Mel was in her early 30’s when I first started working with her. She was an exceptionally intelligent and charming woman, who had been halfway through a PhD in Parasitology, studying the reproductive processes of deer ticks (more interesting than it sounds), when she had started to develop manic symptoms. Her behaviour became increasingly erratic over a period of a few months until she could no longer continue with her fieldwork. She was diagnosed with Bipolar Affective Disorder and started on mood stabilising medication.

By the time I became her care co-ordinator, she had had to abandon her studies, and was working as a pharmacy assistant in the local general hospital. She lived alone in a small flat, and was struggling.

Mel generally had very good insight into her disorder. We developed a shorthand for describing her mood fluctuations. On a scale of 1 to 10, 5 was normal mood. Below 5 was low, above 5 was high. She also kept a mood chart, and over time we were able to construct an elegant model of her mood changes over time. She seemed to have a two month cycle, where she would gradually become high, then return to normal, before sliding into depression and then gradually recovering.

I was usually able to give her a score on our scale within a couple of minutes of coming to an appointment. Sometimes she would be confused, lethargic and tearful. At other times, she would be vivacious and giggly. Sometimes she could identify when she was high, but sometimes I had to point this out to her, one such example being when she had told me on entering the room that she had just had her navel pierced and then proceeded to show me!

Mel, her psychiatrist and I worked hard to try and even out these mood fluctuations. We tried a whole range of mood stabilising drugs, with varying degrees of success. Over time, her control over her mood seemed to decrease. She went on long term sick leave, as she was no longer able to manage her job, and eventually gave it up completely. She could no longer afford her car, and got rid of it. She made a successful claim for Disability Living Allowance. The condition was beginning to disable her, and she was acutely aware of this.

The length of time Mel spent at either extreme of her mood cycles seemed to grow longer, especially the depressive periods. During these times, she would isolate herself in her flat, spending up to 18 hours asleep. She put on weight, some of this unfortunately precipitated by medication (Olanzapine, while being a very effective anti-psychotic and mood stabiliser, has the notorious side effect of excessive and often unacceptable weight gain). She even had a brief, informal hospital admission.

We worked with her to try and end this decline. Cheryl, our support worker, got involved with her to increase her motivation and work on plans to reduce her weight. We provided her with funds to pay for membership of the local gym. Our psychiatrist found a mood stabiliser that worked for her, and seemed to both stabilise her and lift her mood. Over a period of months the mood charts she kept religiously began to show a levelling out of her fluctuations.

Mel managed to lose weight, and became much fitter. Her confidence increased, to the extent that one day she confided in Cheryl about her interest in a man who worked in the Charwood art gallery. She would like to meet him, but didn’t know how to go about it. Cheryl offered to go in with her on the premise of being interested in purchasing one of the pictures. I wasn’t sure that match-making was a function of a support worker, but decided that it was worth a try.

One day, Cheryl and Mel went into the art gallery. Cheryl engaged the art dealer in conversation, and gave Mel openings to join in. The man seemed to show a genuine interest in Mel, and actually said to her: “We must go and have a coffee sometime.”

Mel was delighted. So was Cheryl. The cunning plan seemed to have shown promise. But no invitation from the man materialised.

“Well, Mel,” I said to her one day, “it’s up to you now. Why don’t you go in there, and say to him, ‘Hi, I was just passing, and thought I’d take you up on that offer of a coffee’ – and see what happens.”

She decided, with some trepidation, to try it. Cheryl and I waited, with some trepidation, to find out what came of it.

I saw Mel a week later. Her eyes were sparkling.

“I did as you suggested,” she said, “—and it worked! We had a coffee. Then he invited me out to the cinema. And next week he’s taking me out to dinner!”

Things just continued to get better from there on. Despite having been unemployed for 2-3 years, Mel applied for a job doing administrative work in the Zoology department at the local University. And got the job. The relationship with the art dealer continued to grow. After a few months they decided to move in together.

One day, Mel confided that she had stopped taking her medication several months previously. This alarmed me, but there had been no recurrence of her mood swings, so we decided to just see what happened.

Despite my fears, Mel’s mood remained stable. She and her partner bought a house together, out of the Charwood CMHT catchment area. On the last appointment before she moved, I asked her if she wanted a transfer of care to the new area. She said she didn’t but promised she would go to her GP if she was concerned about her mental state.

Three years down the line (I have my spies) everything still seems to be absolutely fine.

There can be happy endings in mental health, after all.

Does Mental Illness Preclude a Career in the Caring Professions?

A history of mental illness can certainly impact on people’s future life and work prospects, even if a person makes a full recovery. One consequence of a history of mental illness can be to affect your ability to live and work in certain foreign countries. I have often heard it said that if you have ever been detained under the Mental Health Act, then the USA will not allow you a visa. This is, however, not strictly speaking the case. The regulations actually state only that someone is not eligible to travel under the ESTA visa waiver arrangements if:

“(b) you currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(c) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.”

There appears to be no impediment for someone with a history of mental illness who is in remission or controlled by medication, and the restrictions only apply where there has been, or is likely to be a recurrence of risky or dangerous behaviour.

In the UK, there is a raft of legislation that is designed to explicitly protect people from the effects of discrimination. In addition to the Human Rights Act 1998, Article 14 of which prohibits discrimination on grounds including disability, there are also the Disability Discrimination Acts of 1995 and 2005, and most recently the Equality Act 2010. The effect of this legislation is to protect people from discrimination for a wide variety of reasons. These include discrimination on grounds of age, religion, sex, race, sexual orientation, and disability.

The Equality Act 2010 makes it unlawful for an employer “to discriminate against or harass a disabled person.” An employer is also required to make reasonable adjustments to accommodate disabled people within the workplace. Interestingly, there is also protection for people “who are associated with a disabled person or who are wrongly perceived as disabled.”

A person with a disability is defined under the Equality Act as having “a physical or mental impairment”. That impairment must have “a substantial and long-term adverse effect on their ability to perform normal day-to-day activities”. Guidance to the Act suggests a wide range of mental health conditions and mental illnesses would be covered by this legislation, including: “depression, schizophrenia, eating disorders, bipolar affective disorders, obsessive compulsive disorders, as well as personality disorders and some self-harming behaviour”.

There is also an interesting list of conditions which would not be considered to qualify as a disability. These include: “fear of significant heights, underestimating the risk associated with dangerous hobbies, such as mountain climbing, or a person consciously taking a higher than normal risk on their own initiative, such as persistently crossing a road when the signals are adverse, or driving fast on highways for own pleasure.” Which seems to exempt the presenters of Top Gear from protection under this legislation.

It has happily been my experience that Public Sector employers in particular take their responsibilities in relation to people with disabilities seriously. I have encountered a number of people with a range of mental health problems who have successfully trained for and obtained jobs in social work or allied professions. There follow a few brief histories.

Joni
Joni was a woman in her 30’s whom I worked with intermittently over quite a few years. I first saw her when she was referred to the CMHT with a history of severe bulimic behaviour. Over a period of months, I helped her work through the issues from her past that had led her to have such problems with her self image. These included a father who was never able to give praise for achievements. On one occasion as a teenager she had obtained a distinction in a musical instrument examination with an overall score of 93%. Her father looked carefully at the certificate and then said: “If only you’d worked a little harder, you could have got 100%.”

Over time, she recovered and was discharged. Several years later, she was referred again. In the intervening time she had trained as a social worker and was actually in employment in an older people’s team in the same local authority that employed me. Then she had become pregnant, had gone on maternity leave, had her baby, returned to work – then the issues with self image and self esteem kicked in again. Her only way of managing this was to return to her bulimic behaviours, with the addition of liberal quantities of alcohol: “An open bottle is an empty bottle.”

