Should People with Personality Disorders Ever Be Sectioned?

 

The DSMV (yes, I am that up-to-date), when discussing the diagnostic criteria for personality disorder, states:

 

“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

• Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
• One or more pathological personality trait domains or trait facets.
• The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
• The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
• The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).”

 

I have to say that this definition is rather harder to understand than the DSMIV criteria, which talks much more clearly about personality disorder as being “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture”. It goes on to talk about how the development of a personality disorder can be traced back at least to adolescence or early adulthood.

 

Personality disorder essentially comes about as a result of abusive or aversive early life experiences. An event, such as sexual abuse, interferes with the normal development of personality. In an effort to cope with such extreme and difficult life experiences, the child or young person can develop coping strategies which can be perceived as “abnormal”, but which within the context of that person’s experiences may be the only way they can survive. A typical example of this is deliberate self harming through cutting or other means, as a way of relieving the individual of emotional distress.

 

While a formal diagnosis of personality disorder may not be given too commonly, I would estimate that at least 50% of patients of a typical Community Mental Health Team could be identified as having at least some of the diagnostic features outlined in the DSMV manual. It’s certainly the case in the Charwood CMHT.

 

Traditionally, and unfortunately too often in the present, the term “personality disorder” has often been used negatively to describe people whose behaviour others find “difficult” or hard to understand. Because personality disorders can be difficult and unrewarding to treat, it has often been the case that doctors make a statement along the lines of: “This person has a personality disorder. They are therefore not mentally ill, are untreatable, and should not therefore receive services.”

 

Unfortunately, one still hears this sentiment, despite the publication in 2003 of Personality disorder: No longer adiagnosis of exclusion. Published by NIMHE, it remains the principal guidance for the development of services for people with personality disorder in this country.

 

The introduction is immediately encouraging:

 

“Personality disorders are common and often disabling conditions. Many people with personality disorder are able to negotiate the tasks of daily living without too much distress or difficulty, but there are others who, because of the severity of their condition, suffer a great deal of distress, and can place a heavy burden on family, friends and those who provide care for them.

 

As with all forms of mental disorder, the majority of people with a personality disorder who require treatment will be cared for within primary care. Only those who suffer the most significant distress or difficulty will be referred to secondary services. This guidance is designed to ensure that once referred, they receive access to appropriate care.”

 

The publication states:

 

“The current 1983 Act is often interpreted as excluding those with personality disorder from compulsory detention because of the requirement that the mental disorder be “treatable”. (i.e. treatment is likely to alleviate or prevent a deterioration in the patient’s condition). Many clinicians have not seen personality disorder as a mental disorder that is treatable. This will change with the new mental health legislation … which removes the treatability clause, and provides a generic description of mental disorder.”

 

The report makes frequent reference to the appropriateness of use of the MHA for the treatment of people with personality disorder, especially in the forensic area. It has been estimated that up to 80% of prisoners have some form of personality disorder.

 

Of course, this was written some years before the 2007 Act amendments to the 1983 Act were finalised. So what does the final Act say?

 

Well, the old definition of “mental disorder” was as follows: “mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind and “mentally disordered” shall be construed accordingly”. The Act also included “mental impairment” and “severe mental impairment”.

 

The new definition is short and concise, being merely “any disorder or disability of the mind”.

 

The revised Act did not in fact remove the concept of treatability, and in fact detention under Sec.3 requires that “appropriate medical treatment is available for him”

 

In an attempt to be helpful Sec.3(4) adds: “references to appropriate medical treatment, in relation to a person suffering from mental disorder, are references to medical treatment which is appropriate in his case, taking into account the nature and degree of the mental disorder and all other circumstances of his case.”

 

The Reference Guide (Para 1.16) adds that “medical treatment” “includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care (as well as medication and other forms of treatment which might more normally be regarded as being “medical”)”. It goes on to say that this medical treatment is “for the purpose of alleviating, or preventing a worsening of, the disorder or one or more of its symptoms or manifestations”.

 

So where have I got with answering the question posed in this post?

 

I think I’ve established that detention under the MHA is possible, since a personality disorder is certainly a mental disorder under the MHA.

