Trying to work but living below subsistence level

I’m currently working with a couple who typify the unintended consequences of recent changes to welfare benefits arising from the recession. Despite their best efforts, the recession has made it impossible to earn a living wage, and they have then been further victimised by the current system, that should be designed to protect the most vulnerable.

Mr and Mrs Jones live in a Housing Association 3 bedroom house. They have lived there for over 30 years, raising 5 children, and maintaining the property immaculately.

Mr Jones works as a self employed landscape gardener. While not making a huge amount from this work, he has nevertheless managed to support himself and his family for many years without recourse to public funds, but when the recession started to bite in 2008, gardening work became scarcer as people tried to find ways of cutting back, and he began to fall into debt.

He started to get depressed. However, he tried to fight this, and in an attempt to meet his ongoing commitments and to service his debts, he took a part time job delivering parcels for a national company. But, already depressed, he found the struggle to keep up with the schedule impossible to manage. He ended up working hours longer than he was paid to in order to meet the delivery targets.

After a few months of this, and still unable to meet his financial commitments, one morning he woke up and was simply unable to get out of bed. He felt terrified to even leave the house, and would have panic attacks at the very thought of going shopping.

He went off sick, and started to receive statutory sick pay. He also made a claim for housing benefit and council tax benefit. But this is where it became even more complicated.

Mrs Jones has a zero hours contract with a local commercial cleaning company. This means that she fills in for the sickness or absence of cleaning staff. Sometimes she works 6 hours a week, sometimes she works 20 hours a week. Some weeks she is not called on at all.

The consequence of her erratic income is to make claiming means tested benefits very haphazard. Each week Mr Jones has  to notify the local authority how much she has earned, and benefits are then paid accordingly. Of course, there is always a delay in calculating and paying these benefits, which means that there is little guaranteed money coming into the house to pay essential bills. Mr Jones is having difficulty trying to pay the prescription charges for the antidepressant and other medication he has been prescribed to try to help him recover.

To add to Mr & Mrs Jones’ woes, because their children are all adult and have left home, they have two unused bedrooms, so are penalised further by the “bedroom tax”. For the first time in their lives, they are falling into arrears with their rent.

Their current predicament is unsustainable. But what should they do?

 Mr Jones has lost 3 stone in weight because of his depression and anxiety. He considers that leaving the house to walk to the post box on the corner on his own without having a panic attack at the moment is a major achievement. If he went back to work, the stress of his delivery job would precipitate a major relapse. In his current state of mind, there is no way he should return to that job, but his job as a gardener is also unsustainable.

Should Mrs Jones continue doing her job? Her irregular income creates havoc with their finances, and it would surely be better for them as a couple if she stopped work altogether, so that they would at least be able to count on a regular income from benefits, inadequate though it is, especially with the additional penalty of the bedroom tax.

Should they attempt to move to smaller accommodation to reduce their rent and stop being penalised? The problem with that is that hundreds of others in social housing in the area are also trying to do the same thing, and as a consequence, one bedroom properties are in very short supply. And is it really just that a couple who have been exemplary tenants, and who have put their lives into maintaining their house as a much loved home, should have to leave it?

As a mental health worker, whose job it is to aid recovery from mental illness, I would have to advise Mr & Mrs Jones to stop working completely, and be reliant on benefits. That way, their income would be regular and stable, they would be entitled to help with prescription and dental treatment, and they might be able to at least pay essential bills, even if they would not be able to service their debts.

What a shame it is that the welfare system is not designed to facilitate those people who want to work, even if only part time, but instead makes it impossible for them to work. And of course, if Mr Jones remained without work, he would start to be subject to capability for work assessments, whether there was work for him or not. Would that harassment hasten his recovery? I think not.

What You Need to Know If You’re Sectioned

So, you’ve been detained under the Mental Health Act 1983, and you’re in hospital. It’s most likely you’ve been detained under either Section 2 or Section 3.

Section 2

A Sec.2 lasts for up to 28 days. The purpose of detention under Sec.2 is to assess you to decide if you have a mental disorder.

 

There are two grounds for a Sec.2:

“(a) he is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period; and
(b) he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons.”

Two doctors will have assessed you and will have decided that, in their opinion, you have a mental disorder. An Approved Mental Health Professional will have “interviewed you in a suitable manner” and would have had to satisfy themselves that detention in a hospital “is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need”.

