Although Nearest Relatives can attend Tribunals, they rarely do. Sometimes this is because they want to distance themselves from the legal process, or do not wish to confront their detained relative. It can be difficult to side with the psychiatrist and AMHP when their patently unwell relative is protesting that they do not need to be detained. The patient may not be able to recognise that their relative may really have their interests at heart, or may even be frankly terrified of them.
I have attended a few Tribunals where the Nearest Relatives have had a crucial role to play in assisting the Tribunal members to reach a decision. Sometimes this has been by the relatives telling some harsh truths about the patient. Sometimes they have facilitated their discharge in the face of opposition from the professionals.
Doreen was a woman in her early 60’s. She had a history of bipolar affective disorder going back nearly 40 years. During that time she had had a number of acute admissions under the Mental Health Act, most recently about 6 years previously. She normally managed well with a fortnightly depot injection and some oral mood stabilising medication. In fact she literally swore by its efficacy: “That injection,” she once told me, “it’s fucking marvellous!”
Doreen was a large and imposing lady. Even when well, she probably ran a bit fast: she was always loud, and often very crude, but in an amiable and rather likeable way. She tended to fill a room, both in reality, because of her bulk, but also with her gravely voice, which had been roughened and deepened by her 50 cigarettes a day habit, and her frequent peels of laughter after having told a particularly off colour joke.
It as unclear what had precipitated this admission; her husband thought that she had stopped her medication because of fears it was causing her constipation. The result, however, was that her behaviour became more and more unmanageable by her usually very tolerant husband, and even the input of the Crisis Team could not prevent an admission to hospital. When she decided to leave a few days later, she was placed under Sec.3.
Outraged at this, she appealed.
She had a manager’s hearing within a couple of weeks. I wrote her Social Circumstances Report. I interviewed her husband, who told me that he thought she needed a combination of oral and injected medication. He did not feel she was well enough to be at home at present. I put this in my report. When I interviewed Doreen for the report, she was still clearly displaying symptoms of hypomania, talking very quickly, darting around from subject to subject – and also displayed symptoms of paranoia, focusing on ward staff and her husband. The ward staff, she confided in me, were trying to kill her. She had a fixed belief that the nurses were “wicked animals” who had left her for dead suffering from hypothermia. Her husband, she told me, was a wicked old man who was also trying to kill her, in order to inherit her jewels.
The manager’s hearing considered her case, but did not discharge her from detention.
Doreen remained on the ward, protesting that she did not want oral medication. She continued to be happy to have her depot injection, as she always had been, but she became more and more unmanageable on the ward, being openly hostile to female staff, at times slapping nurses as they passed her in the corridor, and was also sexually disinhibited with male staff and patients. The ward decided to transfer her to the local PICU (Psychiatric Intensive Care Unit).
The PICU is classified as a low secure unit. This means that it is locked. I attended her first review. I had to go through an airlock, leaving any sharp objects, keys, and my mobile phone at reception. Doreen was still voluble and showed evidence of hypomania, but was not being verbally or physically aggressive to staff. She did, however, attempt to seduce the male nurse who was present at the meeting. She continued to refuse oral medication, but appeared more settled. After about a month a date for a Tribunal was set.
I interviewed both her and her husband for the report. He told me that he was willing for his wife to return to the marital home, as long as her mood was stable and she was complying with her medication. Certain areas of need have been identified, including some aids and adaptations to the house, and a support worker to take Doreen out. He was also considering taking early retirement in order to spend more time with her. Doreen's mental state did seem to have improved, but there was still evidence of pressure of speech, as well as evidence of disinhibition in the content of her conversation with me. Her relationship had clearly improved with her husband, who had been visiting her on the ward. However, she remained adamant that she should never have been detained, and that she did not need oral medication. I concluded in my report that "although I am aware of some improvement in Doreen's mental state, she is still presenting with a mental illness of a nature and degree that warrants her continued detention under Sec.3, and that were she not detained under the Mental Health Act she would intend to leave the ward and return home. This would not be in the interests of Doreen, or her nearest relative and carer, and could jeopardise her long term rehabilitation prospects." I suggested that she should return to the local ward prior to her eventual discharge home.
When I arrived at the PICU, not only was her husband there, but her daughter and son-in-law had also come. Although her husband had told me only 2 weeks before that he still had worries about her returning home, he was now saying that he wanted her home as soon as possible. They all went off into a side room with Doreen’s solicitor.
With Doreen's consent, her husband and daughter both attended the Tribunal. The solicitor invited them to give evidence to the Tribunal regarding the arrangements they could make to care for Doreen and maintain her mental stability. They were prepared to take her home with them today, were the Tribunal minded to discharge her.
The Tribunal were so minded, she was discharged for the Sec.3 with immediate effect and she went home with her relatives that day.
And reader, to this day Doreen is still at home with her husband, still in good mental health, still accepting her depot injection, and still not taking any oral medication.
Tuesday, 19 April 2011
Thursday, 7 April 2011
When Detained Patients Appeal Part IV: How To Get Off Your Section
Despite the title of this post, I’m not completely gamekeeper turned poacher – as an AMHP I do take the view that some people with severe mental disorder need to be detained under the Mental Health Act for assessment and/or treatment. However, if you are a detained patient who does not want to remain in hospital, here are some hints and tips that might make your stay a little shorter.
1. Appeal against your detention
When you are detained under a section of the MHA, it is the duty of the AMHP who detained you, and of the hospital staff, to inform you of your rights to appeal. Staff have a duty to help you if you want to appeal. Your case will then be heard by an independent Tribunal which is part of the judicial system. Around 15% of appeals to Tribunals are successful.
A formal appeal to a Tribunal will also concentrate the mind of the psychiatrist. If you are making a good recovery, they may well decide to discharge you from detention prior to the actual date of the appeal.
2. Get a solicitor
Patients detained under the MHA have the right to free legal aid regardless of their incomes. There are solicitors with special training who will take on this work. The hospital staff will put you in touch with an approved solicitor. Although a patient can use almost anyone to help them present their case in a Tribunal, your chances will be improved by having a qualified legal representative.
3. Allow the solicitor to present your case
Although Tribunals make an effort to appear as informal as possible, it is nevertheless essentially a court of law. The chairman of the Tribunal, whose status is equivalent to a judge, will not appreciate the patient making constant interruptions or challenging the testimonies of the psychiatrist or AMHP. The patient can ask their solicitor to point out inaccuracies or discrepancies in written and verbal reports. The solicitor will frequently pick up on these issues without prompting. Don’t make the mistake that Norman did (When Detained Patients Appeal Part II, 16th March 2011).
4. Be wary of opportunities to speak to the Tribunal
I’ve seen many cases appear to go well in the Tribunal right up until the moment when the patient is asked by the medical member or the chairman to tell them more about how they are or if they have anything they wish to say to the Tribunal. Many a paranoid or psychotic patient has then gone into great detail about their delusions or hallucinations, thereby proving that they have a mental illness “of a nature or degree which warrants detention in hospital” for assessment or treatment, and which would then make it very difficult for the Tribunal to discharge them. Don’t make the mistake that Denise did (Just Another Day, 3rd September 2009).
I remember one Tribunal I attended. The patient had sat there quietly throughout, allowing his solicitor to question the psychiatrist and his care coordinator. It had been going quite well for him. The solicitor had certainly made the psychiatrist look uncomfortable at times. The medical member then said to him: “Is there anything you would like to tell us?”
“Yes,” he replied. “I don’t need any medication or anything like that. I’d be perfectly all right if it wasn’t for these voices. They never leave me alone. They’re always going on at me to do bad things. I think it’s my psychiatrist, he projects them into my head from a transmitter on his desk. I had a brain implant inserted into my head many years ago which has made me half robot and half human. The implant picks up the signals and I then hear them. Those voices, they drive me mad, I tell you.”
He did not get off his section.
5. Do not threaten or assault the psychiatrist or other staff
This does not look good in a report to the Tribunal. It will also tend to stay with you in every future risk assessment.
6. Take the prescribed medication
Psychiatrists do as a rule want their patients to get better. Nowadays there is intense pressure on hospital beds, and psychiatrists do not generally want patients to remain in hospital longer than absolutely necessary. There is a wide range of psychotropic medication that can actually help people with depression, psychosis or mania with their symptoms. Cooperating with the inpatient treatment plan and with plans for your aftercare after discharge will definitely make your stay shorter.
If you are detained under Sec.3 (for treatment) you will inevitably be subject to Sec.117 of the MHA. This refers to the duty of the NHS and the local authority to provide aftercare. The cost of any aftercare provided (including residential or nursing care, as well as provision of community support services) will have to be met by the local authority or the local NHS Trust.
1. Appeal against your detention
When you are detained under a section of the MHA, it is the duty of the AMHP who detained you, and of the hospital staff, to inform you of your rights to appeal. Staff have a duty to help you if you want to appeal. Your case will then be heard by an independent Tribunal which is part of the judicial system. Around 15% of appeals to Tribunals are successful.
A formal appeal to a Tribunal will also concentrate the mind of the psychiatrist. If you are making a good recovery, they may well decide to discharge you from detention prior to the actual date of the appeal.
2. Get a solicitor
Patients detained under the MHA have the right to free legal aid regardless of their incomes. There are solicitors with special training who will take on this work. The hospital staff will put you in touch with an approved solicitor. Although a patient can use almost anyone to help them present their case in a Tribunal, your chances will be improved by having a qualified legal representative.
