One day a notebook belonging to Lenny was found in his room. It was full of rambling drunken notes and tirades (“If you find me dead in the morning, it was because Jerry poisoned my Carlsberg.”) But it also contained some more alarming things. One of them was a "hit list" of named people whom he considered his enemies, mainly people connected with the hostel (I was on the list), as well as diagrams and recipes for molotov cocktails and petrol bombs, and much material outlining a universal conspiracy against him involving the IRA and Neo Nazi organisations, which included the belief that these organizations were systematically arranging for his food to be poisoned.
The hostel manager was understandably alarmed at this and wanted him to be expelled immediately. However, the committee was more sanguine. There was something distinctly Adrian Moleish about his ramblings, and we did not take them to constitute serious threats. Instead it was suggested to Lenny that he might feel more comfortable if he had his own accommodation. I helped him to negotiate with the local council, and he was offered a one bedroom flat.
He was delighted with this, but still suspicious. He seemed to manage reasonably well living on his own. He did agree to a community nurse from the CMHT visiting him, as well as a support worker. From time to time he would turn up unannounced at the CMHT and chat to me. Although he appeared to regard me with suspicion, I suppose he also saw me as offering some sort of continuity in his life.
It became increasingly clear from these informal chats with him that, now he was living alone, his paranoid beliefs were being allowed full rein, and were becoming more elaborate and universal in nature. He was convinced that food bought from supermarkets was poisoned or contaminated with noxious substances including the HIV virus. He talked about seeing members of the Ulster Volunteer Force in Charwood Post Office. He said on one occasion he had barely escaped with his life. If he hadn’t left, he knew they would have opened fire on him.
One day, I received a call from the Charwood Environmental Health Dept. They had received a visit from him in which he had given them an assortment of foodstuffs, including cans of lager, tins of food, and some vegetables, with an accompanying letter outlining the contaminants that had been added to them, and asking them to analyse them for him. We also heard that he had been writing to the manufacturers of various products accusing them of selling him contaminated goods.
We eventually managed to persuade Lenny to attend for an outpatient appointment with the CMHT psychiatrist. I sat in on that assessment. He freely talked about his elaborate delusional beliefs relating to paramilitary groups, Nazi’s, and a conspiracy to contaminate the food of the inhabitants of Charwood in order to subject them to mind control. We arranged for his GP to attend (yes, we were planning a MHA assessment). And we detained him under Sec.3.
This admission brought to light the full, and somewhat unsettling, extent of his acting on these persecutory delusions. On admission, he was found to have a knife and a sock full of broken glass in his bag (for defensive purposes). A few days later, his community nurse, who was visiting his flat in order to collect clothes and toiletries for Lenny, found that the cupboard under his kitchen sink was crammed with home made incendiary devices made from glass bottles filled with petrol. The police and the Army Bomb Disposal Squad attended and disposed of them.
Lenny’s diagnosis was changed: his symptoms were undoubtedly entirely consistent with a diagnosis of paranoid schizophrenia. Did we miss this over the years? Did his earlier diagnosis of borderline personality disorder muddy the waters? Quite possibly.
Lenny was prescribed antipsychotic medication and he did appear to improve. After a few months he was discharged back home, subject to S.117.
For a while he appeared much happier and settled. He even seemed more open and friendly. But it did not last. He gradually became depressed and his self care deteriorated. A few months later, he actually asked to be admitted to hospital. On admission, as his depression was treated, his underlying persecutory and paranoid beliefs emerged, as bad as ever. I had to detain him one again under Sec.3.
This time, however, treatment did not appear to result in any significant improvement in his paranoia, if anything, the depth and extent of his paranoid beliefs increased. He was disruptive on the ward, and so suspicious of the staff and food that it was very difficult to get him to eat anything. He remained completely insightless, and made regular attempts to escape from the ward, on one occasion trying to dig an escape tunnel in the occupational therapy vegetable garden.
In view of Lenny’s history of potential dangerousness, his unshakeable delusions and poor response to treatment, Lenny was transferred to a secure unit. He remained there for three years. During that time, my only contact with him was when I visited him to interview him for Tribunal reports, and to attend Tribunals. Whenever I saw him, he was consistently hostile. “Come to stitch me up again, have you, Masked AMHP?” he would say.
He was never discharged by these Tribunals, not because I had “stitched him up”, but because as soon as he was given the opportunity to speak, he would tell the Tribunal all about the plots by the Nazi’s or various Northern Irish paramilitary organisations to kill him. And then they would nod their heads sympathetically, adjourn for a discussion – and then would invariably uphold the detention.
However, over time, and with a change in his antipsychotic medication, his mental state did improve. One day I visited him for a S.117 review meeting, and he greeted me with a smile, shook me warmly by the hand, and enquired politely about how things were going in Charwood. Over a six month period, he had improved to such an extent that in all the years I had known him I had never actually seen him so well. The review concluded that he could be transferred back to an open ward, with an eventual plan of returning to live in Charwood in independent accommodation.
His improvement continued back in Charwood Psychiatric Unit. We started to make plans for his discharge, applying to the local council for housing. We managed to get him a nice flat surprisingly quickly. And he was discharged from Sec.3 and at last came back to live in Charwood.
Lenny was quite different this time. He engaged with support workers, happily accepted his depot injection, and religiously took his oral medication. He took an interest in decorating and furnishing his flat. He always welcomed me warmly whenever I visited him, and we have long and rational conversations. He hardly drank alcohol at all. For eighteen months he actually seemed happy and fulfilled.
Then one morning one of his support workers returned to the CMHT to say that she had been unable to get a response from him. This was not like Lenny. He enjoyed the visits from the support worker. I went out to investigate further. The flat was on the ground floor, so I tried looking in through the windows. His TV was on in the living room but Lenny was not in there. He wasn’t in the kitchen. The curtains were drawn in his bedroom. It was too early for Lenny to have gone out, and he wouldn’t have done knowing his support worker was visiting.
I called the police. They joined me at his house. We contacted the housing association, who sent a locksmith round to get in through the front door. I followed the police officer inside and we went into one room after another, looking for Lenny.
We found him in his bedroom. It looked as if he had knelt down to change the station on a portable radio on the floor. Then something catastrophic must have happened and he had collapsed backwards, folding down onto his knees, his feet trapped under his body. He was dead. He had probably been dead for two or three days. He died alone, and no-one had found him for two or three days. He was 30 years old.
There was an initial inquest, as the police suspected that he might have taken an overdose. But I didn’t believe that, and the post mortem revealed that he had had an unsuspected heart defect, and had had a heart attack.
His support workers and I attended the interment. His father and sister and a few family members were there. There was no sign of his mother. No friends attended.
Why had Lenny’s life been so bereft and ultimately so sad? What had happened during his childhood that was so bad that he once ran out of the room when I merely started to talk to him about the idea of possibly talking about it at some point in the future? And had whatever happened to him made him how he was, suspicious, lacking in social skills, reluctant to make friends or trust anyone?
Did he ever have an emotionally unstable personality disorder, or did he actually have a psychotic illness that had not been diagnosed? Did the label of personality disorder stop people from looking further? His discharge from detention the first time certainly gave him the unfettered opportunity to develop a full-blown psychosis, as a Tribunal had decided he did not need treatment, and the CMHT had had to back off, for a while at least.
Undoubtedly, his eventual symptoms were text-book signs of paranoid schizophrenia, and these symptoms eventually resolved with the use of antipsychotic medication. And when he was free of psychotic symptoms, there were also no signs of emotionally unstable personality disorder. Would he have spent less time in hospital had he been started on that sort of medication in his teens? Would he have had more of a life before his heart defect eventually killed him?
I don’t have the answers to those questions. All I know now, is that Lenny lived, and then he died.
Sunday, 24 July 2011
Tuesday, 19 July 2011
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.
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.
Sunday, 10 July 2011
Join The Masked AMHP's Facebook group!
The Masked AMHP now has a Facebook group. Join now (or when you can be bothered) to find out what The Masked AMHP's been up to each week, and to discuss the ins and outs of practice as an AMHP. Sec.2 or Sec.3? MHA or MCA? Sometimes it's just too close to call...
You can find the Masked AMHP Facebook Group here!
You can find the Masked AMHP Facebook Group here!
Tuesday, 21 June 2011
Why Be An AMHP?