 

I’ve also established that personality disorder can be regarded as treatable, and that the legal guidance covers the main sorts of treatment that might be used with personality disorder.

 

There is therefore no legal reason why someone with a personality disorder cannot be detained under a section of the MHA.

 

But this is not the same as saying that formal detention should be a routine consideration when an AMHP is presented with someone with a personality disorder.

 

At least half of my caseload as a CMHT worker are people with personality disorders, in particular, emotionally unstable or borderline personality disorder. I’ve written about some of them on the blog. I even detained one under Sec.2 on one occasion. (although didn’t actually admit her).

 

Some of the people I work with will spend periods as an inpatient if their emotional instability becomes so severe that they become dangerous to themselves, although the primary thrust of care planning is always to keep them out of hospital.

 

The care plan of one woman I work with, who frequently engages in self harming and other challenging behaviour, specifically includes a passage stating that, in a crisis, it is unlikely that hospital admission would be helpful.

 

Hospital, and compulsion under the MHA, does certainly have a place in the treatment of severe personality disorder, especially in the forensic sphere, but the NIMHE guidance encourages the use of specialist resources within the community for most people. It is certainly my experience that it is better to work as much as possible with the wishes of the person, and to respect any advance decisions they may make about the use of hospital and compulsion.

 

But that does not mean that the MHA should never be used, or only used with forensic cases. I have discussed this issue at length in my post about the Kerrie Wooltorton case, where a patient with a personality disorder was allowed to die after drinking antifreeze, on the basis that that was what she wanted.

 

In the end, if the requirements for detention are met, then the MHA should be used, if all alternatives, including informal admission, have been exhausted. As well as the basic criteria relating to mental disorder of a nature or degree, for Sec.2, that would be “he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons”, and for Sec.3 “it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section and appropriate medical treatment is available for him”.

Lenny: A Life and Death in the Mental Health System – Part 1

I’ve thought a lot about Lenny over the last few years since his death. I’ve thought about writing his story on this blog for a long time. I feel that I need write about him, since otherwise, Lenny and people like him tend to get forgotten, as if they had never existed. But Lenny did exist, and so this is his life story. This is too long for a single post, so Part 2 will follow in a few days.

I can’t really say much about his early life, as he always refused point blank to discuss anything about his childhood, and would become agitated and distressed if he was pushed about this. All I know is that his parents separated when he was 13. After his parents’ divorce, he lived with his mother.

Lenny first became a patient of psychiatric services at the age of 14, when he was assessed by the Child and Adolescent Mental Health Service (CAMHS). Was there a connection between his parents’ divorce and the beginning of his mental health problems? If so, it was not identified. They diagnosed him with depression, noting that there appeared to be an unhealthy relationship between him and his mother, but at the time no further treatment was offered.

When Lenny was 16 he was admitted to psychiatric hospital, again with a diagnosis of depression, and was followed up this time after discharge. When he reached the age of 17, he was transferred to adult mental health services. That was when I first met him. By now, he was living with his father, who had remarried, after his mother went off to “find herself” in some sort of therapeutic community. The main reason I was asked to see him was because things were becoming increasingly difficult at home, as he did not get on with his step-mother, and this was affecting his mood. I arranged for him to move into a hostel in Charwood.

Lenny lacked skills in making friends, and remained quite isolated within the hostel. He found it difficult to fill his days, but was reluctant to engage in activities that might improve his self confidence. He refused to have any therapy, and used to blow his benefit money on alcohol each week, and spend the next day or two drunk. During these times, he often also took fairly minor overdoses, which he would then tell everyone about, or would try and provoke other hostel residents.

At that time I was on the management committee of the hostel, and the committee members used to have regular fortnightly dinners with the residents. I came to know Lenny quite well, although he always remained suspicious of everyone, and never allowed anyone to get close to him in any way.

Over the 13 years I knew Lenny, I had to assess him under the MHA on a total of 8 occasions. Initially, these were following overdoses. The first two assessments did not result in an admission – there was no real suicidal intent, and hospital admission would not have achieved anything therapeutic.

This behaviour continued, but was generally tolerated by the hostel staff, the committee and the residents. It was simply what Lenny did.