3. Allow the solicitor to present your case
Although Tribunals make an effort to appear as informal as possible, it is nevertheless essentially a court of law. The chairman of the Tribunal, whose status is equivalent to a judge, will not appreciate the patient making constant interruptions or challenging the testimonies of the psychiatrist or AMHP. The patient can ask their solicitor to point out inaccuracies or discrepancies in written and verbal reports. The solicitor will frequently pick up on these issues without prompting. Don’t make the mistake that Norman did (When Detained Patients Appeal Part II, 16th March 2011).
4. Be wary of opportunities to speak to the Tribunal
I’ve seen many cases appear to go well in the Tribunal right up until the moment when the patient is asked by the medical member or the chairman to tell them more about how they are or if they have anything they wish to say to the Tribunal. Many a paranoid or psychotic patient has then gone into great detail about their delusions or hallucinations, thereby proving that they have a mental illness “of a nature or degree which warrants detention in hospital” for assessment or treatment, and which would then make it very difficult for the Tribunal to discharge them. Don’t make the mistake that Denise did (Just Another Day, 3rd September 2009).
I remember one Tribunal I attended. The patient had sat there quietly throughout, allowing his solicitor to question the psychiatrist and his care coordinator. It had been going quite well for him. The solicitor had certainly made the psychiatrist look uncomfortable at times. The medical member then said to him: “Is there anything you would like to tell us?”
“Yes,” he replied. “I don’t need any medication or anything like that. I’d be perfectly all right if it wasn’t for these voices. They never leave me alone. They’re always going on at me to do bad things. I think it’s my psychiatrist, he projects them into my head from a transmitter on his desk. I had a brain implant inserted into my head many years ago which has made me half robot and half human. The implant picks up the signals and I then hear them. Those voices, they drive me mad, I tell you.”
He did not get off his section.
5. Do not threaten or assault the psychiatrist or other staff
This does not look good in a report to the Tribunal. It will also tend to stay with you in every future risk assessment.
6. Take the prescribed medication
Psychiatrists do as a rule want their patients to get better. Nowadays there is intense pressure on hospital beds, and psychiatrists do not generally want patients to remain in hospital longer than absolutely necessary. There is a wide range of psychotropic medication that can actually help people with depression, psychosis or mania with their symptoms. Cooperating with the inpatient treatment plan and with plans for your aftercare after discharge will definitely make your stay shorter.
If you are detained under Sec.3 (for treatment) you will inevitably be subject to Sec.117 of the MHA. This refers to the duty of the NHS and the local authority to provide aftercare. The cost of any aftercare provided (including residential or nursing care, as well as provision of community support services) will have to be met by the local authority or the local NHS Trust.
Wednesday, 23 March 2011
When Detained Patients Appeal – Part III: Trevor and the Tribunal
It appears that I have not been discreet enough. Since my last post, my AMHP student has discovered my identity as The Masked AMHP. I guess that wearing my glasses over the mask wasn't enough after all. I don't think the cowboy hat helped either. Or the rawhide chaps.
Anyway, on to my humiliating experience at Trevor's Tribunal.
Trevor was in his early 20’s. He had been involved with psychiatric services for 4 years. He had spent a good deal of that time detained under Sec.2 or Sec.3 of the MHA in a range of hospitals.
Trevor was very complex. He had not so much a dual diagnosis as a triple diagnosis. He had a history of abuse of drugs, had acquired a diagnosis of paranoid schizophrenia during his frequent hospital stays – and had a psychopathic personality disorder.
He had a serious history of assaults and threats to his parents and to professionals, especially nurses. This began during his first admission. While detained under Sec.3 on Bluebell Ward he had hidden in his room behind the door with the lights out, waiting for a nurse to come looking for him. The female nurse entered the room, and he attempted to strangle her with a ligature – in this case, a tie he had managed to hide. Had she not been able to set off her panic alarm, he could have killed her.
Somewhat surprisingly, he was not charged with an offence, but was instead transferred to a medium secure unit, where one evening while playing a game of table tennis with another nurse, he calmly reached over to get his coffee, and without warning threw the hot drink straight into the nurse’s face, causing serious scalding.
The longer I worked with Trevor, the harder I found him to like.
He regularly appealed against detention during his hospital spells, and an appeal was pending against detention in this particular hospital. The day after this incident I visited him in order to write my social circumstances report. He appeared somewhat the worse for wear, with some fresh contusions on his face, and he was complaining of a sprained wrist. He wished to make a complaint against the staff for excessive restraint.
“After I threw the coffee,” he told me calmly, with the hint of a smile on his face, “the staff used excessive control and restraint. They didn’t need to grab me. I just stood back and put my hands up. I expected them to escort me to the seclusion room. I wasn’t going to struggle.”
It is possible that staff were overzealous in restraining him. However, in view of his history (he had also held his GP at knife point on another occasion that led to his detention under the MHA) and what he had done out of the blue the previous evening, it is quite possible that the staff were frankly terrified of him and weren’t about to take any more risks.
The main thing I learned from his account of this incident was that Trevor knew exactly what he was doing. He had not been told to scald the nurse by a voice. He had not had any delusional beliefs about the nurse. He had just decided to do it for the sheer hell of it, having learned that being a detained patient absolved him of responsibility for his actions.
I wrote several social circumstances reports for Trevor over a number of years, and was responsible for detaining him under the MHA on a couple of occasions. The last time was somewhat unusual. Before the 2007 Act came into force, the application form for Sec.3 required the Approved Social Worker (the predecessor to the AMHP) to state the nature of the mental disorder that required treatment. There was a space in which to enter: “mental illness, mental impairment, severe mental impairment, psychopathic disorder (whichever of these is appropriate)”. For the only time, I inserted both “mental illness” and “psychopathic disorder”.
He had been an informal patient for a period of time, and had been stretching the boundaries of acceptable behaviour for some weeks. We were reluctant to use the MHA again, but following an assessment by the local forensic consultant psychiatrist, who had been prepared to make a formal diagnosis of psychopathic disorder and recommended that he should be admitted to a specialist unit, we assessed him again. During the assessment, his room was searched and a bag containing large shards of glass which he had taken out of a skip during unescorted ground leave was found in a drawer. He was just too dangerous.
Trevor was transferred again to a medium secure unit, and again appealed against detention. While there, he had unexpectedly suffered from a seizure and had been admitted to a local general hospital. While there, he took a syringe from a nurse and darted them in the face with it. Again, having played the detained patient card, he was not arrested or charged with an offence. He was instead transferred to another secure unit.
I attended the Appeal Tribunal at this new secure unit, which was a long way from Charwood. Trevor had only been there for a few weeks, and the consultant there, although knowing his history, had found him to be compliant and fairly agreeable. I was the only person at the Tribunal who had known him over an extended period of time.
We had been looking for a specialist unit that would be able to treat the psychopathic aspect of Trevor’s mental disorder. Just before the tribunal, we had heard that a suitable unit had accepted him. I had also heard that funding had been agreed for this specialist (and eye-wateringly expensive) placement.
I had spent a considerable time preparing the report. I had interviewed Trevor’s parents, who were frankly terrified of him, since they had on a many occasions borne the brunt of his violent and unpredictable behaviour. They had told me that they were no longer able to provide a home for him, and were in full agreement with our plans to admit him to a specialist unit. I included this in my report.
I also included a detailed account of Trevor’s history of dangerousness and of the numerous and frankly disastrous attempts that had been made to manage him in the community. He had been tried in hostels, in supported accommodation, and in his own flat. Regardless of the level of support provided, he had invariably alienated his neighbours, had threatened support staff, had done his best to avoid medication, except for the illegal sort, and had invariably ended up in a police cell being assessed under the Mental Health Act.
I concluded my report: “While dangerous and unpredictable outbursts remain a feature of Trevor’s behaviour, combined with an unwillingness to cooperate with community staff to reduce risk and relapse, Trevor would continue to be an unacceptable risk to members of the public and those professionals attempting to help him, and further incidents of violence could lead to even more restrictive measures needing to be taken. He is fortunate that the incidents against the person outlined in this report were not referred to the police. For these reasons, I do not consider that it is appropriate to discharge him from compulsory detention at this time”.
Trevor’s solicitor presented Trevor’s case to the Tribunal. He wished to challenge the grounds for detention, and cross examined the consultant at some length. He made much of the fact that this particular consultant had not been witness to any of the unpredictable and dangerous behaviour outlined in his history. The consultant, when asked, felt unable to say that Trevor had a mental disorder of a “degree” to justify detention under the MHA, stressing instead the “nature”. Establishing the existence of a mental disorder of a “nature or degree” is a crucial requirement in a Tribunal, otherwise the Tribunal would be legally bound to discharge the patient. However, it is actually only necessary to establish nature or degree, not both.
This particular Tribunal seemed to forget this. Trevor’s solicitor encouraged this oversight. Trevor was on his best behaviour. He certainly did not present as being psychotic. (To be frank, I was never convinced that he had any significant psychosis. But the diagnosis had stuck fast.) He was also being almost embarrassingly polite to the Tribunal members. When dealing with people in positions of power, he usually either ignored them, insulted them, or attempted to assault them. I had at various times experienced all three.
I had the urge to remind the Tribunal of this point of law relating to “nature or degree”, since the consultant was clearly not going to, but I also knew that Tribunals do not expect or welcome interruptions, and like those present to keep quiet unless spoken to.
It came time for me to be examined over my report. The solicitor picked out the point I had made about his parents not wanting him home.
“Mr Masked ASW”, he asked (this was before I was The Masked AMHP), “have you spoken to Trevor’s parents recently?”
As is often the case, the report had been prepared several weeks previously. I said that I had not.
“Then would you be surprised to know that only yesterday Trevor’s parents said that they would be delighted to have their son home to live with them?”
I agreed that I would be very surprised to hear this.
