(Please note that this was written in 2011. A lot has changed in service provision across the country since then, and some things may have changed. But I still think that the assessment process outlined in this post is how community mental health assessments ought to be, and if your own assessment falls short of this, then you should complain. January 2015)
When someone with a mental health problem goes to their GP, they are often apprehensive about what will happen next. Who will they be referred to in order to help them with their problems? Will they have to wait months, then see a psychiatrist in an office in a hospital many miles away? Or will they be asked to wait in a side room while the GP surreptitiously calls for men in white coats to drag them off in a strait jacket?
Let me reassure you: the last scenario is very unlikely to happen: for a start, psychiatrists and AMHP’s do not wear white coats. And I have never in the 30+ years I have been working with people with mental health problems seen a strait jacket in use in a psychiatric setting; I think nowadays they are only used by escapologists and stage illusionists!
Routes for referrals from GP’s to secondary mental health services for adults vary across the country, so it’s difficult to generalise. Many people will not even get as far as a Community Mental Health Team. Although approximately one in four people will experience some sort of mental health problem during the course of their lifetime, most commonly depression or anxiety disorders, most of those people will be treated solely by their GP.
In the last few years the focus of intervention for common mental health problems has been in Primary Care. The nationwide Improving Access to Psychological Therapies (IAPT) scheme has created teams of practitioners whose remit is to accept referrals from GP’s, or even directly from members of the public, for assessment and treatment for mild to moderate depression and other common mental health problems. They will then provide fairly short term treatment via talking therapies such as Cognitive Behavioural Therapy.
Many Mental Health Trusts also provide mental health link workers who work within GP practices and engage in brief assessment, treatment and sign-posting of patients referred to them directly by the GP.
Assuming that it is decided that a particular person’s problems are too complex or acute for intervention in Primary Care, they will, at least in the Charwood area, be referred for assessment by the Charwood Community Mental Health Team.
The Team will then arrange for an assessment appointment within two weeks of referral, or within 3 days if the GP considers it is urgent. Dire emergencies will go directly to the local Crisis Team for assessment the same day. The Charwood CMHT team consists of:
• a consultant psychiatrist
• a senior registrar, who is in the advanced stages of training
• a junior doctor, who may be a GP trainee or in the earlier stages of psychiatric training
• a clinical psychologist
• a cognitive behavioural therapist
• an occupational therapist
• several community mental health nurses
• several social workers, some of whom are also AMHP’s
• a couple of support workers
Any one of those may undertake the initial assessment. A person referred to a CMHT is unlikely to see a psychiatrist on the first occasion, unless the GP has specifically asked for a review of medication, or for confirmation of a formal diagnosis, or if the person has a complex presentation of a mixture of physical and mental health problems.
Millie – an example
Millie is 22 years old. She has presented to her GP in tears, saying she has been cutting herself because she feels so bad. She has felt like ending her life, but has made no actual plans. She has recently split up from her partner after he assaulted her. She is sleeping poorly, has lost weight, and is currently off sick from work. She had been on an antidepressant for about a year, and the GP had changed this about 3 months ago, as her mood had not improved.
Millie comes to the CMHT in some trepidation, not sure what to expect. In fact, the CMHT is one department in a modern, light and airy centre, which includes a GP surgery, a physiotherapy department, the community alcohol and drug service, a dentist, podiatry, and various outpatient departments. (However, you should have seen our old offices.)
The Masked AMHP greets Millie and invites her into a small but pleasant interview room. I begin by explaining to her what a CMHT is, and how any one member of the team may make an initial assessment, and that she is seeing me not because I am a social worker, but because I am a member of the multidisciplinary team.
There is a standard assessment process, as we have an electronic form that we have to fill in which covers a wide range of factors, including past and present risk behaviour, any forensic history, the use of alcohol or non-prescribed drugs, etc. But I begin with some obligatory basic information giving and gathering: I explain our confidentiality procedures, and ask her about her next of kin, religion, employment status, ethnic origins, and make sure we have contact phone numbers for her. I then read her a précis of the GP’s letter (leaving out statements like “I would be grateful if you could see this sorry young lass”).
I then ask her to tell me in her own words what problems she has that she would like help with. I feel it is always best to begin with open questions which allow the person to unfold and explain their problems in their own way. Sometimes people are very reticent about talking about their problems; at other times, it is difficult to shut them up or keep them on track.
Millie is neatly and appropriately dressed. She is wearing makeup. She looks underweight. She has poor eye contact. She looks down most of the time, wringing her hands unconsciously. She speaks quietly and haltingly. All these observations are relevant to the assessment, as they help to give an impression of the person’s mood, and what their level of personal care is.
Millie says that she has felt low “for most of my life”. I ask her to tell me more about her life, beginning from birth. Does she have siblings? Did her parents live together, or did they separate during her childhood? How would she describe her childhood? Did she ever experience any form of abuse as a child?
As she talks she reveals that, although she had supportive parents, she experienced years of bullying at secondary school. That was when she first began to cut herself. She was intelligent, and obtained 10 A-C grades at GCSE. She started doing A levels, but then became pregnant at 17 by her boyfriend at the time and decided to leave school and move in with him. However, she lost the baby at 5 months, and the relationship broke down. She took a serious overdose, and needed medical intervention, although there was no mental health follow up at the time.
Millie moved back in with her parents for a few months, and got a job doing office administration. She has been working in the same work setting for over 3 years She then moved in with another boyfriend, and they lived together for a year, but he began drinking heavily and 6 months ago he beat her up quite badly. She has lived alone since then. She is still waiting for the court hearing, but in the meantime he has been harassing her by phoning and texting her, often when drunk, sometimes pleading with her to take him back, and sometimes making threats.
Any person’s life story is important: it can reveal a lot about the origins of current mental health problems. Gradually, using a combination of open and closed questions, Millie reveals important factors which can help to identify exactly what her problems are and how best to manage them.
There is no evidence on assessment of any psychotic illness. However, she does have symptoms of clinical depression, including sleep disturbance, loss of appetite with accompanying weight loss, and some suicidal ideation.
Towards the end of the assessment, which takes about an hour, I ask her if there is anything else she would like to tell me, or if there is anything she would like to ask me. She tells me that misses her baby, and starts to cry. She says she wants to join him. We talk some more about this. I am particularly keen to understand what she means by “joining”. She says she has been considering taking another overdose, but feels she is too cowardly to try it again. I then conclude the assessment and I inform her that the assessment will be discussed in the multidisciplinary team and she will be informed within a week or so what the outcome of the assessment was.
Although I have been developing a formulation of her problems during the assessment, it is afterwards, when writing it up, that I draw all the factors together and come to a conclusion to present to the team meeting. What is important is not just to know what her mental health symptoms are, but what caused them in the first place.
The bullying at school was clearly a significant factor. Her unhappiness and sense of powerlessness led to her beginning to self harm as a soothing strategy to release these emotions. Although she stopped by the time she entered 6th form, she has now returned to this strategy as a means of coping with her current feelings.
The miscarriage was also a key life event, and it had become clear that she was still grieving the loss of this baby. This sense of loss may have been reawakened by the ending of the second major relationship in her life.
Additionally, she was experiencing some signs of post traumatic stress as a result of the assault by her boyfriend. He had attempted to strangle her, and at one point she had thought she was going to die. This can be a risk indicator for the development of a subsequent full blown post traumatic stress disorder, although a formal diagnosis would not normally be made until symptoms had been in existence for at least 6 months. It was probably too early to decide this, especially as the trauma was being kept alive by having to wait for a court hearing for his assault, and her apprehension at having to give evidence. She was, however, receiving input from Victim Support. They were also helping her to deal with the ongoing issues of harassment.
All these factors had led to Millie experiencing chronic low level depression, which had now become worse due to the combination of adverse life events.
The final part of my assessment is to devise a draft plan for intervention. There are clear risk issues to consider: Millie has taken an overdose in the past, and is thinking of doing this again. She consequently needs ongoing involvement with the CMHT, with work to reduce risk. She also needs help to identify other ways of dealing with negative emotion other than self harming. The immediate plan would therefore involve the allocation of a care coordinator, as well as arranging for a medical review by one of the team psychiatrists, as Millie does not seem to be responding very well to her current medication. In the longer term, she may benefit from cognitive behavioural therapy, especially if her symptoms of post traumatic stress become chronic. This can also help her to change the thinking patterns which have led to chronic and recurrent depressive feelings. She may also need help relating to the loss of her unborn baby. There may be external services available for her to be referred to as part of her treatment.
I hope this example shows the thinking and reasoning that goes into a mental health assessment. It is vital to get the overall picture, and not just focus on identifying behaviours or signs that might indicate the existence the symptoms of a specific mental disorder. Labelling is not the most important thing.
I’m afraid that I can only describe my own experiences of assessment. I would like to think that every Mental Health Trust has thorough, consistent and comprehensive assessment processes, designed to meet the needs of people with mental health problems. All I can really say is this is what you should expect.
Wednesday, 17 August 2011
Tuesday, 9 August 2011
Does Mental Illness Preclude a Career in the Caring Professions?