This time, talking therapy did not work. She became more despairing and desperate, her drinking and binge eating became increasingly out of her control, and one afternoon, when I discovered her about to take all her medication, I arranged for her informal admission to Bluebell ward in Charwood Hospital.

Once she was there, she changed her mind about the admission. She was detained under Sec.5(2) and a request was made for her to be detained under Sec.2 MHA. Because of my close involvement in her treatment on a voluntary basis, as well as the fact that she was essentially a work colleague, I arranged for a social worker with no association with her to undertake the assessment, and she was detained under Sec.2.

She remained in hospital for several weeks. Her mood improved. She acknowledged that she had an alcohol problem. She agreed to take antabuse as a means of controlling her alcohol consumption. It was agreed to give her a trial dose. As a routine measure, she was breathalysed immediately before. She tested positive as over the limit. She was still drinking, even on the ward, even as she was about to start antabuse.
A specialist alcohol treatment centre was sourced, and she agreed to go there. This involved residential stays as well as outpatient appointments over many months. As the centre undertook complete care management, I did not see her again.

But a year or so later, I heard that she was working, as a social worker, for the neighbouring local authority.

Joan
Joan was 20 years old. She was two years through a course training to be an occupational therapist when she made a very serious attempt to kill herself. She had cut her wrists as well as mutilating her body with a knife, and nearly died before she was found by her flat mate. She spent a couple of months in hospital, which meant that she had missed too much of her final year to catch up.

I liaised with the college. She had been a good student, and they were keen for her to complete the course, providing her mental health was good enough. As her care coordinator, I worked with her through her recovery from depression. We also worked on the issues from her earlier life that had led to this extreme act. She responded well to treatment. By the end of the academic year I was able to reassure her tutor that Joan was well enough to be able to retake her final year. As this was in another part of the country, I did not have any further professional involvement with her, although I did hear that she had passed her course.

A couple of years later I happened to be visiting a psychiatric hospital in a neighbouring county, and was taken by a colleague to the staff canteen. Joan was there. She had a job as a psychiatric OT.

John
John was working as a qualified social worker in a voluntary agency working with young people leaving care when he had his first episode of bipolar affective disorder. I first met him while he was an inpatient. He had been on a short term contract, and it had ended. He was very despondent, because he believed that, with a diagnosis of bipolar affective disorder, he would never get another job as a social worker again.

I tried to reassure him. I talked to him about the legal requirement on prospective employers not to discriminate on the grounds of his mental illness. I gave him some case histories. I encouraged him to come clean on his applications about his medical history when the time came, but to point out that these experiences could enhance his practice as a social worker. The session appeared to go well, and he left in a more positive frame of mind.

So what was the outcome for John? Well, not all my stories have sad endings. John did get a job as a social worker in a local authority. And to the best of my knowledge, he is still in employment, despite, or possibly even because of, his bipolar affective disorder.

When Detained Patients Appeal Part V: Nearest Relatives and Tribunals

Although Nearest Relatives can attend Tribunals, they rarely do. Sometimes this is because they want to distance themselves from the legal process, or do not wish to confront their detained relative. It can be difficult to side with the psychiatrist and AMHP when their patently unwell relative is protesting that they do not need to be detained. The patient may not be able to recognise that their relative may really have their interests at heart, or may even be frankly terrified of them.

I have attended a few Tribunals where the Nearest Relatives have had a crucial role to play in assisting the Tribunal members to reach a decision. Sometimes this has been by the relatives telling some harsh truths about the patient. Sometimes they have facilitated their discharge in the face of opposition from the professionals.

Doreen was a woman in her early 60’s. She had a history of bipolar affective disorder going back nearly 40 years. During that time she had had a number of acute admissions under the Mental Health Act, most recently about 6 years previously. She normally managed well with a fortnightly depot injection and some oral mood stabilising medication. In fact she literally swore by its efficacy: “That injection,” she once told me, “it’s fucking marvellous!”

Doreen was a large and imposing lady. Even when well, she probably ran a bit fast: she was always loud, and often very crude, but in an amiable and rather likeable way. She tended to fill a room, both in reality, because of her bulk, but also with her gravely voice, which had been roughened and deepened by her 50 cigarettes a day habit, and her frequent peels of laughter after having told a particularly off colour joke.

It as unclear what had precipitated this admission; her husband thought that she had stopped her medication because of fears it was causing her constipation. The result, however, was that her behaviour became more and more unmanageable by her usually very tolerant husband, and even the input of the Crisis Team could not prevent an admission to hospital. When she decided to leave a few days later, she was placed under Sec.3.

Outraged at this, she appealed.

She had a manager’s hearing within a couple of weeks. I wrote her Social Circumstances Report. I interviewed her husband, who told me that he thought she needed a combination of oral and injected medication. He did not feel she was well enough to be at home at present. I put this in my report. When I interviewed Doreen for the report, she was still clearly displaying symptoms of hypomania, talking very quickly, darting around from subject to subject – and also displayed symptoms of paranoia, focusing on ward staff and her husband. The ward staff, she confided in me, were trying to kill her. She had a fixed belief that the nurses were “wicked animals” who had left her for dead suffering from hypothermia. Her husband, she told me, was a wicked old man who was also trying to kill her, in order to inherit her jewels.

The manager’s hearing considered her case, but did not discharge her from detention.

Doreen remained on the ward, protesting that she did not want oral medication. She continued to be happy to have her depot injection, as she always had been, but she became more and more unmanageable on the ward, being openly hostile to female staff, at times slapping nurses as they passed her in the corridor, and was also sexually disinhibited with male staff and patients. The ward decided to transfer her to the local PICU (Psychiatric Intensive Care Unit).

The PICU is classified as a low secure unit. This means that it is locked. I attended her first review. I had to go through an airlock, leaving any sharp objects, keys, and my mobile phone at reception. Doreen was still voluble and showed evidence of hypomania, but was not being verbally or physically aggressive to staff. She did, however, attempt to seduce the male nurse who was present at the meeting. She continued to refuse oral medication, but appeared more settled. After about a month a date for a Tribunal was set.

I interviewed both her and her husband for the report. He told me that he was willing for his wife to return to the marital home, as long as her mood was stable and she was complying with her medication. Certain areas of need have been identified, including some aids and adaptations to the house, and a support worker to take Doreen out. He was also considering taking early retirement in order to spend more time with her. Doreen's mental state did seem to have improved, but there was still evidence of pressure of speech, as well as evidence of disinhibition in the content of her conversation with me. Her relationship had clearly improved with her husband, who had been visiting her on the ward. However, she remained adamant that she should never have been detained, and that she did not need oral medication. I concluded in my report that "although I am aware of some improvement in Doreen's mental state, she is still presenting with a mental illness of a nature and degree that warrants her continued detention under Sec.3, and that were she not detained under the Mental Health Act she would intend to leave the ward and return home. This would not be in the interests of Doreen, or her nearest relative and carer, and could jeopardise her long term rehabilitation prospects." I suggested that she should return to the local ward prior to her eventual discharge home.

When I arrived at the PICU, not only was her husband there, but her daughter and son-in-law had also come. Although her husband had told me only 2 weeks before that he still had worries about her returning home, he was now saying that he wanted her home as soon as possible. They all went off into a side room with Doreen’s solicitor.