The primary purpose of detention under Sec.2 is to assess you to see if you do, in fact, have a mental disorder or not. Although the detention is for assessment, you can be given treatment as well.

Section 3

A Sec.3 lasts for up to 6 months, although it is fairly unusual for someone to be detained as long as this. The purpose of detaining under Sec.3 is in order to give you the treatment it is thought you need for a mental disorder.

There are three grounds for a Sec.3:

“(a) he is suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital; and
(b) it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section; and
(c) appropriate medical treatment is available for him.”

Again, you will have been assessed by an Approved Mental Health Professional and two doctors.

The sort of treatment you will receive is primarily at the discretion of the hospital psychiatrist. However, Electro Convulsive Therapy (ECT) cannot be given to a detained patient unless they consent and are deemed to have the capacity to consent. See this post for more details about ECT.

A Sec.2 cannot be extended beyond 28 days. However, a Sec.3 can be extended for another 6 months. It can be extended beyond that, in which case the renewal would then last for 1 year.

“Mental disorder”

Both sections depend on establishing whether or not you have a mental disorder. The definition of “mental disorder” in the Act is very wide, being “any disorder or disability of the mind”.

The Code of Practice does however suggest a range of conditions which could be considered to be mental disorders. These include the following, although this is not an exhaustive list:

• affective disorders, such as depression and bipolar disorder
• schizophrenia and delusional disorders
• neurotic, stress-related and somatoform disorders, such as anxiety, phobic disorders, obsessive compulsive disorders, post-traumatic stress disorder and hypochondriacal disorders
• organic mental disorders such as dementia and delirium
• personality and behavioural changes caused by brain injury or damage
• personality disorders
• mental and behavioural disorders caused by psychoactive substance use
• eating disorders, non-organic sleep disorders and non-organic sexual disorders
• autistic spectrum disorders (including Asperger’s syndrome)
• behavioural and emotional disorders of children and adolescents     

As a rule, you cannot be detained under the Mental Health Act purely on the grounds that you have a learning disability, unless it is associated with “abnormally aggressive or seriously irresponsible conduct”.

Dependence of alcohol or drugs is not in itself considered to be a mental disorder.

What you can do

Everyone detained under Sec.2 and Sec.3 has the right to appeal.

If you’re appealing against a Sec.2, you will have to do this within the first 14 days of your detention. An independent Tribunal will then hear your appeal within a week.

If you’re appealing against a Sec.3, you can appeal at any time during the 6 months of the detention, and after that during any renewal.

An appeal against a Sec.3 can be considered by a panel of hospital managers. These are not staff of the hospital, but lay people who have an interest in mental health issues and who also have the time to devote to these duties. They would hear your appeal within a couple of weeks. If they do not discharge you from the section, then a Tribunal would hear your appeal within a month or two.

A Tribunal consists of a panel of three – the judge, who is a lawyer, the medical member, who is a psychiatrist, and specialist lay member, who is generally a lay person with a particular interest and experience in working with people with mental health problems, such as an AMHP, a nurse, or someone with extensive experience in the voluntary sector. Tribunals are part of the Judiciary, and are in effect a court of law, although they are much more informal than a normal court hearing.

For both a Managers’ Hearing and a Tribunal you are entitled to have a legal representative to present your case. These are solicitors with particular training and knowledge of mental disorder. You will not have to pay for this representative. Alternatively, you can appoint any other person to represent you, apart from people who are themselves detained under the MHA or who are inpatients in the hospital.

You will be allowed to attend the hearing, and will also be allowed to take part and have your say. The other people present at these hearings will be your representative, your Consultant Psychiatrist or one of his junior doctors, a hospital nurse involved with your care, and someone from the community mental health team, who could be a social worker, a community mental health nurse or an occupational therapist. Your nearest relative can also attend if you want them to. There will also be a clerk.

Both a Managers Hearing and a Tribunal Hearing will have access to three reports: a medical report compiled by the patient’s psychiatrist, a nursing report, and a social circumstances report written by someone from the community team.

Both Tribunals and Managers have to be satisfied that you are “suffering from mental disorder of a nature or degree which makes it appropriate for the patient to be liable to be detained in hospital” for either assessment or treatment. For a Sec.2 they also have to be satisfied that the patient’s detention “is justified in the interests of the patient’s own health or safety or with a view to the protection of others”, while for a Sec.3 they also have to be convinced that “it is necessary for the health or safety of the patient or for the protection of others that the patient should receive such treatment”. For Sec.3 they also have to be satisfied that the appropriate medical treatment is available.