One day, however, when he had been at the hostel for 3 years, and was approaching 21 years of age, he went to a day centre he sporadically attended armed with a large knife and threatened to kill himself in front of the staff and other service users. He was arrested by the police and I then conducted my third assessment under the MHA. This time I somewhat reluctantly concluded that I had no option but to detain him under Sec.3 for treatment.

He remained on the ward for several months, but would not engage in therapeutic activities, and resisted other treatment. But he remained a significant risk if he were discharged. For several years his main diagnosis had been that of depression, but his consultant at that time concluded that he had a personality disorder, and that the only suitable treatment was enforced psychotherapy in a secure unit. I was not sure about this – not that I did not think that he probably did have a borderline personality disorder, but my concern was whether it was either ethical or possible to engage someone in psychotherapy against their will. Nevertheless, funding for this was agreed, a suitable hospital was identified, and Lenny was transferred there.

Lenny hated it. He hated being forced to conform. He hated having to attend therapeutic groups. He hated having to attend sessions with clinical psychologists and occupational therapists. In fact, he hated everything and everybody. Although I had had no control over this transfer, he blamed me. He appealed against his detention.

The Tribunal was interesting. His Charwood psychiatrist presented a report and attended the Tribunal hearing. But he had made some errors in his report. He had stated that he could find no evidence of formal psychiatric disorder, but also stated that Lenny had a borderline personality disorder. Both the Tribunal and Lenny’s solicitor picked up on this. If Lenny did not have a mental disorder of a nature or degree sufficient to warrant his detention for treatment, then the Tribunal would have no option but to discharge him. So how did this statement accord with his diagnosis?

The psychiatrist tied himself in knots trying to justify the contradictory statements. But he was sinking without trace. The Tribunal were from the beginning sceptical about the idea of enforcing psychotherapy, and the inpatient psychiatrist was unable to state that this treatment was making any difference to Lenny’s mental state. So what justification could there be for continuing to detain him if treatment was not alleviating his problems? Lenny’s solicitor was pushing at an open door. The Tribunal discharged him, leaving just enough time to identify an address to discharge him to. Lenny stated that his sister, who lived in Charwood, would gladly offer him a place to live.

A week later, he moved in with his sister. I visited him at her home. He had used his new freedom to begin drinking again. His sister did not like this behaviour in front of her children. She wasn’t prepared to keep him.

There happened to be a vacancy at the hostel, so he returned there. He refused any further contact with the CMHT, although I continued to see him from my involvement with the hostel committee.

Something had changed about him. Although his sporadic alcohol abuse continued as before, he became even more suspicious and reclusive. For the next couple of years he remained at the hostel, where he started to make odd allegations about other residents, sometimes (usually when drunk) alleging that people were contaminating his food or his drink, or were trying to poison him.

To be continued

Next time: Lenny's incarceration in a secure unit for three years -- and eventual freedom.

Just One More Section 4

Sometimes the sheer grinding unfairness of it all can seem almost overwhelming…

I had known Pam for over 10 years. She had a diagnosis of borderline personality disorder. She had had a terrible life. She had been very badly sexually abused by her father as a child. Her escape from the abuse at home had been to deliberately commit offences in order to be given youth custody – it seemed terribly sad that a juvenile detention centre was seen by her as a place of safety and comfort.

Once she became an adult, she moved into a local hostel, where she lived for several years. She would manage quite well for months at a time, but then some untoward life event would take place, and this would precipitate her into a downward spiral of hopelessness. Her main coping strategies at these times were to starve herself and abuse alcohol.

During this time, a brief relationship resulted in perhaps the only good thing that had happened to Pam – she gave birth to a son. She obtained her own flat, where she lived with her son with comparatively little support for about three years. She even got a job in a café in Charwood.

Then her employer raped her. Pam’s response to this was to hit the bottle and to stop eating. She became thin and physically weak, and eventually stopped taking even fluids. She was no longer able to look after her son.

Over the years she had been detained under the Mental Health Act on several occasions for varying periods of time, but this time I managed to find respite care in a nursing home for her. She accepted this, and her son went into temporary care with foster parents.