A history of mental illness can certainly impact on people’s future life and work prospects, even if a person makes a full recovery. One consequence of a history of mental illness can be to affect your ability to live and work in certain foreign countries. I have often heard it said that if you have ever been detained under the Mental Health Act, then the USA will not allow you a visa. This is, however, not strictly speaking the case. The regulations actually state only that someone is not eligible to travel under the ESTA visa waiver arrangements if:
“(b) you currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(c) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.”
There appears to be no impediment for someone with a history of mental illness who is in remission or controlled by medication, and the restrictions only apply where there has been, or is likely to be a recurrence of risky or dangerous behaviour.
In the UK, there is a raft of legislation that is designed to explicitly protect people from the effects of discrimination. In addition to the Human Rights Act 1998, Article 14 of which prohibits discrimination on grounds including disability, there are also the Disability Discrimination Acts of 1995 and 2005, and most recently the Equality Act 2010. The effect of this legislation is to protect people from discrimination for a wide variety of reasons. These include discrimination on grounds of age, religion, sex, race, sexual orientation, and disability.
The Equality Act 2010 makes it unlawful for an employer “to discriminate against or harass a disabled person.” An employer is also required to make reasonable adjustments to accommodate disabled people within the workplace. Interestingly, there is also protection for people “who are associated with a disabled person or who are wrongly perceived as disabled.”
A person with a disability is defined under the Equality Act as having “a physical or mental impairment”. That impairment must have “a substantial and long-term adverse effect on their ability to perform normal day-to-day activities”. Guidance to the Act suggests a wide range of mental health conditions and mental illnesses would be covered by this legislation, including: “depression, schizophrenia, eating disorders, bipolar affective disorders, obsessive compulsive disorders, as well as personality disorders and some self-harming behaviour”.
There is also an interesting list of conditions which would not be considered to qualify as a disability. These include: “fear of significant heights, underestimating the risk associated with dangerous hobbies, such as mountain climbing, or a person consciously taking a higher than normal risk on their own initiative, such as persistently crossing a road when the signals are adverse, or driving fast on highways for own pleasure.” Which seems to exempt the presenters of Top Gear from protection under this legislation.
It has happily been my experience that Public Sector employers in particular take their responsibilities in relation to people with disabilities seriously. I have encountered a number of people with a range of mental health problems who have successfully trained for and obtained jobs in social work or allied professions. There follow a few brief histories.
Joni
Joni was a woman in her 30’s whom I worked with intermittently over quite a few years. I first saw her when she was referred to the CMHT with a history of severe bulimic behaviour. Over a period of months, I helped her work through the issues from her past that had led her to have such problems with her self image. These included a father who was never able to give praise for achievements. On one occasion as a teenager she had obtained a distinction in a musical instrument examination with an overall score of 93%. Her father looked carefully at the certificate and then said: “If only you’d worked a little harder, you could have got 100%.”
Over time, she recovered and was discharged. Several years later, she was referred again. In the intervening time she had trained as a social worker and was actually in employment in an older people’s team in the same local authority that employed me. Then she had become pregnant, had gone on maternity leave, had her baby, returned to work – then the issues with self image and self esteem kicked in again. Her only way of managing this was to return to her bulimic behaviours, with the addition of liberal quantities of alcohol: “An open bottle is an empty bottle.”
This time, talking therapy did not work. She became more despairing and desperate, her drinking and binge eating became increasingly out of her control, and one afternoon, when I discovered her about to take all her medication, I arranged for her informal admission to Bluebell ward in Charwood Hospital.
Once she was there, she changed her mind about the admission. She was detained under Sec.5(2) and a request was made for her to be detained under Sec.2 MHA. Because of my close involvement in her treatment on a voluntary basis, as well as the fact that she was essentially a work colleague, I arranged for a social worker with no association with her to undertake the assessment, and she was detained under Sec.2.
She remained in hospital for several weeks. Her mood improved. She acknowledged that she had an alcohol problem. She agreed to take antabuse as a means of controlling her alcohol consumption. It was agreed to give her a trial dose. As a routine measure, she was breathalysed immediately before. She tested positive as over the limit. She was still drinking, even on the ward, even as she was about to start antabuse.
A specialist alcohol treatment centre was sourced, and she agreed to go there. This involved residential stays as well as outpatient appointments over many months. As the centre undertook complete care management, I did not see her again.
But a year or so later, I heard that she was working, as a social worker, for the neighbouring local authority.
Joan
Joan was 20 years old. She was two years through a course training to be an occupational therapist when she made a very serious attempt to kill herself. She had cut her wrists as well as mutilating her body with a knife, and nearly died before she was found by her flat mate. She spent a couple of months in hospital, which meant that she had missed too much of her final year to catch up.
I liaised with the college. She had been a good student, and they were keen for her to complete the course, providing her mental health was good enough. As her care coordinator, I worked with her through her recovery from depression. We also worked on the issues from her earlier life that had led to this extreme act. She responded well to treatment. By the end of the academic year I was able to reassure her tutor that Joan was well enough to be able to retake her final year. As this was in another part of the country, I did not have any further professional involvement with her, although I did hear that she had passed her course.
A couple of years later I happened to be visiting a psychiatric hospital in a neighbouring county, and was taken by a colleague to the staff canteen. Joan was there. She had a job as a psychiatric OT.
John
John was working as a qualified social worker in a voluntary agency working with young people leaving care when he had his first episode of bipolar affective disorder. I first met him while he was an inpatient. He had been on a short term contract, and it had ended. He was very despondent, because he believed that, with a diagnosis of bipolar affective disorder, he would never get another job as a social worker again.
I tried to reassure him. I talked to him about the legal requirement on prospective employers not to discriminate on the grounds of his mental illness. I gave him some case histories. I encouraged him to come clean on his applications about his medical history when the time came, but to point out that these experiences could enhance his practice as a social worker. The session appeared to go well, and he left in a more positive frame of mind.
So what was the outcome for John? Well, not all my stories have sad endings. John did get a job as a social worker in a local authority. And to the best of my knowledge, he is still in employment, despite, or possibly even because of, his bipolar affective disorder.
“(b) you currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(c) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.”
There appears to be no impediment for someone with a history of mental illness who is in remission or controlled by medication, and the restrictions only apply where there has been, or is likely to be a recurrence of risky or dangerous behaviour.
In the UK, there is a raft of legislation that is designed to explicitly protect people from the effects of discrimination. In addition to the Human Rights Act 1998, Article 14 of which prohibits discrimination on grounds including disability, there are also the Disability Discrimination Acts of 1995 and 2005, and most recently the Equality Act 2010. The effect of this legislation is to protect people from discrimination for a wide variety of reasons. These include discrimination on grounds of age, religion, sex, race, sexual orientation, and disability.
The Equality Act 2010 makes it unlawful for an employer “to discriminate against or harass a disabled person.” An employer is also required to make reasonable adjustments to accommodate disabled people within the workplace. Interestingly, there is also protection for people “who are associated with a disabled person or who are wrongly perceived as disabled.”
A person with a disability is defined under the Equality Act as having “a physical or mental impairment”. That impairment must have “a substantial and long-term adverse effect on their ability to perform normal day-to-day activities”. Guidance to the Act suggests a wide range of mental health conditions and mental illnesses would be covered by this legislation, including: “depression, schizophrenia, eating disorders, bipolar affective disorders, obsessive compulsive disorders, as well as personality disorders and some self-harming behaviour”.
There is also an interesting list of conditions which would not be considered to qualify as a disability. These include: “fear of significant heights, underestimating the risk associated with dangerous hobbies, such as mountain climbing, or a person consciously taking a higher than normal risk on their own initiative, such as persistently crossing a road when the signals are adverse, or driving fast on highways for own pleasure.” Which seems to exempt the presenters of Top Gear from protection under this legislation.
It has happily been my experience that Public Sector employers in particular take their responsibilities in relation to people with disabilities seriously. I have encountered a number of people with a range of mental health problems who have successfully trained for and obtained jobs in social work or allied professions. There follow a few brief histories.
Joni
Joni was a woman in her 30’s whom I worked with intermittently over quite a few years. I first saw her when she was referred to the CMHT with a history of severe bulimic behaviour. Over a period of months, I helped her work through the issues from her past that had led her to have such problems with her self image. These included a father who was never able to give praise for achievements. On one occasion as a teenager she had obtained a distinction in a musical instrument examination with an overall score of 93%. Her father looked carefully at the certificate and then said: “If only you’d worked a little harder, you could have got 100%.”
Over time, she recovered and was discharged. Several years later, she was referred again. In the intervening time she had trained as a social worker and was actually in employment in an older people’s team in the same local authority that employed me. Then she had become pregnant, had gone on maternity leave, had her baby, returned to work – then the issues with self image and self esteem kicked in again. Her only way of managing this was to return to her bulimic behaviours, with the addition of liberal quantities of alcohol: “An open bottle is an empty bottle.”
This time, talking therapy did not work. She became more despairing and desperate, her drinking and binge eating became increasingly out of her control, and one afternoon, when I discovered her about to take all her medication, I arranged for her informal admission to Bluebell ward in Charwood Hospital.