With Doreen's consent, her husband and daughter both attended the Tribunal. The solicitor invited them to give evidence to the Tribunal regarding the arrangements they could make to care for Doreen and maintain her mental stability. They were prepared to take her home with them today, were the Tribunal minded to discharge her.

The Tribunal were so minded, she was discharged for the Sec.3 with immediate effect and she went home with her relatives that day.

And reader, to this day Doreen is still at home with her husband, still in good mental health, still accepting her depot injection, and still not taking any oral medication.

When Detained Patients Appeal – Part II

Although many detained patients may find this difficult to believe, psychiatrists and care coordinators do not want to keep people detained under the MHA if it is not clinically justified. People will tend to have their sections removed as soon as the clinical team feels that their mental state has improved enough that they can either be discharged, or will remain as informal patients. Many detained patients will come to recognise the necessity for medication once they have received treatment for a period of time.

Care Coordinators and psychiatrists will also not want to have to write a report for a Tribunal or Managers Hearing, or appear at a Tribunal or Managers Hearing, unless it appears absolutely necessary. If a patient gets as far as the date of the hearing, it is likely to be because they are not yet well enough to recognise the need for treatment.

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 promptly leave hospital and stop 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 non payment of the mortgage and was living in a caravan on a residential caravan 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 in order 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 by the out of hours AMHP.

On admission to Bluebell Ward, he refused all medication and promptly appealed. I was asked to write the social circumstances report.

When I interviewed him for the report, he was exceptionally 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 I did think showed that he was likely to be mentally ill.

I concluded that “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 does appear to be abnormally fixated on the 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, at present 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, without considerable further assessment, a process which Norman is unlikely to allow voluntarily.”

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, since they were all about his custody battle, but which he attempted to quote from at length. After a few minutes, the chairman had clearly become 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 haughtily.

The Chairman, who might possibly have been a barrister, 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 and conscientious man with a real interest in mental disorder, whom I had seen representing many patients in Tribunals and Managers Hearings.

His solicitor attempted 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 Chairman became increasingly irritated. Norman’s solicitor looked increasingly desperate as he saw any chance of his client being discharged evaporating.

Eventually, the Chairman 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 George Orwell’s estimable book 1984.”

This was enough for the Chairman. 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 he was detained under Sec.3 and treatment for bipolar affective disorder was commenced.

He inevitably appealed again, but within a few weeks, as a result of 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.

Vanessa – A Postscript

In my last post I talked about my experiences nearly 20 years ago with Vanessa, a woman with bipolar affective disorder. There’s a little more to the story.

Following her detention under Sec.3 Vanessa made a very good recovery – although she continued to harbour paranoid and delusional thoughts focused on me. Because of this, I made sure I kept a low profile. She remained a patient of the CMHT for a few years, was detained on one more occasion, but then, as she remained stable, she was eventually discharged.

Mental Health Services had nothing more to do with Vanessa for another 17 years. Then out of the blue the GP referred her to the CMHT again. He was concerned about her, as in the previous 7 days her presentation had changed markedly: she was becoming increasingly irritable, suspicious and paranoid, was experiencing poor sleep, was not eating, had lost weight, and was reported to be exhibiting pressure of speech.

I had not forgotten her. I continued with my policy of being invisible as far as Vanessa was concerned, and made sure another member of the Team saw her. As she was so unstable, the Crisis Team became involved, but she refused to cooperate with them. One evening over the weekend the police were called after she made threats to kill one of her neighbours, and she was detained under Sec.136 and taken to a place of safety for assessment. However, when assessed (and without access to any background knowledge) she presented as calm and rational, and was allowed to go home, with her assurance that she would engage with the Crisis Team in home treatment.

When they visited, however, she was again uncooperative, and appeared hypomanic and irritable, still expressing paranoid ideas about her neighbour, and waving a rolling pin around in a threatening way. Eventually, she forcefully told the Crisis Team to leave, although not in those words (I do try to avoid the use of the word “fuck” in this blog if I can help it). Her sons, who were now in their 20’s but still living with her, were also expressing anxieties about her behaviour, and were saying that they could not cope with her any longer. An assessment under the Mental Health Act was becoming inevitable.

Unfortunately, when the request came, I was the only AMHP in the team available.

Not without a degree of trepidation, I went to her house with her Community Nurse and two psychiatrists, both of whom fortunately knew her.

17 years on, here I was again at her door. I determined to take a back seat and be as invisible as possible. If I went in behind the others, she might not even notice I was there.

Yeah, sure.

“What the fuck are you doing here?” she said to me, glaring venomously past the others and fixing her eyes on me.

Determined to avoid confrontation, I said, “Look, I’m here because I have no choice. I will respect your wishes if you don’t want me to stay. I’m happy to leave right now.”

I moved towards the living room door.

“You’re not going anywhere,” she said. “Stay here where I can see you.”

I perched on the arm of a sofa, as near the door as possible, ready to make a quick – very quick – exit if required.

“I didn’t tell you you could sit down,” she said, so I stood up again.

“I hit him once,” she said to the nurse and the psychiatrists. “Didn’t I?” she glared at me again.

“You certainly did,” I replied meekly.

“Are you being fucking sarcastic?” she growled.

“Honestly, I’m not.”

“Perhaps I should hit you again. I’ve a good mind to hit you again. It’d teach you a fucking lesson about not being sarcastic when you’re sectioning someone.”

Vanessa looked around at the others. “Do you know what happened the last time he came round here?” she began. “He told a joke. Do you know what he said? He certainly wasn’t very fucking professional. He said: ‘What’s the difference between a social worker and a Rottweiler? You get your kids back from a Rottweiler.’ What sort of a joke is that for a social worker to tell a single parent with kids? It’s fucking outrageous! He should have got the sack!””

I began to feel offended. She had misremembered. She had forgotten that it had been her who had told the joke, not me! Over all those intervening years, whenever she had thought about that particular day she had it fixed in her mind that it had been me who had told the joke. If she had ever told a friend about that day, she would have told them her account of the story.

I didn’t want the other professionals to think I might have been so unprofessional as to tell jokes during a Mental Health Act assessment. But I knew that if I disagreed with her it would inflame her still more.

I felt that my presence in the room would only make things worse. She might be more reasonable if I were absent. Without saying any more to her, and without waiting for her permission, I left the room.

One of her sons was in the hallway, keeping out of the way. He indicated to me to come into the kitchen with him.

This worried me too. What would be his memory of my last visit to this house? Would he blame me for what had happened?

“I really didn’t tell that joke,” I said to him. “It was your mother who told that joke to me.”

“Yes I know that,” he replied reassuringly. “I do remember how ill mum was back then. But I haven’t seen her like this for years and years.” He was clearly upset by it all

We talked things over. Since I was still the AMHP in this assessment, I obtained more information from him about her mental state over the last week or so and possible precipitants or triggers, and discussed with him the possibility that she may be detained again. He was completely happy with this.

I slipped out to my car, and waited for the others. I was satisfied that she needed to be admitted to hospital. Her presentation was exactly the same as it had been all those years ago.

But in the end, it was all a bit of an anticlimax. Once I had left, she became much calmer. After further discussion with the psychiatrists, she agreed to an informal admission. Detention under the Mental Health Act wasn’t necessary after all. She even agreed to the nurse taking her to the hospital. And that’s what happened.

Assault and Battery – and Arrows

Vanessa was a woman in her late 20’s, who lived on an estate in Charwood with her two sons, aged 6 and 8. Vanessa had bipolar affective disorder. About 20 years ago, over a two year period, I had to assess her under the Mental Health Act on 8 separate occasions, invariably during a hypomanic episode.

