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.
Sunday, 20 June 2010
Monday, 14 June 2010
This Much I Know Part 2
Be aware of your body language and general demeanour
• It is usually best to maintain good, although not too intense, eye contact. However, people who are plainly paranoid may find this threatening, in which case, avoid too much eye contact when talking to them.
• Appear to be relaxed – even if you aren’t. Sit down if possible, although it is generally better to perch than to be enveloped in a saggy armchair, in case you need to make a quick exit.
• Do not get into the personal space of the patient.
• Maintain an even tone when talking, even if the patient is shouting.
• Do not show that you are frightened or intimidated by a patient.
A foot in the door can be a lot quicker than a Sec.135 warrant
• Remember that under Sec.115(1) of the MHA: “An approved mental health professional may at all reasonable times enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.”
• This is one of the powers of the AMHP, and does give a degree of authority to enter a patient’s house. It may be worth pointing this out to an uncooperative patient before going off to the magistrate.
• It is also worth remembering Sec.129 MHA relating to obstruction:
“(1) Any person who without reasonable cause
(a) refuses to allow the inspection of any premises; or
(b) refuses to allow the visiting, interviewing or examination of any person by a person authorised in that behalf by or under this Act or to give access to any person to a person so authorised; or…
(d) otherwise obstructs any such person in the exercise of his functions,
shall be guilty of an offence.”
• I have to say, however, that I have never had to make use of that particular section, and I am not aware of anyone actually being arrested in connection with this offence. But there’s always a first time.
Try to give the patient choices
• Always show respect for the patient.
• Depending on the degree of capacity of the patient, it is reasonable to explain the choices available to them. You will of course explain the purpose of the assessment. This can include explanation of the options available, such as home treatment, informal admission to hospital, or admission under the MHA.
• Once a decision has been made to admit, offering a choice of admission by ambulance or car, for example, can often result in the patient feeling they have some control over the process and they are then more likely to make a positive choice to go to hospital and can be less likely to object when the time comes to be admitted.
Know when to use the police
• Don’t expose yourself to an unacceptable degree of risk.
• If you have evidence of violence or aggression, arrange for the police to accompany you.
• The police may not actually be required, but it is good to at least alert the police to the possibility that they may be required and to get an incident number, or ideally to have them nearby.
• In my experience, a police uniform, rather than provoking a patient, can be very calming to an agitated or hostile patient.
• Patients will often be more amenable to cooperating with the assessment in the presence of the police.
• Police can be good intermediaries when the AMHP is being seen as the villain of the piece.
• The Police are often very good at explaining to the patient the necessity of cooperating with the admission process.
• In my experience it is rare for the police to actually have to use physical restraint to facilitate an admission.
Never be alone
• Once the assessment has been concluded, and the papers have been signed, doctors are usually very keen to be off. Make sure they don’t leave you on your own with a patient. At the very least, make sure there are relatives or other professionals with you (students can be useful in these circumstances!). Involve the police if you need to.
A Mental Health Act assessment, especially when it takes place at the patient’s home, can be very distressing for the relatives as well as the patient
• Don’t forget the likely distress the relative already has, or the additional distress the relative may have witnessing the actual process.
• Try to spend time explaining to the relative what is happening, the reasoning behind any decisions, and what will happen next.
• It may be appropriate to give the relative the option of accompanying the patient to hospital: this can also assist in reassuring the patient.
• Make sure the relative knows where the patient is going, and other information, such as the phone number of the ward, visiting times, etc.
When dealing with situations of high risk, at times I ask myself the following question:
• “Would I rather justify my decisions to an Appeal Tribunal or to an Inquest?”
• This does not necessarily mean you should always take the “safe” course, but this question can concentrate your mind.
• There are occasions when it’s definitely in the interests of the patient to return control to them (even if you do have a sleepless night!). It may even restore their faith in Mental Health Services.
You’re always an AMHP
• Once you become an AMHP, it begins to pervade your day to day practise.
• You may be sitting chatting to a service user. Something they say sets alarm bells ringing, and suddenly the interview takes a different course. Suddenly you have your AMHP hat on. But equally suddenly, (and undetectably) you can take it off again.
• If you work in a Mental Health Team, it soon becomes second nature to see case discussions in the light of duties and powers under the Mental Health Act (and the Mental Capacity Act). You may not even say anything differently; but you are thinking differently.