In order to satisfy themselves of these factors, they will use the reports supplied, but will also hear verbal evidence presented by those present. This gives a chance for you and your representative to cross examine the other people present and to give your side. They can then decide one of three things: not to discharge you, to discharge you with immediate effect, or to direct that you be discharged at a future date.

It’s worth appealing, because often a psychiatrist will decide to discharge you from your section before the appeal is heard, and even if they don’t, about 15% of people who appeal are discharged by the Tribunal.

What Do You Call a Person Who Receives Mental Health Services?

A description or a label?

There are people who have had bad experiences of mental health services – you only have to look in the comments sections of my posts on this blog to find people who have nothing good to say about mental health services  -- who would answer “victim”. (I just thought I’d get that in first).

But this is actually a serious question. When I started out as a social worker in the late 1970’s, social workers, and probation officers come to that, had “clients”. I didn’t then, and still don’t, think there is anything innately wrong with this term. After all, solicitors have clients. Architects have clients. Advertising companies have clients.

There is nothing pejorative or demeaning about the word “client”. It simply indicates that there is some form of consultative partnership going on. There is no hint there of any sort of power differential.

But “client” no longer appears to be a satisfactory term. Nurses and doctors have “patients”, but social workers clearly cannot have patients. The Oxford Dictionary definition of the word “patient” is: “a person receiving or registered to receive medical treatment”. Since social workers (or occupational therapists or clinical psychologists) do not actually give medical treatment, the term “patient” does not really apply.

However, I must say that, working in a multidisciplinary team with doctors and nurses, it is easy to refer to “patients”. I try to resist this, not always successfully. This is made a little more difficult by the Mental Health Act referring to people subject to the Act as being “patients”. So there are times when I have to use that term in a professional context when acting as an AMHP.

There has recently been what in my view is a wholly deplorable move, to use the term “customer”. “Customer” does not describe the relationship between a mental health service and someone who receives that service.

The Oxford Dictionary defines “customer” as: “a person who buys goods or services from a shop or business” while the Merriam-Webster Dictionary gives the definition: “one that purchases a commodity or service”. Since someone who sees a mental health professional, either voluntarily or because they have been detained in hospital or are subject to a Community Treatment Order is in no way “buying” or “purchasing” that service.

This is the problem I have with attempts to apply a business model to a public service. Under the new GP led NHS system, the “customer” is not the person in receipt of the service, the customers are actually the Clinical Commissioning Groups (CCG’s) who are in reality purchasing services from the Mental Health Trusts. It is therefore the CCG’s that the Trusts have to satisfy, not the people who actually receive their services.

If shops treated their customers in the way that mental health services treated the recipients of their services, it might go something like this.

Customer: Have you got this blouse in stripes and size 14, please?

Shop Assistant: We’ve got that in stock, but I’m not going to give it to you. You need a pair of leggings in size 16. Here they are. No need to try them on.

So, I think we’re all clear now that “customer” should never be used when referring to people who use mental health, or indeed and public service.

So what have we got left? The popular term currently appears to be “service user”. Even service users refer to themselves as “service users”.

It’s possibly the least worst, but I’m still not convinced that it accurately reflects the role. It still implies that the “service user” has a choice over whether or not to use the service. This is not always the case, especially where the Mental Health Act comes in. Is someone detained against their will under the Mental Health Act “using” that service? Is it indeed a “service” at all?

Is a prisoner serving a sentence in a prison a “service user”? Not if they have no choice over whether or not they want to receive that particular “service”.

The other problem is whether what a social worker, or a nurse, or a psychiatrist, or a psychiatric hospital can be described as a “service”.

A waiter is providing a service. They are quite literally your servant. The customer is always right. It is the job of the waiter to give you what you want, not what the waiter wants to give you. Contrast that with a psychiatrist, for example.

Patient: I’d like 10mg Olanzapine, as well 20mg Citalopram. Oh, and I think I’ll have some 5mg Diazepam prn, just in case I get a bit anxious.

Psychiatrist: No.

So do I have any alternative suggestion? My only alternative is “service recipient”. That is, someone who is in receipt of a service. Or  at a pinch, “client”.

Should Professionals Write Publicly About Real Cases?