Blogger provides a lot of interesting data relating to the readership of one’s blog, not least of which is the rough geographical location of visitors. Although predominantly my readers originate in the UK, there are a lot of people in the USA who follow The Masked AMHP, and I even seem to have a significant readership in South Korea, among other more unexpected places. One of the other interesting pieces of data is the search keywords that people have used that have led them to the site. “Diogenes Syndrome” somewhat surprisingly is by far the most popular search term (I suppose people living voluntarily in squalor worries a lot of people), but quite close behind is the question: “Why be an AMHP?”
I suppose that most of the people asking search engines this question are British mental health practitioners trying to make up their minds about whether or not it’s worth undergoing the fairly extensive training necessary to become an Approved Mental Health Practitioner. When the new role of the AMHP was created, it meant that not just social workers, but also nurses, occupational therapists and clinical psychologists could all apply to become AMHP’s.
I have to say that of the numerous occupational therapists I have met and worked with over the years, none have ever shown the slightest inclination to undertake this function. It’s just not really the sort of thing someone wanting to be an OT would tend to consider.
(Mischievous imaginary scene #1:
CMHT Manager: “What was the outcome of your assessment of Joe Bloggs under the Mental Health Act yesterday?”
Occupational Therapist: “We had a lovely discussion about arts and crafts and then we made a macramé plant pot holder together.”)
I also cannot imagine a clinical psychologist wanting to take on this role – most psychologists I know only ever see patients in their clinical base, and then only if the patient actually wants to see them.
(Mischievous imaginary scene #2:
CMHT Manager: “Could you go out and assess Joe Bloggs under the Mental Health Act?”
Clinical Psychologist: “I can put him on my waiting list, but does he actually want to be sectioned?”)
Our local AMHP course, which has just finished, had 3 community mental health nurses. While I and other AMHP’s involved with the course, were initially sceptical that nurses could take on board the social perspective that is second nature to most social workers, and were particularly worried that nurses might have difficulty in adopting the autonomy that is essential in the AMHP role, we were impressed and reassured at the enthusiasm and willingness to learn new skills that the nurse candidates displayed during their practice placements.
So why be an AMHP, then? Perhaps I can begin to answer that question by giving some of the reasons why I am an AMHP.
Some of the service user readers of this blog might suggest that the main reason why anyone would be an AMHP is so that they can fascistically exert power over helpless mental patients who don’t really have anything wrong with them and are just trying to get on with their lives in their own idiosyncratic ways. Surprisingly enough perhaps, that is not why I am an AMHP.
The AMHP role is a complex one. It is also unique among the tasks of social workers (and other mental health professionals) in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.
Going back to my time as a generic social worker in the 70’s and 80’s, I recall in child protection meetings being told to go out and apply for an Emergency Protection Order on a child, or to initiate care proceedings. In those circumstances, the social worker is merely doing what they are told, executing the corporate decision of the agency, regardless of their own possible misgivings.
I have to say that one of the things I enjoyed about working as a generic out of hours emergency duty worker was the autonomy. Whatever the case, whether it be a report of child abuse, a elderly person requiring emergency care, or a request for a Mental health Act assessment, there were no managers around to tell you what to do or what not to do. You could make your own executive decisions, carry them out, then pass the case on to the local area the following day.
If you would like more autonomy in your job, then being an AMHP can provide that. Of course, a consequence of the autonomy you have as an AMHP is that you have to take full professional responsibility for your decision, whatever it may be, and its consequences.
AMHP’s have an in depth knowledge of law and have a responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.
Even though some patients subjected to this assessment process may regard that assessment as a foregone conclusion, the AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment. As a social worker, if you can pull all that off, I think that’s pretty cool.
The AMHP role does indeed consist of a range of powers, but the AMHP has a range of duties as well. The following lists are not exhaustive, but include the main powers and duties.
Powers include:
The training is fairly rigorous. Our local AMHP course is based in the School of Social Work at the local university. It is equivalent academically to post graduate level, and can give credits towards a higher degree. That may be both an incentive and disincentive, depending on how much you might enjoy academic work. The course extends over several months, including taught modules and a practice placement, which means that candidates are away from their normal workplace for an extended period. Candidates have to submit a number of written assignments, as well as a portfolio giving evidence of their competence to practice. And they have to take a law exam.
However, at the end of all that, the new AMHP is in possession of an impressive breadth and depth of knowledge and skills, which they can then use and develop in their day to day work, as well as when being called upon to undertake AMHP duties. I have said before on this blog that your skills and knowledge as an AMHP can inform and enhance your entire professional outlook.
Qualifying as an AMHP and being Approved is not, however, the end of it. AMHP’s have to be re-approved every 5 years. They have to show evidence throughout that time that they have practiced as an AMHP, that they have had regular supervision of their practice, and that they have undertaken at least three days’ refresher training each year during that time. That may be regarded as onerous, but it also allows the luxury of uninterrupted time when you only have to consider matters of pure professional interest, unhindered by the pressures of one’s day to day job.
And what about the pay? Although contracts for AMHP’s vary with different employers, there is always an acknowledgement that the AMHP has a senior and exacting role, and AMHP’s are rewarded monetarily in various ways, either through enhanced increments to basic pay, or by a separate monthly AMHP payment. But when you consider that I as an AMHP receive less per month for all that responsibility and expertise than a Sec.12 approved doctor does for making a single recommendation under the MHA, then it is not exactly a way to get rich quick.
So why be an AMHP? For me, I like the autonomy, the ability to reach my own conclusions independently of outside pressures, the use of knowledge and experience in a crisis, the necessity to think on my feet, to manage situations of extreme stress while remaining calm and in charge of the process, and the satisfaction of knowing that I have done the best I can in often very difficult situations. And then, hopefully, to see someone recover and be able to function as an individual again.
One day I was in conversation with a woman whom I had assessed under the MHA in the past on several occasions. Sometimes I had had to detain her against her will, and on other occasions she had agreed to informal admission. She suddenly said to me: “I want you to know that I’m really grateful to you for sectioning me. I was really ill then, but didn’t know it. I couldn’t have been left like that. You helped me to get better.” That’s what makes it all worthwhile.
I suppose that most of the people asking search engines this question are British mental health practitioners trying to make up their minds about whether or not it’s worth undergoing the fairly extensive training necessary to become an Approved Mental Health Practitioner. When the new role of the AMHP was created, it meant that not just social workers, but also nurses, occupational therapists and clinical psychologists could all apply to become AMHP’s.
I have to say that of the numerous occupational therapists I have met and worked with over the years, none have ever shown the slightest inclination to undertake this function. It’s just not really the sort of thing someone wanting to be an OT would tend to consider.
(Mischievous imaginary scene #1:
CMHT Manager: “What was the outcome of your assessment of Joe Bloggs under the Mental Health Act yesterday?”
Occupational Therapist: “We had a lovely discussion about arts and crafts and then we made a macramé plant pot holder together.”)
I also cannot imagine a clinical psychologist wanting to take on this role – most psychologists I know only ever see patients in their clinical base, and then only if the patient actually wants to see them.
(Mischievous imaginary scene #2:
CMHT Manager: “Could you go out and assess Joe Bloggs under the Mental Health Act?”
Clinical Psychologist: “I can put him on my waiting list, but does he actually want to be sectioned?”)
Our local AMHP course, which has just finished, had 3 community mental health nurses. While I and other AMHP’s involved with the course, were initially sceptical that nurses could take on board the social perspective that is second nature to most social workers, and were particularly worried that nurses might have difficulty in adopting the autonomy that is essential in the AMHP role, we were impressed and reassured at the enthusiasm and willingness to learn new skills that the nurse candidates displayed during their practice placements.
So why be an AMHP, then? Perhaps I can begin to answer that question by giving some of the reasons why I am an AMHP.
Some of the service user readers of this blog might suggest that the main reason why anyone would be an AMHP is so that they can fascistically exert power over helpless mental patients who don’t really have anything wrong with them and are just trying to get on with their lives in their own idiosyncratic ways. Surprisingly enough perhaps, that is not why I am an AMHP.
The AMHP role is a complex one. It is also unique among the tasks of social workers (and other mental health professionals) in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.
Going back to my time as a generic social worker in the 70’s and 80’s, I recall in child protection meetings being told to go out and apply for an Emergency Protection Order on a child, or to initiate care proceedings. In those circumstances, the social worker is merely doing what they are told, executing the corporate decision of the agency, regardless of their own possible misgivings.