Once she was there, she changed her mind about the admission. She was detained under Sec.5(2) and a request was made for her to be detained under Sec.2 MHA. Because of my close involvement in her treatment on a voluntary basis, as well as the fact that she was essentially a work colleague, I arranged for a social worker with no association with her to undertake the assessment, and she was detained under Sec.2.
She remained in hospital for several weeks. Her mood improved. She acknowledged that she had an alcohol problem. She agreed to take antabuse as a means of controlling her alcohol consumption. It was agreed to give her a trial dose. As a routine measure, she was breathalysed immediately before. She tested positive as over the limit. She was still drinking, even on the ward, even as she was about to start antabuse.
A specialist alcohol treatment centre was sourced, and she agreed to go there. This involved residential stays as well as outpatient appointments over many months. As the centre undertook complete care management, I did not see her again.
But a year or so later, I heard that she was working, as a social worker, for the neighbouring local authority.
Joan
Joan was 20 years old. She was two years through a course training to be an occupational therapist when she made a very serious attempt to kill herself. She had cut her wrists as well as mutilating her body with a knife, and nearly died before she was found by her flat mate. She spent a couple of months in hospital, which meant that she had missed too much of her final year to catch up.
I liaised with the college. She had been a good student, and they were keen for her to complete the course, providing her mental health was good enough. As her care coordinator, I worked with her through her recovery from depression. We also worked on the issues from her earlier life that had led to this extreme act. She responded well to treatment. By the end of the academic year I was able to reassure her tutor that Joan was well enough to be able to retake her final year. As this was in another part of the country, I did not have any further professional involvement with her, although I did hear that she had passed her course.
A couple of years later I happened to be visiting a psychiatric hospital in a neighbouring county, and was taken by a colleague to the staff canteen. Joan was there. She had a job as a psychiatric OT.
John
John was working as a qualified social worker in a voluntary agency working with young people leaving care when he had his first episode of bipolar affective disorder. I first met him while he was an inpatient. He had been on a short term contract, and it had ended. He was very despondent, because he believed that, with a diagnosis of bipolar affective disorder, he would never get another job as a social worker again.
I tried to reassure him. I talked to him about the legal requirement on prospective employers not to discriminate on the grounds of his mental illness. I gave him some case histories. I encouraged him to come clean on his applications about his medical history when the time came, but to point out that these experiences could enhance his practice as a social worker. The session appeared to go well, and he left in a more positive frame of mind.
So what was the outcome for John? Well, not all my stories have sad endings. John did get a job as a social worker in a local authority. And to the best of my knowledge, he is still in employment, despite, or possibly even because of, his bipolar affective disorder.
Sunday, 24 July 2011
Lenny: A Life and Death in the Mental Health System – Part 2
One day a notebook belonging to Lenny was found in his room. It was full of rambling drunken notes and tirades (“If you find me dead in the morning, it was because Jerry poisoned my Carlsberg.”) But it also contained some more alarming things. One of them was a "hit list" of named people whom he considered his enemies, mainly people connected with the hostel (I was on the list), as well as diagrams and recipes for molotov cocktails and petrol bombs, and much material outlining a universal conspiracy against him involving the IRA and Neo Nazi organisations, which included the belief that these organizations were systematically arranging for his food to be poisoned.
The hostel manager was understandably alarmed at this and wanted him to be expelled immediately. However, the committee was more sanguine. There was something distinctly Adrian Moleish about his ramblings, and we did not take them to constitute serious threats. Instead it was suggested to Lenny that he might feel more comfortable if he had his own accommodation. I helped him to negotiate with the local council, and he was offered a one bedroom flat.
He was delighted with this, but still suspicious. He seemed to manage reasonably well living on his own. He did agree to a community nurse from the CMHT visiting him, as well as a support worker. From time to time he would turn up unannounced at the CMHT and chat to me. Although he appeared to regard me with suspicion, I suppose he also saw me as offering some sort of continuity in his life.
It became increasingly clear from these informal chats with him that, now he was living alone, his paranoid beliefs were being allowed full rein, and were becoming more elaborate and universal in nature. He was convinced that food bought from supermarkets was poisoned or contaminated with noxious substances including the HIV virus. He talked about seeing members of the Ulster Volunteer Force in Charwood Post Office. He said on one occasion he had barely escaped with his life. If he hadn’t left, he knew they would have opened fire on him.
One day, I received a call from the Charwood Environmental Health Dept. They had received a visit from him in which he had given them an assortment of foodstuffs, including cans of lager, tins of food, and some vegetables, with an accompanying letter outlining the contaminants that had been added to them, and asking them to analyse them for him. We also heard that he had been writing to the manufacturers of various products accusing them of selling him contaminated goods.
We eventually managed to persuade Lenny to attend for an outpatient appointment with the CMHT psychiatrist. I sat in on that assessment. He freely talked about his elaborate delusional beliefs relating to paramilitary groups, Nazi’s, and a conspiracy to contaminate the food of the inhabitants of Charwood in order to subject them to mind control. We arranged for his GP to attend (yes, we were planning a MHA assessment). And we detained him under Sec.3.
This admission brought to light the full, and somewhat unsettling, extent of his acting on these persecutory delusions. On admission, he was found to have a knife and a sock full of broken glass in his bag (for defensive purposes). A few days later, his community nurse, who was visiting his flat in order to collect clothes and toiletries for Lenny, found that the cupboard under his kitchen sink was crammed with home made incendiary devices made from glass bottles filled with petrol. The police and the Army Bomb Disposal Squad attended and disposed of them.
Lenny’s diagnosis was changed: his symptoms were undoubtedly entirely consistent with a diagnosis of paranoid schizophrenia. Did we miss this over the years? Did his earlier diagnosis of borderline personality disorder muddy the waters? Quite possibly.
Lenny was prescribed antipsychotic medication and he did appear to improve. After a few months he was discharged back home, subject to S.117.
For a while he appeared much happier and settled. He even seemed more open and friendly. But it did not last. He gradually became depressed and his self care deteriorated. A few months later, he actually asked to be admitted to hospital. On admission, as his depression was treated, his underlying persecutory and paranoid beliefs emerged, as bad as ever. I had to detain him one again under Sec.3.
This time, however, treatment did not appear to result in any significant improvement in his paranoia, if anything, the depth and extent of his paranoid beliefs increased. He was disruptive on the ward, and so suspicious of the staff and food that it was very difficult to get him to eat anything. He remained completely insightless, and made regular attempts to escape from the ward, on one occasion trying to dig an escape tunnel in the occupational therapy vegetable garden.
In view of Lenny’s history of potential dangerousness, his unshakeable delusions and poor response to treatment, Lenny was transferred to a secure unit. He remained there for three years. During that time, my only contact with him was when I visited him to interview him for Tribunal reports, and to attend Tribunals. Whenever I saw him, he was consistently hostile. “Come to stitch me up again, have you, Masked AMHP?” he would say.
He was never discharged by these Tribunals, not because I had “stitched him up”, but because as soon as he was given the opportunity to speak, he would tell the Tribunal all about the plots by the Nazi’s or various Northern Irish paramilitary organisations to kill him. And then they would nod their heads sympathetically, adjourn for a discussion – and then would invariably uphold the detention.
However, over time, and with a change in his antipsychotic medication, his mental state did improve. One day I visited him for a S.117 review meeting, and he greeted me with a smile, shook me warmly by the hand, and enquired politely about how things were going in Charwood. Over a six month period, he had improved to such an extent that in all the years I had known him I had never actually seen him so well. The review concluded that he could be transferred back to an open ward, with an eventual plan of returning to live in Charwood in independent accommodation.
His improvement continued back in Charwood Psychiatric Unit. We started to make plans for his discharge, applying to the local council for housing. We managed to get him a nice flat surprisingly quickly. And he was discharged from Sec.3 and at last came back to live in Charwood.
Lenny was quite different this time. He engaged with support workers, happily accepted his depot injection, and religiously took his oral medication. He took an interest in decorating and furnishing his flat. He always welcomed me warmly whenever I visited him, and we have long and rational conversations. He hardly drank alcohol at all. For eighteen months he actually seemed happy and fulfilled.
Then one morning one of his support workers returned to the CMHT to say that she had been unable to get a response from him. This was not like Lenny. He enjoyed the visits from the support worker. I went out to investigate further. The flat was on the ground floor, so I tried looking in through the windows. His TV was on in the living room but Lenny was not in there. He wasn’t in the kitchen. The curtains were drawn in his bedroom. It was too early for Lenny to have gone out, and he wouldn’t have done knowing his support worker was visiting.
I called the police. They joined me at his house. We contacted the housing association, who sent a locksmith round to get in through the front door. I followed the police officer inside and we went into one room after another, looking for Lenny.
We found him in his bedroom. It looked as if he had knelt down to change the station on a portable radio on the floor. Then something catastrophic must have happened and he had collapsed backwards, folding down onto his knees, his feet trapped under his body. He was dead. He had probably been dead for two or three days. He died alone, and no-one had found him for two or three days. He was 30 years old.
There was an initial inquest, as the police suspected that he might have taken an overdose. But I didn’t believe that, and the post mortem revealed that he had had an unsuspected heart defect, and had had a heart attack.
His support workers and I attended the interment. His father and sister and a few family members were there. There was no sign of his mother. No friends attended.