Some sort of visual metaphor

I had a very interesting and thought provoking email correspondence with a reader of The Masked AMHP blog recently. The reader initially found the accounts on the blog of real situations interesting and at times amusing, but then started to think about how they would feel if they were reading about themselves. The reader raised issues of privacy, confidentiality, ethics and the power relationship inherent between a mental health professional and a service user.

Regular readers of this blog will be aware that I often write about actual cases I have been involved with as an AMHP and a social worker. There are a number of reasons why I do this.

Probably the primary reason is to provide a window into my professional life in order to inform service users, other professionals, and the public in general – to demystify working with people with mental health problems.

Most people will never come across an AMHP in their daily lives, and will have little if anything to do with the Mental Health Act. The role of the Approved Mental Health Professional is therefore little known to the general public and even less understood. And yet, AMHP’s have wide ranging powers and duties, which can seriously impinge on the freedom of people who experience mental disorder.

I think, therefore, that giving case studies from the point of view of the AMHP/social worker, in which I explore the thought processes and decision making that goes on during an assessment under the MHA, can be helpful, and perhaps can go some way to dispelling the common belief among some service users that AMHP’s are interested in nothing more than exerting power. One reason why I write therefore is to try to counter the beliefs exemplified in this recent comment on the Blog:

“Your disgusting and pathetic idea that you have the right to detain people against their will based on their mind even if they have not committed any crime is disgustingly pitiful. Anyone who is a believer in "psychiatry" "mental illness" "mental disorders" is no different than bigoted racists and concentration camps. You think you have a right to play God over another person's life based on their difference in mind? You'll go down as nothing more than a discriminatory bigot.”

Another reason is to provide information likely to be useful to students, AMHP trainees and other professionals. It seems to me that a good way of providing that information is to show how theory and legislation is actually applied in real life situations.

Academics may be able to describe the theoretical application of law, but when you are working in the real world, where they may be no beds, long delays waiting for an ambulance, problems in getting help from other professionals, then applying the law in those circumstances can appear very different.

Another reason why I write about real cases with which I have been involved is that it can be therapeutic to me. Sometimes I need to talk about situations I have been in. it helps me to debrief, to make sense of some of the things that have happened to me.

And another reason is simply because sometimes I think people’s stories need to be told. Some of the people I have written about are deceased. They have led remarkable or tragic lives, but these lives, and their life stories, would be forgotten if they were not written about somewhere. I hope I always write with empathy for the person, and I always make great efforts not to be patronising.

Of course, when I am writing about real people, I always change their names, and I also make other changes to the details of people in order to make them less identifiable. Everything I write about is set in the fictional town of “Charwood”. And of course, my real name is not “The Masked AMHP”. But I do take on board my email correspondent’s concerns that individuals may still be identifiable.

So how can I justify my blog?

For a start, there are many precedents. It is not uncommon for doctors, especially psychiatrists, to write about real cases. Many medical journals recount detailed, although anonymous, case histories of people with unusual medical conditions. There is so much detail in these that the patient should be able to identify themselves. Perhaps the doctor hopes that they will be unable to access the particular medical journal in which their case histories are detailed.

Although written by a journalist, Flora Rheta Schreiber, a good example of a whole book devoted to a single patient is Sybil, the story of a woman with dissociative identity disorder. This book was published in 1973 and later made into a film.

The eminent and humane neurologist Dr Oliver Sacks has written many books about his patients, including Awakenings, about his attempts to help patients with encephalitis lethargica, and The Man Who Mistook His Wife for a Hat. The latter book consists of a series of true stories of patients of his with a range of unusual neurological conditions. The patient referred to in the title is a man with visual agnosia, who was unable to distinguish between inanimate objects and people. However fictionalised these accounts may be, these people must still have been identifiable to themselves and their relatives.

The established and extensive literature of case studies, both academic and commercial does therefore lead me to believe that there can be a justification as long as it is done with respect and sensitivity.

I have also had many positive comments from service users about the contents of the blog. Here are a couple of comments I have received on the blog. The first is from a service user:

“Having been detained 3 times under section 3, to be honest its nice to read accounts from the other side instead of seeing the other side as the enemy, like you do when you are unwell. And the endings may seem sad & unfortunate, but often the people are ending up receiving the help they need even though they may not want it.”

And here is one from the relative of someone with mental health problems:

“Incredible - after YEARS and YEARS of trying to understand the CRAZY behaviour of a relative - this is it. Thank you for this blog, it doesn't change anything but to read this happens... it's felt like a never ending nightmare and at times as if I was the crazy one for imagining what was happening.”

