My First Mental Health Act Assessment (Part II)

Fast forward to 1981. After two years working as an unqualified generic social worker I did a two year Certificate of Qualification in Social Work course (in those days the training was only two years, and the official social work qualification was the CQSW), and then returned to work in my old area office.

I had been qualified for about a year when the new area officer, Gerald, called me into his office.

“We’ve got a request for a Mental Health Act Assessment. Fancy doing it?”

“I’m not sure I’m qualified to act as a Mental Welfare Officer,” I replied nervously. “I haven’t had any training or anything.”

“Have a look on your social work warrant. What does it say?”

I looked at my ID card. The front had a passport photograph of me, sporting the obligatory long hair and beard of a male social worker of the time, along with my name and the local authority. The back said who and what I was and had the signature of the Director of Social Services. In rather small print in one corner there was a statement which I had never bothered to study: “The holder is authorised to act as a Mental Welfare Officer for the purposes of the Mental Health Act 1959.”

I read this out.

“There you go then,” Gerald said, and proceeded to give me the details of the request.

And that was my full initiation into the arcane world of Mental Welfare Officers.

The person I had to assess was an informal patient on one of the wards of the local Victorian asylum which thankfully no longer exists. Peter was a married man in his 40’s who had been admitted because he was believed to be delusional. Although he had initially agreed to the admission, he was now suspicious that the hospital was a part of the conspiracy against him.

I spent an hour reading up on the Mental Health Act and the relevant sections. I was desperately trying to remember the training I had had on my social work course and the things I had learned from observing a few assessments carried out by other MWO’s. Then I went to the ward to interview the patient.

He seemed pleased to see me.

“This will explain everything,” he said, giving me an exercise book filled with neat handwriting.

I started to read it. It detailed his life when working as an engineer in an African state that had previously been under colonial rule. He had basically lived, with his wife, in a post colonial enclave, which, he said in his account, was run by the Masons. He had never been much enamoured of the Masons, and when he discovered that they were providing local women to single (and married) British men for “personal services”, he decided to blow the whistle on the whole thing.

The Masons had, of course, objected to this, and, according to him, had made it impossible for him to continue working there and he had then returned to his home town in England. Even there, he told me, he had continued to be hounded by the Masons, who were preventing him from getting work and were making his life not worth living.

“And now,” he said, after I had read at least some of the exercise book, “they’re getting to me here. They’re drugging me, they don’t want me to tell. They want to kill me!”

I had little difficulty in reaching the conclusion that Peter was extremely unwell, and was displaying clear symptoms of psychosis, including paranoid delusions. The consultant had already completed a medical recommendation, and another doctor had already been to assess him and had left his recommendation. Although I was unable to contact his nearest relative to discuss the assessment with her, I duly completed an application under Sec.25 for assessment (this was the 1959 Act, remember).

It felt good. It had been a comparatively straightforward assessment – the patient was already in hospital, and was displaying clear signs of mental illness. I felt I had managed the whole thing rather well

A few days later, I visited his wife to discuss the situation with her. I told her about the contents of the exercise book, and his belief that the Masons had been conspiring against him.

“Oh yes,” she said. “All that’s true. It did happen. It really got him down. We had to leave the country because of it.”

A month later I completed my second Mental Health Act Assessment when I detained him under Sec.26 of the 1959 Act, for treatment. He was still clearly unwell, but this time he had a diagnosis of depression.

My First Mental Health Act Assessment (Part I)

It was 1976. I had my first job as an unqualified social worker (most social workers were unqualified in those days) in an area office with a mixed rural and semi urban catchment area. I had been working there for 2 months when Gordon, the area officer, called me into his room.

“Would you like to come out with me on a Mental Health Act assessment?” he asked.

Gordon was in his late 50’s. Before the major reorganisation of national social services a few years previously (arising from the Seebohm report, for those who may be interested), he had been what was known as a Mental Welfare Officer. Mental Welfare Officers were what we would now call AMHP’s. MWO’s were created by the Mental Health Act 1959, which introduced the concept of the independent lay person who made final decisions about detention in hospital based on the recommendations of doctors.

Of course I said yes. I was completely new to social work, and keen for experience.

The assessment was on a lady in her 50’s. She was the manager of a social security office. Her GP had rung Gordon because neighbours were reporting that she was wandering around in her garden dressed in nothing but her nightie. It was a chilly November morning, so this was a matter of some concern.

Gordon told me that she was known for this. She would go for months or years without any problems, then one day would wake up and be completely bonkers. A spell in hospital invariably sorted her out.

We met the GP at her house, a nice bungalow in the countryside. We didn’t bother to knock on the door, since we could see her wandering around in the garden in a diaphanous negligee. To see a woman of that age (or any woman come to that) so scantily clad was at the time quite a shock to me, but Gordon took it in his stride.