I have to say that one of the things I enjoyed about working as a generic out of hours emergency duty worker was the autonomy. Whatever the case, whether it be a report of child abuse, a elderly person requiring emergency care, or a request for a Mental health Act assessment, there were no managers around to tell you what to do or what not to do. You could make your own executive decisions, carry them out, then pass the case on to the local area the following day.
If you would like more autonomy in your job, then being an AMHP can provide that. Of course, a consequence of the autonomy you have as an AMHP is that you have to take full professional responsibility for your decision, whatever it may be, and its consequences.
AMHP’s have an in depth knowledge of law and have a responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.
Even though some patients subjected to this assessment process may regard that assessment as a foregone conclusion, the AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment. As a social worker, if you can pull all that off, I think that’s pretty cool.
The AMHP role does indeed consist of a range of powers, but the AMHP has a range of duties as well. The following lists are not exhaustive, but include the main powers and duties.
Powers include:
- The power to make an application for compulsory admission to hospital under Sec.2, Sec.3 or Sec.4
- The power to make an application for guardianship under Sec.7
- The power to convey the patient to hospital or to authorise others to do so
- The power to enter and inspect premises – other than a hospital - where someone is not receiving proper care
- The power to apply for a warrant to search for and remove patients or persons living alone in need of care under Sec.135(1)
- The power to remove and return patients within UK, or to take or re-take detained patients absent without leave (S.18 and S.138)
- The duty to interview the patient “in a suitable manner” (Sec.13(2))
- The duty to respond to a request by a Nearest Relative to assess someone under the MHA (Sec.13(4))
- The duty to consult the patient’s Nearest Relative when considering a Sec.3 (or guardianship)
- The duty to inform the patient’s Nearest Relative when detaining under Sec.2
- The duty to interview a person removed to a "place of safety" by police under S.136
- The duty to consider an application for a patient to be made subject to Supervised Community treatment under Sec.17A
The training is fairly rigorous. Our local AMHP course is based in the School of Social Work at the local university. It is equivalent academically to post graduate level, and can give credits towards a higher degree. That may be both an incentive and disincentive, depending on how much you might enjoy academic work. The course extends over several months, including taught modules and a practice placement, which means that candidates are away from their normal workplace for an extended period. Candidates have to submit a number of written assignments, as well as a portfolio giving evidence of their competence to practice. And they have to take a law exam.
However, at the end of all that, the new AMHP is in possession of an impressive breadth and depth of knowledge and skills, which they can then use and develop in their day to day work, as well as when being called upon to undertake AMHP duties. I have said before on this blog that your skills and knowledge as an AMHP can inform and enhance your entire professional outlook.
Qualifying as an AMHP and being Approved is not, however, the end of it. AMHP’s have to be re-approved every 5 years. They have to show evidence throughout that time that they have practiced as an AMHP, that they have had regular supervision of their practice, and that they have undertaken at least three days’ refresher training each year during that time. That may be regarded as onerous, but it also allows the luxury of uninterrupted time when you only have to consider matters of pure professional interest, unhindered by the pressures of one’s day to day job.
And what about the pay? Although contracts for AMHP’s vary with different employers, there is always an acknowledgement that the AMHP has a senior and exacting role, and AMHP’s are rewarded monetarily in various ways, either through enhanced increments to basic pay, or by a separate monthly AMHP payment. But when you consider that I as an AMHP receive less per month for all that responsibility and expertise than a Sec.12 approved doctor does for making a single recommendation under the MHA, then it is not exactly a way to get rich quick.
So why be an AMHP? For me, I like the autonomy, the ability to reach my own conclusions independently of outside pressures, the use of knowledge and experience in a crisis, the necessity to think on my feet, to manage situations of extreme stress while remaining calm and in charge of the process, and the satisfaction of knowing that I have done the best I can in often very difficult situations. And then, hopefully, to see someone recover and be able to function as an individual again.
One day I was in conversation with a woman whom I had assessed under the MHA in the past on several occasions. Sometimes I had had to detain her against her will, and on other occasions she had agreed to informal admission. She suddenly said to me: “I want you to know that I’m really grateful to you for sectioning me. I was really ill then, but didn’t know it. I couldn’t have been left like that. You helped me to get better.” That’s what makes it all worthwhile.
Tuesday, 14 June 2011
Should People Be Stopped From Committing Suicide?
I still remember, during my training as an Approved Social Worker back in 1984, being told that, just because someone wanted to kill themselves, it didn’t necessarily mean that they had a mental disorder or that they ought to be detained under the Mental Health Act. This informed (and at times complicated) the decisions I had to take under the MHA over the years.
I was once asked to assess a man who had been detained under Sec.136 after he had tried to hang himself. He had made a serious attempt. He meant to do it. But when I assessed him in the police station I could find no evidence at all of any mental illness. He was distressed that his wife had left him. He had wanted to show her how her decision to leave him had made him feel. He was likely to make some further attempt on his life. But he wasn’t actually depressed, He was reacting to an adverse life event. My impression was that, even though he presented a significant suicide risk, it would be through petulance rather than mental disorder. I did not feel that I could justify detaining him under the MHA, even for assessment.
He succeeded in killing himself two weeks later.
I once worked with a service user who suffered from chronic and disabling osteoarthritis. She was largely confined to her home, needed considerable support with day to day living, and was often in extreme pain. She confided in me one day that she had been studying efficient and painless methods of suicide, and that she had stockpiled a supply of the medication necessary to dispatch her with as little fuss and disturbance as possible. She explained that this was her insurance, that if she considered that her quality of life was so impaired by her condition as to be worthless, then she knew she could quietly and discretely end her life.
I respected this. She had capacity, she had a chronic condition, which although not necessarily life threatening, could at some stage make her life intolerable – and knowing that she had some control over her destiny actually allowed her to keep on. It never crossed my mind to consider the use of the Mental Health Act.
But I have been troubled for some time by the implications of another case which made the headlines a couple of years ago.
Kerrie Wooltorton was 26 when she committed suicide in September 2007. She had swallowed antifreeze, and although she had herself called an ambulance and had allowed herself to be taken to hospital, she had refused the treatment which would have saved her life. The doctors in charge of her treatment allowed her to die.
Why had they done this? Because three days before she had written what was described in press reports as a “living will” in which she stated that she was “100% aware” of the consequences of her actions and that she did not want to receive treatment.
When I read the reports of the Inquest into this case, which was concluded two years later in September 2009, I was aghast.
It was stated that she had an “incurable emotionally unstable personality disorder”, that she had a long history of self harm (she had taken 9 similar does of antifreeze in the year before her death), and that she had been sectioned and admitted to psychiatric hospital on a number of occasions in the past. Nevertheless, despite this history of mental disorder and extensive past use of the Mental Health Act, her renal consultant stated in the Inquest that “she was in no state to resist me and I could have forced treatment on her, but I don't think it was the right thing to do. I feel it would have been assault.” A spokesman for the hospital said: “It is a double-bind for doctors. She was very clear in her wishes. To have forced treatment on her would have been unlawful.”
The coroner concluded: “My judgement is that Kerrie had mental capacity. She had the right to refuse treatment and could not have been treated without her consent. Her decision to refuse treatment was consistent and she never changed her mind. The doctor went over and above what was required of him. He discussed the case with clinical colleagues, took a second opinion from a fellow consultant and sought advice from the medical director. A deliberate decision to die may appear repugnant, but any treatment to have saved Kerrie's life in the absence of her consent would have been unlawful.”
Being an AMHP, I was virtually shouting out as I read this report: “Duh? What about the Mental Health Act? Was an AMHP (or ASW, as 2007 was before the creation of AMHP’s) involved in this decision? Were two Sec.12 approved doctors asked to give an opinion? What about “mental disorder” within the meaning of the Act? And what’s a “living will” when it’s at home?"
After I’d had a lie down, I looked more closely at this case. It appeared to hinge on the issue of capacity and her “living will”. By the time of the Inquest, the Mental Capacity Act had been in force for a couple of years. The issues that this Act brought to bear were blamed for this bizarre decision to allow her to die. An analysis of the case by Professor Sheila A M McLean, a Professor of Law and Ethics in Medicine, published on the BMJ website, assumed that the “living will” was in fact an “advance directive” covered by the Mental Capacity Act. She concentrated on issues of mental competency and concluded that:
“A doctor who imposes treatment in the face of a competent refusal would be guilty of assaulting the patient. However dreadful it must be for healthcare professionals to watch a person who could be saved die for want of available treatment, they have no alternative but to do so… Ms Wooltorton was adult, competent and able at the relevant time to reject treatment. This was her right and, as such, had to be respected.”