These sorts of comments do help me to think that it is worthwhile and ethically justified writing The Masked AMHP blog.

The British Association of Social Workers (BASW), as well as The College of Social Work (TCSW) and the Health and Care Professions Council (HCPC) all have policies about the use of social media.

The BASW Social Media Policy encourages positive uses of social media. Its policy document states: “Social media can help individuals and organisations to better understand, engage with and respond to people. It can contribute to making services more transparent and accountable. The use of social technology and social networking enables people to collaborate, build relationships and share information and resources.”

It goes on to say: “Social workers should use social media as a positive platform for exchanging ideas and knowledge and to promote the social work profession, being aware that they are acting as ambassadors for social work when they are on-line.”

Rebecca Joy Novell, in a recent Guardian article, writes: “The largely negative portrayal of social workers in mainstream media has a palpable effect on the confidence of practitioners. When the public see a social worker on TV show EastEnders unfairly and without query removing a child from Lola, a capable mother, it's no surprise that their understanding of our role is warped. The damaging consequences should not be underestimated.”

She goes on to observe: “Challenging these negative portrayals and presenting an honest picture of what we do is essential for restoring confidence in our profession. The media is central in shaping public perception and, subsequently, in shaping local and national policy. While it may not be possible for every social worker to represent their profession on prime-time television, it is possible for every social worker to have an online blog and a Twitter account.”

Rebecca argues that social workers (and indeed other professionals) writing about their jobs on social media sites almost amounts to an obligation, and can have very positive benefits for promoting a job that is often misunderstood and sidelined by the media and Parliament.

The feedback I have had from The College of Social Work indicates that my blog presents social work in a positive light. I hope that I can continue to do that while also respecting the people I write about.

What Is An AMHP?

It's not compulsory for AMHP's to wear this T-shirt

Well I’m glad you asked me that. AMHP is an acronym of “Approved Mental Health Professional”.

 

Is that it?

 

Do you want more?

 

Well, yes.

 

(Sighs). OK, here goes. The Mental Health Act 2007 amended the Mental Health Act 1983. One of the amendments was to create the “Approved Mental Health Professional”. The AMHP has a very important role to play in the functioning of the Mental Health Act.

 

Hang on a minute. The Mental Health Act. What’s that exactly?

 

(Sighs even more deeply). OK. The Mental Health Act lays down the legal framework in which people can be compulsorily admitted and detained in psychiatric hospitals. It covers ordinary members of the public who might become mentally disordered, as well as “mentally disordered offenders” – people who have committed criminal offences and who have gone to court, but who may need assessment or treatment for mental disorder.

 

Except for people who are dealt with through the courts, the involvement of an AMHP is necessary in order to make decisions about whether or not someone needs to be admitted to hospital for assessment or treatment.

 

So why do you need an AMHP then?

 

I was coming to that. An AMHP helps to provide a remedy to excessive medicalisation of the process of assessing and treating people with mental disorder. Doctors can make recommendations that someone should be detained in hospital, but it is up to the AMHP to make the final decision. It is also the responsibility of the AMHP to ensure that the law is being applied correctly.

 

So what is an AMHP then?

 

An AMHP can be a social worker, a psychiatric nurse, an occupational therapist or a clinical psychologist. A doctor cannot be an AMHP. Before the 2007 Act, only social workers could do the job. Then, they were called “ASW’s”.

 

Tell me more about what an AMHP actually does.

 

With pleasure. 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.

 

AMHP’s have had to undergo extensive specialist training, and therefore have an in depth knowledge of law and have the 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 and other legislation, such as the Mental Capacity Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.

 

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.

 

Shall I tell you about the powers and duties of the AMHP?

 

I’m beginning to wish I’d never asked you a question in the first place. But go on.

 

I could do a Powerpoint presentation if you like.

 

Please don’t.

 

Very well. As briefly as possible then.

 AMHP powers:

• 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)

AMHP duties:

• 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

Do you have any more questions?

 

Not now, thanks. I really must be going. Actually, I do have one: how do you actually pronounce “AMHP”?

 

I’m really glad you asked me that. On a day to day basis, you obviously don’t want to be saying “Approved Mental Health Professional” all the time. You could pronounce each initial, eg. “Ay Em Aitch Pee”, or you could just pronounce it “Amp”. Personally, I favour “Amp”, as “The Masked Amp” sounds cool, but “The Masked Ay Em Aitch Pee” just sounds silly.