Most of the time I liked Vanessa. Most of the time she liked me. I felt I knew her. And that was my mistake.

Her default state was to be vivacious and amusing. When she was high, her vivaciousness increased exponentially. She could be deliberately (and also unintentionally) funny.

I remember one evening assessing her in her home. She had taken a liking to the GP. A great liking. She started to flirt with him. Ignoring the psychiatrist and me, she concentrated all her powers on attempting to seduce him with her feminine wiles. She did this by the device of lighting a match, fixing her eyes on his, then pretending to blow the match out. Her lips quivered seductively, on the point, the very cusp, of extinguishing the flame. Her breath would cause the flame to tremble and gutter. But then, teasingly, she would desist, allowing it to burn a little longer, narrowing her eyes a little as she gazed into the GP’s own perplexed and startled eyes. She repeated this with increasing levels of salaciousness. And finally, at the moment when the flame was about to reach her fingers, she delivered the coup de grace.

We were all entranced by this display. But it didn’t stop us detaining her.

It also didn’t seem to interfere with my ability to work with her. Usually, when she recovered, she would recognise that, if on occasion I had had to exert my authority under the Mental Health Act, it was done in the interests of herself and her sons, and did not hold it against me. But over time, an edge of irritability and maliciousness crept into her character, especially when she was high.

The last assessment I undertook (at least in that two year period – there was one more, but that will remain for another post) was also the most spectacular. We knew Vanessa was going to become unwell again because she was refusing her medication. It was only a matter of time. One day, her community nurse reported that she was becoming high again. I contacted the Consultant Psychiatrist and the GP, and in the meantime, we went out to see her to see if she might agree to an informal admission.

“Hi there, Vanessa,” I said as she opened the door. “You can probably guess why I’ve been asked to come to see you.”

Her face was sour. “You’d better come in, I suppose,” she said, ungraciously.

It was the middle of summer. Her two boys were at home. She sent them to play upstairs. The three of us sat in her kitchen. She made herself and the nurse a cup of coffee, but pointedly did not ask me. As I asked her questions about how she had been and whether or not she was taking her medication, she just stared at me with increasing animosity. Finally, she looked at the nurse and said to him, “Is he always this much of an arsehole? Shall I throw this coffee over him?”

“Actually, Vanessa, I wouldn’t do that,” the nurse said supportively.

She suddenly stood up and started to shout at me. I backed off.

“You always come here smarming your way in, then you put me in hospital when there’s nothing whatever the matter with me. I know your fucking game, mate – you’re trying to get my kids aren’t you?”

I tried to reassure her, but she wasn’t having any of it. She left the kitchen and went into her living room. I followed her.

“I’m going out for some fresh air,” she shouted. “I can’t stand the stink in here!” She went out of the patio doors into her back garden. The nurse and I cautiously followed her.

She continued to shout to no-one in particular. “The arsehole’s here to steal my kids!”

The neighbours could certainly hear her. They knew her when she was well, and they knew her when she was unwell. They knew something interesting was going to happen. Down the terrace in either direction, I could see people bringing out their deckchairs or leaning out of upstairs windows in order to get the best vantage point of the spectacle to come.

I didn’t particularly like conducting a Mental Health Act assessment with such a large audience.

“Let’s go inside, shall we?” I said. "You don’t want everyone watching, do you?”

Vanessa did not like this suggestion at all. She suddenly launched herself towards me, arms flailing. She proceeded to box my ears, hitting me hard on either side of the head and knocking my glasses into the grass.

I backed off, while the nurse grabbed her from behind and pinned her arms to her sides, giving me a chance to find my glasses.

“Leave my kids alone!” she shouted, her arms moving uselessly as the nurse attempted to restrain her.

“Leave our mum alone!” her boys shouted at me from the upstairs window.

Before I knew what was happening, they started firing down a rain of toy arrows, which, although the suckers were not actually painful, were certainly humiliating, especially as the observing neighbours were making appreciative comments.

Vanessa broke free from the nurse and ran back through the house and out of the front door.

I followed her, keeping a safe distance, grateful to get away from the arrows.

“Have you heard a joke?” she shouted at the top of her voice to the entire street. “It’s a fucking funny joke. It goes like this.”

She started to walk down the street, shouting as she went. As she passed each car, she deftly snapped off its radio aerial.

“What’s the difference between a Rottweiler and a Social Worker?” she shouted. “You’ll like this, it’s a fucking funny joke. You get your kids back from a Rottweiler! There, that’s a funny fucking joke isn’t it?”

She continued in this vein until she reached the end of the street and went off through the estate.

A police car came round the corner and stopped. The lone police officer wound down his window as the nurse and I approached.

“We’ve had a complaint,” he said. “A report of shouting.”

I explained to him what was happening, and suggested that she be detained under Sec.136 so that she could be taken to a place of safety to be assessed (with less risk to the assessors).

“I think you’ll need more than one officer to detain her,” I said. “She’s wild.” I explained what had happened to me. He did not seem impressed.

“I’ve got a colleague in another car on the way,” he said. “I’m sure we can handle her.”

As he was talking to us, we heard his colleague over the police radio.

“I’ve located the suspect,” we heard him say. “I’m about to apprehend her.” Then we heard a lot of shouting and screaming. “Assistance requested – aah!” we heard the other officer say.

“You get your fucking kids back from a Rottweiler!” we heard Vanessa shout in the background.

The officer drove off at full speed to assist his colleague.

I went to the police station. By the time I was ushered into the custody office, I knew Vanessa was there. I could hear her shouting at the top of her voice from one of the cells. She was saying something about Social Workers and Rottweilers.

Ricky, No Wonder

Ricky was an electrician. He also had bipolar affective disorder. The two things did not necessarily go well together.

Back in the mists of time (well, in the very early years of the 1983 Mental Health Act at any rate) I was called on to assess Ricky on two separate occasions.

You’ve read my advice to AMHP’s in the previous two posts. Now see how many rules were broken during these assessments.

The First Assessment

I was called by Dr Grundy, an old style country GP, an amiable but slightly idiosyncratic man, as most country GP’s seemed to be back then.

“Ricky’s gone completely bonkers, old chap,” he said. “He was doing some electrical work at my house, but this morning didn’t turn up. He eventually rang me to say that he had run out of electricity and had been delayed because he was generating some more to bring over to replenish my supply. I think he might need sectioning.”

I arranged to meet with Dr Grundy at Ricky’s house, which was in a small village. Ricky answered the front door, and it was immediately apparent that he was as high as the proverbial kite.

“Come in, come in,” he said expansively, without enquiring as to who I was (he recognised Dr Grundy) or the purpose of our visit. “Let me take your hats. No hats? Well let me give you some hats!” He himself was wearing a deerstalker at a jaunty angle, and he rummaged in a chest of drawers in the hallway, muttering, “Everyone must have hats, everyone must have hats”, until he finally produced a straw hat and a motor cycle helmet which he gave to us. Dr Grundy put on the straw hat, but I put the motorcycle helmet down (There are some things I draw the line at.)

“Dr Grundy thinks you may not be well at the moment,” I began. “He thinks maybe you need to be in hospital.”

“Does he, does he? Hospital, eh? Hospital. Lots of different hats in hospital, aren’t there?”

“You can have as many hats as you like, if you go to hospital,” Dr Grundy said. I rather wished he hadn’t. You shouldn’t lie to patients.

Somewhat to my surprise, Ricky agreed. I think he was dazzled by the thought of all the hats he would be able to wear.