The non-legal member of the Tribunal looked at me closely. “Isn’t it a pity,” he said, “that you did not check before the Tribunal and furnish us with an addendum?”
I had to agree that it was a pity. I was certain that Trevor’s parents had only changed their minds under duress, and because they could not say to his face that they did not want anything further to do with him. But I could not say this to the Tribunal. I was getting the feeling that things were not going well.
Then Trevor had the opportunity to say anything he wanted to say to the Tribunal.
“The Masked ASW,” he said. “I don’t trust him. He’s had it in for me for years. He lies in his reports about me. He doesn’t even try to get the facts right.”
The three Tribunal members looked accusingly at me.
“Trevor certainly doesn’t appear to be suffering from any mental disorder today, does he?” the chairman observed.
I wanted to reply that actually, Trevor was providing ample evidence to the Tribunal of his psychopathic disorder, the existence of which appeared to have been forgotten by them, but again, it was not my place to speak, and I had to remain silent.
After a brief adjournment, Trevor was discharged from Sec.3 with immediate effect.
When I eventually saw a copy of the written adjudication, the Tribunal stressed the lack of evidence of mental illness, and stated as a finding of fact that as the relationship between Trevor and myself had broken down irretrievably, my evidence carried little if any weight.
I felt sick. I felt this was an implicit attack on my professional integrity. It was clear that they had believed Trevor, and therefore they believed that I would act in an unprofessional manner. That really hurt. What hurt even more, was the knowledge that an opportunity had been lost for Trevor to receive treatment that could reduce his risk to others.
The Tribunal had also disregarded crucial aspects of Trevor’s diagnosis and risk factors, and I felt that they had possibly even reached a perverse decision which amounted to a breach of the law. But I had no power to challenge this decision. I brought it up with my superiors, but neither the Mental Health Trust nor the Local Authority had any interest in making a legal challenge, so nothing happened. It was too late anyway.
Trevor went home. 6 weeks later, his parents threw him out. He took a load of drugs, attacked some strangers in the street, and was detained again. And so it went on. Several years down the line, after much more mayhem, Trevor was eventually placed in the specialist unit that had been identified in the first place.
Anyway, on to my humiliating experience at Trevor's Tribunal.
Trevor was in his early 20’s. He had been involved with psychiatric services for 4 years. He had spent a good deal of that time detained under Sec.2 or Sec.3 of the MHA in a range of hospitals.
Trevor was very complex. He had not so much a dual diagnosis as a triple diagnosis. He had a history of abuse of drugs, had acquired a diagnosis of paranoid schizophrenia during his frequent hospital stays – and had a psychopathic personality disorder.
He had a serious history of assaults and threats to his parents and to professionals, especially nurses. This began during his first admission. While detained under Sec.3 on Bluebell Ward he had hidden in his room behind the door with the lights out, waiting for a nurse to come looking for him. The female nurse entered the room, and he attempted to strangle her with a ligature – in this case, a tie he had managed to hide. Had she not been able to set off her panic alarm, he could have killed her.
Somewhat surprisingly, he was not charged with an offence, but was instead transferred to a medium secure unit, where one evening while playing a game of table tennis with another nurse, he calmly reached over to get his coffee, and without warning threw the hot drink straight into the nurse’s face, causing serious scalding.
The longer I worked with Trevor, the harder I found him to like.
He regularly appealed against detention during his hospital spells, and an appeal was pending against detention in this particular hospital. The day after this incident I visited him in order to write my social circumstances report. He appeared somewhat the worse for wear, with some fresh contusions on his face, and he was complaining of a sprained wrist. He wished to make a complaint against the staff for excessive restraint.
“After I threw the coffee,” he told me calmly, with the hint of a smile on his face, “the staff used excessive control and restraint. They didn’t need to grab me. I just stood back and put my hands up. I expected them to escort me to the seclusion room. I wasn’t going to struggle.”
It is possible that staff were overzealous in restraining him. However, in view of his history (he had also held his GP at knife point on another occasion that led to his detention under the MHA) and what he had done out of the blue the previous evening, it is quite possible that the staff were frankly terrified of him and weren’t about to take any more risks.
The main thing I learned from his account of this incident was that Trevor knew exactly what he was doing. He had not been told to scald the nurse by a voice. He had not had any delusional beliefs about the nurse. He had just decided to do it for the sheer hell of it, having learned that being a detained patient absolved him of responsibility for his actions.
I wrote several social circumstances reports for Trevor over a number of years, and was responsible for detaining him under the MHA on a couple of occasions. The last time was somewhat unusual. Before the 2007 Act came into force, the application form for Sec.3 required the Approved Social Worker (the predecessor to the AMHP) to state the nature of the mental disorder that required treatment. There was a space in which to enter: “mental illness, mental impairment, severe mental impairment, psychopathic disorder (whichever of these is appropriate)”. For the only time, I inserted both “mental illness” and “psychopathic disorder”.
He had been an informal patient for a period of time, and had been stretching the boundaries of acceptable behaviour for some weeks. We were reluctant to use the MHA again, but following an assessment by the local forensic consultant psychiatrist, who had been prepared to make a formal diagnosis of psychopathic disorder and recommended that he should be admitted to a specialist unit, we assessed him again. During the assessment, his room was searched and a bag containing large shards of glass which he had taken out of a skip during unescorted ground leave was found in a drawer. He was just too dangerous.
Trevor was transferred again to a medium secure unit, and again appealed against detention. While there, he had unexpectedly suffered from a seizure and had been admitted to a local general hospital. While there, he took a syringe from a nurse and darted them in the face with it. Again, having played the detained patient card, he was not arrested or charged with an offence. He was instead transferred to another secure unit.
I attended the Appeal Tribunal at this new secure unit, which was a long way from Charwood. Trevor had only been there for a few weeks, and the consultant there, although knowing his history, had found him to be compliant and fairly agreeable. I was the only person at the Tribunal who had known him over an extended period of time.
We had been looking for a specialist unit that would be able to treat the psychopathic aspect of Trevor’s mental disorder. Just before the tribunal, we had heard that a suitable unit had accepted him. I had also heard that funding had been agreed for this specialist (and eye-wateringly expensive) placement.
I had spent a considerable time preparing the report. I had interviewed Trevor’s parents, who were frankly terrified of him, since they had on a many occasions borne the brunt of his violent and unpredictable behaviour. They had told me that they were no longer able to provide a home for him, and were in full agreement with our plans to admit him to a specialist unit. I included this in my report.
I also included a detailed account of Trevor’s history of dangerousness and of the numerous and frankly disastrous attempts that had been made to manage him in the community. He had been tried in hostels, in supported accommodation, and in his own flat. Regardless of the level of support provided, he had invariably alienated his neighbours, had threatened support staff, had done his best to avoid medication, except for the illegal sort, and had invariably ended up in a police cell being assessed under the Mental Health Act.
I concluded my report: “While dangerous and unpredictable outbursts remain a feature of Trevor’s behaviour, combined with an unwillingness to cooperate with community staff to reduce risk and relapse, Trevor would continue to be an unacceptable risk to members of the public and those professionals attempting to help him, and further incidents of violence could lead to even more restrictive measures needing to be taken. He is fortunate that the incidents against the person outlined in this report were not referred to the police. For these reasons, I do not consider that it is appropriate to discharge him from compulsory detention at this time”.
Trevor’s solicitor presented Trevor’s case to the Tribunal. He wished to challenge the grounds for detention, and cross examined the consultant at some length. He made much of the fact that this particular consultant had not been witness to any of the unpredictable and dangerous behaviour outlined in his history. The consultant, when asked, felt unable to say that Trevor had a mental disorder of a “degree” to justify detention under the MHA, stressing instead the “nature”. Establishing the existence of a mental disorder of a “nature or degree” is a crucial requirement in a Tribunal, otherwise the Tribunal would be legally bound to discharge the patient. However, it is actually only necessary to establish nature or degree, not both.
This particular Tribunal seemed to forget this. Trevor’s solicitor encouraged this oversight. Trevor was on his best behaviour. He certainly did not present as being psychotic. (To be frank, I was never convinced that he had any significant psychosis. But the diagnosis had stuck fast.) He was also being almost embarrassingly polite to the Tribunal members. When dealing with people in positions of power, he usually either ignored them, insulted them, or attempted to assault them. I had at various times experienced all three.
I had the urge to remind the Tribunal of this point of law relating to “nature or degree”, since the consultant was clearly not going to, but I also knew that Tribunals do not expect or welcome interruptions, and like those present to keep quiet unless spoken to.
It came time for me to be examined over my report. The solicitor picked out the point I had made about his parents not wanting him home.
“Mr Masked ASW”, he asked (this was before I was The Masked AMHP), “have you spoken to Trevor’s parents recently?”
As is often the case, the report had been prepared several weeks previously. I said that I had not.
“Then would you be surprised to know that only yesterday Trevor’s parents said that they would be delighted to have their son home to live with them?”
I agreed that I would be very surprised to hear this.
The non-legal member of the Tribunal looked at me closely. “Isn’t it a pity,” he said, “that you did not check before the Tribunal and furnish us with an addendum?”
I had to agree that it was a pity. I was certain that Trevor’s parents had only changed their minds under duress, and because they could not say to his face that they did not want anything further to do with him. But I could not say this to the Tribunal. I was getting the feeling that things were not going well.
Then Trevor had the opportunity to say anything he wanted to say to the Tribunal.
“The Masked ASW,” he said. “I don’t trust him. He’s had it in for me for years. He lies in his reports about me. He doesn’t even try to get the facts right.”
The three Tribunal members looked accusingly at me.
“Trevor certainly doesn’t appear to be suffering from any mental disorder today, does he?” the chairman observed.