Why had Lenny’s life been so bereft and ultimately so sad? What had happened during his childhood that was so bad that he once ran out of the room when I merely started to talk to him about the idea of possibly talking about it at some point in the future? And had whatever happened to him made him how he was, suspicious, lacking in social skills, reluctant to make friends or trust anyone?
Did he ever have an emotionally unstable personality disorder, or did he actually have a psychotic illness that had not been diagnosed? Did the label of personality disorder stop people from looking further? His discharge from detention the first time certainly gave him the unfettered opportunity to develop a full-blown psychosis, as a Tribunal had decided he did not need treatment, and the CMHT had had to back off, for a while at least.
Undoubtedly, his eventual symptoms were text-book signs of paranoid schizophrenia, and these symptoms eventually resolved with the use of antipsychotic medication. And when he was free of psychotic symptoms, there were also no signs of emotionally unstable personality disorder. Would he have spent less time in hospital had he been started on that sort of medication in his teens? Would he have had more of a life before his heart defect eventually killed him?
I don’t have the answers to those questions. All I know now, is that Lenny lived, and then he died.
The hostel manager was understandably alarmed at this and wanted him to be expelled immediately. However, the committee was more sanguine. There was something distinctly Adrian Moleish about his ramblings, and we did not take them to constitute serious threats. Instead it was suggested to Lenny that he might feel more comfortable if he had his own accommodation. I helped him to negotiate with the local council, and he was offered a one bedroom flat.
He was delighted with this, but still suspicious. He seemed to manage reasonably well living on his own. He did agree to a community nurse from the CMHT visiting him, as well as a support worker. From time to time he would turn up unannounced at the CMHT and chat to me. Although he appeared to regard me with suspicion, I suppose he also saw me as offering some sort of continuity in his life.
It became increasingly clear from these informal chats with him that, now he was living alone, his paranoid beliefs were being allowed full rein, and were becoming more elaborate and universal in nature. He was convinced that food bought from supermarkets was poisoned or contaminated with noxious substances including the HIV virus. He talked about seeing members of the Ulster Volunteer Force in Charwood Post Office. He said on one occasion he had barely escaped with his life. If he hadn’t left, he knew they would have opened fire on him.
One day, I received a call from the Charwood Environmental Health Dept. They had received a visit from him in which he had given them an assortment of foodstuffs, including cans of lager, tins of food, and some vegetables, with an accompanying letter outlining the contaminants that had been added to them, and asking them to analyse them for him. We also heard that he had been writing to the manufacturers of various products accusing them of selling him contaminated goods.
We eventually managed to persuade Lenny to attend for an outpatient appointment with the CMHT psychiatrist. I sat in on that assessment. He freely talked about his elaborate delusional beliefs relating to paramilitary groups, Nazi’s, and a conspiracy to contaminate the food of the inhabitants of Charwood in order to subject them to mind control. We arranged for his GP to attend (yes, we were planning a MHA assessment). And we detained him under Sec.3.
This admission brought to light the full, and somewhat unsettling, extent of his acting on these persecutory delusions. On admission, he was found to have a knife and a sock full of broken glass in his bag (for defensive purposes). A few days later, his community nurse, who was visiting his flat in order to collect clothes and toiletries for Lenny, found that the cupboard under his kitchen sink was crammed with home made incendiary devices made from glass bottles filled with petrol. The police and the Army Bomb Disposal Squad attended and disposed of them.
Lenny’s diagnosis was changed: his symptoms were undoubtedly entirely consistent with a diagnosis of paranoid schizophrenia. Did we miss this over the years? Did his earlier diagnosis of borderline personality disorder muddy the waters? Quite possibly.
Lenny was prescribed antipsychotic medication and he did appear to improve. After a few months he was discharged back home, subject to S.117.
For a while he appeared much happier and settled. He even seemed more open and friendly. But it did not last. He gradually became depressed and his self care deteriorated. A few months later, he actually asked to be admitted to hospital. On admission, as his depression was treated, his underlying persecutory and paranoid beliefs emerged, as bad as ever. I had to detain him one again under Sec.3.
This time, however, treatment did not appear to result in any significant improvement in his paranoia, if anything, the depth and extent of his paranoid beliefs increased. He was disruptive on the ward, and so suspicious of the staff and food that it was very difficult to get him to eat anything. He remained completely insightless, and made regular attempts to escape from the ward, on one occasion trying to dig an escape tunnel in the occupational therapy vegetable garden.
In view of Lenny’s history of potential dangerousness, his unshakeable delusions and poor response to treatment, Lenny was transferred to a secure unit. He remained there for three years. During that time, my only contact with him was when I visited him to interview him for Tribunal reports, and to attend Tribunals. Whenever I saw him, he was consistently hostile. “Come to stitch me up again, have you, Masked AMHP?” he would say.
He was never discharged by these Tribunals, not because I had “stitched him up”, but because as soon as he was given the opportunity to speak, he would tell the Tribunal all about the plots by the Nazi’s or various Northern Irish paramilitary organisations to kill him. And then they would nod their heads sympathetically, adjourn for a discussion – and then would invariably uphold the detention.
However, over time, and with a change in his antipsychotic medication, his mental state did improve. One day I visited him for a S.117 review meeting, and he greeted me with a smile, shook me warmly by the hand, and enquired politely about how things were going in Charwood. Over a six month period, he had improved to such an extent that in all the years I had known him I had never actually seen him so well. The review concluded that he could be transferred back to an open ward, with an eventual plan of returning to live in Charwood in independent accommodation.
His improvement continued back in Charwood Psychiatric Unit. We started to make plans for his discharge, applying to the local council for housing. We managed to get him a nice flat surprisingly quickly. And he was discharged from Sec.3 and at last came back to live in Charwood.
Lenny was quite different this time. He engaged with support workers, happily accepted his depot injection, and religiously took his oral medication. He took an interest in decorating and furnishing his flat. He always welcomed me warmly whenever I visited him, and we have long and rational conversations. He hardly drank alcohol at all. For eighteen months he actually seemed happy and fulfilled.
Then one morning one of his support workers returned to the CMHT to say that she had been unable to get a response from him. This was not like Lenny. He enjoyed the visits from the support worker. I went out to investigate further. The flat was on the ground floor, so I tried looking in through the windows. His TV was on in the living room but Lenny was not in there. He wasn’t in the kitchen. The curtains were drawn in his bedroom. It was too early for Lenny to have gone out, and he wouldn’t have done knowing his support worker was visiting.
I called the police. They joined me at his house. We contacted the housing association, who sent a locksmith round to get in through the front door. I followed the police officer inside and we went into one room after another, looking for Lenny.
We found him in his bedroom. It looked as if he had knelt down to change the station on a portable radio on the floor. Then something catastrophic must have happened and he had collapsed backwards, folding down onto his knees, his feet trapped under his body. He was dead. He had probably been dead for two or three days. He died alone, and no-one had found him for two or three days. He was 30 years old.
There was an initial inquest, as the police suspected that he might have taken an overdose. But I didn’t believe that, and the post mortem revealed that he had had an unsuspected heart defect, and had had a heart attack.
His support workers and I attended the interment. His father and sister and a few family members were there. There was no sign of his mother. No friends attended.
Why had Lenny’s life been so bereft and ultimately so sad? What had happened during his childhood that was so bad that he once ran out of the room when I merely started to talk to him about the idea of possibly talking about it at some point in the future? And had whatever happened to him made him how he was, suspicious, lacking in social skills, reluctant to make friends or trust anyone?
Did he ever have an emotionally unstable personality disorder, or did he actually have a psychotic illness that had not been diagnosed? Did the label of personality disorder stop people from looking further? His discharge from detention the first time certainly gave him the unfettered opportunity to develop a full-blown psychosis, as a Tribunal had decided he did not need treatment, and the CMHT had had to back off, for a while at least.
Undoubtedly, his eventual symptoms were text-book signs of paranoid schizophrenia, and these symptoms eventually resolved with the use of antipsychotic medication. And when he was free of psychotic symptoms, there were also no signs of emotionally unstable personality disorder. Would he have spent less time in hospital had he been started on that sort of medication in his teens? Would he have had more of a life before his heart defect eventually killed him?
I don’t have the answers to those questions. All I know now, is that Lenny lived, and then he died.
Tuesday, 19 July 2011
Lenny: A Life and Death in the Mental Health System – Part 1
I’ve thought a lot about Lenny over the last few years since his death. I’ve thought about writing his story on this blog for a long time. I feel that I need write about him, since otherwise, Lenny and people like him tend to get forgotten, as if they had never existed. But Lenny did exist, and so this is his life story. This is too long for a single post, so Part 2 will follow in a few days.
I can’t really say much about his early life, as he always refused point blank to discuss anything about his childhood, and would become agitated and distressed if he was pushed about this. All I know is that his parents separated when he was 13. After his parents’ divorce, he lived with his mother.
Lenny first became a patient of psychiatric services at the age of 14, when he was assessed by the Child and Adolescent Mental Health Service (CAMHS). Was there a connection between his parents’ divorce and the beginning of his mental health problems? If so, it was not identified. They diagnosed him with depression, noting that there appeared to be an unhealthy relationship between him and his mother, but at the time no further treatment was offered.