The brief respite turned into a longer placement. She responded very well to the rehabilitation programme, and after a few months she was ready to live independently again. We helped her get a housing transfer out of Charwood, and she moved into a new house in a new town away from bad memories, and her son was returned to her. Although this town was in the area of another Mental Health Trust, the plan was for Charwood CMHT to keep her on until she was more settled.

All was well for a couple of months. Then she got a text message from the man who had raped her (although we didn’t know about this till later). She saw her world falling apart again. She responded in her usual way. We tried to reason with her, but she could not see that abusing alcohol and starving herself was putting herself and her son at risk.

A day or so later, Pam rang Children’s Social Services to say that she was too drunk to pick her son up from school and could they send a social worker to collect him?

Not a good plan. Their response was to get a Police Protection Order and remove her son to foster carers. They then visited her to let her know what was happening. Pam told them in no uncertain terms that she would kill herself. Late in the afternoon, they asked me to assess her under the Mental Health Act.

I went out straight away to assess the damage. Her support worker was with her. Pam was very drunk and very hopeless, and very physically weak and frail. I could not reason with her. She was intent on killing herself if left alone. As far as she was concerned, the removal of her son was the end of the world. She had nothing at all left to live for.

There was no way we could leave her like this. She needed to be in hospital. And there was no way she was going to agree.

I rang Woodland House to arrange a bed. There weren’t any.

I tried to contact Pam’s consultant, but he was unavailable, and his mobile was turned off. I spoke to the duty doctor. Although Pam was still under the Charwood CMHT, since she was no longer living in the Mental Health Trust catchment area, they refused to come out to assess.

I rang the duty doctor for the Mental Health Trust covering the town she now lived in. He, too, refused to come out – because she was not their patient.

Things were not looking good. I went to see the GP who had been out to see her earlier. I decided that the only option in the circumstances was to go for admission under Sec.4. The GP gave me a medical recommendation.

But before I could complete the application, I had to get a bed.

I rang Woodland House again. They still had no beds. Not even for a Sec.4. They said they’d try and find one and get back to me as soon as possible.

I went back to Pam’s house to provide some support to her support worker, who by now was beginning to flag. Judging by the number of empty cider bottles in the kitchen, Pam must have drunk going on for 4 or more litres of strong cider that day, at least until the middle of the afternoon. Fatigue and the effects of the alcohol were beginning to kick in. I told her what was happening. She hardly responded. I think by then she just wanted an end to it all, whatever that end might be.

I did not get a call from Woodland House until two hours later. They had at last found a bed. But it was in a private hospital. 70 miles away.

By now I was beginning to feel almost as tired and despondent as Pam.

I rang the private hospital and spoke to the bed manager. She wanted more information so that she could decide whether or not to admit. Whether or not to admit! I did not feel happy at this suggestion, and shared this with her.

I spoke to the hospital’s duty doctor. He began by insisting on an assessment by Pam’s Consultant before accepting admission. I pointed out that if such an assessment had been possible, she would not be being admitted under Sec.4. It appeared to be an issue more to do with whether funding had been arranged than whether she needed admitting.

It took the private hospital another half an hour before they eventually agreed to the admission. By now it was 9.30 pm. I had received the request at 5.00 pm. Section 4’s were not supposed to take this long. And I still had to physically get her to the hospital.

Having finally obtained a bed, I then had to arrange transport. Should I get an ambulance to take her, I wondered? I considered this for all of 10 seconds before dismissing it. It is not uncommon in our area to have to wait two hours for an ambulance to take a detained patient to a psychiatric hospital. And that’s if it is the local psychiatric hospital. To get an ambulance to take a patient to a hospital two counties away was even more fraught with difficulties.

I decided to take Pam myself. By now, she was very drowsy, and very unlikely to put up much resistance to being taken to hospital. I asked very very nicely, and her support worker agreed to act as escort. And so eventually, at nearly midnight, Pam was admitted to a hospital bed.

Then all I had to do was drive the 70-odd miles home again. And of course taking a detour to drop off the support worker back at her car on the way.

Unexpectedly happy ending
Yes, there is a happy ending to this story. Pam spent about two months in hospital, the Sec.4 being converted to a Sec.2, and then a further application being made for Sec.3. She eventually went back to her new home. I managed to transfer her care to the local community mental health team. She got her son back. And 8 years on, he’s still with her.