I wanted to reply that actually, Trevor was providing ample evidence to the Tribunal of his psychopathic disorder, the existence of which appeared to have been forgotten by them, but again, it was not my place to speak, and I had to remain silent.
After a brief adjournment, Trevor was discharged from Sec.3 with immediate effect.
When I eventually saw a copy of the written adjudication, the Tribunal stressed the lack of evidence of mental illness, and stated as a finding of fact that as the relationship between Trevor and myself had broken down irretrievably, my evidence carried little if any weight.
I felt sick. I felt this was an implicit attack on my professional integrity. It was clear that they had believed Trevor, and therefore they believed that I would act in an unprofessional manner. That really hurt. What hurt even more, was the knowledge that an opportunity had been lost for Trevor to receive treatment that could reduce his risk to others.
The Tribunal had also disregarded crucial aspects of Trevor’s diagnosis and risk factors, and I felt that they had possibly even reached a perverse decision which amounted to a breach of the law. But I had no power to challenge this decision. I brought it up with my superiors, but neither the Mental Health Trust nor the Local Authority had any interest in making a legal challenge, so nothing happened. It was too late anyway.
Trevor went home. 6 weeks later, his parents threw him out. He took a load of drugs, attacked some strangers in the street, and was detained again. And so it went on. Several years down the line, after much more mayhem, Trevor was eventually placed in the specialist unit that had been identified in the first place.
Wednesday, 16 March 2011
When Detained Patients Appeal – Part II
Although many detained patients may find this difficult to believe, psychiatrists and care coordinators do not want to keep people detained under the MHA if it is not clinically justified. People will tend to have their sections removed as soon as the clinical team feels that their mental state has improved enough that they can either be discharged, or will remain as informal patients. Many detained patients will come to recognise the necessity for medication once they have received treatment for a period of time.
Care Coordinators and psychiatrists will also not want to have to write a report for a Tribunal or Managers Hearing, or appear at a Tribunal or Managers Hearing, unless it appears absolutely necessary. If a patient gets as far as the date of the hearing, it is likely to be because they are not yet well enough to recognise the need for treatment.
Norman was a man in his early 50’s. He came from a fairly wealthy middle class family, was educated in a public school, obtained a degree in Chemistry and had a high profile job in a pharmaceutical company for some years before setting up his own consultancy company.
He married and had one son. The couple divorced after 4 years.
He was dissatisfied that custody of his son was given to his wife, and embarked on a series of legal challenges which went all the way to the House of Lords. He insisted on conducting his own cases. He continued to challenge court decisions for over 20 years. He had a reputation as a “vexatious litigant”.
In the previous 10-15 years he had been detained under Sec.2 MHA on several occasions. A tentative diagnosis of bipolar affective disorder was made, but he never spent more than a couple of weeks in hospital. He invariably appealed against detention, and represented himself in the Tribunal. He was invariably discharged from detention, would promptly leave hospital and stop medication.
By the time I became involved with him, Norman had lost all contact with his son, his consultancy had gone into liquidation, he had been evicted from his home for non payment of the mortgage and was living in a caravan on a residential caravan site paid for by his long suffering mother, as he refused to claim benefits.
One day he went to his bank to request a loan in order to continue with his endless appeals over custody of his son (who by now was 30 years old). When the bank manager refused, he attempted to remove the computer from the manager’s desk in lieu of a loan. He was arrested, and detained under Sec.2 MHA by the out of hours AMHP.
On admission to Bluebell Ward, he refused all medication and promptly appealed. I was asked to write the social circumstances report.
When I interviewed him for the report, he was exceptionally arrogant and dismissive. That was not in itself evidence of mental illness, but his grandiose delusions about his life, and his denial of the dire consequences of his futile litigation over the years I did think showed that he was likely to be mentally ill.
I concluded that “it appears likely that Norman has a mental disorder that could be amenable to treatment. However, he has only ever been detained in hospital for short periods of time for assessment, and as far as I can see has never had any treatment which could have a significant impact on mental illness. He does appear to be abnormally fixated on the past perceived injustices relating to custody of the child of the marriage, to the extent that after all this time he is unable to lead anything approaching a normal life. However, at present it is impossible to say whether this obsession is delusional and amounts to a treatable mental illness or is merely an extreme manifestation of despair arising from real injustice, without considerable further assessment, a process which Norman is unlikely to allow voluntarily.”
As usual, Norman represented himself at the Tribunal. He treated the Tribunal as an adversarial court of law, and had huge quantities of documents, none of which had relevance to his appeal, since they were all about his custody battle, but which he attempted to quote from at length. After a few minutes, the chairman had clearly become irritated, and ordered him to stop talking. He asked Norman if he would consider having legal representation.
“I think, with all respect, your honour, that I have more knowledge of legal process than most of the jumped up barristers that inhabit the Inns of Court,” he replied haughtily.
The Chairman, who might possibly have been a barrister, adjourned the Tribunal, insisting that Norman appoint a legal representative.
A week later, the Tribunal reconvened. This time Norman had a solicitor representing him, an eminently reasonable and conscientious man with a real interest in mental disorder, whom I had seen representing many patients in Tribunals and Managers Hearings.
His solicitor attempted to present Norman’s case for discharge from detention. But Norman was not prepared to sit silently, and instead continually interrupted him, correcting him constantly on minor and irrelevant factual points. The Chairman became increasingly irritated. Norman’s solicitor looked increasingly desperate as he saw any chance of his client being discharged evaporating.
Eventually, the Chairman ordered Norman to be quiet, otherwise he would be asked to leave the Tribunal. Norman reluctantly agreed to this, but had to be reminded several times, as he found the impulse to challenge every minor point almost too much to suppress.
“I put it to you, Doctor,” he interrupted at one point while the psychiatrist was being interviewed, “that your entire psychiatric edifice is a farrago of nonsense which is designed only to control the minds of those few remaining independent thinkers in this country in which we find ourselves having to live, in an ever increasing verisimilitude to the terrifying world described in George Orwell’s estimable book 1984.”
This was enough for the Chairman. He asked for Norman to be removed from the room, and the rest of the hearing was conducted in his absence.
He was not discharged from his section, and indeed, following a ward discussion in which it was forcefully argued that, if it was considered that Norman had a serious mental disorder, then he should be treated for it, a week later he was detained under Sec.3 and treatment for bipolar affective disorder was commenced.
He inevitably appealed again, but within a few weeks, as a result of treatment, he began to emerge, as a butterfly emerges from a chrysalis, as a civil, polite and thoughtful man, who could at last see that his behaviour for the last 20 years had been irrational and pointless. He was discharged from detention before his appeal was heard, remained for a further period as an informal patient, and then was discharged to more appropriate accommodation.
Care Coordinators and psychiatrists will also not want to have to write a report for a Tribunal or Managers Hearing, or appear at a Tribunal or Managers Hearing, unless it appears absolutely necessary. If a patient gets as far as the date of the hearing, it is likely to be because they are not yet well enough to recognise the need for treatment.
Norman was a man in his early 50’s. He came from a fairly wealthy middle class family, was educated in a public school, obtained a degree in Chemistry and had a high profile job in a pharmaceutical company for some years before setting up his own consultancy company.
He married and had one son. The couple divorced after 4 years.
He was dissatisfied that custody of his son was given to his wife, and embarked on a series of legal challenges which went all the way to the House of Lords. He insisted on conducting his own cases. He continued to challenge court decisions for over 20 years. He had a reputation as a “vexatious litigant”.
In the previous 10-15 years he had been detained under Sec.2 MHA on several occasions. A tentative diagnosis of bipolar affective disorder was made, but he never spent more than a couple of weeks in hospital. He invariably appealed against detention, and represented himself in the Tribunal. He was invariably discharged from detention, would promptly leave hospital and stop medication.
By the time I became involved with him, Norman had lost all contact with his son, his consultancy had gone into liquidation, he had been evicted from his home for non payment of the mortgage and was living in a caravan on a residential caravan site paid for by his long suffering mother, as he refused to claim benefits.
One day he went to his bank to request a loan in order to continue with his endless appeals over custody of his son (who by now was 30 years old). When the bank manager refused, he attempted to remove the computer from the manager’s desk in lieu of a loan. He was arrested, and detained under Sec.2 MHA by the out of hours AMHP.
On admission to Bluebell Ward, he refused all medication and promptly appealed. I was asked to write the social circumstances report.
When I interviewed him for the report, he was exceptionally arrogant and dismissive. That was not in itself evidence of mental illness, but his grandiose delusions about his life, and his denial of the dire consequences of his futile litigation over the years I did think showed that he was likely to be mentally ill.
I concluded that “it appears likely that Norman has a mental disorder that could be amenable to treatment. However, he has only ever been detained in hospital for short periods of time for assessment, and as far as I can see has never had any treatment which could have a significant impact on mental illness. He does appear to be abnormally fixated on the past perceived injustices relating to custody of the child of the marriage, to the extent that after all this time he is unable to lead anything approaching a normal life. However, at present it is impossible to say whether this obsession is delusional and amounts to a treatable mental illness or is merely an extreme manifestation of despair arising from real injustice, without considerable further assessment, a process which Norman is unlikely to allow voluntarily.”
As usual, Norman represented himself at the Tribunal. He treated the Tribunal as an adversarial court of law, and had huge quantities of documents, none of which had relevance to his appeal, since they were all about his custody battle, but which he attempted to quote from at length. After a few minutes, the chairman had clearly become irritated, and ordered him to stop talking. He asked Norman if he would consider having legal representation.
“I think, with all respect, your honour, that I have more knowledge of legal process than most of the jumped up barristers that inhabit the Inns of Court,” he replied haughtily.