When Lenny was 16 he was admitted to psychiatric hospital, again with a diagnosis of depression, and was followed up this time after discharge. When he reached the age of 17, he was transferred to adult mental health services. That was when I first met him. By now, he was living with his father, who had remarried, after his mother went off to “find herself” in some sort of therapeutic community. The main reason I was asked to see him was because things were becoming increasingly difficult at home, as he did not get on with his step-mother, and this was affecting his mood. I arranged for him to move into a hostel in Charwood.
Lenny lacked skills in making friends, and remained quite isolated within the hostel. He found it difficult to fill his days, but was reluctant to engage in activities that might improve his self confidence. He refused to have any therapy, and used to blow his benefit money on alcohol each week, and spend the next day or two drunk. During these times, he often also took fairly minor overdoses, which he would then tell everyone about, or would try and provoke other hostel residents.
At that time I was on the management committee of the hostel, and the committee members used to have regular fortnightly dinners with the residents. I came to know Lenny quite well, although he always remained suspicious of everyone, and never allowed anyone to get close to him in any way.
Over the 13 years I knew Lenny, I had to assess him under the MHA on a total of 8 occasions. Initially, these were following overdoses. The first two assessments did not result in an admission – there was no real suicidal intent, and hospital admission would not have achieved anything therapeutic.
This behaviour continued, but was generally tolerated by the hostel staff, the committee and the residents. It was simply what Lenny did.
One day, however, when he had been at the hostel for 3 years, and was approaching 21 years of age, he went to a day centre he sporadically attended armed with a large knife and threatened to kill himself in front of the staff and other service users. He was arrested by the police and I then conducted my third assessment under the MHA. This time I somewhat reluctantly concluded that I had no option but to detain him under Sec.3 for treatment.
He remained on the ward for several months, but would not engage in therapeutic activities, and resisted other treatment. But he remained a significant risk if he were discharged. For several years his main diagnosis had been that of depression, but his consultant at that time concluded that he had a personality disorder, and that the only suitable treatment was enforced psychotherapy in a secure unit. I was not sure about this – not that I did not think that he probably did have a borderline personality disorder, but my concern was whether it was either ethical or possible to engage someone in psychotherapy against their will. Nevertheless, funding for this was agreed, a suitable hospital was identified, and Lenny was transferred there.
Lenny hated it. He hated being forced to conform. He hated having to attend therapeutic groups. He hated having to attend sessions with clinical psychologists and occupational therapists. In fact, he hated everything and everybody. Although I had had no control over this transfer, he blamed me. He appealed against his detention.
The Tribunal was interesting. His Charwood psychiatrist presented a report and attended the Tribunal hearing. But he had made some errors in his report. He had stated that he could find no evidence of formal psychiatric disorder, but also stated that Lenny had a borderline personality disorder. Both the Tribunal and Lenny’s solicitor picked up on this. If Lenny did not have a mental disorder of a nature or degree sufficient to warrant his detention for treatment, then the Tribunal would have no option but to discharge him. So how did this statement accord with his diagnosis?
The psychiatrist tied himself in knots trying to justify the contradictory statements. But he was sinking without trace. The Tribunal were from the beginning sceptical about the idea of enforcing psychotherapy, and the inpatient psychiatrist was unable to state that this treatment was making any difference to Lenny’s mental state. So what justification could there be for continuing to detain him if treatment was not alleviating his problems? Lenny’s solicitor was pushing at an open door. The Tribunal discharged him, leaving just enough time to identify an address to discharge him to. Lenny stated that his sister, who lived in Charwood, would gladly offer him a place to live.
A week later, he moved in with his sister. I visited him at her home. He had used his new freedom to begin drinking again. His sister did not like this behaviour in front of her children. She wasn’t prepared to keep him.
There happened to be a vacancy at the hostel, so he returned there. He refused any further contact with the CMHT, although I continued to see him from my involvement with the hostel committee.
Something had changed about him. Although his sporadic alcohol abuse continued as before, he became even more suspicious and reclusive. For the next couple of years he remained at the hostel, where he started to make odd allegations about other residents, sometimes (usually when drunk) alleging that people were contaminating his food or his drink, or were trying to poison him.
To be continued
Next time: Lenny's incarceration in a secure unit for three years -- and eventual freedom.
I can’t really say much about his early life, as he always refused point blank to discuss anything about his childhood, and would become agitated and distressed if he was pushed about this. All I know is that his parents separated when he was 13. After his parents’ divorce, he lived with his mother.
Lenny first became a patient of psychiatric services at the age of 14, when he was assessed by the Child and Adolescent Mental Health Service (CAMHS). Was there a connection between his parents’ divorce and the beginning of his mental health problems? If so, it was not identified. They diagnosed him with depression, noting that there appeared to be an unhealthy relationship between him and his mother, but at the time no further treatment was offered.
When Lenny was 16 he was admitted to psychiatric hospital, again with a diagnosis of depression, and was followed up this time after discharge. When he reached the age of 17, he was transferred to adult mental health services. That was when I first met him. By now, he was living with his father, who had remarried, after his mother went off to “find herself” in some sort of therapeutic community. The main reason I was asked to see him was because things were becoming increasingly difficult at home, as he did not get on with his step-mother, and this was affecting his mood. I arranged for him to move into a hostel in Charwood.
Lenny lacked skills in making friends, and remained quite isolated within the hostel. He found it difficult to fill his days, but was reluctant to engage in activities that might improve his self confidence. He refused to have any therapy, and used to blow his benefit money on alcohol each week, and spend the next day or two drunk. During these times, he often also took fairly minor overdoses, which he would then tell everyone about, or would try and provoke other hostel residents.
At that time I was on the management committee of the hostel, and the committee members used to have regular fortnightly dinners with the residents. I came to know Lenny quite well, although he always remained suspicious of everyone, and never allowed anyone to get close to him in any way.
Over the 13 years I knew Lenny, I had to assess him under the MHA on a total of 8 occasions. Initially, these were following overdoses. The first two assessments did not result in an admission – there was no real suicidal intent, and hospital admission would not have achieved anything therapeutic.
This behaviour continued, but was generally tolerated by the hostel staff, the committee and the residents. It was simply what Lenny did.
One day, however, when he had been at the hostel for 3 years, and was approaching 21 years of age, he went to a day centre he sporadically attended armed with a large knife and threatened to kill himself in front of the staff and other service users. He was arrested by the police and I then conducted my third assessment under the MHA. This time I somewhat reluctantly concluded that I had no option but to detain him under Sec.3 for treatment.
He remained on the ward for several months, but would not engage in therapeutic activities, and resisted other treatment. But he remained a significant risk if he were discharged. For several years his main diagnosis had been that of depression, but his consultant at that time concluded that he had a personality disorder, and that the only suitable treatment was enforced psychotherapy in a secure unit. I was not sure about this – not that I did not think that he probably did have a borderline personality disorder, but my concern was whether it was either ethical or possible to engage someone in psychotherapy against their will. Nevertheless, funding for this was agreed, a suitable hospital was identified, and Lenny was transferred there.
Lenny hated it. He hated being forced to conform. He hated having to attend therapeutic groups. He hated having to attend sessions with clinical psychologists and occupational therapists. In fact, he hated everything and everybody. Although I had had no control over this transfer, he blamed me. He appealed against his detention.
The Tribunal was interesting. His Charwood psychiatrist presented a report and attended the Tribunal hearing. But he had made some errors in his report. He had stated that he could find no evidence of formal psychiatric disorder, but also stated that Lenny had a borderline personality disorder. Both the Tribunal and Lenny’s solicitor picked up on this. If Lenny did not have a mental disorder of a nature or degree sufficient to warrant his detention for treatment, then the Tribunal would have no option but to discharge him. So how did this statement accord with his diagnosis?
The psychiatrist tied himself in knots trying to justify the contradictory statements. But he was sinking without trace. The Tribunal were from the beginning sceptical about the idea of enforcing psychotherapy, and the inpatient psychiatrist was unable to state that this treatment was making any difference to Lenny’s mental state. So what justification could there be for continuing to detain him if treatment was not alleviating his problems? Lenny’s solicitor was pushing at an open door. The Tribunal discharged him, leaving just enough time to identify an address to discharge him to. Lenny stated that his sister, who lived in Charwood, would gladly offer him a place to live.
A week later, he moved in with his sister. I visited him at her home. He had used his new freedom to begin drinking again. His sister did not like this behaviour in front of her children. She wasn’t prepared to keep him.
There happened to be a vacancy at the hostel, so he returned there. He refused any further contact with the CMHT, although I continued to see him from my involvement with the hostel committee.
Something had changed about him. Although his sporadic alcohol abuse continued as before, he became even more suspicious and reclusive. For the next couple of years he remained at the hostel, where he started to make odd allegations about other residents, sometimes (usually when drunk) alleging that people were contaminating his food or his drink, or were trying to poison him.
To be continued
Next time: Lenny's incarceration in a secure unit for three years -- and eventual freedom.
Sunday, 10 July 2011
Join The Masked AMHP's Facebook group!