“Let’s go then,” he said. “No time to waste. No time at all.” He strode out of the house and climbed into the doctor’s Volvo estate, which Dr Grundy had left unlocked. (Rule 47: Never leave your car unlocked when conducting a Mental Health Act Assessment.) He then locked all the doors from the inside.

Dr Grundy knocked on the car window. Ricky beamed out at him. Dr Grundy mimed winding down the window. Ricky also mimed winding down the window. Dr Grundy found this amusing. So, it must be said, did I. But then, Ricky hadn’t locked himself in my car.

Eventually, after a great deal of furious miming on the part of Dr Grundy, Ricky cottoned on and wound the window down a little way.

“Can I help you, Dr Grundy?” he asked in a serious voice.

Dr Grundy choked a little on his laughter, then said, “Would you be a very good chap and get out of my car? You’ll be going in the other car.”

Ricky leaned out of the window and looked at my car dubiously. “That looks like a German car. I don’t like German cars.”

“It’s not a German car,” I assured him.

“I like this car better,” he said, and wound the window up again. He started to move the steering wheel round as if he were driving.

Dr Grundy was trying so hard to control his mirth that I began to fear he might have an aneurysm. But he had a cunning plan. The tailgate was unlocked, so he opened it and crawled into the boot, then climbed over the back seat until he could unlock one of the doors. It was the first time I had seen a GP get so hands on during a Mental Health Act Assessment.

Ricky eventually agreed to get into my car. I had him sit in the back seat. But as I was alone, and the doctor needed to get back to his surgery, I did not have an escort.

However, Ricky seemed more than happy about going to hospital, and we set off on the 15 mile journey.

He laughed and chuckled and fidgeted in the back seat. I wondered what he was up to, and tried to keep an eye on him in my rear view mirror. At one point he said, “Are you sure this isn’t a German car?”

“No it definitely isn’t a German car. It’s a Fiat. A Fiat 127.”

“Only I don’t like the Germans. They fought us in the War, you know. Who makes Fiats?”

“The Italians,” I replied, without thinking.

“Weren’t the Italians in the War too, on the German side?” he asked, a little threateningly I thought.

“Er, no, I’m sure there weren’t,” I lied.

“Well, that’s all right then,” he said, and went back to his chuckling and fidgeting.

Eventually we arrived at the hospital. I pulled my seat forward to let him out.

That was when I discovered that Ricky had taken a screwdriver with him. And throughout the journey, he had been systematically removing all the screws he could find in the back of the car. The screws were in a tidy heap on the back seat. The component parts of the interior of the rear of my car were in another tidy heap.

The Second Assessment

I received another request from Dr Grundy to assess Ricky a year or so later. Deciding that it was likely that Ricky would agree to an informal admission if required, I went out initially without Dr Grundy this time.

The front door was ajar. I knocked, but there was no reply. The garage door was open, so I had a look. Ricky’s nearly new Rover was parked inside. However, there was something badly wrong with it. The words: “Brooom! Broooom!” were written down the side of it in large letters in matt black emulsion. The driver’s door was open. Ricky had obviously been busy with his screwdriver again, because most of the dashboard had been dismantled, and dials and wires and various other components were scattered all over the front seats.

I went into the house, calling Ricky’s name. There was no reply. I went into his living room. There was again something very wrong about the room. It was dark, for one thing, although it was the middle of the day, so I turned on the light. That was when I realised that Ricky had painted the glass of the windows with matt black paint. The TV was on in the corner, but he had obscured the screen with matt black paint.

I continued on my journey through the house, into the kitchen, where I saw that the central heating thermostat had been dismantled and was hanging from the wall. The lid of the chest freezer was up, and inside was a dismantled toaster.

But there was still no sign of Ricky.

I went out of the open back door and into the back garden. I finally found him in the greenhouse, sitting on a deck chair and wearing his deerstalker hat and sunglasses. He beamed up at me, lifted up his sunglasses, winked at me broadly, and then gave me a piece of paper. On it he had written: “Jul Aug Sep Oct No Wonder!” I puzzled over this for a few moments, then suddenly realised that this was a list of abbreviations for months of the year, but he had then gone off on a tangent: classic flight of ideas.

“I think it’s time you went to hospital again,” I said to him. Ricky nodded and stood up.

But this time I made sure he didn’t have a screwdriver with him.

Daisy's Story: Part 2

The hostel where Daisy had lived for over 15 years decided that they could no longer manage her and gave her notice to quit while she was in hospital. In the event, this was to Daisy’s advantage, as being a vulnerable and potentially homeless person, she was allocated a nice flat away from a hostel environment. When she was recovered, she moved into her new flat, with some community support. She was content. For about 5 years she remained well, although her physical health did not improve. Through her continued obesity, she developed Type II diabetes, and her liking for sweet and fatty foods made it difficult to control. Her legs had become ulcerated, probably because of her poor control of her diabetes. But her mental state remained so stable that the CMHT reduced its involvement to little more than periodic medical reviews with the team psychiatrist and weekly support with practical things such as shopping.

Then her father died. She was understandably upset, but this also served to destabilise her. Over a period of a few months, her manic symptoms returned. By now, her daughter was an adult and frequently visited her in her flat.

One Friday, her daughter came to the CMHT to tell us that she had visited Daisy and had found her mother washing her cups and plates in the washing machine. When she tried to challenge her about this, she explained to her that a Shaman had told her this was the best way to do it, as it would bode well for the future. Daisy had also phoned the RSPCA to report the presence of a five inch diameter spider in her bath (she was very exact about this), and had also reported to the police an attempt to burgle her flat from below (it was a groundfloor flat). She was again spending lots of money on food, and her fridge was crammed with smoked salmon, pate de fois gras, roast partridge, oysters, and champagne. Her daughter had also found her prescription of lithium, with evidence that few had been taken in the last couple of weeks.

Daisy happened to have an appointment with the psychiatrist that afternoon, so I stood by to find out the outcome of this. The psychiatrist popped her head round my door. “I think you’d better come in,” she said.

Daisy was sitting regally in the psychiatrist’s room.

“Oh, hello,” Daisy said when she saw me. “Have you come to section me? I’m not going to hospital, because I will die of a heart attack if I step foot in a hospital. They’re bad places. People are always dying in hospitals. Best to avoid them completely. A Shaman has foretold this. So it will come to pass.”

She continued in this vein for some minutes, despite attempts to ask her questions and discuss the situation with her. Her GP and her daughter joined us, and got no further with her than we had. It was becoming clear that Daisy needed to go to hospital again.

I took her daughter to one side.

“Your mother needs to go into hospital, I’m afraid. She’s clearly not going to agree to an informal admission this time. Since we know her diagnosis and we know she needs treatment, we’re planning to use Sec.3 of the Mental Health Act. As her Nearest Relative under the Act, I need to know if you have any objection to this.”

“Actually, I do,” she told me. “There’s a friend of hers coming this weekend, and mother would be very disappointed if she missed him.”

Her daughter would not be swayed in this. So we could not proceed with an admission under Sec.3 at that point.

We cobbled together a plan for the weekend. Her daughter would try to get her medication into her, and her care co-ordinator would review her on Monday and we would take it from there. The ward were alerted to the possible imminent need of an admission and a bed was reserved

As it happened, things did not go well over the weekend. Daisy would not take her medication, she became so excited by the prospect of her friend visiting that she did not sleep at all, and her mood continued to spiral out of control. Somehow or other, her daughter managed to persuade her to go into hospital, and on Monday she was making her presence felt on the ward.