 

So you think that “Masked Amp” sounds cool, do you?

 

Yes I do. You can go now.

If The Masked AMHP Blog was Written by Sir Arthur Conan-Doyle

The Masked AMHP sucked contemplatively on his electronic Meerschaum pipe as he leafed through a well-thumbed copy of The Mental Health Act Manual. A shaft of sunlight shone through the office window and illuminated his Stetson.

 

“Fascinating,” he said eventually, blowing out a pollution-free smoke-like substance into the atmosphere. “Jones suggests that the design of door handles or the use of key pads making it difficult for a confused patient to leave the hospital or care home would not constitute a deprivation of liberty, and yet I have seen many such godforsaken individuals clawing hopelessly at the exit doors who are clearly making patently clear their wish to leave their place of incarceration. Would it not be more legally sound for such persons to receive the legal safeguards afforded by detention under the Mental Health Act?”

 

Tonto, the Masked AMHP’s faithful and attentive, although not that bright, AMHP trainee, looked up from his iPad, on which he had been diligently reading the latest post on the Masked AMHP blog while furiously taking notes for one of his assignments and gazed in awe at his mentor.

 

“By Jove, Masked AMHP,” he exclaimed. “I do believe you may be correct! I am quite certain that Jones will have to amend his next edition in the light of your observation!"

 

“Indubitably, my dear Tonto,” The Masked AMHP replied insouciantly, tapping away at an email to Richard Jones.

 

Just then the phone rang.

 

“Allow me to get that, Masked AMHP,” Tonto intoned, anxious to be of use, picking up the receiver. He listened intently, then passed it over to the Masked AMHP.

 

“There’s a distraught woman in reception,” he said. “She’s concerned about the mental state of her partner. I’m a little out of my depth with that, I’m afraid, just being a humble trainee.”

 

“Ah, Section 13 brackets 4,” The Masked AMHP muttered. “Let’s go down and see her, shall we?”

 

A few minutes later The Masked AMHP and his humble AMHP trainee were ensconced in an interview room with a tearful young woman.

 

“I’m so worried about Johnny,” she sobbed pitifully. “At first we had such a wonderful relationship, but lately he’s been shutting himself away in the study for hours on end. He tells me to go away if I put my head round the door, and I can hear him shouting and muttering to himself. I fear that he is hearing voices that no-one else can hear, which must mean he is developing schizophrenia and must be incarcerated in a psychiatric hospital under Section 2 of the Mental Health Act for assessment!

 

The Masked AMHP sat deep in thought, while the AMHP trainee tried to comfort the poor woman by dabbing at her eyes with his pocket handkerchief and offering her an extra strong mint.

 

At last he said, “Tell me, my dear young lady, how long have you lived with your, ahem, fiancé?”

 

“It’s 5 and a half months to the day,” she replied, blowing her nose loudly but at the same time daintily on Tonto’s handkerchief.

 

“And what did he do to occupy his free time before you began to share a house?”

 

“I believe he owned a Playstation 3. But he put it away in the attic when I moved in with him.”

 

“And how does his visage appear currently?” The Masked AMHP enquired.

 

“When I have seen him, he has a terrible haunted look, as if he is being pursued by all the demons in Hell! Oh, sir, do you suppose he is having visual hallucinations? That would be just too, too terrible.”

 

“Aha! I believe we have the solution to this little problem,” The Masked AMHP said triumphantly. “I do not need to interview your partner in a suitable manner, or indeed in any manner at all. For it is plain to see that he is not mentally ill in any way!”

 

Tonto and the young lady gazed in amazement at The Masked AMHP.

 

“By Jove, Masked AMHP!” Tonto pronounced. “How can you tell that without even examining the poor chap?”

 

“It’s simple,” The Masked AMHP continued. “He likes to play games on the Playstation 3, but infatuation for this young lady has led him to abstain for several months. But The Last of Us has just come out on the Playstation, and he just had to play it, didn’t he? Of course he has a haunted look! It’s a terrifying game! But he’s no more mentally disordered than most of the current Cabinet!”

 

Back in the office, The Masked AMHP sat back and fired up his electronic Meerschaum pipe, as he dictated his AMHP Assessment Report to his AMHP trainee.

 

“And of course,” The Masked AMHP concluded, “I didn’t need to interview him in any case, because it wasn’t a Section 13 brackets 4 nearest relative request at all! She couldn’t be his nearest relative – because they hadn’t been living together as husband and wife for at least six months!”