However, Stuart Sorensen, writing in Community Care, came to what I would consider to be a more reasonable conclusion. He pointed out that the Mental Capacity Act's Code of Practice “is clear that the Act does not support suicide, assisted dying or mercy killing”. His conclusion was that her clear intention to end her life:
“means that she cannot be seen as decision-maker in the eyes of the law. The power to decide passes to the care team who have to act in what they reasonably believe to be her best interests. It seems reasonable to doubt that best interests means watching her die slowly and presumably painfully from acute poisoning.”
No-one at the time appeared to have considered the dubious legal basis on which Kerrie had written her “living will”. The Government’s own guidance to the implementation of the MCA issued in July 2007 stated that the section of the MCA covering advance decisions would not come into force until 1st October 2007 and that “most advance decisions, refusing life-sustaining treatments, made before October 2007 are unlikely to meet the specific requirements of the Act.” Not only would Kerrie Wooltorton’s advance decision not have complied with the Code of Practice to the MCA, but since it was written and executed in September 2007, it would not have been valid in any case. That in itself should have provided sufficient justification for the hospital to have disregarded her “living will” and to have provided her with treatment.
So what conclusions should an AMHP reach when confronted with a similar situation?
The case of GJ v The Foundation Trust (2009) EWHC 2972 (Fam), although relating to Deprivation of Liberty under the Mental Capacity Act, presents a potentially relevant finding that “the MHA has primacy” over the MCA: that essentially, where both the MHA and the MCA may apply to a case of “detention”, whether through Sec. 2 or 3 of the MHA or Deprivation of Liberty under the MCA, then the MHA should be used. In other words, the MCA could legitimately be disregarded in a case such as Kerrie Wooltorton’s, and an assessment could take place under the MHA with an AMHP and two psychiatrists.
Advance decisions and issues of capacity do not necessarily have much bearing on decisions taken under the MHA, and the concept of “capacity” is not a factor which has to be taken into account when reaching a conclusion about detention under the MHA, providing the other factors were established.
Were such an assessment to take place today, all that the assessment team would need to establish would be:
I was once asked to assess a man who had been detained under Sec.136 after he had tried to hang himself. He had made a serious attempt. He meant to do it. But when I assessed him in the police station I could find no evidence at all of any mental illness. He was distressed that his wife had left him. He had wanted to show her how her decision to leave him had made him feel. He was likely to make some further attempt on his life. But he wasn’t actually depressed, He was reacting to an adverse life event. My impression was that, even though he presented a significant suicide risk, it would be through petulance rather than mental disorder. I did not feel that I could justify detaining him under the MHA, even for assessment.
He succeeded in killing himself two weeks later.
Fortunately, I had arranged for him to have a medical review. On the day he killed himself, he had been assessed by both a junior doctor and a consultant psychiatrist. They both also concluded that, despite a significant suicide risk, he did not have a mental disorder.
On another occasion I was asked to assess another man who was an informal patient in hospital after having made a suicide attempt. When I assessed him, he presented with a perfectly normal mood and no discernible evidence of depression or other mental disorder. He said that he had had an enjoyable life up until then, but told me matter-of-factly that it would only go downhill from here and he therefore did not see the point of continuing to live. He was 30 years old.
This was a difficult decision. There were two medical recommendations for assessment under Sec.2 MHA, but I was struggling to justify to myself detaining him in the absence of any evidence that I could find of actual mental disorder. In the end, I concluded that, in view of the fact that two doctors were prepared to state that he was “suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment”, the safest option was to detain him. This was a case of deciding whether I would rather justify my decision to a Tribunal or an Inquest.
I once worked with a service user who suffered from chronic and disabling osteoarthritis. She was largely confined to her home, needed considerable support with day to day living, and was often in extreme pain. She confided in me one day that she had been studying efficient and painless methods of suicide, and that she had stockpiled a supply of the medication necessary to dispatch her with as little fuss and disturbance as possible. She explained that this was her insurance, that if she considered that her quality of life was so impaired by her condition as to be worthless, then she knew she could quietly and discretely end her life.
I respected this. She had capacity, she had a chronic condition, which although not necessarily life threatening, could at some stage make her life intolerable – and knowing that she had some control over her destiny actually allowed her to keep on. It never crossed my mind to consider the use of the Mental Health Act.
But I have been troubled for some time by the implications of another case which made the headlines a couple of years ago.
Kerrie Wooltorton was 26 when she committed suicide in September 2007. She had swallowed antifreeze, and although she had herself called an ambulance and had allowed herself to be taken to hospital, she had refused the treatment which would have saved her life. The doctors in charge of her treatment allowed her to die.
Why had they done this? Because three days before she had written what was described in press reports as a “living will” in which she stated that she was “100% aware” of the consequences of her actions and that she did not want to receive treatment.
When I read the reports of the Inquest into this case, which was concluded two years later in September 2009, I was aghast.
It was stated that she had an “incurable emotionally unstable personality disorder”, that she had a long history of self harm (she had taken 9 similar does of antifreeze in the year before her death), and that she had been sectioned and admitted to psychiatric hospital on a number of occasions in the past. Nevertheless, despite this history of mental disorder and extensive past use of the Mental Health Act, her renal consultant stated in the Inquest that “she was in no state to resist me and I could have forced treatment on her, but I don't think it was the right thing to do. I feel it would have been assault.” A spokesman for the hospital said: “It is a double-bind for doctors. She was very clear in her wishes. To have forced treatment on her would have been unlawful.”
The coroner concluded: “My judgement is that Kerrie had mental capacity. She had the right to refuse treatment and could not have been treated without her consent. Her decision to refuse treatment was consistent and she never changed her mind. The doctor went over and above what was required of him. He discussed the case with clinical colleagues, took a second opinion from a fellow consultant and sought advice from the medical director. A deliberate decision to die may appear repugnant, but any treatment to have saved Kerrie's life in the absence of her consent would have been unlawful.”
Being an AMHP, I was virtually shouting out as I read this report: “Duh? What about the Mental Health Act? Was an AMHP (or ASW, as 2007 was before the creation of AMHP’s) involved in this decision? Were two Sec.12 approved doctors asked to give an opinion? What about “mental disorder” within the meaning of the Act? And what’s a “living will” when it’s at home?"
After I’d had a lie down, I looked more closely at this case. It appeared to hinge on the issue of capacity and her “living will”. By the time of the Inquest, the Mental Capacity Act had been in force for a couple of years. The issues that this Act brought to bear were blamed for this bizarre decision to allow her to die. An analysis of the case by Professor Sheila A M McLean, a Professor of Law and Ethics in Medicine, published on the BMJ website, assumed that the “living will” was in fact an “advance directive” covered by the Mental Capacity Act. She concentrated on issues of mental competency and concluded that:
“A doctor who imposes treatment in the face of a competent refusal would be guilty of assaulting the patient. However dreadful it must be for healthcare professionals to watch a person who could be saved die for want of available treatment, they have no alternative but to do so… Ms Wooltorton was adult, competent and able at the relevant time to reject treatment. This was her right and, as such, had to be respected.”
However, Stuart Sorensen, writing in Community Care, came to what I would consider to be a more reasonable conclusion. He pointed out that the Mental Capacity Act's Code of Practice “is clear that the Act does not support suicide, assisted dying or mercy killing”. His conclusion was that her clear intention to end her life:
“means that she cannot be seen as decision-maker in the eyes of the law. The power to decide passes to the care team who have to act in what they reasonably believe to be her best interests. It seems reasonable to doubt that best interests means watching her die slowly and presumably painfully from acute poisoning.”
No-one at the time appeared to have considered the dubious legal basis on which Kerrie had written her “living will”. The Government’s own guidance to the implementation of the MCA issued in July 2007 stated that the section of the MCA covering advance decisions would not come into force until 1st October 2007 and that “most advance decisions, refusing life-sustaining treatments, made before October 2007 are unlikely to meet the specific requirements of the Act.” Not only would Kerrie Wooltorton’s advance decision not have complied with the Code of Practice to the MCA, but since it was written and executed in September 2007, it would not have been valid in any case. That in itself should have provided sufficient justification for the hospital to have disregarded her “living will” and to have provided her with treatment.