Gordon put on a rather scary fixed smile which I assume he thought was reassuring and the three of us approached her.

“Hello, June,” he said, “What seems to be the problem?”

She turned and looked at us. She looked at me with an interest that alarmed me. This was the first mad person I had ever seen. What might she do?

“I came out to see the fairies,” she eventually replied. “They’re everywhere. They’re so lovely.”

“Yes, they are, aren’t they?” Gordon replied. I assumed he was “humouring” her. “Why don’t we go inside? It’s quite chilly out here isn’t it?”

She allowed herself to be led through the garden into her house, her bare toes sinking into the damp grass as she went.

Gordon and the GP had a discussion in her kitchen. It didn’t take long. The GP filled in a form and then Gordon filled in another form. This was known then as a Section 29, when someone was detained with only one medical recommendation. Under the 1983 Act it would be a Section 4, which should only be used in cases of dire emergency. However, in those days it was almost impossible to get a psychiatrist to leave the safety of the ward, and Section 29’s were a not uncommon way of getting people to hospital, when the consultant would then convert it to a Section 25 at his leisure.

“Why don’t we go for a ride in my car?” Gordon asked June. “Just put on your coat and come with me.”

“Where are we going?” she asked.

“Just for a nice ride,” he said reassuringly.

I knew even then that this was not the right way to relieve someone of their liberty. Shouldn’t you always tell the truth, even to someone who seemed to be quite literally “away with the fairies”?

Throughout the drive to the hospital, Gordon continued with a stream of reassuring lies, and as we drew up outside the ward he told her that “it would only be a few days. You’ll have a nice rest and be right as rain in no time.” He knew she would probably be in there for several months; hospital admissions generally seemed to be much longer than they are now.

Gordon’s approach seemed to me to be dishonest and underhand. I did not feel he gave June the proper respect. I resolved that I would do my best never to deceive, mislead or patronise a mental health patient, should I ever become a Mental Welfare Officer.

The little girl with the rat on her shoulder

I always find it fascinating how certain forms of dementia can produce the most vivid and outlandish of hallucinations in older people. One man was troubled because “there are 3,474,263 people in my room and they won’t go away.” When I went to assess another elderly man he had pulled up his fitted carpet and piled all his furniture in the corner of the room. When I asked him why he had done this he told me that “there’s lots of calves coming out of the floor and I’m trying to find out where they’re coming from.” There was also a pair of dogs with a litter of pups in the corner, and he would not go into his bedroom because “the ceiling’s covered with thousands of spiders.”

Ethel was an elderly lady with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He sleeps in the garden now – I can’t sleep because I don’t know what he’ll be up to next.” When I assessed her last year, she was adamant that this man existed. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under Sec.2 MHA, and on discharge agreed to take medication and accept a package of home care -- although she was still absolutely convinced there was a man living in her garden.

A few months later the older people’s psychiatrist came to see me. The man in the garden was causing Ethel more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.

I went round with the psychiatrist, Ethel’s GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder. The man was “getting on her nerves.”

Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.

In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state. The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect. It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.

In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment, and this time we decided to go for a Sec.3. “I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.

She complained of chest pains on the way to hospital. I began to panic inside – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.

“But I haven’t had anything to eat today,” she said.

Leroy

The phone rang.

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

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

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

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

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

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

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

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

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

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

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

Moral: AMHP’s and psychiatrists are not infallible.

Is it OK to use the word “section” as a verb?

AMHP’s and other mental health professionals use the word “section” all the time when referring to someone being detained under the Mental Health Act. Even patients often use the word as a verb: “You’re not going to section me, are you?”

For those who don’t work in the mental health field, I will give a more detailed explanation. The MHA gives powers to apply for the detention in hospital of people with mental disorder. Specific sections of the MHA lay down these powers, for example, Section 2 allows someone to be detained for assessment for up to 28 days, and Section 3 allows detention for treatment for up to 6 months. Normally two doctors make recommendations that someone should be detained, and the AMHP then makes the final decision and completes the application. Once all the paperwork has been completed and the AMHP has signed his or her application, that person is then formally detained under the MHA, even if they are not yet in hospital. The formal detention gives the AMHP powers to arrange for the patient to be taken to hospital against their will, by whatever means necessary. This will usually involve an ambulance, and may also involve the police.

To talk about “sectioning” someone is therefore a form of shorthand: “Fred’s going hypomanic again. I think we’re going to have to section him.” (Instead of: “I think we’re going to have to assess him under the Mental Health Act to see if he needs to be detained.”) “Adele took an overdose and was sectioned last night.”(Instead of: “Adele was assessed under the Mental Health Act and detained in hospital.”)