The Masked AMHP now has a Facebook group. Join now (or when you can be bothered) to find out what The Masked AMHP's been up to each week, and to discuss the ins and outs of practice as an AMHP. Sec.2 or Sec.3? MHA or MCA? Sometimes it's just too close to call...
You can find the Masked AMHP Facebook Group here!
You can find the Masked AMHP Facebook Group here!
Tuesday, 21 June 2011
Why Be An AMHP?
Blogger provides a lot of interesting data relating to the readership of one’s blog, not least of which is the rough geographical location of visitors. Although predominantly my readers originate in the UK, there are a lot of people in the USA who follow The Masked AMHP, and I even seem to have a significant readership in South Korea, among other more unexpected places. One of the other interesting pieces of data is the search keywords that people have used that have led them to the site. “Diogenes Syndrome” somewhat surprisingly is by far the most popular search term (I suppose people living voluntarily in squalor worries a lot of people), but quite close behind is the question: “Why be an AMHP?”
I suppose that most of the people asking search engines this question are British mental health practitioners trying to make up their minds about whether or not it’s worth undergoing the fairly extensive training necessary to become an Approved Mental Health Practitioner. When the new role of the AMHP was created, it meant that not just social workers, but also nurses, occupational therapists and clinical psychologists could all apply to become AMHP’s.
I have to say that of the numerous occupational therapists I have met and worked with over the years, none have ever shown the slightest inclination to undertake this function. It’s just not really the sort of thing someone wanting to be an OT would tend to consider.
(Mischievous imaginary scene #1:
CMHT Manager: “What was the outcome of your assessment of Joe Bloggs under the Mental Health Act yesterday?”
Occupational Therapist: “We had a lovely discussion about arts and crafts and then we made a macramé plant pot holder together.”)
I also cannot imagine a clinical psychologist wanting to take on this role – most psychologists I know only ever see patients in their clinical base, and then only if the patient actually wants to see them.
(Mischievous imaginary scene #2:
CMHT Manager: “Could you go out and assess Joe Bloggs under the Mental Health Act?”
Clinical Psychologist: “I can put him on my waiting list, but does he actually want to be sectioned?”)
Our local AMHP course, which has just finished, had 3 community mental health nurses. While I and other AMHP’s involved with the course, were initially sceptical that nurses could take on board the social perspective that is second nature to most social workers, and were particularly worried that nurses might have difficulty in adopting the autonomy that is essential in the AMHP role, we were impressed and reassured at the enthusiasm and willingness to learn new skills that the nurse candidates displayed during their practice placements.
So why be an AMHP, then? Perhaps I can begin to answer that question by giving some of the reasons why I am an AMHP.
Some of the service user readers of this blog might suggest that the main reason why anyone would be an AMHP is so that they can fascistically exert power over helpless mental patients who don’t really have anything wrong with them and are just trying to get on with their lives in their own idiosyncratic ways. Surprisingly enough perhaps, that is not why I am an AMHP.
The AMHP role is a complex one. It is also unique among the tasks of social workers (and other mental health professionals) in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.
Going back to my time as a generic social worker in the 70’s and 80’s, I recall in child protection meetings being told to go out and apply for an Emergency Protection Order on a child, or to initiate care proceedings. In those circumstances, the social worker is merely doing what they are told, executing the corporate decision of the agency, regardless of their own possible misgivings.
I have to say that one of the things I enjoyed about working as a generic out of hours emergency duty worker was the autonomy. Whatever the case, whether it be a report of child abuse, a elderly person requiring emergency care, or a request for a Mental health Act assessment, there were no managers around to tell you what to do or what not to do. You could make your own executive decisions, carry them out, then pass the case on to the local area the following day.
If you would like more autonomy in your job, then being an AMHP can provide that. Of course, a consequence of the autonomy you have as an AMHP is that you have to take full professional responsibility for your decision, whatever it may be, and its consequences.
AMHP’s have an in depth knowledge of law and have a responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.
Even though some patients subjected to this assessment process may regard that assessment as a foregone conclusion, the AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment. As a social worker, if you can pull all that off, I think that’s pretty cool.
The AMHP role does indeed consist of a range of powers, but the AMHP has a range of duties as well. The following lists are not exhaustive, but include the main powers and duties.
Powers include:
The training is fairly rigorous. Our local AMHP course is based in the School of Social Work at the local university. It is equivalent academically to post graduate level, and can give credits towards a higher degree. That may be both an incentive and disincentive, depending on how much you might enjoy academic work. The course extends over several months, including taught modules and a practice placement, which means that candidates are away from their normal workplace for an extended period. Candidates have to submit a number of written assignments, as well as a portfolio giving evidence of their competence to practice. And they have to take a law exam.
However, at the end of all that, the new AMHP is in possession of an impressive breadth and depth of knowledge and skills, which they can then use and develop in their day to day work, as well as when being called upon to undertake AMHP duties. I have said before on this blog that your skills and knowledge as an AMHP can inform and enhance your entire professional outlook.
Qualifying as an AMHP and being Approved is not, however, the end of it. AMHP’s have to be re-approved every 5 years. They have to show evidence throughout that time that they have practiced as an AMHP, that they have had regular supervision of their practice, and that they have undertaken at least three days’ refresher training each year during that time. That may be regarded as onerous, but it also allows the luxury of uninterrupted time when you only have to consider matters of pure professional interest, unhindered by the pressures of one’s day to day job.
And what about the pay? Although contracts for AMHP’s vary with different employers, there is always an acknowledgement that the AMHP has a senior and exacting role, and AMHP’s are rewarded monetarily in various ways, either through enhanced increments to basic pay, or by a separate monthly AMHP payment. But when you consider that I as an AMHP receive less per month for all that responsibility and expertise than a Sec.12 approved doctor does for making a single recommendation under the MHA, then it is not exactly a way to get rich quick.
So why be an AMHP? For me, I like the autonomy, the ability to reach my own conclusions independently of outside pressures, the use of knowledge and experience in a crisis, the necessity to think on my feet, to manage situations of extreme stress while remaining calm and in charge of the process, and the satisfaction of knowing that I have done the best I can in often very difficult situations. And then, hopefully, to see someone recover and be able to function as an individual again.
One day I was in conversation with a woman whom I had assessed under the MHA in the past on several occasions. Sometimes I had had to detain her against her will, and on other occasions she had agreed to informal admission. She suddenly said to me: “I want you to know that I’m really grateful to you for sectioning me. I was really ill then, but didn’t know it. I couldn’t have been left like that. You helped me to get better.” That’s what makes it all worthwhile.
I suppose that most of the people asking search engines this question are British mental health practitioners trying to make up their minds about whether or not it’s worth undergoing the fairly extensive training necessary to become an Approved Mental Health Practitioner. When the new role of the AMHP was created, it meant that not just social workers, but also nurses, occupational therapists and clinical psychologists could all apply to become AMHP’s.
I have to say that of the numerous occupational therapists I have met and worked with over the years, none have ever shown the slightest inclination to undertake this function. It’s just not really the sort of thing someone wanting to be an OT would tend to consider.
(Mischievous imaginary scene #1:
CMHT Manager: “What was the outcome of your assessment of Joe Bloggs under the Mental Health Act yesterday?”
Occupational Therapist: “We had a lovely discussion about arts and crafts and then we made a macramé plant pot holder together.”)
I also cannot imagine a clinical psychologist wanting to take on this role – most psychologists I know only ever see patients in their clinical base, and then only if the patient actually wants to see them.
(Mischievous imaginary scene #2:
CMHT Manager: “Could you go out and assess Joe Bloggs under the Mental Health Act?”
Clinical Psychologist: “I can put him on my waiting list, but does he actually want to be sectioned?”)
Our local AMHP course, which has just finished, had 3 community mental health nurses. While I and other AMHP’s involved with the course, were initially sceptical that nurses could take on board the social perspective that is second nature to most social workers, and were particularly worried that nurses might have difficulty in adopting the autonomy that is essential in the AMHP role, we were impressed and reassured at the enthusiasm and willingness to learn new skills that the nurse candidates displayed during their practice placements.
So why be an AMHP, then? Perhaps I can begin to answer that question by giving some of the reasons why I am an AMHP.
Some of the service user readers of this blog might suggest that the main reason why anyone would be an AMHP is so that they can fascistically exert power over helpless mental patients who don’t really have anything wrong with them and are just trying to get on with their lives in their own idiosyncratic ways. Surprisingly enough perhaps, that is not why I am an AMHP.
The AMHP role is a complex one. It is also unique among the tasks of social workers (and other mental health professionals) in that the AMHP is acting as an autonomous professional rather than an agent of their employees, whether is be a local authority or an NHS Trust. An AMHP cannot be told by a manager to “go out and section” someone. All they can be asked to do is to conduct an assessment under the MHA and reach their own conclusion based on all the evidence.
Going back to my time as a generic social worker in the 70’s and 80’s, I recall in child protection meetings being told to go out and apply for an Emergency Protection Order on a child, or to initiate care proceedings. In those circumstances, the social worker is merely doing what they are told, executing the corporate decision of the agency, regardless of their own possible misgivings.
