My First Mental Health Act Assessment (Part III)

On 28th September 1983 the 1959 Mental Health Act was rescinded. I ceased being a Mental Welfare Officer and on that day became an Approved Social Worker. It certainly sounded more modern, as did the 1983 Mental Health Act itself, which incorporated more human rights safeguards in the process of compulsory detention in hospital.

As well as having a few more assessments under the 1959 Act under my belt, those to be designated as ASW’s had actually had some training in the new Act, so this time I felt a little more prepared when I received my first request for an MHA assessment under the 1983 Act two weeks later.

I was on call, and the request came in the early evening. Her name was Emma. She was in her 30’s, married with two young children, with a diagnosis of bipolar affective disorder. She had been seen by her GP earlier in the day, but had removed herself from his presence when it looked as if he might be considering admitting her to hospital. She was now in a police station about 25 miles away from the town where I worked, detained under Sec.136, having been removed to a place of safety from a public place by a police officer who had reason to believe she may have been mentally disordered. She therefore had to be assessed by an ASW and a medical practitioner.

(All the sections in the 1959 Act changed in the new 1983 Act – Sec.25 became Sec.2, Sec.26 became Sec.3, Sec.29 became Sec.4 – with the exception of Sec.136, the only Section the police could impose, which remained the same. We ASW’s assumed it was because the police would never be able to remember a new number, but perhaps we were too cynical.)

Before I went out to see her, I took the precaution of visiting the GP, who was still in surgery, and got more information. She had been going high for a few weeks, and had managed to obtain a bank loan, purchase a franchise with an international cosmetics chain, and had opened an office in the town, despite having no experience in this field whatever.

I obtained from him two medical recommendations – one for Sec.2, and another for Sec.4 – just in case – and then set off for the police station.

When I interviewed her, Emma seemed quite calm. She was clearly extremely tired, having not slept for several days, but sensibly recognised that it would be a good idea to go home, take some medication, and get some sleep.

I decided that, having assessed her, she did not need detaining, and could therefore be discharged from the Sec.136. The police sergeant thought otherwise. He had read Sec.136 of the Act, which stated that the purpose of detention under Sec.136 was for the person “to be examined by a registered medical practitioner and to be interviewed by an approved social worker”. Since she had not been examined at the police station by a medical practitioner, he could not allow her to leave the police station. He was probably right. However, my interpretation of the Act at that time was that since she had been assessed by a medical practitioner that day, she did not need assessing again by another medical practitioner in order to fulfil the requirements of Sec.136.

After a considerable and sometimes heated discussion, he acceded to my superior knowledge and allowed me to take her back to her home town, with a female special constable as an escort.

What an interesting journey that was. Once we had set off, Emma started to go high again. I realised that she was rapid cycling. As we drove, she became more and more charismatic, and even appeared to physically increase in stature. It was an awe-inspiring sight. A messianic glow seemed to emanate from her being as she told us about her plans for world domination through the cosmetics industry. I was becoming steadily more alarmed the more I drove – would the car be big enough for the three of us, or would she continue to inflate indefinitely until the car burst asunder? The female special constable however, with very little experience of mental illness, was drawn completely under Emma’s spell. Not only did she take issue with my opinion that Emma was mentally unwell, but she was even considering investing her life savings in Emma’s scheme.

At last we arrived at her home. By then I had serious misgivings about leaving her with her husband and children in this state, and when her husband saw her, I could tell he was even less happy than I was. She had no intention of taking her medication and going to bed; she was instead going to her new office to order even more of the cosmetics, right then, and then she was going to see her solicitor to get a divorce.

I knew that chaos would ensue if I were to leave her, and in those days without mobile phones I suddenly felt extremely tired and lonely and isolated. Why on earth did I ever decide I wanted to be an ASW?