Sec.117 Aftercare: A Brief Guide for Patients and Relatives

I quite often get emails from relatives of people with mental illness asking questions relating to Sec.117 of the Mental Health Act 1983. From the information they give, it often appears that the regulations and guidance relating to Sec.117 are not being adhered to, or patients and relatives are not being kept in the loop when arrangements for aftercare are being made. I thought therefore that it might be helpful to lay out the basics relating to Sec.117 for the benefit of the consumer, so to speak.

 

What is Sec.117?

 

Sec.117 lays down a duty for the local authority and the NHS to provide services for people who have been detained and then discharged from certain sections of the Act. The most common section is Sec.3, where a patient has been detained for treatment. There are some other sections of the Act relating to people who have committed criminal offences for whom Sec.117 also applies. These are Sections 37, 45A, 47 and 48. Detention under these sections is much less common.

 

A patient who has only ever been an informal patient, or who has only ever been detained under Sec.2 (for assessment) is not entitled to aftercare under Sec.117. However, this does not mean that someone with mental health needs, but who has never been detained for treatment, is not entitled to services.

 

What is Sec.117 Aftercare?

 

The Code of Practice to the Mental Health Act says:

 

“After-care is a vital component in patients’ overall treatment and care. As well as meeting their immediate needs for health and social care, after-care should aim to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital. (27.5)”

 

Before anyone detained under the relevant sections is discharged from hospital, there has to be a meeting involving any relevant professionals or others, including the patient, relatives, and carers. There’s an extensive list in the Code of Practice as to what should be considered (27.13). These include: the psychological needs of the patient, as well as their family and carers; their physical healthcare; daytime activities or employment; appropriate accommodation; identified risks and safety issues; social, cultural or spiritual needs; assistance in welfare rights and managing finances; contingency plans and crisis contact details. There are many other things to be considered as well.

 

Once the patient is discharged, there have to be regular reviews in the community.

 

Will I have to pay for aftercare?

 

The most significant aspect of Sec.117 is that any aftercare provided under this section cannot be charged for. The MHA Reference Guide observes: “Because the Act provides no power to charge anyone for after-care services provided under section 117, they must be provided free of charge.” (24.18) Therefore, the patient cannot be charged for the cost of day care services, or residential care, for example, as long as it is specifically to meet the mental health needs of the patient.

 

Are there any exceptions to this?

 

There are some things that are not covered by Sec.117 aftercare. These are things which are considered to be basic needs, and not needs arising from the person’s mental health problems. These things include food and clothing, and rent for a flat. It may also be considered that if someone had mental health problems and a physical disability, needs arising from the physical disability might not be covered, and might therefore be chargeable, subject to an individual’s personal resources, of course.

 

I am the nearest relative of someone who has been detained in hospital under Sec.3 MHA. What can I expect to happen?

 

There should be regular Sec.117 Aftercare planning meetings. These take place while the person is an inpatient and well before they are discharged, and also periodically, usually at 6 monthly intervals, once they have been discharged.

 

At the meeting there should be the patient, their nearest relative, a representative of the local authority (for instance, a social worker), the patient’s Psychiatrist, a nurse, and then anyone else who might be involved in providing their aftercare, for example, someone from a day centre or a care home.

 

This meeting should set out what the patient’s mental health needs are, and what services are required to support them with these needs once they are discharged. The aftercare plan could be very simple, for example, stating that the patient will see a mental health professional regularly, that they should have regular outpatient appointments and that they should take specified medication. However, an aftercare plan may also entail placement in a residential care home, attending a day centre, the involvement of other professionals or care providers, etc.

 

Is Sec.117 aftercare time limited?

 

Sec.117 aftercare has no time limit. As long as the patient continues to require aftercare, even at a basic level, such as periodic outpatient reviews with a psychiatrist, then Sec.117 aftercare rules will continue to apply. Sec.117 aftercare can only cease if both the mental health service and the local authority are in agreement that it is no longer necessary, and they have to make a formal decision about this.

 

If someone has been detained under Sec.3 once 10 years ago, but since then has had a number of informal admissions, or admissions under Sec.2 alone, the subsequent admissions do not invalidate or strike out Sec.117. There should still be Sec.117 aftercare planning meetings even for someone who is an informal patient, no matter how long ago it was that they were detained under Sec.3.