When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.

Should People with Personality Disorders Ever Be Sectioned?

 

The DSMV (yes, I am that up-to-date), when discussing the diagnostic criteria for personality disorder, states:

 

“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

• Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
• One or more pathological personality trait domains or trait facets.
• The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
• The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
• The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).”

 

I have to say that this definition is rather harder to understand than the DSMIV criteria, which talks much more clearly about personality disorder as being “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture”. It goes on to talk about how the development of a personality disorder can be traced back at least to adolescence or early adulthood.

 

Personality disorder essentially comes about as a result of abusive or aversive early life experiences. An event, such as sexual abuse, interferes with the normal development of personality. In an effort to cope with such extreme and difficult life experiences, the child or young person can develop coping strategies which can be perceived as “abnormal”, but which within the context of that person’s experiences may be the only way they can survive. A typical example of this is deliberate self harming through cutting or other means, as a way of relieving the individual of emotional distress.

 

While a formal diagnosis of personality disorder may not be given too commonly, I would estimate that at least 50% of patients of a typical Community Mental Health Team could be identified as having at least some of the diagnostic features outlined in the DSMV manual. It’s certainly the case in the Charwood CMHT.

 

Traditionally, and unfortunately too often in the present, the term “personality disorder” has often been used negatively to describe people whose behaviour others find “difficult” or hard to understand. Because personality disorders can be difficult and unrewarding to treat, it has often been the case that doctors make a statement along the lines of: “This person has a personality disorder. They are therefore not mentally ill, are untreatable, and should not therefore receive services.”

 

Unfortunately, one still hears this sentiment, despite the publication in 2003 of Personality disorder: No longer adiagnosis of exclusion. Published by NIMHE, it remains the principal guidance for the development of services for people with personality disorder in this country.

 

The introduction is immediately encouraging:

 

“Personality disorders are common and often disabling conditions. Many people with personality disorder are able to negotiate the tasks of daily living without too much distress or difficulty, but there are others who, because of the severity of their condition, suffer a great deal of distress, and can place a heavy burden on family, friends and those who provide care for them.

 

As with all forms of mental disorder, the majority of people with a personality disorder who require treatment will be cared for within primary care. Only those who suffer the most significant distress or difficulty will be referred to secondary services. This guidance is designed to ensure that once referred, they receive access to appropriate care.”

 

The publication states:

 

“The current 1983 Act is often interpreted as excluding those with personality disorder from compulsory detention because of the requirement that the mental disorder be “treatable”. (i.e. treatment is likely to alleviate or prevent a deterioration in the patient’s condition). Many clinicians have not seen personality disorder as a mental disorder that is treatable. This will change with the new mental health legislation … which removes the treatability clause, and provides a generic description of mental disorder.”

 

The report makes frequent reference to the appropriateness of use of the MHA for the treatment of people with personality disorder, especially in the forensic area. It has been estimated that up to 80% of prisoners have some form of personality disorder.

 

Of course, this was written some years before the 2007 Act amendments to the 1983 Act were finalised. So what does the final Act say?

 

Well, the old definition of “mental disorder” was as follows: “mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind and “mentally disordered” shall be construed accordingly”. The Act also included “mental impairment” and “severe mental impairment”.

 

The new definition is short and concise, being merely “any disorder or disability of the mind”.

 

The revised Act did not in fact remove the concept of treatability, and in fact detention under Sec.3 requires that “appropriate medical treatment is available for him”

 

In an attempt to be helpful Sec.3(4) adds: “references to appropriate medical treatment, in relation to a person suffering from mental disorder, are references to medical treatment which is appropriate in his case, taking into account the nature and degree of the mental disorder and all other circumstances of his case.”

 

The Reference Guide (Para 1.16) adds that “medical treatment” “includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care (as well as medication and other forms of treatment which might more normally be regarded as being “medical”)”. It goes on to say that this medical treatment is “for the purpose of alleviating, or preventing a worsening of, the disorder or one or more of its symptoms or manifestations”.

 

So where have I got with answering the question posed in this post?

 

I think I’ve established that detention under the MHA is possible, since a personality disorder is certainly a mental disorder under the MHA.

 

I’ve also established that personality disorder can be regarded as treatable, and that the legal guidance covers the main sorts of treatment that might be used with personality disorder.

 

There is therefore no legal reason why someone with a personality disorder cannot be detained under a section of the MHA.

 

But this is not the same as saying that formal detention should be a routine consideration when an AMHP is presented with someone with a personality disorder.

 

At least half of my caseload as a CMHT worker are people with personality disorders, in particular, emotionally unstable or borderline personality disorder. I’ve written about some of them on the blog. I even detained one under Sec.2 on one occasion. (although didn’t actually admit her).

 

Some of the people I work with will spend periods as an inpatient if their emotional instability becomes so severe that they become dangerous to themselves, although the primary thrust of care planning is always to keep them out of hospital.

 

The care plan of one woman I work with, who frequently engages in self harming and other challenging behaviour, specifically includes a passage stating that, in a crisis, it is unlikely that hospital admission would be helpful.