So what conclusions should an AMHP reach when confronted with a similar situation?
The case of GJ v The Foundation Trust (2009) EWHC 2972 (Fam), although relating to Deprivation of Liberty under the Mental Capacity Act, presents a potentially relevant finding that “the MHA has primacy” over the MCA: that essentially, where both the MHA and the MCA may apply to a case of “detention”, whether through Sec. 2 or 3 of the MHA or Deprivation of Liberty under the MCA, then the MHA should be used. In other words, the MCA could legitimately be disregarded in a case such as Kerrie Wooltorton’s, and an assessment could take place under the MHA with an AMHP and two psychiatrists.
Advance decisions and issues of capacity do not necessarily have much bearing on decisions taken under the MHA, and the concept of “capacity” is not a factor which has to be taken into account when reaching a conclusion about detention under the MHA, providing the other factors were established.
Were such an assessment to take place today, all that the assessment team would need to establish would be:
- Is the patient suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment (or assessment and treatment)?
- If so, is it in the interests of the patient’s health or safety?
Monday, 30 May 2011
Who Is Your Nearest Relative?
Blog Reader: I say, Masked AMHP, you’ve been promising to write a post about how to identify the Nearest Relative of a patient detained under the Mental Health Act for the last couple of years. Isn’t it time you got round to it?
Masked AMHP: Do I really have to?
BR: I’m sure we’d all appreciate it.
MA: Can’t I write about a history of mental health legislation instead?
BR: Save it for a future post. I want to know about Nearest Relatives!
MA: Oh, very well then. What do you want to know exactly?
BR: I want you to describe the process of identifying the Nearest Relative within the Meaning of the Mental Health Act. But so that I can understand it.
MA: You want the moon on a stick, don’t you? Don’t you know that Richard Jones devotes 12 pages of very small print in the 13th Edition of the Mental Health Act Manual to the identification of the Nearest Relative? (Available new from Amazon for only £68.82!)
BR: Does he? How interesting. But I’m sure you can do it in fewer pages. And stop advertising.
MA: OK then, I’ll have a go. But you may get a headache.
BR: I’ve got some Solpadol (available from all good chemists!)
MA: You’ll need them. And you stop advertising as well. Let’s see, where to start? Well, you need to understand right from the beginning that the Next of Kin is not necessarily the same as the Nearest Relative. You can choose your Next of Kin, but your Nearest Relative (I’m going to use the term NR from now on, as I’m fed up of typing Nearest Relative over and over again), is set in stone. Sort of. Sec.26 of the MHA defines the Nearest Relative, although to be honest, Chapter 33 of the Reference Guide to The Mental Health Act 1983 explains it more clearly. By the way, did you see how I’ve mastered hyperlinks in my blog?
BR: Stop showing off and get on with it.
MA: (Takes deep breath) Here goes then. The NR is the first person you encounter in the following list:
MA: I’ve only just begun. There’s rather more. Any relative has to be at least 18 years of age to count as the NR – unless they are a parent (unlikely, I’d have thought) or a husband, wife, civil partner, or living with the patient for at least 6 months as the husband, wife or civil partner. Oh, and adoptive children count as natural children. Then, of course, to quote from the Act: “Any relationship of the half-blood shall be treated as a relationship of the whole blood, and an illegitimate person shall be treated as the legitimate child of (a) his mother, and (b) if his father has parental responsibility for him within the meaning of Section 3 of the Children Act 1989, his father.” And of course, you have to remember that despite that, a relation of the whole blood will take precedence over the same relation of the half-blood.
BR: That sounds a bit Harry Potterish.
MA: Don’t be sarcastic. But since you’ve mentioned it, applying these rules, who is Harry Potter’s NR?
BR: Well, let’s see, both his parents are dead. He lives with the Dursleys, who we are told are his only living relatives. So it must be his uncle, Vernon?
MA: Nope. Vernon is not a blood relative. His aunt, Petunia, is the sister of Lily Potter, Harry’s deceased mother. She’s definitely over 18, so Petunia Dursley is Harry Potter’s NR within the meaning of the MHA.
BR: Well, I’m glad we’ve got that straight. Do you think Harry’s likely to need sectioning?
MA: Well, he thinks he has special powers, he sees all sorts of strange things that other people can’t see, he hears voices other people can’t hear – what do you think?
BR: I think you’re beginning to spoil the magic of the Harry Potter series for me...
MA: Right, back to the NR. If there is more than one person who comes in the same place in the list, then the eldest takes precedence, regardless of gender.
BR: OK, so I don’t have a partner, and I don’t have any children, but I have a mother and father. That would mean that the elder of the two would be my NR.
MA: That’s right! And if you didn’t have any surviving parents, but you had several brothers and sisters, the eldest would be your NR if there was no-one higher up in the list. And so on. But there are exceptions.
BR: Of course. There are always exceptions.
MA: A relative who lives with, or cares for, the patient, takes precedence over any other relatives. So if a patient lived with their youngest daughter, then the daughter would count over any other children, as long as she was over 18. If you are married or in a civil partnership, but separated or abandoned by your partner, then that person cannot count as your nearest relative. Oh, and if a relative permanently lives abroad, then they don’t count.
BR: What if you can’t find anyone on the list?
MA: Well, if you have lived with someone for at least 5 years, but not as a husband, wife, or same sex partner, then they would count. So if you were a lodger, your landlady might count as NR if you had no other living relatives. And finally, the NR can delegate someone else to act as the patient’s NR.
BR: Is that basically it, then?
MA: Well, I won’t go in to people detained under Part III of the MHA, that is, via the criminal justice system, as they don’t legally have NR’s.
BR: Why not?
MA: No idea. Anyway, let’s give you a little test. Here’s a real case where I had to reach a decision about who was the NR. Fanny was 67 years old. She lived alone. She had been married, but had divorced many years previously. She did not have any children. She had 5 or 6 brothers and sisters who lived in the area. The oldest of these lives in Spain. One brother lived nearby and used to visit her several times a week and help her with shopping and so on. Her father had had a son before he married her mother. This half brother was older than any of her other siblings, but he lived many miles away and had only ever seen his sister a few times. Who is Fanny’s NR?
BR: Well, the oldest of her siblings, regardless of contact? That would be the half brother.
MA: That’s what I thought too. So I contacted him, but he was ill and didn’t want to undertake the role of NR. So he appointed his daughter to act as NR, and I consulted her, and put her name on the section papers. But I was wrong.
BR: (Incredulously) The Masked AMHP was wrong?
MA: Yes. I’d forgotten two things. The first was that relatives of the full blood take precedence over relatives of the half-blood. The second was that a relative who was a carer of the patient took precedence over other relatives. So the brother who lived nearby and helped her with shopping was her actual NR. And I used him the next time I had to section her.
BR: That’s a pretty serious mistake. Didn’t you get in trouble?
MA: Well, “to the best of my knowledge and belief” I had identified the half brother. You only have to show that you have taken reasonable steps to establish the NR. I rectified it next time. Even the Masked AMHP can make mistakes, OK?
BR: So that’s all there is to know about establishing the NR for the purposes of the MHA?
MA: Would you like to know about children subject to Care Orders? The NR rules don’t apply to them. Oh, and the NR of a patient can change over time – if they get married, for instance, or if a child reaches the age of 18. Oh, and –
BR: That’s quite enough for one post, thank you. Nice to talk to you.
MA: Nice to talk to you, too. I hope you’ll drop in again sometime, when I might tell you all about the history of mental health legislation.
BR: I can’t wait.
Masked AMHP: Do I really have to?
BR: I’m sure we’d all appreciate it.
MA: Can’t I write about a history of mental health legislation instead?
BR: Save it for a future post. I want to know about Nearest Relatives!
MA: Oh, very well then. What do you want to know exactly?
BR: I want you to describe the process of identifying the Nearest Relative within the Meaning of the Mental Health Act. But so that I can understand it.
MA: You want the moon on a stick, don’t you? Don’t you know that Richard Jones devotes 12 pages of very small print in the 13th Edition of the Mental Health Act Manual to the identification of the Nearest Relative? (Available new from Amazon for only £68.82!)
BR: Does he? How interesting. But I’m sure you can do it in fewer pages. And stop advertising.
MA: OK then, I’ll have a go. But you may get a headache.
BR: I’ve got some Solpadol (available from all good chemists!)