In an attempt to regain control of the situation I calmly but firmly indicated to her that this was not a wise thing to do, that she was extremely unwell, and that she really had no option but to go to hospital. Somewhat to my surprise, she agreed that I could indeed take her to hospital, so before she could change her mind I marched her to the car, again accompanied by the female special constable, who by now realised that something was severely amiss with Emma and was now reluctant to sit next to her, or even be in the same vehicle, and drove the 15 miles to the hospital, knowing that if I could get her safely ensconced on the ward, then if necessary we could keep her there on a Sec.5(2).

By 11.00 pm we arrived at the hospital, and we walked down the long, dim, silent corridors until we at least reached the ward. I sat her down in the nursing office with the admitting nurse, beginning to allow myself to feel relief. This was when she drew her trump card.

“I’m not staying,” she said.

“But you agreed that you would go to hospital.”

“I agreed that I would go to hospital. I didn’t agree that I would be admitted!” She gazed at me in triumph. She had outwitted me.

But I had my own trump card. I left the room for a few minutes, filled in a form, and returned.

“Emma,” I said to her, “you are now detained under Sec.4 of the Mental Health Act 1983. That means that you have been admitted for assessment for up to 72 hours. There is no right of appeal against that decision.”

The Consultant converted this to a Sec.2 the following day, which of course did provide her with the right to appeal. So two weeks later I had my first Mental Health Review Tribunal of the 1983 Act. But that’s another story.

Is it a sin to section Jesus Christ?

The call came from the local police. They had a 19 year old male in the cells on a Sec.136. He had been found walking the streets in the middle of the night stark naked. When asked to give his name, he told them that he was Jesus Christ.

I spoke to his mother on the phone to get some background. She told me that he had been involved in a car accident a year ago in which his friend was killed. He subsequently became involved in a local evangelical Christian church. He had successfully completed his “A” Levels and then spent his gap year travelling around Asia. He was due to go to University in a few weeks time. He had no history of mental illness, but his mother told me that he was a regular user of cannabis, ecstasy and PCP, and that he had been behaving increasingly oddly over the previous few days.

I went out to assess him. The consultant, the duty GP and I crammed into his cell to see him, as he refused to come out to the interview room. Martin was sitting cross-legged on the floor, completely naked. He had refused all attempts to cover him. He was wearing handcuffs, having refused to allow the police to remove them.

He smiled beatifically at me as I entered, blessed me and told me that he forgave me for my sins. I thanked him and asked him why we would not let the police take the handcuffs off.

“Martin needs to be punished,” he answered. “I am Jesus, the Second Coming. My Dad is God. I am presently inhabiting Martin’s body, as he was killed in a car accident a year ago. Martin is the spawn of Satan, you see.”

“That’s interesting,” I said. “The problem I have is this. I have several times seen people who thought they were Jesus Christ, and they have invariably turned out not to be.”

He considered this, the smile faltering momentarily on his face. Then the sunny smile reappeared and he said, “I’ll prove it to you, my son. I have many powers. I can read your thoughts.”

“Okay, so what am I thinking right now?”

He studied me for a while, then replied: “You’re thinking I’m crazy.”

“Well,” I said, “that really is uncanny.”

We left him in his cell in order to discuss our conclusions. Although he had no previous history of mental illness, it was clear that he was psychotic. It was possible that this had been triggered by drug use, and that the car accident may have contributed to this episode. However, he was so florid there was no option but to detain him under Sec.2 MHA for further assessment.

I returned to Martin’s cell to inform him what was happening. He turned his awesome smile on me as I explained.

“I have made an application for your detention in hospital under Sec.2 of the Mental Health Act. This means you will be detained for up to 28 days. I had to make this decison based on the balance of probabilities: what is more likely, that you are indeed Jesus Christ, as you say, or that you are mentally ill. I am afraid that it is more likely that you are mentally ill than that you are the Second Coming. You do have the right to appeal against this decision.”

His smile completely left his face and was replaced with a poisonous glare. For the first time during the assessment, he appeared to be irritated.

“I died on the fucking cross for you!” he snarled as I left the cell.

A happy ending: Martin made a rapid recovery in hospital. He probably did have a drug induced psychosis. He went to university as planned.

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.