I have to say that one of the things I enjoyed about working as a generic out of hours emergency duty worker was the autonomy. Whatever the case, whether it be a report of child abuse, a elderly person requiring emergency care, or a request for a Mental health Act assessment, there were no managers around to tell you what to do or what not to do. You could make your own executive decisions, carry them out, then pass the case on to the local area the following day.
If you would like more autonomy in your job, then being an AMHP can provide that. Of course, a consequence of the autonomy you have as an AMHP is that you have to take full professional responsibility for your decision, whatever it may be, and its consequences.
AMHP’s have an in depth knowledge of law and have a responsibility for upholding the law when conducting assessments under the MHA. They can use that knowledge to ensure that the rights of those being assessed are protected, and can provide a counter to the medical model of mental health, introducing a more rounded social perspective to the process. They need to use their knowledge not just of mental health legislation but also the Human Rights Act. This can give them the confidence to disagree with the doctors, and to seek out and suggest alternatives to hospital admission.
Even though some patients subjected to this assessment process may regard that assessment as a foregone conclusion, the AMHP will draw on all the information available on that individual, not just the medical and clinical factors. This includes their individual social and cultural circumstances, the possible risks and protective factors, as well as their knowledge of mental illness and the legal process, in order to try and reach a just and equitable conclusion which will balance the rights of the patient with their possible need for protection and treatment. As a social worker, if you can pull all that off, I think that’s pretty cool.
The AMHP role does indeed consist of a range of powers, but the AMHP has a range of duties as well. The following lists are not exhaustive, but include the main powers and duties.
Powers include:
- The power to make an application for compulsory admission to hospital under Sec.2, Sec.3 or Sec.4
- The power to make an application for guardianship under Sec.7
- The power to convey the patient to hospital or to authorise others to do so
- The power to enter and inspect premises – other than a hospital - where someone is not receiving proper care
- The power to apply for a warrant to search for and remove patients or persons living alone in need of care under Sec.135(1)
- The power to remove and return patients within UK, or to take or re-take detained patients absent without leave (S.18 and S.138)
- The duty to interview the patient “in a suitable manner” (Sec.13(2))
- The duty to respond to a request by a Nearest Relative to assess someone under the MHA (Sec.13(4))
- The duty to consult the patient’s Nearest Relative when considering a Sec.3 (or guardianship)
- The duty to inform the patient’s Nearest Relative when detaining under Sec.2
- The duty to interview a person removed to a "place of safety" by police under S.136
- The duty to consider an application for a patient to be made subject to Supervised Community treatment under Sec.17A
The training is fairly rigorous. Our local AMHP course is based in the School of Social Work at the local university. It is equivalent academically to post graduate level, and can give credits towards a higher degree. That may be both an incentive and disincentive, depending on how much you might enjoy academic work. The course extends over several months, including taught modules and a practice placement, which means that candidates are away from their normal workplace for an extended period. Candidates have to submit a number of written assignments, as well as a portfolio giving evidence of their competence to practice. And they have to take a law exam.
However, at the end of all that, the new AMHP is in possession of an impressive breadth and depth of knowledge and skills, which they can then use and develop in their day to day work, as well as when being called upon to undertake AMHP duties. I have said before on this blog that your skills and knowledge as an AMHP can inform and enhance your entire professional outlook.
Qualifying as an AMHP and being Approved is not, however, the end of it. AMHP’s have to be re-approved every 5 years. They have to show evidence throughout that time that they have practiced as an AMHP, that they have had regular supervision of their practice, and that they have undertaken at least three days’ refresher training each year during that time. That may be regarded as onerous, but it also allows the luxury of uninterrupted time when you only have to consider matters of pure professional interest, unhindered by the pressures of one’s day to day job.
And what about the pay? Although contracts for AMHP’s vary with different employers, there is always an acknowledgement that the AMHP has a senior and exacting role, and AMHP’s are rewarded monetarily in various ways, either through enhanced increments to basic pay, or by a separate monthly AMHP payment. But when you consider that I as an AMHP receive less per month for all that responsibility and expertise than a Sec.12 approved doctor does for making a single recommendation under the MHA, then it is not exactly a way to get rich quick.
So why be an AMHP? For me, I like the autonomy, the ability to reach my own conclusions independently of outside pressures, the use of knowledge and experience in a crisis, the necessity to think on my feet, to manage situations of extreme stress while remaining calm and in charge of the process, and the satisfaction of knowing that I have done the best I can in often very difficult situations. And then, hopefully, to see someone recover and be able to function as an individual again.
One day I was in conversation with a woman whom I had assessed under the MHA in the past on several occasions. Sometimes I had had to detain her against her will, and on other occasions she had agreed to informal admission. She suddenly said to me: “I want you to know that I’m really grateful to you for sectioning me. I was really ill then, but didn’t know it. I couldn’t have been left like that. You helped me to get better.” That’s what makes it all worthwhile.
Tuesday, 14 June 2011
Should People Be Stopped From Committing Suicide?
I still remember, during my training as an Approved Social Worker back in 1984, being told that, just because someone wanted to kill themselves, it didn’t necessarily mean that they had a mental disorder or that they ought to be detained under the Mental Health Act. This informed (and at times complicated) the decisions I had to take under the MHA over the years.
I was once asked to assess a man who had been detained under Sec.136 after he had tried to hang himself. He had made a serious attempt. He meant to do it. But when I assessed him in the police station I could find no evidence at all of any mental illness. He was distressed that his wife had left him. He had wanted to show her how her decision to leave him had made him feel. He was likely to make some further attempt on his life. But he wasn’t actually depressed, He was reacting to an adverse life event. My impression was that, even though he presented a significant suicide risk, it would be through petulance rather than mental disorder. I did not feel that I could justify detaining him under the MHA, even for assessment.
He succeeded in killing himself two weeks later.
I once worked with a service user who suffered from chronic and disabling osteoarthritis. She was largely confined to her home, needed considerable support with day to day living, and was often in extreme pain. She confided in me one day that she had been studying efficient and painless methods of suicide, and that she had stockpiled a supply of the medication necessary to dispatch her with as little fuss and disturbance as possible. She explained that this was her insurance, that if she considered that her quality of life was so impaired by her condition as to be worthless, then she knew she could quietly and discretely end her life.
I respected this. She had capacity, she had a chronic condition, which although not necessarily life threatening, could at some stage make her life intolerable – and knowing that she had some control over her destiny actually allowed her to keep on. It never crossed my mind to consider the use of the Mental Health Act.
But I have been troubled for some time by the implications of another case which made the headlines a couple of years ago.
Kerrie Wooltorton was 26 when she committed suicide in September 2007. She had swallowed antifreeze, and although she had herself called an ambulance and had allowed herself to be taken to hospital, she had refused the treatment which would have saved her life. The doctors in charge of her treatment allowed her to die.
Why had they done this? Because three days before she had written what was described in press reports as a “living will” in which she stated that she was “100% aware” of the consequences of her actions and that she did not want to receive treatment.
When I read the reports of the Inquest into this case, which was concluded two years later in September 2009, I was aghast.
It was stated that she had an “incurable emotionally unstable personality disorder”, that she had a long history of self harm (she had taken 9 similar does of antifreeze in the year before her death), and that she had been sectioned and admitted to psychiatric hospital on a number of occasions in the past. Nevertheless, despite this history of mental disorder and extensive past use of the Mental Health Act, her renal consultant stated in the Inquest that “she was in no state to resist me and I could have forced treatment on her, but I don't think it was the right thing to do. I feel it would have been assault.” A spokesman for the hospital said: “It is a double-bind for doctors. She was very clear in her wishes. To have forced treatment on her would have been unlawful.”
The coroner concluded: “My judgement is that Kerrie had mental capacity. She had the right to refuse treatment and could not have been treated without her consent. Her decision to refuse treatment was consistent and she never changed her mind. The doctor went over and above what was required of him. He discussed the case with clinical colleagues, took a second opinion from a fellow consultant and sought advice from the medical director. A deliberate decision to die may appear repugnant, but any treatment to have saved Kerrie's life in the absence of her consent would have been unlawful.”
Being an AMHP, I was virtually shouting out as I read this report: “Duh? What about the Mental Health Act? Was an AMHP (or ASW, as 2007 was before the creation of AMHP’s) involved in this decision? Were two Sec.12 approved doctors asked to give an opinion? What about “mental disorder” within the meaning of the Act? And what’s a “living will” when it’s at home?"
After I’d had a lie down, I looked more closely at this case. It appeared to hinge on the issue of capacity and her “living will”. By the time of the Inquest, the Mental Capacity Act had been in force for a couple of years. The issues that this Act brought to bear were blamed for this bizarre decision to allow her to die. An analysis of the case by Professor Sheila A M McLean, a Professor of Law and Ethics in Medicine, published on the BMJ website, assumed that the “living will” was in fact an “advance directive” covered by the Mental Capacity Act. She concentrated on issues of mental competency and concluded that:
“A doctor who imposes treatment in the face of a competent refusal would be guilty of assaulting the patient. However dreadful it must be for healthcare professionals to watch a person who could be saved die for want of available treatment, they have no alternative but to do so… Ms Wooltorton was adult, competent and able at the relevant time to reject treatment. This was her right and, as such, had to be respected.”