Although I confess to using this term when talking to other professionals, I don’t necessarily feel entirely comfortable about it. Is it jargon? Does it demean or depersonalise people with mental disorder? I would never use the term with a patient, and always explain exactly what is happening when an assessment is taking place. This is not only good basic practice, it is a legal requirement. That is why I try to avoid using the word in this blog or in the written reports I have to provide when sectioning (sorry, detaining) someone.

Why is there never a bed when you really, really need one?

I’d barely had time to get into work and make myself a coffee when I received a request for a MHA assessment. The GP was at the patient’s house, the patient was agitated, verbally aggressive, deluded and psychotic, an ambulance crew and the police were in attendance, and the GP needed an AMHP as soon as possible. I rang him straight away. He sounded nearly as agitated as the patient, a woman in her 50’s who had recently had her bowel and colon removed following cancer. He had gone round expecting a medical problem, only to find she was apparently acutely mentally ill. In addition to a stoma bag, she had a range of physical health problems, the most concerning of which was insulin dependent diabetes, since she was refusing to check her blood glucose levels and had not taken any insulin for a day.

Her name rang a bell. I looked in my records and realised that I had detained her under Sec.2 nineteen years previously. I realised that I actually remembered that assessment. She had then presented in an extremely bizarre fashion. On interview she was drinking glass after glass of water, could not keep still, was unable to engage in any sort of conversation, and would periodically walk out of the room into her back garden and scream “FUCK OFF!!” at the top of her voice, before coming back in and sitting down again as if nothing had happened.

Her records showed that she had subsequently had involvement with community mental health services for health anxiety, rather than psychosis, and had received more than one course of cognitive behavioural therapy.

Whatever her history, she was presenting as an acute emergency. I tried the local psychiatrist to see if she could attend, but she was unable to. In the circumstances, I decided I should go out and assess the situation without obtaining a psychiatrist, since the nearest available Sec.12 approved psychiatrist was about 30 miles away, and there really didn’t seem time to ring round to find one.

Within a few minutes of receiving the call I was at Mavis’s house – it was easy to find, as there were an ambulance and two police cars parked outside. As I approached the open front door, I could hear her shouting and swearing, and it became clear that she was presenting in a similar way to how she had all those years ago. Her vocabulary consisted mainly of the word “fuck”, and no-one seemed to have any control. I introduced myself and asked her if she remembered me. She actually appeared to recall my involvement with her in the past, but still told me to fuck off, as there was nothing wrong with her except that she had Aids.

Taking the partner to one side, I found out that she had had major surgery because of cancer a few months ago. His mother had died two weeks ago, and Mavis had attended an outpatient appointment just a few days ago in connection with something that had shown up on X-Ray on her lung. Although there was in fact nothing to worry about, it appeared this was the tipping point which had apparently precipitated a reactivation of her health anxiety and a stress-induced psychosis. She believed she had Aids, despite having several times had negative blood tests, and was displaying delusions relating to sex. She refused to consider medication, including her insulin and usual prescribed medication, would not agree to seeing a psychiatrist, and the carer was quite clearly at the end of his tether. I therefore decided the best course of action was to detain her under an emergency Sec.4 with a single medical recommendation from the GP, on the basis that obtaining a second medical recommendation would involve undesirable delay. He was very pleased to oblige, and gratefully scuttled off to his more normal patients.

With an ambulance crew and the police present, what could possibly go wrong? She would be in the local psychiatric unit within half an hour.

I rang Bluebell ward, our local admission ward.

“Hello, I’m an AMHP and I have just detained Mavis under Sec.4 and need a bed.”

“Will that be a female bed?”

“Mavis is a female, yes.”

“We don’t have a female bed.”

“Well how about Snowdrop ward?”

“I’ll ask them... (pause)… They haven’t got a bed either.”

“How about a leave bed?”

“There’s no-one on leave.”

“I happen to know Janice is on leave at the moment.”

“Janice is back for the ward round.”

“Can you find out from the ward round if they’ll be discharging anyone?”

OK… (Another pause)… No they’re not.”

“Look, I need a bed urgently.” I explained why. “Can I speak to the bed manager?”

“She’s in the 136 suite and can’t be contacted at present.”

“What about the charge nurse?”

“I’m just a bank nurse. Do you want to speak to someone else?”

“Yes, how about the charge nurse?”

“I don’t know where he is.”

“I have someone on a Sec.4 who needs a bed urgently. You will have to find one.”

“Do we have to find a bed?”

“Yes, you do.”

“I’ll try and find somebody and ring you back.”

A paramedic came up to me. “Can we get this patient off to hospital now?”

I screamed inside.

“There doesn’t seem to be a bed. I’m trying to get one. God knows where it’ll be. The last time there wasn’t a bed the nearest bed was 70 miles away.”