MA: You’ll need them. And you stop advertising as well. Let’s see, where to start? Well, you need to understand right from the beginning that the Next of Kin is not necessarily the same as the Nearest Relative. You can choose your Next of Kin, but your Nearest Relative (I’m going to use the term NR from now on, as I’m fed up of typing Nearest Relative over and over again), is set in stone. Sort of. Sec.26 of the MHA defines the Nearest Relative, although to be honest, Chapter 33 of the Reference Guide to The Mental Health Act 1983 explains it more clearly. By the way, did you see how I’ve mastered hyperlinks in my blog?
BR: Stop showing off and get on with it.
MA: (Takes deep breath) Here goes then. The NR is the first person you encounter in the following list:
- husband, wife or civil partner;
- son or daughter;
- father or mother;
- brother or sister;
- grandparent;
- grandchild;
- uncle or aunt;
- nephew or niece.
MA: I’ve only just begun. There’s rather more. Any relative has to be at least 18 years of age to count as the NR – unless they are a parent (unlikely, I’d have thought) or a husband, wife, civil partner, or living with the patient for at least 6 months as the husband, wife or civil partner. Oh, and adoptive children count as natural children. Then, of course, to quote from the Act: “Any relationship of the half-blood shall be treated as a relationship of the whole blood, and an illegitimate person shall be treated as the legitimate child of (a) his mother, and (b) if his father has parental responsibility for him within the meaning of Section 3 of the Children Act 1989, his father.” And of course, you have to remember that despite that, a relation of the whole blood will take precedence over the same relation of the half-blood.
BR: That sounds a bit Harry Potterish.
MA: Don’t be sarcastic. But since you’ve mentioned it, applying these rules, who is Harry Potter’s NR?
BR: Well, let’s see, both his parents are dead. He lives with the Dursleys, who we are told are his only living relatives. So it must be his uncle, Vernon?
MA: Nope. Vernon is not a blood relative. His aunt, Petunia, is the sister of Lily Potter, Harry’s deceased mother. She’s definitely over 18, so Petunia Dursley is Harry Potter’s NR within the meaning of the MHA.
BR: Well, I’m glad we’ve got that straight. Do you think Harry’s likely to need sectioning?
MA: Well, he thinks he has special powers, he sees all sorts of strange things that other people can’t see, he hears voices other people can’t hear – what do you think?
BR: I think you’re beginning to spoil the magic of the Harry Potter series for me...
MA: Right, back to the NR. If there is more than one person who comes in the same place in the list, then the eldest takes precedence, regardless of gender.
BR: OK, so I don’t have a partner, and I don’t have any children, but I have a mother and father. That would mean that the elder of the two would be my NR.
MA: That’s right! And if you didn’t have any surviving parents, but you had several brothers and sisters, the eldest would be your NR if there was no-one higher up in the list. And so on. But there are exceptions.
BR: Of course. There are always exceptions.
MA: A relative who lives with, or cares for, the patient, takes precedence over any other relatives. So if a patient lived with their youngest daughter, then the daughter would count over any other children, as long as she was over 18. If you are married or in a civil partnership, but separated or abandoned by your partner, then that person cannot count as your nearest relative. Oh, and if a relative permanently lives abroad, then they don’t count.
BR: What if you can’t find anyone on the list?
MA: Well, if you have lived with someone for at least 5 years, but not as a husband, wife, or same sex partner, then they would count. So if you were a lodger, your landlady might count as NR if you had no other living relatives. And finally, the NR can delegate someone else to act as the patient’s NR.
BR: Is that basically it, then?
MA: Well, I won’t go in to people detained under Part III of the MHA, that is, via the criminal justice system, as they don’t legally have NR’s.
BR: Why not?
MA: No idea. Anyway, let’s give you a little test. Here’s a real case where I had to reach a decision about who was the NR. Fanny was 67 years old. She lived alone. She had been married, but had divorced many years previously. She did not have any children. She had 5 or 6 brothers and sisters who lived in the area. The oldest of these lives in Spain. One brother lived nearby and used to visit her several times a week and help her with shopping and so on. Her father had had a son before he married her mother. This half brother was older than any of her other siblings, but he lived many miles away and had only ever seen his sister a few times. Who is Fanny’s NR?
BR: Well, the oldest of her siblings, regardless of contact? That would be the half brother.
MA: That’s what I thought too. So I contacted him, but he was ill and didn’t want to undertake the role of NR. So he appointed his daughter to act as NR, and I consulted her, and put her name on the section papers. But I was wrong.
BR: (Incredulously) The Masked AMHP was wrong?
MA: Yes. I’d forgotten two things. The first was that relatives of the full blood take precedence over relatives of the half-blood. The second was that a relative who was a carer of the patient took precedence over other relatives. So the brother who lived nearby and helped her with shopping was her actual NR. And I used him the next time I had to section her.
BR: That’s a pretty serious mistake. Didn’t you get in trouble?
MA: Well, “to the best of my knowledge and belief” I had identified the half brother. You only have to show that you have taken reasonable steps to establish the NR. I rectified it next time. Even the Masked AMHP can make mistakes, OK?
BR: So that’s all there is to know about establishing the NR for the purposes of the MHA?
MA: Would you like to know about children subject to Care Orders? The NR rules don’t apply to them. Oh, and the NR of a patient can change over time – if they get married, for instance, or if a child reaches the age of 18. Oh, and –
BR: That’s quite enough for one post, thank you. Nice to talk to you.
MA: Nice to talk to you, too. I hope you’ll drop in again sometime, when I might tell you all about the history of mental health legislation.
BR: I can’t wait.
Monday, 9 May 2011
When Nearest Relatives Object
The Mental Health Act gives the Nearest Relatives of patients subject to the Act specific legal powers. These include the right to apply for the discharge of a detained patient from hospital, as well as a veto of use of detention under Sec.3.
If an AMHP decides that a patient needs to be detained under Sec.3 of the Mental Health Act for treatment, they have a legal duty to consult with the identified Nearest Relative. Form A6, which is the form the AMHP uses to make an application for detention under Sec.3, is more concerned with issues relating to consultation with the Nearest Relative than anything else. The AMHP has to show that he or she has identified the Nearest Relative (I’ll deal with this arcane process in a future post, as it tends to involve incantations and the construction of pentagrams) and that consultation has taken place. If the AMHP has been unable to identify the NR, or has not been able to consult with the identified NR, then they have to state this and give reasons.
The purpose of the AMHP’s consultation with the NR is partly to inform them of their rights and powers under the Act, but mainly to find out whether or not they have any objection to their relative being detained. The AMHP has to certify that the NR “has not notified me…that he or she objects to this application being made”.
This is a crucial difference between Sec.2 and Sec.3. The AMHP only has to notify the NR that a Sec.2 application is being made. They do not otherwise have a say in the process. However, if the NR does object to the Sec.3, then no application can be made. The only way round this is for the AMHP to go to the High Court to apply for the NR to be displaced. They can only do this if there are compelling reasons, such as evidence that the NR is acting unreasonably or if they lack mental capacity. This is often a long and onerous process, involving the local authority’s legal department and the High Court. During that time the patient can often remain in suspended animation on an eternal Sec.2. It’s certainly not something that an AMHP can do on their mobile while standing in a patient’s kitchen.
AMHP’s can get into serious trouble if they do not properly consult with the NR. There have been a couple of legal decisions regarding this issue. One recent one was TTM v Hackney Borough Council and Others, 14th January 2011 in the Appeal Court. This concerned a patient who had been detained for 10 days under Sec.3 in a hospital in spite of the fact that the patient’s nearest relative had objected and no application for that relative‘s displacement had been made. The court found that the AMHP had acted unreasonably and in breach of the law, and that the patient had therefore been detained unlawfully, not just under domestic law, but also in breach of his rights under the Human Rights Act. This meant that the patient was eligible to claim compensation for unlawful imprisonment.