• You find yourself contributing to discussions in ward rounds or team case reviews in the context of possibilities under the MHA.
• Do these discussions and interviews constitute Mental Health Act assessments? In a way, yes. But they can also remove the need to go down the MHA route. It can save a lot of time when a quick chat with a Consultant removes the need for a full blown assessment.
Occasionally, I entertain a little fantasy
• I am in a theatre, watching a play.
• One of the actors begins to behave erratically. They fluff or change their lines, they interrupt other actors when they’re not supposed to, they laugh inappropriately, they don’t respond to cues, they move round the set knocking things over. They start fighting with other members of the cast. Eventually, the curtain falls prematurely.
• A murmur rises from the audience, wondering what has gone wrong, wondering what is happening.
• After a few minutes, the director parts the curtains and stands at the front of the stage.
• “Excuse me,” he announces, his voice rising over the audience. “But is there an Approved Mental Health Professional in the house?”
• It is usually best to maintain good, although not too intense, eye contact. However, people who are plainly paranoid may find this threatening, in which case, avoid too much eye contact when talking to them.
• Appear to be relaxed – even if you aren’t. Sit down if possible, although it is generally better to perch than to be enveloped in a saggy armchair, in case you need to make a quick exit.
• Do not get into the personal space of the patient.
• Maintain an even tone when talking, even if the patient is shouting.
• Do not show that you are frightened or intimidated by a patient.
A foot in the door can be a lot quicker than a Sec.135 warrant
• Remember that under Sec.115(1) of the MHA: “An approved mental health professional may at all reasonable times enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.”
• This is one of the powers of the AMHP, and does give a degree of authority to enter a patient’s house. It may be worth pointing this out to an uncooperative patient before going off to the magistrate.
• It is also worth remembering Sec.129 MHA relating to obstruction:
“(1) Any person who without reasonable cause
(a) refuses to allow the inspection of any premises; or
(b) refuses to allow the visiting, interviewing or examination of any person by a person authorised in that behalf by or under this Act or to give access to any person to a person so authorised; or…
(d) otherwise obstructs any such person in the exercise of his functions,
shall be guilty of an offence.”
• I have to say, however, that I have never had to make use of that particular section, and I am not aware of anyone actually being arrested in connection with this offence. But there’s always a first time.
Try to give the patient choices
• Always show respect for the patient.
• Depending on the degree of capacity of the patient, it is reasonable to explain the choices available to them. You will of course explain the purpose of the assessment. This can include explanation of the options available, such as home treatment, informal admission to hospital, or admission under the MHA.
• Once a decision has been made to admit, offering a choice of admission by ambulance or car, for example, can often result in the patient feeling they have some control over the process and they are then more likely to make a positive choice to go to hospital and can be less likely to object when the time comes to be admitted.
Know when to use the police
• Don’t expose yourself to an unacceptable degree of risk.
• If you have evidence of violence or aggression, arrange for the police to accompany you.
• The police may not actually be required, but it is good to at least alert the police to the possibility that they may be required and to get an incident number, or ideally to have them nearby.
• In my experience, a police uniform, rather than provoking a patient, can be very calming to an agitated or hostile patient.
• Patients will often be more amenable to cooperating with the assessment in the presence of the police.
• Police can be good intermediaries when the AMHP is being seen as the villain of the piece.
• The Police are often very good at explaining to the patient the necessity of cooperating with the admission process.
• In my experience it is rare for the police to actually have to use physical restraint to facilitate an admission.
Never be alone
• Once the assessment has been concluded, and the papers have been signed, doctors are usually very keen to be off. Make sure they don’t leave you on your own with a patient. At the very least, make sure there are relatives or other professionals with you (students can be useful in these circumstances!). Involve the police if you need to.
A Mental Health Act assessment, especially when it takes place at the patient’s home, can be very distressing for the relatives as well as the patient
• Don’t forget the likely distress the relative already has, or the additional distress the relative may have witnessing the actual process.
• Try to spend time explaining to the relative what is happening, the reasoning behind any decisions, and what will happen next.
• It may be appropriate to give the relative the option of accompanying the patient to hospital: this can also assist in reassuring the patient.
• Make sure the relative knows where the patient is going, and other information, such as the phone number of the ward, visiting times, etc.