The Chairman, who might possibly have been a barrister, adjourned the Tribunal, insisting that Norman appoint a legal representative.
A week later, the Tribunal reconvened. This time Norman had a solicitor representing him, an eminently reasonable and conscientious man with a real interest in mental disorder, whom I had seen representing many patients in Tribunals and Managers Hearings.
His solicitor attempted to present Norman’s case for discharge from detention. But Norman was not prepared to sit silently, and instead continually interrupted him, correcting him constantly on minor and irrelevant factual points. The Chairman became increasingly irritated. Norman’s solicitor looked increasingly desperate as he saw any chance of his client being discharged evaporating.
Eventually, the Chairman ordered Norman to be quiet, otherwise he would be asked to leave the Tribunal. Norman reluctantly agreed to this, but had to be reminded several times, as he found the impulse to challenge every minor point almost too much to suppress.
“I put it to you, Doctor,” he interrupted at one point while the psychiatrist was being interviewed, “that your entire psychiatric edifice is a farrago of nonsense which is designed only to control the minds of those few remaining independent thinkers in this country in which we find ourselves having to live, in an ever increasing verisimilitude to the terrifying world described in George Orwell’s estimable book 1984.”
This was enough for the Chairman. He asked for Norman to be removed from the room, and the rest of the hearing was conducted in his absence.
He was not discharged from his section, and indeed, following a ward discussion in which it was forcefully argued that, if it was considered that Norman had a serious mental disorder, then he should be treated for it, a week later he was detained under Sec.3 and treatment for bipolar affective disorder was commenced.
He inevitably appealed again, but within a few weeks, as a result of treatment, he began to emerge, as a butterfly emerges from a chrysalis, as a civil, polite and thoughtful man, who could at last see that his behaviour for the last 20 years had been irrational and pointless. He was discharged from detention before his appeal was heard, remained for a further period as an informal patient, and then was discharged to more appropriate accommodation.
Monday, 7 March 2011
When Detained Patients Appeal – Part I
In the last few weeks I’ve been doing some training sessions for AMHP students, which has kept me away from posting on the blog for a while. In fact, I’ve currently got an AMHP trainee on placement with me (although I don’t think they realise their placement is with The Masked AMHP. I’m very discreet.) One of the sessions was on Appeal Tribunals and Managers Hearings. Since I have not written much about appeal hearings in the blog, I thought I would devote this post to the process of appealing against detention under the MHA. Since I am not trying to give a two hour lecture, some of the more complex aspects have been simplified or omitted.
All patients detained under Sec.2 or Sec.3 have a right to appeal against these orders. (Interestingly, these rights of appeal also apply to detention under Sec.4. However, since Sec.4 is (a) not that common, (b) lasts only a maximum of 72 hours, and (c) is generally converted to a Sec.2 within 24 hours of admission, there is such a tiny window of opportunity to appeal that I am personally unaware of any appeals against Sec.4 either being made or actually considered by a Tribunal.) Those subject to Guardianship (Sec.7) and Supervised Community Treatment (Sec.17A) also have similar rights of appeal, although I won’t go into these here. Nor will I go into rights of appeal against Court mental health orders.
Although the principle arbiter is what is known as the 1st Tier Tribunal, Hospital Managers (who are actually unpaid and serve an executive function rather than being employed managers of the hospital) can also convene a hearing, in particular for Sec.3, when a managers hearing can take place much sooner than a Tribunal hearing.
These hearings are independent of the hospital. A hearing of the hospital managers consists of a panel of at least three hospital managers, who are basically people with an interest in mental health issues and who also have the time to devote to these duties. (In practice I'm afraid this tends to mean middle aged women who do not need to work full time).
A 1st Tier Tribunal consists of a panel of three – the chairman, who is a lawyer, the medical member, who is a psychiatrist, and a non-legal 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. Since 2008 Tribunals have been part of the Judiciary.
People detained under Sec.2 must apply to the Tribunal for discharge within the first 14 days of detention, whereas people detained under Sec. 3 may apply to the Tribunal for discharge at any time in the 6 month period of detention. If their detention continues beyond the first 6 months, they can appeal at any time during the period of renewal.
The other people present at these hearings will be: the patient; the patient’s representative (who is generally a solicitor but may basically be any other person, apart from people also detained under the MHA or who are inpatients in that hospital); the patient’s Consultant Psychiatrist; a hospital nurse involved with the patient’s care; and someone from the community mental health team, who could be a social worker, a community mental health nurse or an occupational therapist. The patient’s nearest relative may also be present, as well as 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 the patient is “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”. Also for Sec.3 they have to be satisfied that 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 the patient and his representative to cross examine the other people present and to give their side. They can then decide one of three things: not to discharge the patient, to discharge the patient with immediate effect, or to direct that the patient be discharged at a future date, usually in order for suitable arrangements to be made for their discharge.
In 2008, which is the most recent date I could find for these statistics, 13% of patients whose cases were heard by Tribunal were discharged (a total of 967 out of 7295). It’s worth noting that a further 5862 patients were discharged from detention by their psychiatrists before the date of the hearing – in other words, the patient’s appeal can make their psychiatrist think twice about continuing to keep them on section.
It’s also worth knowing (at least if you are a detained patient) that Tribunals in particular can give the psychiatrist, the nurse, and the social worker, or other community representative, a tough time. They can also adjourn the hearing if they want more information about alternatives to detention, and can order people to attend to provide information or to explain, for example, why appropriate community resources are not available. I have attended Tribunals that have been adjourned so that senior managers in the NHS can be ordered to attend in order to account for why they have been dragging their heels over allowing funding for care homes or nursing placements. It’s amazing how quickly financial decisions can be made in these circumstances.
So that, in 1000 words, is a very brief overview. In the last few years I’ve attended 55 Tribunals and Managers Hearings (and written far more reports). Next time I’ll write about some of those appeals.
All patients detained under Sec.2 or Sec.3 have a right to appeal against these orders. (Interestingly, these rights of appeal also apply to detention under Sec.4. However, since Sec.4 is (a) not that common, (b) lasts only a maximum of 72 hours, and (c) is generally converted to a Sec.2 within 24 hours of admission, there is such a tiny window of opportunity to appeal that I am personally unaware of any appeals against Sec.4 either being made or actually considered by a Tribunal.) Those subject to Guardianship (Sec.7) and Supervised Community Treatment (Sec.17A) also have similar rights of appeal, although I won’t go into these here. Nor will I go into rights of appeal against Court mental health orders.
Although the principle arbiter is what is known as the 1st Tier Tribunal, Hospital Managers (who are actually unpaid and serve an executive function rather than being employed managers of the hospital) can also convene a hearing, in particular for Sec.3, when a managers hearing can take place much sooner than a Tribunal hearing.
These hearings are independent of the hospital. A hearing of the hospital managers consists of a panel of at least three hospital managers, who are basically people with an interest in mental health issues and who also have the time to devote to these duties. (In practice I'm afraid this tends to mean middle aged women who do not need to work full time).
A 1st Tier Tribunal consists of a panel of three – the chairman, who is a lawyer, the medical member, who is a psychiatrist, and a non-legal 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. Since 2008 Tribunals have been part of the Judiciary.
People detained under Sec.2 must apply to the Tribunal for discharge within the first 14 days of detention, whereas people detained under Sec. 3 may apply to the Tribunal for discharge at any time in the 6 month period of detention. If their detention continues beyond the first 6 months, they can appeal at any time during the period of renewal.
The other people present at these hearings will be: the patient; the patient’s representative (who is generally a solicitor but may basically be any other person, apart from people also detained under the MHA or who are inpatients in that hospital); the patient’s Consultant Psychiatrist; a hospital nurse involved with the patient’s care; and someone from the community mental health team, who could be a social worker, a community mental health nurse or an occupational therapist. The patient’s nearest relative may also be present, as well as 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 the patient is “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”. Also for Sec.3 they have to be satisfied that 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 the patient and his representative to cross examine the other people present and to give their side. They can then decide one of three things: not to discharge the patient, to discharge the patient with immediate effect, or to direct that the patient be discharged at a future date, usually in order for suitable arrangements to be made for their discharge.
In 2008, which is the most recent date I could find for these statistics, 13% of patients whose cases were heard by Tribunal were discharged (a total of 967 out of 7295). It’s worth noting that a further 5862 patients were discharged from detention by their psychiatrists before the date of the hearing – in other words, the patient’s appeal can make their psychiatrist think twice about continuing to keep them on section.
It’s also worth knowing (at least if you are a detained patient) that Tribunals in particular can give the psychiatrist, the nurse, and the social worker, or other community representative, a tough time. They can also adjourn the hearing if they want more information about alternatives to detention, and can order people to attend to provide information or to explain, for example, why appropriate community resources are not available. I have attended Tribunals that have been adjourned so that senior managers in the NHS can be ordered to attend in order to account for why they have been dragging their heels over allowing funding for care homes or nursing placements. It’s amazing how quickly financial decisions can be made in these circumstances.
So that, in 1000 words, is a very brief overview. In the last few years I’ve attended 55 Tribunals and Managers Hearings (and written far more reports). Next time I’ll write about some of those appeals.
Wednesday, 19 January 2011
Of Animals and Mental Health Act Assessments
Animals quite often figure in a social worker’s day to day work. This is because of Sec.48 of the National Assistance Act 1948, which states essentially that where a person has been admitted to hospital or admitted to a care home and they are deemed to be unable to deal with their property “it shall be the duty of the local authority to take reasonable steps to prevent or mitigate loss or damage”. This means that a social worker may have to ensure that a house has been locked up and made secure; it also means that a social worker may have to ensure that any animals the person owns are cared for.