She remained as an informal patient for about month. Then I received a request to assess her for detention under Sec.3. Although Daisy was showing no signs of wishing to leave the ward, she was also not taking her medication. In addition, she resisted attempts to stabilise her diabetes by refusing to have blood glucose tests or take her diabetic medication.

“Oh, it’s you again, is it?” she said, when I went into her room, accompanied by a female social work student as a chaperone. She was sitting in a chair beside her bed. Her legs had recently been rebandaged, but she seemed intent on loosening the bandages.

“You like me, don’t you? I know you do. That’s why you keep coming to see me. You are undressing me with your eyes. You want to get in my knickers, don’t you? Would you like to see my knickers?”

I was suddenly very glad I was not on my own.

“Daisy,” I said. “I am here, again, to see whether or not you need to be detained in hospital for treatment.

“Treatment? Treatment? I don’t need any treatment. There’s nothing wrong with me.”

“You are mentally unwell at present. And you’re also physically unwell. You’re not letting the staff help you manage your diabetes. You keep interfering with your bandages on your legs.”

“I don’t need any help with my diabetes. I’ve been taught by a Shaman how to control my diabetes with my will alone. In any case, diabetes does not really exist. It’s only a shortage of sugar in the diet that creates the illusion of diabetes. Everything’s an illusion. These bandages are an illusion. They’re not really there at all.”

“Well, it they’re not really there, perhaps you could leave them alone,” I said, becoming slightly irritated.

“Are you being sarcastic? Because if you are, I shall have to ask you to leave.”

Our conversation continued in this vein for some minutes. It was clear that she was manic, that she was delusional, that she would not accept the treatment she needed, and that her mental illness was also affecting her physical health. She did need to be detained.

But her inpatient stay dragged on and on this time. Her mental state did not seem to improve. In some ways, it seemed to deteriorate.

The hospital gave her a brain scan. The results weren’t good. There was evidence of atrophy in her frontal lobes. She was developing dementia in addition to her mental illness. This would explain her disinhibition.

But there was no treatment for this. And she would continue to deteriorate.

Daisy was eventually placed under Guardianship (Sec.7 MHA) and transferred to a nursing home. Five years on she is still there. She seems to enjoy it there, but still protests that she wants to return to her flat in Charwood, where she would be able to make her diabetes fade away using only the power of her will and a regular supply of doughnuts.

Daisy's Story: Part 1

People with bipolar affective disorder are frequently intelligent and fascinating. They can lead completely normal and often exceptional lives, sometimes with medication and sometimes without. But bipolar disorder can also destroy people. There is no moral to this story, but this is, I am very much afraid, not a story with a happy ending.

I first met Daisy when she was admitted to the local hostel for people with mental health needs in the 1980’s. I was on the management committee at the time. She had a diagnosis of bipolar affective disorder. She was in her thirties and had spent a long time in hospital following an acute manic episode. The illness had effectively destroyed her life. Up until then she had been happily married, with a young daughter, living in a nice house in a nice part of Charwood, and working in the town as an assistant bank manager. She was an intelligent woman who had great ambition. But the onset of bipolar affective disorder had changed all that.

As her mental illness took hold, she became more and more grandiose and disinhibited. Her work suffered. She lavishly spent money she didn’t have on ridiculous schemes. She began to neglect her daughter. She embarked on reckless affairs which put increasing strain on her marriage. Eventually everything imploded and she was admitted to hospital. During her incarceration her husband filed for divorce and got custody of their daughter. He kept the house and she became effectively homeless. By the time she was admitted to the hostel, she was thin and ghostly in appearance, hardly ever saying a word, afraid to look anyone in the eye, and on an extensive medication regime of mood stabilisers and antipsychotics.

Over a number of years, however, I saw her gradually change. Several different combinations and doses of medication were tried, and her personality and something of her old spark began to return. At the regular dinners the committee members had with residents, she began to converse more, and her intellect began to shine through. She was a personable, articulate, well educated and vivacious woman, with good conversational skills. In time, she moved on to a self contained flat attached to the hostel, requiring less and less support.

But then, over 15 years on from her first breakdown, the bipolar disorder began to kick in again, and she became more and more manic. She began to spend large amounts of money on huge quantities of luxury foods which she could not possibly eat, and which was inevitably wasted. Since she had a very good pension from the bank where she had worked, she had accumulated a large amount of savings which she proceeded to squander. She was disinhibited, swearing in a way she would never normally have done, and flirting indiscriminately with males and females alike.

Eventually I was asked to assess her under the Mental Health Act. We arranged for her to come to the CMHT offices. When she arrived the button on her jeans was undone, as was her zip, and her jeans were halfway down her buttocks. She had put on a lot of weight, and much of this was on display. She was completely oblivious to this, and when she saw me she told me to “fuck off” before I could even speak to her, directed an impressive range of swearwords at several invisible people in the room, then walked out again.

I caught up with her again a day or two later, when she came to see her care coordinator at the CMHT. Although Daisy appeared a little less elevated than the day before, she nevertheless spoke rapidly and intensely, and was very difficult to interrupt. I gradually told her that in my opinion she was exhibiting symptoms consistent with hypomania, and listed them, explaining their meaning and the direct evidence I had to support my opinion. These included pressure of speech, flight of ideas, disinhibition -- arising not only from her state of dress yesterday but also from numerous occasions in which she had spoken loudly and inappropriately about her romantic and sexual desires for a male friend of hers, and the reckless spending of money.

“None of that is true, and you know it! I’ll have you for slander. I have friends in the legal profession who will sue you! I’ve only got to ring them!” she told me with the absolute certainty that only the most manic (and deluded) can possess. “If you persist in carrying on in that tone, I shall have no alternative but to hit you across the head!”

“Daisy,” I began, as calmly as possible. “If you were to hit me, it would only confirm my opinion. You would never dream of doing something like that if you were well. I do think you need to be in hospital at present.”

“Well,” she said, “If you’re thinking of sectioning me, I shall just have to jump in front of a lorry! What do you think of that?”

I did not think this was a good idea. However, I also did not think she was likely to carry out this threat.

“Look, why don’t you take a little more medication. You might be able to avoid going into hospital.”

She thought about this – for about a millisecond.

“And why don’t you go and fuck yourself!” she answered.

Her care coordinator decided to contribute to the conversation. “Daisy, that is an idea. I could take you to see Dr Drinkwater [her GP]. Let’s see what he thinks.”

Daisy liked Dr Drinkwater. “He is a very good friend of mine,” she said. “I do trust him. I’ll ask him what he thinks.”

I heard later from her care coordinator that Dr Drinkwater had agreed with me, and had recommended an increase in her medication. Amazingly, she had agreed to this. She therefore avoided a compulsory admission, and in time her manic episode subsided.

Two years later, however, she became manic again. All the symptoms had returned. Once again I was asked to assess her under the Mental Health Act.

She agreed to come and see me at the CMHT, arriving like a galleon in full sail, and walked into an interview, saying, “You can tell that fucker I’m here, and let’s see if he dares to section me.”

I sat down with her. “Hello, Daisy. You know what this is about. You know I have to assess you under the Mental Health Act, and you know I have the power to detain you if I think it is necessary. However, the last time we were in this situation, that didn’t happen, did it?”

“I can’t imagine why you think I need to go to hospital. I’ve asked all my friends, and they all agree that there’s nothing wrong with me.” She proceeded to give me the full details of all the people she had consulted and what they had said, at breakneck speed, so that it was impossible to interrupt her or get a word in edgeways. So I just sat there for a few minutes, waiting for her to stop.