When dealing with situations of high risk, at times I ask myself the following question:
• “Would I rather justify my decisions to an Appeal Tribunal or to an Inquest?”
• This does not necessarily mean you should always take the “safe” course, but this question can concentrate your mind.
• There are occasions when it’s definitely in the interests of the patient to return control to them (even if you do have a sleepless night!). It may even restore their faith in Mental Health Services.
You’re always an AMHP
• Once you become an AMHP, it begins to pervade your day to day practise.
• You may be sitting chatting to a service user. Something they say sets alarm bells ringing, and suddenly the interview takes a different course. Suddenly you have your AMHP hat on. But equally suddenly, (and undetectably) you can take it off again.
• If you work in a Mental Health Team, it soon becomes second nature to see case discussions in the light of duties and powers under the Mental Health Act (and the Mental Capacity Act). You may not even say anything differently; but you are thinking differently.
• You find yourself contributing to discussions in ward rounds or team case reviews in the context of possibilities under the MHA.
• Do these discussions and interviews constitute Mental Health Act assessments? In a way, yes. But they can also remove the need to go down the MHA route. It can save a lot of time when a quick chat with a Consultant removes the need for a full blown assessment.
Occasionally, I entertain a little fantasy
• I am in a theatre, watching a play.
• One of the actors begins to behave erratically. They fluff or change their lines, they interrupt other actors when they’re not supposed to, they laugh inappropriately, they don’t respond to cues, they move round the set knocking things over. They start fighting with other members of the cast. Eventually, the curtain falls prematurely.
• A murmur rises from the audience, wondering what has gone wrong, wondering what is happening.
• After a few minutes, the director parts the curtains and stands at the front of the stage.
• “Excuse me,” he announces, his voice rising over the audience. “But is there an Approved Mental Health Professional in the house?”
Sunday, 6 June 2010
This Much I Know Part 1: (Not Necessarily Reliable) Advice from an Old AMHP to a New AMHP
I have now corrected the section on transporting to hospital so that it now actually makes sense.
It is not always necessary to arrange two doctors before attending a MHA assessment.
• I know that quite a lot of AMHP’s will automatically arrange for two doctors to attend when receiving any request for an assessment under the MHA. While this can sometimes save time, it can also cause delays – I know that I’ve often spent an hour or two trying to locate a Sec.12 doctor, and sometimes have not managed it at all.
• There are often occasions when an initial assessment by the AMHP can obviate the need for doctors to attend – remember, you are an AMHP, therefore you are the one making a final decision. If you make the initial assessment and conclude that the patient is not detainable, or there is a clear alternative, or the patient is willing to have an informal admission, then those two medical recommendations would be irrelevant.
• It’s obviously more difficult if you have a long way to go, but if the patient is just round the corner, perhaps in the local police station, then you are in an ideal position to make a rapid decision as to whether or not it is appropriate to use the MHA.
• (And yes, I know that a doctor and an AMHP have to assess a patient detained under Sec.136 – but if the Forensic Medical Examiner has seen the patient you don’t necessarily need a second doctor in order to make your own assessment. There’s been many a time when someone detained under Sec.136 in a police station overnight has no detectable mental disorder when assessed in the morning, by which time they’ve sobered up and have nothing more serious than a bad headache.)
The top of a wheelie bin can provide a good surface for completing the section forms.
Know when to make a strategic retreat.
• Someone I was assessing under the Mental Health Act in their home at one point said to the psychiatrist and me:
“I will count to 10. If you are still in my house by then, I will kill you.”
We left.
Be creative when arranging for transport to hospital.
• While it is usually best for a patient to be transported in an ambulance, especially if they have been formally detained, there are many factors to consider. At least in the area I work, it can sometimes take 2 hours or more for an ambulance to actually turn up. This delay may not necessarily be in the best interests of either the patient or their relatives. There are many occasions when I have had to work very hard to keep the patient or their relatives calm while waiting for transport.
• Consequently, taking into account Para 11.2 of the MHA Code of Practice (“Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people") as well as Para 11.21 (“AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient.“), at times I have taken the professional decision to transport the patient by car (but always with at least one escort, and preferably two).
• If you do decide that it is appropriate to transport the patient by car, I would recommend that the patient sits in the back seat behind the front passenger seat, with the escort beside them.