This has led to some unusual requests. One night when I was on call, I was contacted by the local police about a couple of New Age travellers, who lived in a traditional horse drawn caravan and would tour the commons of the county, camping for a few nights at a time at each one. They had had a fire in their caravan and it had been burnt out. They therefore needed emergency accommodation. And so did their two horses and a dog.
The prospect of finding accommodation for a couple of able bodied people at such short notice was remote. The prospect of finding emergency accommodation for two horses was virtually impossible. This called for some lateral thinking.
After a lot of ringing around I managed to contact a voluntary organisation who were able to provide a large tarpaulin and deliver it to the site. The travellers were therefore able to construct a bender using the tarpaulin and remain on the common. This meant that they could also continue to look after their dog and their horses. Problem solved.
Not all such requests are so unusual: most involve dogs and cats, having to arrange accommodation in kennels or catteries. Social workers have a list of places and organisations who are prepared to accommodate animals in an emergency, and are generally able to take these situations in their stride.
Dolores was a lady in her 60’s who lived alone in a housing association bungalow. She had a history of schizophrenia going back 30 or more years. Periodically she would decide to have a break from medication. This would then lead to a gradual deterioration in her mental state until she reached a point when she could not longer care for herself adequately and was terrorising her neighbours. I had known her on and off for about 15 years, being called on periodically to assess her under the MHA when all other avenues had been tried.
I had last seen Dolores a few months previously when she had managed to stop having her regular injection by the cunning expedient of informing her community nurse that she was moving out of the area. The local older people’s mental health service had fallen for this ruse for several months, until they were eventually alerted to the fact that she was still in her bungalow in Charwood when they started to receive reports that she had destroyed her pension book, had thrown out her furniture and all her electrical equipment, and was then arrested after she broke an elderly neighbour’s window and made threats to kill her. I had then detained her under Sec.3 MHA. After a couple of months she recovered and returned home. Since she was reluctant to have a depot injection, she was discharged on oral antipsychotic medication.
This was just what she wanted. She soon stopped taking her medication, and before long reports were again being received that she was behaving in bizarre and unacceptable ways. I was again asked to assess her.
Knowing Dolores had a cat, I had already made tentative plans for it to be looked after, and even had a cat basket in the boot of my car, just in case.
I went out with her consultant psychiatrist, her GP, her community nurse and an AMHP trainee. Dolores allowed us into the house, but was suspicious of our motives. She believed that the only reason we were there were so that we could take her bungalow from her and live in it ourselves, perhaps as some sort of mental health professional commune. She was keen to challenge her diagnosis of schizophrenia with some intriguing logical constructs which went like this:
(1) People with schizophrenia hear voices. She does not hear voices. Therefore she does not have schizophrenia.
(2) The Yorkshire Ripper has schizophrenia. She is not the Yorkshire Ripper. Therefore she does not have schizophrenia.
She took a copy of the Oxford Companion to the Mind from her bookshelf.
“I’ve read all about schizophrenia in this book,” she said. “So you can’t pull the wool over my eyes. Here. See what it says for yourself.”
She suddenly flung the book at me, which I was fortunately able to dodge. If I’ve learned anything in my years as an AMHP, it is always to be ready to take evasive action.
We took the decision to detain her under Sec.3 for treatment. This was on the basis that her diagnosis was known, it was known what treatment she required, she would not agree to that treatment being provided in the community, her presentation was entirely consistent with her usual relapse profile, and she had been detained under Sec.3 only a few months previously.
Not surprisingly, Dolores objected. In the circumstances, I felt it was wise to call the police, who very obligingly attended. She liked the police. If there’s something else I have learned, it is that older ladies who are being detained under the MHA are often partial to a man in uniform.
While we waited for the ambulance, I decided to complete the necessary arrangements to accommodate Dolores’ cat.
The cat was not happy about having a house full of strangers. The cat was also not happy about the plan to remove it. It hid behind a sideboard. When we moved the sideboard, it ran off and hid behind the curtain. When we moved the curtain it ran into the kitchen and hid under a kitchen cabinet. When I reached under to get it, it ran out of the kitchen and into the bedroom, where it secreted itself first behind the wardrobe, and then under the bed.
The AMHP trainee was keen to help. She crawled under the bed, and after a scuffle emerged triumphantly with the cat in her hands, which we popped into the cat basket.
However, this was not the only thing the AMHP trainee had emerged with. The cat had understandably been frightened by the strangers in the bungalow and by our efforts to catch it. It had been very frightened. So frightened that it had emptied its bowels under the bed. The product of this action was now liberally smeared all over the AMHP trainee’s blouse.
So while I went off with Dolores and the ambulance to the hospital, the AMHP trainee went home to have a shower and change her clothes.
AMHP learning points
1. If AMHP’s wore uniforms would they receive a better reception? Discuss.
2. Don’t ever crawl under a bed to retrieve a frightened cat.
This has led to some unusual requests. One night when I was on call, I was contacted by the local police about a couple of New Age travellers, who lived in a traditional horse drawn caravan and would tour the commons of the county, camping for a few nights at a time at each one. They had had a fire in their caravan and it had been burnt out. They therefore needed emergency accommodation. And so did their two horses and a dog.
The prospect of finding accommodation for a couple of able bodied people at such short notice was remote. The prospect of finding emergency accommodation for two horses was virtually impossible. This called for some lateral thinking.
After a lot of ringing around I managed to contact a voluntary organisation who were able to provide a large tarpaulin and deliver it to the site. The travellers were therefore able to construct a bender using the tarpaulin and remain on the common. This meant that they could also continue to look after their dog and their horses. Problem solved.
Not all such requests are so unusual: most involve dogs and cats, having to arrange accommodation in kennels or catteries. Social workers have a list of places and organisations who are prepared to accommodate animals in an emergency, and are generally able to take these situations in their stride.
Dolores was a lady in her 60’s who lived alone in a housing association bungalow. She had a history of schizophrenia going back 30 or more years. Periodically she would decide to have a break from medication. This would then lead to a gradual deterioration in her mental state until she reached a point when she could not longer care for herself adequately and was terrorising her neighbours. I had known her on and off for about 15 years, being called on periodically to assess her under the MHA when all other avenues had been tried.
I had last seen Dolores a few months previously when she had managed to stop having her regular injection by the cunning expedient of informing her community nurse that she was moving out of the area. The local older people’s mental health service had fallen for this ruse for several months, until they were eventually alerted to the fact that she was still in her bungalow in Charwood when they started to receive reports that she had destroyed her pension book, had thrown out her furniture and all her electrical equipment, and was then arrested after she broke an elderly neighbour’s window and made threats to kill her. I had then detained her under Sec.3 MHA. After a couple of months she recovered and returned home. Since she was reluctant to have a depot injection, she was discharged on oral antipsychotic medication.
This was just what she wanted. She soon stopped taking her medication, and before long reports were again being received that she was behaving in bizarre and unacceptable ways. I was again asked to assess her.
Knowing Dolores had a cat, I had already made tentative plans for it to be looked after, and even had a cat basket in the boot of my car, just in case.
I went out with her consultant psychiatrist, her GP, her community nurse and an AMHP trainee. Dolores allowed us into the house, but was suspicious of our motives. She believed that the only reason we were there were so that we could take her bungalow from her and live in it ourselves, perhaps as some sort of mental health professional commune. She was keen to challenge her diagnosis of schizophrenia with some intriguing logical constructs which went like this:
(1) People with schizophrenia hear voices. She does not hear voices. Therefore she does not have schizophrenia.
(2) The Yorkshire Ripper has schizophrenia. She is not the Yorkshire Ripper. Therefore she does not have schizophrenia.
She took a copy of the Oxford Companion to the Mind from her bookshelf.
“I’ve read all about schizophrenia in this book,” she said. “So you can’t pull the wool over my eyes. Here. See what it says for yourself.”
She suddenly flung the book at me, which I was fortunately able to dodge. If I’ve learned anything in my years as an AMHP, it is always to be ready to take evasive action.
We took the decision to detain her under Sec.3 for treatment. This was on the basis that her diagnosis was known, it was known what treatment she required, she would not agree to that treatment being provided in the community, her presentation was entirely consistent with her usual relapse profile, and she had been detained under Sec.3 only a few months previously.
Not surprisingly, Dolores objected. In the circumstances, I felt it was wise to call the police, who very obligingly attended. She liked the police. If there’s something else I have learned, it is that older ladies who are being detained under the MHA are often partial to a man in uniform.
While we waited for the ambulance, I decided to complete the necessary arrangements to accommodate Dolores’ cat.
The cat was not happy about having a house full of strangers. The cat was also not happy about the plan to remove it. It hid behind a sideboard. When we moved the sideboard, it ran off and hid behind the curtain. When we moved the curtain it ran into the kitchen and hid under a kitchen cabinet. When I reached under to get it, it ran out of the kitchen and into the bedroom, where it secreted itself first behind the wardrobe, and then under the bed.
The AMHP trainee was keen to help. She crawled under the bed, and after a scuffle emerged triumphantly with the cat in her hands, which we popped into the cat basket.
However, this was not the only thing the AMHP trainee had emerged with. The cat had understandably been frightened by the strangers in the bungalow and by our efforts to catch it. It had been very frightened. So frightened that it had emptied its bowels under the bed. The product of this action was now liberally smeared all over the AMHP trainee’s blouse.
So while I went off with Dolores and the ambulance to the hospital, the AMHP trainee went home to have a shower and change her clothes.