Another case where the then Approved Social Worker (as it was before the changes to the MHA bringing in AMHP’s) became unstuck was GD v The Managers of the Dennis Scott Unit at Edgware Community Hospital and The London Borough of Barnet, Queen’s Bench Division (Administrative Court), 27th June 2008 (Case law decisions have snappy titles, don't they?). In this case, the patient’s NR was his father. The patient was well known to mental health services with a diagnosis of schizophrenia, and it was also known that his father preferred natural remedies for his son’s mental illness over conventional hospital treatment and would be likely to object to an application under Sec.3 being made. There was also the very real fear, as it had happened in the past, that the father would hide him if he knew that an assessment was going to take place. Consequently, the ASW did not contact the NR before the assessment, and only let him know by leaving a message when the assessment was actually taking place. When the NR returned the call 20 minutes later, the paperwork had already been completed. He then indicated in no unclear terms his feelings about this and his objection. The ASW had by then filled in the section of the form indicating that it had been “impracticable” to consult with the NR. The Judge in the case found that the patient had been illegally detained because the ASW had deliberately failed to make adequate attempts to consult with the NR as he knew that the NR would object.
I have fortunately never been in the position of having to apply to displace a Nearest Relative. In my experience, it is fairly rare for Nearest Relatives to object to detention, although they may at times have misgivings, and quite often do not wish the patient to think that they have colluded in the admission. In these cases, I attempt to reassure the relative that although they have not objected, that is not the same as agreeing, and that the final decision, and responsibility, lies with the AMHP.
However, there are times when ascertaining the views of the Nearest Relative can be fraught with problems. There follow a few from my personal experience.
Charlotte
This was a case from the dim and distant past of the Mental Health Act, even before the 1983 Act. Charlotte was a 17 year old girl who was an informal patient in the local psychiatric hospital. She had had a very disturbed and abusive childhood, and had been rejected by her parents and spent several years in local authority children’s homes. She had been admitted after displaying bizarre and irrational behaviour. Following admission to the psychiatric ward, which in those days was a ward in the general hospital, and was directly beneath the prenatal and post natal wards, she had gone upstairs and wandered onto the post natal ward, where she had been apprehended in the act of attempting to remove one of the babies.
A request was made for her to be detained under the equivalent of Sec.3, which under the 1959 Act was known as Sec.26. This was in itself unusual, as patients had to be at least 18 years of age to be detained under Sec.26, with one exception: if the person had a psychopathic disorder. Since this was the case with Charlotte, she could be detained under this section.
I had to consult with her father, who was her Nearest Relative, to establish whether or not he objected to her being detained. In those days of generic social work teams (we’re talking about the early 1980’s), I worked in the same office as her social worker, and was aware that she was estranged from her parents, who had explicitly stated that they wished to have nothing to do with Charlotte. However, I considered that the requirements of the MHA overrode this instruction, and that I had to attempt to make contact with him. I rang him on his home number. His wife answered the phone. Charlotte’s father was at work. I explained to Charlotte’s mother the reason why I was ringing, and asked her to get Charlotte’s father to ring me.
A few minutes later I received a call from her father. Before I had a chance to explain in more detail the reasons for my call, he launched into a clearly prepared statement: “Social Services are aware of our instructions that we do not wish to have any contact concerning our daughter. If you attempt to make any further contact with us in any way, then I shall lodge a formal complaint with the Director of Social Services.” He then hung up.
I had at least made an effort to consult with Charlotte’s Nearest Relative. I had even spoken to him, briefly. And he had not indicated in his statement that he objected to her detention under the Act. So I felt in the circumstances that I could with hand on heart state on the form that I had consulted with the NR and that they had not objected.
Cathy
Cathy was an intelligent and well educated woman in her 30’s. Following a still birth, she slid into a vicious and intractable depression. She was admitted to hospital as an informal patient, but I was subsequently asked to assess her under the MHA and she was detained under Sec.2 for assessment. After a period of assessment, a further request was made for her detention under Sec.3 for treatment. I agreed to this and consulted with her nearest relative, which in this case was her mother. Her mother worked in a mental health voluntary organisation, and therefore had some knowledge of mental illness. I consulted with her and she did not object to Cathy being detained.
Cathy remained in hospital for over a year, but after a range of treatments her depression improved and she was discharged to the address of a friend. However, within a couple of months her mood had deteriorated drastically, and she took a serious overdose. She was again admitted informally to hospital from a medical ward, but then refused treatment. I assessed her again and applied for her detention under Sec.2 for further assessment. After three weeks it was clear that she was going to need a longer period of treatment as an inpatient, to which she would not agree, as she wanted to leave hospital in order explicitly to end her life.
It was clear that Cathy was going to need to be detained under Sec.3 again, so I contacted her mother in order to consult with her. To my surprise, she was very reluctant to consider her daughter’s further detention.
“Her life is pretty awful, isn’t it? She’s spent an awful amount of time in hospital. She doesn’t really have anything to live for, does she? Perhaps she ought to be allowed to die,” she said to me.
I was somewhat taken aback. I found it difficult to believe that Cathy's mother could even consider the alternative to detention as an option.
My own view was that Cathy suffered from a serious mental illness that was treatable. It was because of her mental illness that Cathy wanted to kill herself. She did not have the capacity to make a rational decision about ending her life or accepting treatment. I would be failing in my duty of care to Cathy if I allowed her to take her own discharge from hospital in order to kill herself.
I shared all this with her mother. The conversation continued for over an hour. She eventually reluctantly agreed that she should be kept in hospital for treatment.
Cathy did recover, was discharged from hospital after few months, remained well this time, and was never detained again.
Cheryl
Cheryl was a woman in her early 40's with bipolar affective disorder. She had a history of having acute manic episodes when subjected to excessive stress. When she became unwell, she frequently needed acute admission under the Mental health Act, as she rarely had enough insight to recognise she was becoming unwell. She had three children, but none of them were old enough to be her nearest relative, so when she needed detaining I always consulted with her mother as nearest relative.
She had been out of hospital for about three years when she again had an acute manic episode. This was accompanied by paranoia, classic symptoms of bipolar disorder, including pressure of speech, flight or ideas, an inability to sleep, concentrate or eat, as well as symptoms of paranoia, believing that she and her daughter were victims of pornography, as well as the belief that she had two wombs and had had dozens of babies, all of whom had been given away to paedophiles.
I went out with the consultant psychiatrist and her GP and it did not take long to decide that Cheryl needed to be admitted to hospital. She did say that she would go informally, but I did not feel that she had the capacity to agree, and was in any case likely to change her mind at any time. I obtained two medical recommendations and then consulted with her nearest relative. Her eldest son was now 19 years old, and therefore now counted as her nearest relative. He was present in the house and had been involved in the assessment. I took him to one side and asked him whether he had any objection to his mother being detained under Sec.3.
He did object.
I discussed the situation with him. He recognised that his mother needed to be in hospital, but did not want her to be detained. He wanted her to go in informally. He said that if his mother refused to go in at the point of admission, then he would have no objection to me detaining her then, but otherwise he could not agree.
I could understand his feelings. He had seen his mother being sectioned on several previous occasions, and at times she had been so disturbed that police had been involved and she had been taken to the police station. (On one occasion, Cheryl had been so keen to see the pastor of the local church, she had literally driven through the doors of the church and had ended up in the aisle.) This was also his first experience of being consulted as the nearest relative. He probably felt, as many relatives do, that his mother might blame him if he was perceived to have been endorsing her admission.
So I respected his wishes and we took her in informally. Fortunately, it worked out, and Cheryl agreed to treatment in hospital which rapidly brought her back to normal.
If an AMHP decides that a patient needs to be detained under Sec.3 of the Mental Health Act for treatment, they have a legal duty to consult with the identified Nearest Relative. Form A6, which is the form the AMHP uses to make an application for detention under Sec.3, is more concerned with issues relating to consultation with the Nearest Relative than anything else. The AMHP has to show that he or she has identified the Nearest Relative (I’ll deal with this arcane process in a future post, as it tends to involve incantations and the construction of pentagrams) and that consultation has taken place. If the AMHP has been unable to identify the NR, or has not been able to consult with the identified NR, then they have to state this and give reasons.
The purpose of the AMHP’s consultation with the NR is partly to inform them of their rights and powers under the Act, but mainly to find out whether or not they have any objection to their relative being detained. The AMHP has to certify that the NR “has not notified me…that he or she objects to this application being made”.
This is a crucial difference between Sec.2 and Sec.3. The AMHP only has to notify the NR that a Sec.2 application is being made. They do not otherwise have a say in the process. However, if the NR does object to the Sec.3, then no application can be made. The only way round this is for the AMHP to go to the High Court to apply for the NR to be displaced. They can only do this if there are compelling reasons, such as evidence that the NR is acting unreasonably or if they lack mental capacity. This is often a long and onerous process, involving the local authority’s legal department and the High Court. During that time the patient can often remain in suspended animation on an eternal Sec.2. It’s certainly not something that an AMHP can do on their mobile while standing in a patient’s kitchen.