When interviewing a patient, make sure you are sitting between the patient and the door
• In case you need to make a quick exit.
Section 4 does have its place
• I’ve given a number of examples of my use of Section 4 in the blog. In every case it has been out of dire necessity rather than choice.
• A Section 4 can save time, but only if you have identified that it is a genuine emergency and obtaining a second doctor would involve undesirable delay.
• It should never be seen as expedient or a “quick fix”.
It is not always necessary to arrange two doctors before attending a MHA assessment.
• I know that quite a lot of AMHP’s will automatically arrange for two doctors to attend when receiving any request for an assessment under the MHA. While this can sometimes save time, it can also cause delays – I know that I’ve often spent an hour or two trying to locate a Sec.12 doctor, and sometimes have not managed it at all.
• There are often occasions when an initial assessment by the AMHP can obviate the need for doctors to attend – remember, you are an AMHP, therefore you are the one making a final decision. If you make the initial assessment and conclude that the patient is not detainable, or there is a clear alternative, or the patient is willing to have an informal admission, then those two medical recommendations would be irrelevant.
• It’s obviously more difficult if you have a long way to go, but if the patient is just round the corner, perhaps in the local police station, then you are in an ideal position to make a rapid decision as to whether or not it is appropriate to use the MHA.
• (And yes, I know that a doctor and an AMHP have to assess a patient detained under Sec.136 – but if the Forensic Medical Examiner has seen the patient you don’t necessarily need a second doctor in order to make your own assessment. There’s been many a time when someone detained under Sec.136 in a police station overnight has no detectable mental disorder when assessed in the morning, by which time they’ve sobered up and have nothing more serious than a bad headache.)
The top of a wheelie bin can provide a good surface for completing the section forms.
Know when to make a strategic retreat.
• Someone I was assessing under the Mental Health Act in their home at one point said to the psychiatrist and me:
“I will count to 10. If you are still in my house by then, I will kill you.”
We left.
Be creative when arranging for transport to hospital.
• While it is usually best for a patient to be transported in an ambulance, especially if they have been formally detained, there are many factors to consider. At least in the area I work, it can sometimes take 2 hours or more for an ambulance to actually turn up. This delay may not necessarily be in the best interests of either the patient or their relatives. There are many occasions when I have had to work very hard to keep the patient or their relatives calm while waiting for transport.
• Consequently, taking into account Para 11.2 of the MHA Code of Practice (“Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people") as well as Para 11.21 (“AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient.“), at times I have taken the professional decision to transport the patient by car (but always with at least one escort, and preferably two).
• If you do decide that it is appropriate to transport the patient by car, I would recommend that the patient sits in the back seat behind the front passenger seat, with the escort beside them.
When interviewing a patient, make sure you are sitting between the patient and the door
• In case you need to make a quick exit.
Section 4 does have its place
• I’ve given a number of examples of my use of Section 4 in the blog. In every case it has been out of dire necessity rather than choice.
• A Section 4 can save time, but only if you have identified that it is a genuine emergency and obtaining a second doctor would involve undesirable delay.
• It should never be seen as expedient or a “quick fix”.
Wednesday, 5 May 2010
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.
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.
Wednesday, 21 April 2010
A Little More on Section 4
(This assessment took place before the Mental Capacity Act 2005 came into force. Had the MCA been in place at the time, the outcome might have been very different.)
Ernie was in his late 80’s. He lived alone and had no known relatives. In recent months the GP had become concerned about possible dementia, and he had been seen by a psychiatrist on one occasion.
It was the middle of winter. The GP had visited Ernie and found him crouched in front of a one bar electric fire, surrounded by squalor, and with a strong smell of excrement in the air. She was very concerned about swelling in his legs, and had arranged for an ambulance to take him to hospital. But when the ambulance had arrived, Ernie had refused to leave his bungalow, and so the ambulance went away. The GP then made a request for him to be detained under the Mental Health Act.
In view of his frailty and the possibility of a life threatening condition, I went out straight away and did a home visit with the GP. His bungalow was pretty much as she had described it. There was evidence of many years of neglect: plastic carrier bags filled with junk and rubbish filled his hallway, his kitchen was filthy, with little evidence of food, the walls were black with grime, and spiders’ webs hung from the corners of the rooms. Ernie himself was sitting in his armchair in front of his fire when we came in (his front door was not locked).