AMHP learning points
1. If AMHP’s wore uniforms would they receive a better reception? Discuss.
2. Don’t ever crawl under a bed to retrieve a frightened cat.
Tuesday, 11 January 2011
Community Treatment Orders and the Role of the AMHP
After the frippery of the last two posts, here is a hefty New Year analysis of Community Treatment Orders, complete with references and tasty statistics. (Don’t forget to put me in your references, AMHP trainees!)
The 2007 Mental Health Act introduced a new role for AMHP’s: functions relating to the new powers of Community Treatment Orders. These functions were “to agree (or not) to the making of a Community Treatment Order (CTO) (s.17A); the extension of a CTO (s20A); conditions to be included in a CTO (s17B); and revocation of a CTO(s17F)” (Mental Health Act 2007 New Roles, NIMHE, October 2008).
Previously, the nearest equivalent had been Sec.25A, relating to Aftercare under Supervision. Sec.25A, inserted into the MHA in 1996, had been intended to provide a legal framework to ensure that patients who had been detained under Sec.3 could be treated in the community. However, Sec.25A never really had any legal teeth to enforce this. Essentially, the patient had to agree to the imposition of aftercare under supervision. If they disagreed, then no order could be made, and they would just have to be discharged anyway when they were well enough. Even if they did agree, they could change their mind at any time, and not much could practically be done about it.
I was only ever involved in one discharge under Sec.25A. The patient, who had been in hospital under Sec.3 for several years, willingly agreed to a comprehensive plan for aftercare in the predischarge meetings. However, the instant he had been formally discharged from Sec.3, he changed his mind about it all. Within a fortnight, he had stopped his medication and began to hide from his care coordinator, and two weeks later he turned up at his parents’ house in the middle of the night, beside himself with fear because everyone in Charwood was listening to his thoughts on their TV’s and the CIA had tracker drones scanning his every move. Within a month of being on Sec.25A he was back in hospital under Sec.3. Sec.25A never really caught on.
Community Treatment Orders, however, are something different. They were also quite controversial, since various Human Rights organisations had concerns about the proposed powers, which could compel patients to have treatment in the community on pain of being recalled to hospital if they refused.
There are certainly ethical issues with CTO’s. Can it ever be right to force people who are not detained in hospital to take medication against their will? But then what is the alternative? The stated purpose of CTO’s is “to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.” (25.2 MHA Code of Practice) That sounds pretty good, doesn’t it?
In addition, the power is designed only to be used with severely mentally disordered people who are at high risk of relapse, often referred to as “revolving door” patients – people like Jenny, about whom I wrote in July 2009 (“God told me not to answer the door!”), who are having to be repeatedly admitted to hospital, often under the MHA. Those frequent relapses and admissions, when the person may take many months in hospital to recover, are likely to be far more harmful to their quality of life than the imposition of controls that may actually allow them to function normally and live a fulfilled life in their own homes.
There is an odd thing, though, about CTO’s. This is the role of the AMHP in the whole process. ASW’s, AMHP’s predecessors, had specific and extensive powers in relation to the detention of patients under the 1983 MHA. As I have often described on this blog, the ASW/AMHP has the power, and the responsibility, to arrange for the detention and admission of a mentally disordered patient. Doctors can recommend, but it is the ASW/AMHP who makes the final decision – and who takes the consequences for that decision. The ASW/AMHP is acting independently of the local authority that approves them. Despite the opinions of some patients that AMHP’s enjoy exerting their power, the reality is that it is an onerous and stressful task that is never taken lightly.
But CTO’s put the AMHP in the position of merely recommending and endorsing the decision of the Responsible Clinician (RC), the psychiatrist in charge of the patient. Their role, although essential to the legal process, is comparatively minor. In practice, it consists of little more than signing a brief, preprinted statement on a piece of paper.
The AMHP becomes involved in the CTO process in three ways. In the case of the making of the CTO in the first place, the AMHP is presented with a form (CTO1) already largely filled out by the RC. The AMHP then has to sign that he or she agrees that the patient meets the legal criteria, that the CTO is appropriate, and that any conditions that the RC has made are necessary or appropriate. In the case of the extension of a CTO beyond the initial 6 months (CTO7) the AMHP again has to agree that the patient meets the criteria and that extension is appropriate.
When a patient has been recalled to hospital by the RC under the powers of the CTO and it appears they will need to remain in hospital for more than 72 hours, the RC will then reinvoke the original Sec.3 by revoking the CTO. Then the AMHP simply has to agree on form CTO5 that the patient meets the criteria for detention in hospital, and that it is appropriate to revoke the CTO.
However, a funny thing about CTO’s is the remarkable lack of rules or guidance relating to the discharge of the AMHP’s role. AMHP’s are subject to all sorts of requirements relating to the detention of patients, laid down either in the Act itself, or in guidance in the form of the Reference Guide and the Code of Practice. These include having to interview the patient “in a suitable manner” before making a decision, the correct identification of the Nearest Relative, notifying the patient and their nearest relative of their rights under the Act, having to write a detailed report explaining and justifying their decisions, and ensuring that all other the legal requirements have been met. Failure to do any of these things may lead to accusations that the AMHP has acted in bad faith or even illegally.
But when it comes to CTO’s, there is no requirement to write a report (unless you disagree with the psychiatrist). Department of Health guidance published in 2008 states only: “In making these judgements, the AMHP is expected to bring knowledge of the patient’s social situation into the discussion. This may require discussion with the patient’s care co-ordinator or key worker so that information about the patient’s home, family, informal support networks, cultural background, and so on can all form part of the decisions which are taken about SCT.” (Supervised Community Treatment: A Guide for Practitioners, DH, Sep 2008) There is no actual requirement even to interview the patient or consult with the nearest relative. There also seems to be no guidance as to what would constitute grounds to disagree with the consultant’s view. Somehow, that doesn’t feel right.
Although CTO’s have been in force since the end of 2008, it wasn’t until a few months ago that I was actually called upon to discharge my AMHP functions. I have now signed a CTO1 (making a CTO) and a CTO5 (revoking a CTO). (So that now makes me an expert, of course.)
Although I am sure that many AMHP’s, after two years of the new powers, will have been involved in plenty of CTO’s, especially if they are hospital based, and can therefore easily pop down the corridor to fill in a form, it came as something of a surprise to me to suddenly be exercising a new function. So I consulted with other colleagues as to how to go about making the assessment and the decision. That was when I fully realised the lack of guidance and procedural protocols. The other AMHP’s, even those who had been involved in many CTO’s, all seemed somehow uncomfortable with the whole process, all approaching the task in their own ways, and as much in the dark about it all as I was.
The first request I received was for a CTO on a 14 year old girl who had been in hospital for over a year under Sec.3. That in itself put me outside my comfort zone – in my day to day work I only work with adults. She had a diagnosis of bipolar affective disorder. This made me even more uncomfortable – it had always been my belief that the usual age of onset for bipolar affective disorder was somewhere in the mid 20’s to mid 30’s. Could a child therefore even receive this diagnosis? Child and Adolescent Psychiatry was even more mysterious than I had thought.
However, it was not my role as AMHP to question a diagnosis. I simply had to “decide whether to agree with the patient’s responsible clinician that the patient meets the criteria for SCT, and (if so) whether SCT is appropriate.” (25.24, MHA Code of Practice). I also had to “consider the wider social context for the patient. Relevant factors may include any support networks the patient may have, the potential impact on the rest of the patient’s family, and employment issues. The AMHP should consider how the patient’s social and cultural background may influence the family environment in which they will be living and the support structures potentially available.” (25.24,25.25 Code of Practice)
So I consulted with the hospital RC (who was actually making the CTO), as well as the community RC (who would be managing the CTO). I spoke to the Care Coordinator. I interviewed the patient, who was on S.117 home leave in Charwood, and her mother. I read the girl’s psychiatric notes. Then I wrote a report, simply using as headings the factors to be taken into account. Then the hospital RC posted the CTO1 to me (I wasn’t going to drive 120 miles to fill in a form). When I received it, I filled in my part, then posted it back. And when he received it a couple of days later, it was completed and she became subject to Supervised Community Treatment. And that was the end of my involvement, although I suppose I may be called on to be involved in any renewal process after the first 6 months.
The other piece of work I have so far done was a revocation of a CTO following a recall to hospital. This related to Leroy, who I wrote about in this blog in May 2009. Leroy had been on a CTO for over a year, but on Christmas Day he was found naked by police in Charwood town centre, stopping cars and kissing the windows. Ill advised use of amphetamine was believed to be implicated. He had been informally admitted to Bluebell Ward, but it was clear, despite the amphetamine wearing off, that he was unwell and would need to remain in hospital for more than 72 hours.
I felt more comfortable with this. I knew Leroy well, I knew his relapse signature, and it seemed likely that it would be appropriate for him to remain in hospital for treatment. It also seemed that the CTO seemed to be having some positive effect, as in the 18 months since he had been subject to Supervised Community Treatment, acute admissions to hospital had gone down. A bit. And the length of time he then spent in hospital had also reduced. So I interviewed him, wrote a report, and signed my bit of the CTO5.
There’s one other thing that leaves me feeling a little uncomfortable about CTO’s. That is, that they are very popular.
Often, it takes quite a while for mental health professionals get used to legal changes like this. Not so with CTO’s.
In a document published in October 2010 (In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10) the total number of patients placed on CTO’s in 2008-9 was 2,109. In 2009-10 it had virtually doubled to 4,020. Over the same period, the number of patients detained under Sec.3 (only people detained under Sec.3 and some forensic sections can be placed on a CTO) was completely static, at 21,538 for 2008-9 and 21,332 in 2009-10.
This means that within two years of the introduction of CTO’s nearly 19% of patients detained in hospital under Sec.3 were discharged on a CTO. And since CTO’s are often being kept in place for a year or more, this could mean a growing accumulation of patient in the community on CTO’s.