During this monologue something strange and unexpected started to happen. Liquid started to flood from her seat onto the floor all around her. After a moment of shocked surprise I realised that she was urinating. She clearly eventually realised this too. She stopped talking, in order, it seemed, to give it her full attention.

The cascade of urine seemed to be interminable, but probably lasted no more than 4 or 5 minutes. She obviously needed to go. The puddle on the carpet began to extend inexorably towards me. I moved my feet discreetly.

Daisy sat there looking totally unconcerned as steam rose around her and the room filled with a miasma of hot urine. When she had completely finished, and the Niagara of urine had finally abated, she said with immense dignity, “I do have a urinary tract infection, you know,” as if no further explanation were necessary.

This time, Daisy did go to hospital.

“You’ll Have a Cup of Tea...”

I was on night duty and received the call from the GP early in the evening. Keith was a patient of his in his 50’s. He was a divorced man who lived alone in his own bungalow. He worked as an engineer. He had no previous history of mental illness, but had this evening turned up at the surgery complaining of sleep problems. The sleep problems seemed to relate to Keith spending every night working on a special project in his garage. He was adapting a Reliant Robin.

(For the benefit of those who have never encountered this form of vehicle, the Reliant Robin was a rather flimsy and unstable three wheeled car made of fibreglass, which is now thankfully no longer in production. Their cornering ability was notoriously bad. I once witnessed a Reliant Robin attempting to turn rather faster than it should. The car rolled over onto its side. The driver climbed out, shook his head, pushed it back onto its three wheels, and drove on.)

After a few minutes Keith confided to the GP that the special adaptation he was fitting to this Reliant Robin was an antigravity drive. At this point the doctor gently suggested that it might be a good idea if he were to see a psychiatrist. Keith did not take kindly to this, was uncharacteristically rude to the doctor, and abruptly left the surgery.

The doctor thought that Keith might be showing symptoms of bipolar affective disorder: in particular, grandiose delusions, as well as boundless energy, poor sleep, irritability, and pressure of speech.

I arranged to meet him with a psychiatrist at Keith’s house. It was mid evening by the time we got there, and dark. Keith answered the door, I explained who we were, and he rather reluctantly let us in.

When we were in his living room, I asked him, “Tell me more about your project.”

Despite his reticence, this was clearly a topic close to his heart, and he could not resist telling us about it, the sentences flooding out almost faster than he could move his lips.

“I received a vision about a week ago,” he said. “It was a plan for an antigravity device. It came from the Dog Star. Incidentally, the inhabitants of the Dog Star aren’t at all like dogs, you know, they’re more like furry slugs, and they all fly around on antigravity platforms. They chose me because of my engineering know how. I’ve managed to get most of the parts, and I’m making the ones I can’t buy myself.”

“Why a Reliant Robin?” I asked. “It’s somehow seems an unlikely car to fit an antigravity drive into.”

“Ah,” he said. “You might think that, but you’d be wrong. It’s exactly the right vehicle. You see, it’s made of fibreglass. That means it won’t interfere with the antigravity rays.”

I thought about this. I could see that this made a kind of sense. But not enough.

“I think it might be a good idea if you went into hospital for a while,” I said to him.

“What on earth for?”

“I think you may be mentally unwell at the moment.”

“They said people would think that. Well, you can all just get out of my house. Go on, get out!”

We retreated rapidly, especially as he had picked up a golf club and was waving it about in a threatening way, and heard him locking his front door as soon as we were outside.

It was strange that Keith had suddenly appeared to develop full blown symptoms of bipolar disorder in his 50’s with no previous history of any mental illness. We wondered if there was some organic cause. Whatever the reason, in view of his unpredictability and irritability, we decided that he needed to be in hospital, and was clearly not going to agree to this. We completed an application under Sec.2 MHA, for assessment. Then I called the police.

Four police officers in two police cars turned up a few minutes later. They knocked on his door, but he would not open it. We could see him peering out of his window at us. It looked as if I might have to get a magistrate’s warrant under Sec.135, but I decided to have one last try. I made my way to the front of the melee of police standing at his front door, and knocked again. I could see him through the glass on the other side of the door, and knelt down at his letter box.

“Please let us in, Keith, you have been detained under Sec.2 of the Mental Health Act. You’re going to have to go to hospital. If you won’t let us in now, I’ll have to come back later with a warrant.”

There was a pause. Then I heard him unlocking the door. As he opened it I smartly stepped forward and entered, expecting the police to be right behind me. However, as soon as I was in, Keith quickly shut the door and locked it behind us.

The police were on the other side of the door. On the wrong side. I was locked in a house with an unpredictable and irritable detained patient. Who had threatened us with a golf club. And the police were outside.

“You’ll have a cup of tea,” Keith said.

It was important not to panic. It was important to show Keith that I was in control of the situation.

“Actually, Keith, I don’t want a cup of tea. I’m actually feeling quite anxious about this. I’d feel a lot better if you unlocked the door.”

“Feeling anxious are you? Well, you’ll have a cup of tea then.”

I tried to find another way out of the house. I went through room after room. But all the windows and external doors were sealed unit double glazed units, all fitted with locks that could only be opened with a key. And Keith had the key.

“What are you doing?” he asked me ingenuously, as he followed me round the house.

“I’m trying to get out. I don’t like the fact that you’ve locked me in.” I could see the police milling about outside, trying windows and doors, but basically looking powerless and ineffectual.

“You’ll have a cup of tea,” he repeated, putting the kettle on.

“I really don’t want a cup of tea right now, Keith. We need to take you to hospital.”

“You’ll have a cup of tea,” he said again, very firmly, putting some teabags into a pot and pouring in the hot water. “You’ll have a cup of tea. Then we’ll go to the hospital.” He got out some cups.

I began to see what was happening. He too was attempting to retain a measure of control over the situation. It was a stalemate.

“All right,” I said eventually. “We’ll have a cup of tea. Then we’ll go to the hospital.”

“Milk?” he said, smiling. “Sugar?”

So we had a cup of tea. He chatted about this and that, while I drank the tea and tried to hide my panic. Then he unlocked the door, stepped out into the night and calmly got into one of the police cars.

The Mental Health Act Assessment of Fear

One thing I have learned as an AMHP is never to show patients that you are frightened of them. (Come to think of it, hints and tips for AMHP’s would be a good subject for a future blog). I have been in numerous situations over the years where I have anticipated danger or been threatened with harm, but have in reality been physically assaulted only rarely, and generally where I have misjudged a situation. (Mmmm. There’s another subject for a future blog.)

Derek, however, was really scary.

Back in the days when I used to do shifts in the generic out of hours team as well as doing the day job (I’m far too old for that now), referrals from police stations made up a significant amount of the workload. The police station in the county’s only city was a frequent source of these calls. It was a regular occurrence to visit its custody suite, which was in the subterranean bowels of the building with no natural light.

It was fairly late in the evening. Derek, a man in his mid 40’s, had been detained under Sec.135 after behaving bizarrely and aggressively in a public place and I was called to assess him under the MHA. He was apparently an intelligent man, with a degree in engineering, but had convictions for a range of violent offences.

From the comparatively bright and inviting reception area, I was led down several flights of stairs to the custody suite. Derek had already been seen by the duty doctor, and while I waited for the duty psychiatrist to arrive I decided to see him.

I followed the custody sergeant to Derek’s cell, at the end of a long corridor lined with heating pipes and ducts with the cells opening off. The custody sergeant looked uncomfortable.

“You’d better watch this bloke,” he said uneasily. “Don’t trust him.”