It took him a few moments to register we were there. He seemed quite moribund. He was clearly worse than he had been an hour or so ago when the ambulance had come. He barely recognised the GP. He would not allow the GP to give him a proper medical examination. The only coherent thing he said to us was: “I’m not going to no fucking hospital!”
We went back to the GP’s surgery.
“This isn’t a case for the Mental Health Act,” I began. “He’s physically ill. He needs to be in hospital. This is an emergency. He’s getting worse by the minute. We need to get an ambulance out again and bundle him into it, whether he likes the idea or not.”
“But we can’t,” she replied. “He has a diagnosis of dementia. He’s been seen by a psychiatrist. He has a mental disorder. That means we can only admit him under the Mental Health Act.”
“The Mental Health Act really doesn’t come into this. We’re not admitting him for his dementia, we’re admitting him because he’s dying.”
But the GP wasn’t having it. She was convinced that the existence of a diagnosed mental disorder meant that only the Mental Health Act could be used to remove him from his home. Continuing to argue about it was just wasting time, time that Ernie did not have. We had to get him to hospital somehow, and as soon as possible. And we really didn’t have time for a psychiatrist to come out and assess him. So I decided we had to go for admission under Sec.4.
But this only made things much, much worse.
I rang Ambulance Control.
“I need an ambulance for an elderly man detained under Sec.4 of the Mental Health Act. He needs to be admitted to the general hospital. He’s very ill and frail physically. It’ll be a blue light job.”
“We can’t admit someone under Sec.4 to a general hospital. In any case, we’d have to take him to Accident and Emergency first, and if he’s on Sec.4 he could only be taken directly to a ward that will admit him,” the controller helpfully told me.
I could see his point.
“OK,” I eventually said. “We’ll admit him to the psychogeriatric ward. But we need the ambulance as soon as possible. This is an emergency. He’s really very ill.”
“If he’s detained under the Mental Health Act we can only classify your request as urgent, not as an emergency. We will try to get an ambulance to you within an hour.”
I tried to argue this point. But as I have found on many occasions before, arguing with Ambulance Control is invariably futile. And neither is pleading, begging and crying any more effective.
When I rang the hospital to arrange a bed, the bed manager understandably wondered why Ernie wasn’t being taken to a general hospital. I tried to explain. I recognised that almost as soon as he was formally admitted to a psychiatric ward, he would need to be transferred to A & E – a further hurdle to getting him the appropriate medical treatment, but it seemed I had no option. The bed manager reluctantly agreed, and the GP and I completed the application under Sec.4.
I went back to Ernie’s bungalow to wait for the ambulance. In the event it came within half an hour. By now Ernie was so weak, he put up no struggle at all when the ambulance crew lifted him onto a stretcher and got him into the ambulance.
He did not put up any struggle when they took him by stretcher into the psychiatric ward. The ward sister looked askance at Ernie as he was wheeled past her.
“What the hell have you brought him here for in this state? He needs to be on a medical ward!”
I miserably tried to explain yet again why I had taken the decision. By now, I wasn’t even able to convince myself.
He was transferred to A & E within minutes of his formal admission under Sec.4 Mental Health Act, and was then admitted to a medical ward. As he should have been hours previously.
And three days later, he died.
Ernie was in his late 80’s. He lived alone and had no known relatives. In recent months the GP had become concerned about possible dementia, and he had been seen by a psychiatrist on one occasion.
It was the middle of winter. The GP had visited Ernie and found him crouched in front of a one bar electric fire, surrounded by squalor, and with a strong smell of excrement in the air. She was very concerned about swelling in his legs, and had arranged for an ambulance to take him to hospital. But when the ambulance had arrived, Ernie had refused to leave his bungalow, and so the ambulance went away. The GP then made a request for him to be detained under the Mental Health Act.
In view of his frailty and the possibility of a life threatening condition, I went out straight away and did a home visit with the GP. His bungalow was pretty much as she had described it. There was evidence of many years of neglect: plastic carrier bags filled with junk and rubbish filled his hallway, his kitchen was filthy, with little evidence of food, the walls were black with grime, and spiders’ webs hung from the corners of the rooms. Ernie himself was sitting in his armchair in front of his fire when we came in (his front door was not locked).