It may take some convincing that this constitutes the “least restrictive” option.
The 2007 Mental Health Act introduced a new role for AMHP’s: functions relating to the new powers of Community Treatment Orders. These functions were “to agree (or not) to the making of a Community Treatment Order (CTO) (s.17A); the extension of a CTO (s20A); conditions to be included in a CTO (s17B); and revocation of a CTO(s17F)” (Mental Health Act 2007 New Roles, NIMHE, October 2008).
Previously, the nearest equivalent had been Sec.25A, relating to Aftercare under Supervision. Sec.25A, inserted into the MHA in 1996, had been intended to provide a legal framework to ensure that patients who had been detained under Sec.3 could be treated in the community. However, Sec.25A never really had any legal teeth to enforce this. Essentially, the patient had to agree to the imposition of aftercare under supervision. If they disagreed, then no order could be made, and they would just have to be discharged anyway when they were well enough. Even if they did agree, they could change their mind at any time, and not much could practically be done about it.
I was only ever involved in one discharge under Sec.25A. The patient, who had been in hospital under Sec.3 for several years, willingly agreed to a comprehensive plan for aftercare in the predischarge meetings. However, the instant he had been formally discharged from Sec.3, he changed his mind about it all. Within a fortnight, he had stopped his medication and began to hide from his care coordinator, and two weeks later he turned up at his parents’ house in the middle of the night, beside himself with fear because everyone in Charwood was listening to his thoughts on their TV’s and the CIA had tracker drones scanning his every move. Within a month of being on Sec.25A he was back in hospital under Sec.3. Sec.25A never really caught on.
Community Treatment Orders, however, are something different. They were also quite controversial, since various Human Rights organisations had concerns about the proposed powers, which could compel patients to have treatment in the community on pain of being recalled to hospital if they refused.
There are certainly ethical issues with CTO’s. Can it ever be right to force people who are not detained in hospital to take medication against their will? But then what is the alternative? The stated purpose of CTO’s is “to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.” (25.2 MHA Code of Practice) That sounds pretty good, doesn’t it?
In addition, the power is designed only to be used with severely mentally disordered people who are at high risk of relapse, often referred to as “revolving door” patients – people like Jenny, about whom I wrote in July 2009 (“God told me not to answer the door!”), who are having to be repeatedly admitted to hospital, often under the MHA. Those frequent relapses and admissions, when the person may take many months in hospital to recover, are likely to be far more harmful to their quality of life than the imposition of controls that may actually allow them to function normally and live a fulfilled life in their own homes.
There is an odd thing, though, about CTO’s. This is the role of the AMHP in the whole process. ASW’s, AMHP’s predecessors, had specific and extensive powers in relation to the detention of patients under the 1983 MHA. As I have often described on this blog, the ASW/AMHP has the power, and the responsibility, to arrange for the detention and admission of a mentally disordered patient. Doctors can recommend, but it is the ASW/AMHP who makes the final decision – and who takes the consequences for that decision. The ASW/AMHP is acting independently of the local authority that approves them. Despite the opinions of some patients that AMHP’s enjoy exerting their power, the reality is that it is an onerous and stressful task that is never taken lightly.
But CTO’s put the AMHP in the position of merely recommending and endorsing the decision of the Responsible Clinician (RC), the psychiatrist in charge of the patient. Their role, although essential to the legal process, is comparatively minor. In practice, it consists of little more than signing a brief, preprinted statement on a piece of paper.
The AMHP becomes involved in the CTO process in three ways. In the case of the making of the CTO in the first place, the AMHP is presented with a form (CTO1) already largely filled out by the RC. The AMHP then has to sign that he or she agrees that the patient meets the legal criteria, that the CTO is appropriate, and that any conditions that the RC has made are necessary or appropriate. In the case of the extension of a CTO beyond the initial 6 months (CTO7) the AMHP again has to agree that the patient meets the criteria and that extension is appropriate.
When a patient has been recalled to hospital by the RC under the powers of the CTO and it appears they will need to remain in hospital for more than 72 hours, the RC will then reinvoke the original Sec.3 by revoking the CTO. Then the AMHP simply has to agree on form CTO5 that the patient meets the criteria for detention in hospital, and that it is appropriate to revoke the CTO.
However, a funny thing about CTO’s is the remarkable lack of rules or guidance relating to the discharge of the AMHP’s role. AMHP’s are subject to all sorts of requirements relating to the detention of patients, laid down either in the Act itself, or in guidance in the form of the Reference Guide and the Code of Practice. These include having to interview the patient “in a suitable manner” before making a decision, the correct identification of the Nearest Relative, notifying the patient and their nearest relative of their rights under the Act, having to write a detailed report explaining and justifying their decisions, and ensuring that all other the legal requirements have been met. Failure to do any of these things may lead to accusations that the AMHP has acted in bad faith or even illegally.
But when it comes to CTO’s, there is no requirement to write a report (unless you disagree with the psychiatrist). Department of Health guidance published in 2008 states only: “In making these judgements, the AMHP is expected to bring knowledge of the patient’s social situation into the discussion. This may require discussion with the patient’s care co-ordinator or key worker so that information about the patient’s home, family, informal support networks, cultural background, and so on can all form part of the decisions which are taken about SCT.” (Supervised Community Treatment: A Guide for Practitioners, DH, Sep 2008) There is no actual requirement even to interview the patient or consult with the nearest relative. There also seems to be no guidance as to what would constitute grounds to disagree with the consultant’s view. Somehow, that doesn’t feel right.
Although CTO’s have been in force since the end of 2008, it wasn’t until a few months ago that I was actually called upon to discharge my AMHP functions. I have now signed a CTO1 (making a CTO) and a CTO5 (revoking a CTO). (So that now makes me an expert, of course.)
Although I am sure that many AMHP’s, after two years of the new powers, will have been involved in plenty of CTO’s, especially if they are hospital based, and can therefore easily pop down the corridor to fill in a form, it came as something of a surprise to me to suddenly be exercising a new function. So I consulted with other colleagues as to how to go about making the assessment and the decision. That was when I fully realised the lack of guidance and procedural protocols. The other AMHP’s, even those who had been involved in many CTO’s, all seemed somehow uncomfortable with the whole process, all approaching the task in their own ways, and as much in the dark about it all as I was.
The first request I received was for a CTO on a 14 year old girl who had been in hospital for over a year under Sec.3. That in itself put me outside my comfort zone – in my day to day work I only work with adults. She had a diagnosis of bipolar affective disorder. This made me even more uncomfortable – it had always been my belief that the usual age of onset for bipolar affective disorder was somewhere in the mid 20’s to mid 30’s. Could a child therefore even receive this diagnosis? Child and Adolescent Psychiatry was even more mysterious than I had thought.
However, it was not my role as AMHP to question a diagnosis. I simply had to “decide whether to agree with the patient’s responsible clinician that the patient meets the criteria for SCT, and (if so) whether SCT is appropriate.” (25.24, MHA Code of Practice). I also had to “consider the wider social context for the patient. Relevant factors may include any support networks the patient may have, the potential impact on the rest of the patient’s family, and employment issues. The AMHP should consider how the patient’s social and cultural background may influence the family environment in which they will be living and the support structures potentially available.” (25.24,25.25 Code of Practice)
So I consulted with the hospital RC (who was actually making the CTO), as well as the community RC (who would be managing the CTO). I spoke to the Care Coordinator. I interviewed the patient, who was on S.117 home leave in Charwood, and her mother. I read the girl’s psychiatric notes. Then I wrote a report, simply using as headings the factors to be taken into account. Then the hospital RC posted the CTO1 to me (I wasn’t going to drive 120 miles to fill in a form). When I received it, I filled in my part, then posted it back. And when he received it a couple of days later, it was completed and she became subject to Supervised Community Treatment. And that was the end of my involvement, although I suppose I may be called on to be involved in any renewal process after the first 6 months.
The other piece of work I have so far done was a revocation of a CTO following a recall to hospital. This related to Leroy, who I wrote about in this blog in May 2009. Leroy had been on a CTO for over a year, but on Christmas Day he was found naked by police in Charwood town centre, stopping cars and kissing the windows. Ill advised use of amphetamine was believed to be implicated. He had been informally admitted to Bluebell Ward, but it was clear, despite the amphetamine wearing off, that he was unwell and would need to remain in hospital for more than 72 hours.
I felt more comfortable with this. I knew Leroy well, I knew his relapse signature, and it seemed likely that it would be appropriate for him to remain in hospital for treatment. It also seemed that the CTO seemed to be having some positive effect, as in the 18 months since he had been subject to Supervised Community Treatment, acute admissions to hospital had gone down. A bit. And the length of time he then spent in hospital had also reduced. So I interviewed him, wrote a report, and signed my bit of the CTO5.
There’s one other thing that leaves me feeling a little uncomfortable about CTO’s. That is, that they are very popular.
Often, it takes quite a while for mental health professionals get used to legal changes like this. Not so with CTO’s.
In a document published in October 2010 (In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10) the total number of patients placed on CTO’s in 2008-9 was 2,109. In 2009-10 it had virtually doubled to 4,020. Over the same period, the number of patients detained under Sec.3 (only people detained under Sec.3 and some forensic sections can be placed on a CTO) was completely static, at 21,538 for 2008-9 and 21,332 in 2009-10.
This means that within two years of the introduction of CTO’s nearly 19% of patients detained in hospital under Sec.3 were discharged on a CTO. And since CTO’s are often being kept in place for a year or more, this could mean a growing accumulation of patient in the community on CTO’s.
It may take some convincing that this constitutes the “least restrictive” option.
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