Long before we reached Derek’s cell, I could hear a loud and regular pounding sound echoing down the corridor. The custody sergeant’s unease was rubbing off on me. As we came nearer, I could see water flooding out from under the cell door. I couldn’t help wondering what on earth was going on in there.

Derek was monotonously pounding his cell door. The officer called through the grill to him to back off and then unlocked the door and opened it. Looking into the cell, I could see that Derek had tried to flush his shirt down the toilet in the corner of the cell, blocking it and causing it to overflow, covering the floor of the cell with water.

Derek had his back to us when we entered. Since his shirt was halfway round the U-bend, Derek was naked to the waist. He turned round and glared at us.

I felt a surge of shock. He only had one eye. He stared balefully at me with his one eye, but where the other should have been was just an empty pink socket.

My first thought was that he must have flushed his eye down the toilet. This did not help me to maintain my composure. My voice probably sounded a little shaky when I introduced myself.

He put his hand in his pocket and brought out his second eye, which was made of glass. He popped it into his mouth, sucked on it for a moment, and inserted into the empty socket. He then examined me more closely, as if this action had improved his vision. Although this went some way to improving his appearance, it was hardly reassuring. (I learned later that he had lost his eye at the age of 12 while trying to make homemade fireworks in his bedroom).

The officer led him to an interview room. I stood on one side of the desk, with Derek and the officer on the other side and tried to interview him. He was hostile and asked me who I was. He did not appear impressed when I explained. He was clearly agitated and his mood was elevated. At a guess (I did not have access to his medical records) I thought he had bipolar affective disorder and was probably hypomanic. He kept leaning across the desk and getting his face as close to mine as possible. I didn’t like this. I also didn’t like it when he raised his fist and made as if to punch me in the face, stopping his fist just centimetres from my nose. I don’t know how I didn’t involuntarily recoil.

It didn’t take long for me to conclude my assessment, and I indicated to the officer that he could return him to the cell. I was relieved that I had survived the process without needing a visit to the casualty department. When the officer came back to me, I could see that he was trembling. It did not actually help to know that a police officer was even more scared than I was.

“I don’t mind a bit of aggression in this job,” he confided. “But these mental ones – they really put the wind up me.”

Once the duty psychiatrist had seen him (I decided not to take part in that interview) we were in no doubt that he needed to be detained under Sec.2 for assessment. In view of his volatility and potential for aggression, it was decided to transport him in a police van. He was not happy about this, and swore at me as he was led to the vehicle, each wrist cuffed to a police officer, with two others as escorts.

I went on to the hospital to alert them to the admission, and got there before him. I stood back as he was led down the corridor, but at least felt safe, since he was handcuffed and flanked by two big policemen. I made sure that I was far enough away to be out of danger should he decide to lunge at me.

But as he passed me, he turned to look at me once more, swore, and then spat full in my face.

It’s things like that you remember for a long time.

Scary Post Script. It turned out I got off lightly. A couple of years later I was talking to a social worker who worked in the regional secure unit. I discovered that Derek was a patient there. He was detained under Sec.37/41 (a form of detention imposed by the criminal court for serious offences, which means that a patient can only be released with the consent of the Home Secretary). He had blinded someone by throwing acid into their face.

Leroy

The phone rang.

“Hi there, it’s Shirley Adams. I’m ringing about Leroy. I think we may need to section him.”

I knew Shirley. She was the consultant psychiatrist with the Assertive Outreach Team. I also knew Leroy. In fact, I first met Leroy in the 1970’s when he was only 14 years old and I was a very young social worker working at the time with young offenders. They called it Intermediate Treatment back then (I never did understand what “Intermediate Treatment” meant).

Leroy came from just about the only black family living at that time in the small rural town where I work. He and his brothers had consequently suffered a degree of prejudice, especially from the police. For example, while a white 14 year old in the 1970’s would probably have been ignored or just given a verbal warning when caught riding a bicycle without lights, Leroy was taken to juvenile court. He was one of 5 brothers, three of whom in adulthood developed bipolar affective disorder. In fact, I had detained one of his brothers under the Mental Health Act in the past. I had also detained Leroy under the Mental Health Act on two previous occasions, the first time 18 years ago, and more recently three years ago. He was now in his mid forties.

I still vividly remembered the last time I had been involved with him. He was in the habit of disengaging from the community psychiatric team, and would then stop his medication, take lots of amphetamine, and end up with an acute admission, frequently from the police station. This time he had been an informal patient, but had decided to pop home to his flat without bothering to tell anyone, and had not returned. The ward rang to ask if we could get him back. I had gone out with Pam, our criminal justice liaison nurse, and had tentatively knocked on his door, expecting no answer, or at best a distinct lack of cooperation with our plan.

Instead, he immediately opened the door, welcomed us as if we had come to confirm his jackpot win on the National Lottery, and said: “Thank God you’ve come. Please, please take me back to the hospital. It’s terrible here – the TV’s talking to me!” We decided to oblige, but then wished we hadn’t – he became increasingly bizarre during the journey to the hospital, at one point telling me that I was an alien from Alpha Centuri, and then telling me that, although he was not gay, he nevertheless wanted to kiss me – “on the lips”. Once returned to hospital, I detained him under Sec.3. Unfortunately, I then became the focus of some of his paranoid beliefs, and at one stage during his hospitalisation he announced that he wanted to kill me. Even when he had recovered, he remained hostile towards me. That was when he was taken over by the Assertive Outreach Team.

So when Shirley rang me and mentioned Leroy’s name, I felt a degree of trepidation. This feeling increased when she told me that his mental state had been deteriorating over the last few weeks, they believed he was taking amphetamine again, and thought he might have also stopped his medication. His relatives had reported that he had broken his mother’s window the previous week and appeared to be very agitated. Shirley therefore wanted to pay him a visit with an AMHP and another doctor to conduct a formal assessment under the MHA.

Since there was no other AMHP available (there are only two of us in my team), I had no choice.

The following morning Shirley, another Sec.12 doctor and I called at the time he normally expected the Assertive Outreach Team to visit him. He opened the door and to our surprise readily invited us into his flat. Although he eyed me up a little suspiciously, he remained civil and calm, even when we told him the purpose of our visit.

He told us that he had given up “puff and speed” a week ago, and that he had doubled his medication, including his olanzapine and lithium (this did worry his consultant, because he had been known to become lithium toxic in the past). There was some evidence of elevated mood and disinhibited behaviour, eg he lifted up his teeshirt to display his stomach to show us he had lost weight, and talked to us in detail at one point about the colour of his “poo”, but there was no evidence of delusions or hallucinations. He admitted that he had had a disagreement with his mother last week and had “bricked” her window, but said that he had seen his mother yesterday and offered to pay for the repair. He did tell us that he had noticed that car registration numbers looked “phonetical” – twisted and reversed, but this was the only real evidence of abnormal thought processes. We were in his flat for over 45 minutes, and throughout that time he remained amiable and composed. At one stage he agreed to an informal admission if that was considered necessary. He agreed to maintain engagement with the Assertive Outreach Team and said he would cooperate with any community treatment plan.

We slipped into his kitchen to discuss our decision. We were unanimous in feeling that a detention under the MHA could not be justified on the basis of this interview, even taking into account the reports of his relatives. We told him the news, Shirley warned him not to tamper with his prescribed doses of medication and arranged with him for further visits from team members, and then we left.

Two weeks later he was admitted to Bluebell Ward in the middle of the night in the company of the police, and was quickly detained under Sec.3.

Moral: AMHP’s and psychiatrists are not infallible.