However, Stuart Sorensen, writing in Community Care, came to what I would consider to be a more reasonable conclusion. He pointed out that the Mental Capacity Act's Code of Practice “is clear that the Act does not support suicide, assisted dying or mercy killing”. His conclusion was that her clear intention to end her life:
“means that she cannot be seen as decision-maker in the eyes of the law. The power to decide passes to the care team who have to act in what they reasonably believe to be her best interests. It seems reasonable to doubt that best interests means watching her die slowly and presumably painfully from acute poisoning.”
No-one at the time appeared to have considered the dubious legal basis on which Kerrie had written her “living will”. The Government’s own guidance to the implementation of the MCA issued in July 2007 stated that the section of the MCA covering advance decisions would not come into force until 1st October 2007 and that “most advance decisions, refusing life-sustaining treatments, made before October 2007 are unlikely to meet the specific requirements of the Act.” Not only would Kerrie Wooltorton’s advance decision not have complied with the Code of Practice to the MCA, but since it was written and executed in September 2007, it would not have been valid in any case. That in itself should have provided sufficient justification for the hospital to have disregarded her “living will” and to have provided her with treatment.
So what conclusions should an AMHP reach when confronted with a similar situation?
The case of GJ v The Foundation Trust (2009) EWHC 2972 (Fam), although relating to Deprivation of Liberty under the Mental Capacity Act, presents a potentially relevant finding that “the MHA has primacy” over the MCA: that essentially, where both the MHA and the MCA may apply to a case of “detention”, whether through Sec. 2 or 3 of the MHA or Deprivation of Liberty under the MCA, then the MHA should be used. In other words, the MCA could legitimately be disregarded in a case such as Kerrie Wooltorton’s, and an assessment could take place under the MHA with an AMHP and two psychiatrists.
Advance decisions and issues of capacity do not necessarily have much bearing on decisions taken under the MHA, and the concept of “capacity” is not a factor which has to be taken into account when reaching a conclusion about detention under the MHA, providing the other factors were established.
Were such an assessment to take place today, all that the assessment team would need to establish would be:
I was once asked to assess a man who had been detained under Sec.136 after he had tried to hang himself. He had made a serious attempt. He meant to do it. But when I assessed him in the police station I could find no evidence at all of any mental illness. He was distressed that his wife had left him. He had wanted to show her how her decision to leave him had made him feel. He was likely to make some further attempt on his life. But he wasn’t actually depressed, He was reacting to an adverse life event. My impression was that, even though he presented a significant suicide risk, it would be through petulance rather than mental disorder. I did not feel that I could justify detaining him under the MHA, even for assessment.
He succeeded in killing himself two weeks later.
Fortunately, I had arranged for him to have a medical review. On the day he killed himself, he had been assessed by both a junior doctor and a consultant psychiatrist. They both also concluded that, despite a significant suicide risk, he did not have a mental disorder.
On another occasion I was asked to assess another man who was an informal patient in hospital after having made a suicide attempt. When I assessed him, he presented with a perfectly normal mood and no discernible evidence of depression or other mental disorder. He said that he had had an enjoyable life up until then, but told me matter-of-factly that it would only go downhill from here and he therefore did not see the point of continuing to live. He was 30 years old.
This was a difficult decision. There were two medical recommendations for assessment under Sec.2 MHA, but I was struggling to justify to myself detaining him in the absence of any evidence that I could find of actual mental disorder. In the end, I concluded that, in view of the fact that two doctors were prepared to state that he was “suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment”, the safest option was to detain him. This was a case of deciding whether I would rather justify my decision to a Tribunal or an Inquest.
I once worked with a service user who suffered from chronic and disabling osteoarthritis. She was largely confined to her home, needed considerable support with day to day living, and was often in extreme pain. She confided in me one day that she had been studying efficient and painless methods of suicide, and that she had stockpiled a supply of the medication necessary to dispatch her with as little fuss and disturbance as possible. She explained that this was her insurance, that if she considered that her quality of life was so impaired by her condition as to be worthless, then she knew she could quietly and discretely end her life.
I respected this. She had capacity, she had a chronic condition, which although not necessarily life threatening, could at some stage make her life intolerable – and knowing that she had some control over her destiny actually allowed her to keep on. It never crossed my mind to consider the use of the Mental Health Act.
But I have been troubled for some time by the implications of another case which made the headlines a couple of years ago.
Kerrie Wooltorton was 26 when she committed suicide in September 2007. She had swallowed antifreeze, and although she had herself called an ambulance and had allowed herself to be taken to hospital, she had refused the treatment which would have saved her life. The doctors in charge of her treatment allowed her to die.
Why had they done this? Because three days before she had written what was described in press reports as a “living will” in which she stated that she was “100% aware” of the consequences of her actions and that she did not want to receive treatment.
When I read the reports of the Inquest into this case, which was concluded two years later in September 2009, I was aghast.
It was stated that she had an “incurable emotionally unstable personality disorder”, that she had a long history of self harm (she had taken 9 similar does of antifreeze in the year before her death), and that she had been sectioned and admitted to psychiatric hospital on a number of occasions in the past. Nevertheless, despite this history of mental disorder and extensive past use of the Mental Health Act, her renal consultant stated in the Inquest that “she was in no state to resist me and I could have forced treatment on her, but I don't think it was the right thing to do. I feel it would have been assault.” A spokesman for the hospital said: “It is a double-bind for doctors. She was very clear in her wishes. To have forced treatment on her would have been unlawful.”
The coroner concluded: “My judgement is that Kerrie had mental capacity. She had the right to refuse treatment and could not have been treated without her consent. Her decision to refuse treatment was consistent and she never changed her mind. The doctor went over and above what was required of him. He discussed the case with clinical colleagues, took a second opinion from a fellow consultant and sought advice from the medical director. A deliberate decision to die may appear repugnant, but any treatment to have saved Kerrie's life in the absence of her consent would have been unlawful.”
Being an AMHP, I was virtually shouting out as I read this report: “Duh? What about the Mental Health Act? Was an AMHP (or ASW, as 2007 was before the creation of AMHP’s) involved in this decision? Were two Sec.12 approved doctors asked to give an opinion? What about “mental disorder” within the meaning of the Act? And what’s a “living will” when it’s at home?"
After I’d had a lie down, I looked more closely at this case. It appeared to hinge on the issue of capacity and her “living will”. By the time of the Inquest, the Mental Capacity Act had been in force for a couple of years. The issues that this Act brought to bear were blamed for this bizarre decision to allow her to die. An analysis of the case by Professor Sheila A M McLean, a Professor of Law and Ethics in Medicine, published on the BMJ website, assumed that the “living will” was in fact an “advance directive” covered by the Mental Capacity Act. She concentrated on issues of mental competency and concluded that:
“A doctor who imposes treatment in the face of a competent refusal would be guilty of assaulting the patient. However dreadful it must be for healthcare professionals to watch a person who could be saved die for want of available treatment, they have no alternative but to do so… Ms Wooltorton was adult, competent and able at the relevant time to reject treatment. This was her right and, as such, had to be respected.”
However, Stuart Sorensen, writing in Community Care, came to what I would consider to be a more reasonable conclusion. He pointed out that the Mental Capacity Act's Code of Practice “is clear that the Act does not support suicide, assisted dying or mercy killing”. His conclusion was that her clear intention to end her life:
“means that she cannot be seen as decision-maker in the eyes of the law. The power to decide passes to the care team who have to act in what they reasonably believe to be her best interests. It seems reasonable to doubt that best interests means watching her die slowly and presumably painfully from acute poisoning.”
No-one at the time appeared to have considered the dubious legal basis on which Kerrie had written her “living will”. The Government’s own guidance to the implementation of the MCA issued in July 2007 stated that the section of the MCA covering advance decisions would not come into force until 1st October 2007 and that “most advance decisions, refusing life-sustaining treatments, made before October 2007 are unlikely to meet the specific requirements of the Act.” Not only would Kerrie Wooltorton’s advance decision not have complied with the Code of Practice to the MCA, but since it was written and executed in September 2007, it would not have been valid in any case. That in itself should have provided sufficient justification for the hospital to have disregarded her “living will” and to have provided her with treatment.
So what conclusions should an AMHP reach when confronted with a similar situation?
The case of GJ v The Foundation Trust (2009) EWHC 2972 (Fam), although relating to Deprivation of Liberty under the Mental Capacity Act, presents a potentially relevant finding that “the MHA has primacy” over the MCA: that essentially, where both the MHA and the MCA may apply to a case of “detention”, whether through Sec. 2 or 3 of the MHA or Deprivation of Liberty under the MCA, then the MHA should be used. In other words, the MCA could legitimately be disregarded in a case such as Kerrie Wooltorton’s, and an assessment could take place under the MHA with an AMHP and two psychiatrists.
Advance decisions and issues of capacity do not necessarily have much bearing on decisions taken under the MHA, and the concept of “capacity” is not a factor which has to be taken into account when reaching a conclusion about detention under the MHA, providing the other factors were established.
Were such an assessment to take place today, all that the assessment team would need to establish would be:
- Is the patient suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment (or assessment and treatment)?
- If so, is it in the interests of the patient’s health or safety?
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