It took him a few moments to register we were there. He seemed quite moribund. He was clearly worse than he had been an hour or so ago when the ambulance had come. He barely recognised the GP. He would not allow the GP to give him a proper medical examination. The only coherent thing he said to us was: “I’m not going to no fucking hospital!”
We went back to the GP’s surgery.
“This isn’t a case for the Mental Health Act,” I began. “He’s physically ill. He needs to be in hospital. This is an emergency. He’s getting worse by the minute. We need to get an ambulance out again and bundle him into it, whether he likes the idea or not.”
“But we can’t,” she replied. “He has a diagnosis of dementia. He’s been seen by a psychiatrist. He has a mental disorder. That means we can only admit him under the Mental Health Act.”
“The Mental Health Act really doesn’t come into this. We’re not admitting him for his dementia, we’re admitting him because he’s dying.”
But the GP wasn’t having it. She was convinced that the existence of a diagnosed mental disorder meant that only the Mental Health Act could be used to remove him from his home. Continuing to argue about it was just wasting time, time that Ernie did not have. We had to get him to hospital somehow, and as soon as possible. And we really didn’t have time for a psychiatrist to come out and assess him. So I decided we had to go for admission under Sec.4.
But this only made things much, much worse.
I rang Ambulance Control.
“I need an ambulance for an elderly man detained under Sec.4 of the Mental Health Act. He needs to be admitted to the general hospital. He’s very ill and frail physically. It’ll be a blue light job.”
“We can’t admit someone under Sec.4 to a general hospital. In any case, we’d have to take him to Accident and Emergency first, and if he’s on Sec.4 he could only be taken directly to a ward that will admit him,” the controller helpfully told me.
I could see his point.
“OK,” I eventually said. “We’ll admit him to the psychogeriatric ward. But we need the ambulance as soon as possible. This is an emergency. He’s really very ill.”
“If he’s detained under the Mental Health Act we can only classify your request as urgent, not as an emergency. We will try to get an ambulance to you within an hour.”
I tried to argue this point. But as I have found on many occasions before, arguing with Ambulance Control is invariably futile. And neither is pleading, begging and crying any more effective.
When I rang the hospital to arrange a bed, the bed manager understandably wondered why Ernie wasn’t being taken to a general hospital. I tried to explain. I recognised that almost as soon as he was formally admitted to a psychiatric ward, he would need to be transferred to A & E – a further hurdle to getting him the appropriate medical treatment, but it seemed I had no option. The bed manager reluctantly agreed, and the GP and I completed the application under Sec.4.
I went back to Ernie’s bungalow to wait for the ambulance. In the event it came within half an hour. By now Ernie was so weak, he put up no struggle at all when the ambulance crew lifted him onto a stretcher and got him into the ambulance.
He did not put up any struggle when they took him by stretcher into the psychiatric ward. The ward sister looked askance at Ernie as he was wheeled past her.
“What the hell have you brought him here for in this state? He needs to be on a medical ward!”
I miserably tried to explain yet again why I had taken the decision. By now, I wasn’t even able to convince myself.
He was transferred to A & E within minutes of his formal admission under Sec.4 Mental Health Act, and was then admitted to a medical ward. As he should have been hours previously.
And three days later, he died.
Sunday, 18 April 2010
When To Use a Section 4 (and When Not To)
Detention under Section 4 of the Mental Health Act only requires one medical recommendation. It should be used “only in a genuine emergency, where the patient’s need for urgent assessment outweighs the desirability of waiting for a second doctor.” (5.4 Code of Practice). There should be evidence of “an immediate and significant risk of mental or physical harm to the patient or to others; danger of serious harm to property; or a need for physical restraint of the patient.” (5.6 CoP).
In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”
I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.
William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.
One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).
But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.
So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.
So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.
But that was too easy, wasn’t it?
“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”
“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”
“We’ve never had anyone here on a Sec.4.”
“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”
This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.
And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.
In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”
I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.
William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.
One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).
But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.
So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.
So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.
But that was too easy, wasn’t it?
“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”
“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”
“We’ve never had anyone here on a Sec.4.”
“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”
This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.
And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.