AMHP’s can get into serious trouble if they do not properly consult with the NR. There have been a couple of legal decisions regarding this issue. One recent one was TTM v Hackney Borough Council and Others, 14th January 2011 in the Appeal Court. This concerned a patient who had been detained for 10 days under Sec.3 in a hospital in spite of the fact that the patient’s nearest relative had objected and no application for that relative‘s displacement had been made. The court found that the AMHP had acted unreasonably and in breach of the law, and that the patient had therefore been detained unlawfully, not just under domestic law, but also in breach of his rights under the Human Rights Act. This meant that the patient was eligible to claim compensation for unlawful imprisonment.
Another case where the then Approved Social Worker (as it was before the changes to the MHA bringing in AMHP’s) became unstuck was GD v The Managers of the Dennis Scott Unit at Edgware Community Hospital and The London Borough of Barnet, Queen’s Bench Division (Administrative Court), 27th June 2008 (Case law decisions have snappy titles, don't they?). In this case, the patient’s NR was his father. The patient was well known to mental health services with a diagnosis of schizophrenia, and it was also known that his father preferred natural remedies for his son’s mental illness over conventional hospital treatment and would be likely to object to an application under Sec.3 being made. There was also the very real fear, as it had happened in the past, that the father would hide him if he knew that an assessment was going to take place. Consequently, the ASW did not contact the NR before the assessment, and only let him know by leaving a message when the assessment was actually taking place. When the NR returned the call 20 minutes later, the paperwork had already been completed. He then indicated in no unclear terms his feelings about this and his objection. The ASW had by then filled in the section of the form indicating that it had been “impracticable” to consult with the NR. The Judge in the case found that the patient had been illegally detained because the ASW had deliberately failed to make adequate attempts to consult with the NR as he knew that the NR would object.
I have fortunately never been in the position of having to apply to displace a Nearest Relative. In my experience, it is fairly rare for Nearest Relatives to object to detention, although they may at times have misgivings, and quite often do not wish the patient to think that they have colluded in the admission. In these cases, I attempt to reassure the relative that although they have not objected, that is not the same as agreeing, and that the final decision, and responsibility, lies with the AMHP.
However, there are times when ascertaining the views of the Nearest Relative can be fraught with problems. There follow a few from my personal experience.
Charlotte
This was a case from the dim and distant past of the Mental Health Act, even before the 1983 Act. Charlotte was a 17 year old girl who was an informal patient in the local psychiatric hospital. She had had a very disturbed and abusive childhood, and had been rejected by her parents and spent several years in local authority children’s homes. She had been admitted after displaying bizarre and irrational behaviour. Following admission to the psychiatric ward, which in those days was a ward in the general hospital, and was directly beneath the prenatal and post natal wards, she had gone upstairs and wandered onto the post natal ward, where she had been apprehended in the act of attempting to remove one of the babies.
A request was made for her to be detained under the equivalent of Sec.3, which under the 1959 Act was known as Sec.26. This was in itself unusual, as patients had to be at least 18 years of age to be detained under Sec.26, with one exception: if the person had a psychopathic disorder. Since this was the case with Charlotte, she could be detained under this section.
I had to consult with her father, who was her Nearest Relative, to establish whether or not he objected to her being detained. In those days of generic social work teams (we’re talking about the early 1980’s), I worked in the same office as her social worker, and was aware that she was estranged from her parents, who had explicitly stated that they wished to have nothing to do with Charlotte. However, I considered that the requirements of the MHA overrode this instruction, and that I had to attempt to make contact with him. I rang him on his home number. His wife answered the phone. Charlotte’s father was at work. I explained to Charlotte’s mother the reason why I was ringing, and asked her to get Charlotte’s father to ring me.
A few minutes later I received a call from her father. Before I had a chance to explain in more detail the reasons for my call, he launched into a clearly prepared statement: “Social Services are aware of our instructions that we do not wish to have any contact concerning our daughter. If you attempt to make any further contact with us in any way, then I shall lodge a formal complaint with the Director of Social Services.” He then hung up.
I had at least made an effort to consult with Charlotte’s Nearest Relative. I had even spoken to him, briefly. And he had not indicated in his statement that he objected to her detention under the Act. So I felt in the circumstances that I could with hand on heart state on the form that I had consulted with the NR and that they had not objected.
Cathy
Cathy was an intelligent and well educated woman in her 30’s. Following a still birth, she slid into a vicious and intractable depression. She was admitted to hospital as an informal patient, but I was subsequently asked to assess her under the MHA and she was detained under Sec.2 for assessment. After a period of assessment, a further request was made for her detention under Sec.3 for treatment. I agreed to this and consulted with her nearest relative, which in this case was her mother. Her mother worked in a mental health voluntary organisation, and therefore had some knowledge of mental illness. I consulted with her and she did not object to Cathy being detained.
Cathy remained in hospital for over a year, but after a range of treatments her depression improved and she was discharged to the address of a friend. However, within a couple of months her mood had deteriorated drastically, and she took a serious overdose. She was again admitted informally to hospital from a medical ward, but then refused treatment. I assessed her again and applied for her detention under Sec.2 for further assessment. After three weeks it was clear that she was going to need a longer period of treatment as an inpatient, to which she would not agree, as she wanted to leave hospital in order explicitly to end her life.
It was clear that Cathy was going to need to be detained under Sec.3 again, so I contacted her mother in order to consult with her. To my surprise, she was very reluctant to consider her daughter’s further detention.
“Her life is pretty awful, isn’t it? She’s spent an awful amount of time in hospital. She doesn’t really have anything to live for, does she? Perhaps she ought to be allowed to die,” she said to me.
I was somewhat taken aback. I found it difficult to believe that Cathy's mother could even consider the alternative to detention as an option.
My own view was that Cathy suffered from a serious mental illness that was treatable. It was because of her mental illness that Cathy wanted to kill herself. She did not have the capacity to make a rational decision about ending her life or accepting treatment. I would be failing in my duty of care to Cathy if I allowed her to take her own discharge from hospital in order to kill herself.
I shared all this with her mother. The conversation continued for over an hour. She eventually reluctantly agreed that she should be kept in hospital for treatment.
Cathy did recover, was discharged from hospital after few months, remained well this time, and was never detained again.
Cheryl
Cheryl was a woman in her early 40's with bipolar affective disorder. She had a history of having acute manic episodes when subjected to excessive stress. When she became unwell, she frequently needed acute admission under the Mental health Act, as she rarely had enough insight to recognise she was becoming unwell. She had three children, but none of them were old enough to be her nearest relative, so when she needed detaining I always consulted with her mother as nearest relative.
She had been out of hospital for about three years when she again had an acute manic episode. This was accompanied by paranoia, classic symptoms of bipolar disorder, including pressure of speech, flight or ideas, an inability to sleep, concentrate or eat, as well as symptoms of paranoia, believing that she and her daughter were victims of pornography, as well as the belief that she had two wombs and had had dozens of babies, all of whom had been given away to paedophiles.
I went out with the consultant psychiatrist and her GP and it did not take long to decide that Cheryl needed to be admitted to hospital. She did say that she would go informally, but I did not feel that she had the capacity to agree, and was in any case likely to change her mind at any time. I obtained two medical recommendations and then consulted with her nearest relative. Her eldest son was now 19 years old, and therefore now counted as her nearest relative. He was present in the house and had been involved in the assessment. I took him to one side and asked him whether he had any objection to his mother being detained under Sec.3.
He did object.
I discussed the situation with him. He recognised that his mother needed to be in hospital, but did not want her to be detained. He wanted her to go in informally. He said that if his mother refused to go in at the point of admission, then he would have no objection to me detaining her then, but otherwise he could not agree.
I could understand his feelings. He had seen his mother being sectioned on several previous occasions, and at times she had been so disturbed that police had been involved and she had been taken to the police station. (On one occasion, Cheryl had been so keen to see the pastor of the local church, she had literally driven through the doors of the church and had ended up in the aisle.) This was also his first experience of being consulted as the nearest relative. He probably felt, as many relatives do, that his mother might blame him if he was perceived to have been endorsing her admission.
So I respected his wishes and we took her in informally. Fortunately, it worked out, and Cheryl agreed to treatment in hospital which rapidly brought her back to normal.
Subscribe to:
Posts (Atom)