After half an hour of waiting outside the patient’s house, with the carer, and the patient, becoming more and more agitated and distressed, I decided to ring someone at the Crisis Team, whose offices happened to be next door to the ward.

I explained the situation.

“I’ll go into the ward round and see if I can sort something out.”

Ten minutes later my phone rang. “There’s a bed on Snowdrop Ward.”

And finally off we went.

Why are people so afraid of the Mental Capacity Act?

The MCA was designed to provide a legal framework to support actions taken on behalf of people who lacked capacity as long as it was considered to be in their best interests – it exists at least in part to provide additional protection for the decisions and actions relating to people lacking capacity taken by carers and other professionals for things that were already being done under common law. The MCA does not even replace common law. However, many of the professionals involved with people who lack capacity, eg. social workers, staff in care homes, ambulance crews, and even relatives, seem to be interpreting the MCA as preventing them from doing things that are in the best interests of service users. AMHP’s are often finding themselves being asked to use the MHA when the MCA might be more appropriate.

One Friday afternoon I was contacted by an older people’s social worker requesting an assessment of an 85 year old lady, Mary. It was reported that neighbours the previous evening had seen smoke billowing out of her kitchen. She is a widow who lives alone and has been diagnosed with vascular dementia. The social worker had visited her this morning and reported that she appeared agitated and had soiled herself. I initially suggested that if there had been a fire, there may have been a risk of smoke inhalation, etc and that perhaps an ambulance should be called so she could be checked out medically. I also suggested that since she was suffering from dementia, the MCA could be used to provide her with physical medical intervention. The social worker insisted that this was not appropriate, saying that Mary had had a mental capacity assessment (although seemed unclear of the outcome), and that only an assessment under the MHA would be suitable.

I went to see the lady’s GP to ask him if he could attend an assessment with me. He was on duty, looked extremely harassed and seemed about to cry when I asked him to. I went through the list of Sec.12 doctors. They were nearly all either on holiday, already committed to an assessment, or were otherwise unavailable. After over an hour on the phone, I was only able to find one Sec.12 doctor.

I established that Mary has home carers visiting her twice daily. In view of the above I rang the social worker back, saying I was having problems getting the full complement of doctors, and enquiring as to whether additional home care could be provided over the weekend as an alternative to admission. The social worker insisted that this was not feasible.

I eventually managed to persuade the GP to meet with me at the patient’s house with the one Sec.12 doctor, who at least happened to be a phsychogeriatrician. (“Couldn’t you do the assessment with the psychiatrist and then just call me when the papers need signing?” “No.”)

By late afternoon I was finally at the patient’s house. The social worker was there, as well as one of the carers. The psychogeriatrician arrived and began an examination of the patient. It very soon became clear that, even if she did have dementia, she had bad cellulitis and also possibly had an acute infection. The psychiatrist was not therefore prepared to consider a detention under the MHA. I went to look for the social worker, and was given a note by the carer to say that she had gone, and had informed the Nearest Relative, a son who lived 100 miles away, that we would be admitting her to the local psychiatric unit. The GP arrived and concurred with the psychiatrist, and prescribed an antibiotic. The kitchen fire was not nearly bad as had been described, and having talked to the home carer, there did not seem to be any significant deterioration in the patient’s mental state to warrant action being taken then and there, especially since the current problem seemed to be physical illness rather than mental disorder, and I spoke to the son who was already on his way to visit his mother over the weekend. I alerted the Out of Hours service of the action taken, and the possible need for extra home care over the weekend.

End of story? No. Having spent the weekend ruminating over the assessment, I concluded that I had been set up. The social worker really wanted Mary to go into residential care, but did not think they could do it under the MCA. So the social worker thought that if an admission under the MHA could be engineered, it would then be much easier to transfer the patient from hospital to residential care.

And still it rumbled on. Over the next few weeks the local Community Mental Health Team became involved with Mary. The local psychogeriatrician agreed to undertake a formal assessment of capacity. He visited Mary and concluded that, now the infection had cleared up, Mary did indeed lack capacity. He was also prepared to consider that an admission for assessment might be justified. So I again went out with the patient’s consultant and her GP, and this time, based on the two medical recommendations, and taking into account a significant deterioration in the patient’s condition, including a recent fall and a mild head injury which she had refused to have treated, I completed an application for detention under Sec.2, and Mary was admitted to hospital. A month or so later she was transferred to residential care.

So why didn’t I detain her a month earlier? Well, apart from the Sec.12 doctor not being willing to make a recommendation, it seemed to me that, even though Mary did not want to leave her home, and had on several occasions turned ambulance crews away when she had had falls, nevertheless, if she lacked capacity and it was in her best interests, then she could still have been taken to hospital, or even a residential care home, and could have avoided a stay on a psychogeriatric ward.

Such are the trials of the AMHP.