Wednesday, 7 April 2010
Some Notes for Readers of this Blog
When I started writing this blog, it was intended to consist purely of reminiscences of my present and past practice as an Approved Mental Health Professional (and previously Approved Social Worker). Cases were frequently chosen to illustrate the dilemmas and problems with which AMHP’s have to deal. I imagined that the readership (if any) would consist mainly of other AMHP’s or aspiring AMHP’s, and hoped it might be of interest to them.
From the feedback I have received from readers’ comments (which I really appreciate), I am building up a picture of the readership of this blog. As well as other mental health professionals, I am aware that there are also people who have been on the receiving end of the Mental Health Act, as well as others with a wide range of mental illnesses and disorders. This is making me aware that my accounts of assessments under the Mental Health Act might give to those readers an unduly alarming and possibly distorted picture of the consequences of having a mental disorder.
Readers need to be aware that my work as an AMHP is only a comparatively small part of my overall work as a social worker in a community mental health team, and by definition it only deals with crisis situations where people are acutely mentally disordered and may need compulsory detention for their safety and/or the safety of others. I have not written about anyone who has not been subject to an assessment under the MHA.
The people I see in my day to day work have a wide range of mental health problems, including depression, bipolar affective disorder, schizophrenia, personality disorders, anxiety, obsessive compulsive disorder, post traumatic stress disorder, and the long term psychological effects of childhood abuse. The vast majority of them will never find themselves needing to be assessed under the MHA or admitted to a psychiatric ward. Believe it or not, as a team we try to keep people out of hospital. What’s more, the vast majority of the people I see will improve, reach mental equilibrium and stability and be able to manage their disorder, or even recover completely, and will in time move on and cease to require support from mental health services.
I hope that service users and people who might have been detained themselves who read this blog will find it interesting and informative to see the process of assessment from the other side. I hope that they may recognise that AMHP’s are only ever trying to do what is in the interests of the patient and their carers, and that they must comply with the law and adhere to the highest standards. The fact that the AMHP, who makes the actual application for detention, is not a medical professional, is designed as a safeguard against undue medicalisation of the process of assessment in those acute circumstances.
I am aware that some of my accounts appear to have sad or unfortunate endings. I am, of course, only writing about the most severe and difficult situations I have come across in my career.
However, since this is my blog, I can write what I want, so I may also include some accounts of people I have worked with who did not need to be assessed or detained under the MHA, and whose stories have unequivocally happy endings. There are plenty of them.
Thank you all for reading.
From the feedback I have received from readers’ comments (which I really appreciate), I am building up a picture of the readership of this blog. As well as other mental health professionals, I am aware that there are also people who have been on the receiving end of the Mental Health Act, as well as others with a wide range of mental illnesses and disorders. This is making me aware that my accounts of assessments under the Mental Health Act might give to those readers an unduly alarming and possibly distorted picture of the consequences of having a mental disorder.
Readers need to be aware that my work as an AMHP is only a comparatively small part of my overall work as a social worker in a community mental health team, and by definition it only deals with crisis situations where people are acutely mentally disordered and may need compulsory detention for their safety and/or the safety of others. I have not written about anyone who has not been subject to an assessment under the MHA.
The people I see in my day to day work have a wide range of mental health problems, including depression, bipolar affective disorder, schizophrenia, personality disorders, anxiety, obsessive compulsive disorder, post traumatic stress disorder, and the long term psychological effects of childhood abuse. The vast majority of them will never find themselves needing to be assessed under the MHA or admitted to a psychiatric ward. Believe it or not, as a team we try to keep people out of hospital. What’s more, the vast majority of the people I see will improve, reach mental equilibrium and stability and be able to manage their disorder, or even recover completely, and will in time move on and cease to require support from mental health services.
I hope that service users and people who might have been detained themselves who read this blog will find it interesting and informative to see the process of assessment from the other side. I hope that they may recognise that AMHP’s are only ever trying to do what is in the interests of the patient and their carers, and that they must comply with the law and adhere to the highest standards. The fact that the AMHP, who makes the actual application for detention, is not a medical professional, is designed as a safeguard against undue medicalisation of the process of assessment in those acute circumstances.
I am aware that some of my accounts appear to have sad or unfortunate endings. I am, of course, only writing about the most severe and difficult situations I have come across in my career.
However, since this is my blog, I can write what I want, so I may also include some accounts of people I have worked with who did not need to be assessed or detained under the MHA, and whose stories have unequivocally happy endings. There are plenty of them.
Thank you all for reading.
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