 

Hospital, and compulsion under the MHA, does certainly have a place in the treatment of severe personality disorder, especially in the forensic sphere, but the NIMHE guidance encourages the use of specialist resources within the community for most people. It is certainly my experience that it is better to work as much as possible with the wishes of the person, and to respect any advance decisions they may make about the use of hospital and compulsion.

 

But that does not mean that the MHA should never be used, or only used with forensic cases. I have discussed this issue at length in my post about the Kerrie Wooltorton case, where a patient with a personality disorder was allowed to die after drinking antifreeze, on the basis that that was what she wanted.

 

In the end, if the requirements for detention are met, then the MHA should be used, if all alternatives, including informal admission, have been exhausted. As well as the basic criteria relating to mental disorder of a nature or degree, for Sec.2, that would be “he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons”, and for Sec.3 “it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section and appropriate medical treatment is available for him”.

Review: The Pocketbook Guide to MHA Assessments

 

Claire Barcham is an AMHP who has been closely involved for a long time with the development of AMHP practice, including involvement with The College of Social Work as a professional practice development advisor. Based on her own experience, she has written a clear and concise guide to Mental Health Act Assessments.

 

The book is very easy to navigate (take note, Richard Jones). Of course, it is not purporting to be as painstaking and detailed as the Mental Health Act Manual, but is more designed to provide a practical guide to the basic process of assessing people under the MHA.

 

The book is in five parts: The Legal Landscape; Setting up Mental Health Act assessments; Managing MHA assessments and making decisions; Implementing decisions and admission to hospital; and rounding off with the newest addition to the MHA, Community Treatment Orders, in a section on Working with Compulsion in the Community.

 

The first section places the MHA within the wider legal context, including the Human Rights Act and the Mental Capacity Act. It also usefully looks at the interface between the Children Act 1989 and the MHA when considering detaining a child.

 

The second section concentrates on the process of setting up assessments, including the gathering of relevant information, making assessments of risk and urgency, and looking at alternatives. She then reviews the different sorts of situations in which MHA assessments arise, eg following Sec.5(2) and Sec.136, whether the assessment is in hospital or in the community, and also looks at Sec.135. There is a good analysis of issues relating to the Nearest Relative, including identification and displacement.

 

The third section concentrates on the actual assessment. This includes interviewing in a suitable manner, a breakdown of each individual section that involves detention, and the necessary criteria for admission under the MHA.

 

The fourth section looks at the process once a decision has been made. This importantly includes what needs to go on the section papers in order to ensure that they are legal and valid. Guidance on conveyance to hospital is included, as well as a helpful guidance for nurses and staff who receive the patient and the paperwork.

 

The final section compares and contrasts the various methods by which patients can be maintained in the community. This includes appropriate use of Sec.17 leave, guardianship, and of course, Community Treatment Orders.

 

Each section is heavily interspersed with examples from practice, as well as explicit references to legal issues, and also helpful reminders about other relevant legislation to bear in mind in certain situations, in particular, where the Mental Capacity Act may be considered, as well as checklists to guide one through each part of the overall process.

While experienced AMHP’s would probably not need to dip into this book that often, I would wholeheartedly recommend it as a very useful resource for AMHP trainees, social work and mental health nursing students, nurses, police, service users, and indeed anyone with a personal or professional interest in mental health  and the Mental Health Act.



They Don’t Give ATOS: Public Accounts Committee Criticises Work Capability Assessments

It was reported yesterday (8^th February 2013) that the Parliamentary Public Affairs Committee has severely criticised the Department of Work & Pensions for their handling of assessments of the sick and disabled claimants for their capability to work. Responsibility for conducting these assessments has been delegated to ATOS, which was paid £112.4m to carry out 738,000 assessments in 2011/12.

In a report published yesterday, it was stated:

The Work Capability Assessment process is designed to support a fair and objective decision by the department about whether a claimant is fit for work, but in far too many cases the department is getting these decisions wrong at considerable cost to both the taxpayer and the claimant.

The department's decisions were overturned in 38% of appeals, casting doubt on the accuracy of its decision-making.

Poor decision-making causes claimants considerable distress, and the position appears to be getting worse, with Citizens Advice reporting an 83% increase in the number of people asking for support on appeals in the last year alone.

We found the department to be unduly complacent about the number of decisions upheld by the tribunal and believe that the department should ensure that its processes are delivering accurate decision-making and minimising distress to claimants,

The report also stated: "The one-size-fits-all approach fails to account adequately for mental health conditions or those which are rare or fluctuating."

This is something I have written about on more than one occasion (two actually, and now three) in relation to those with mental health disabilities.

Increasing amounts of my time as a worker in a community mental health team are spent attending work capability assessments with mentally ill service users at the local ATOS centre (“local” is a relative term, as the centre is actually 30 miles away from my CMHT). I feel it is incumbent on me to attend these assessments as I know from bitter experience that if I do not, service users will frequently be taken off Employment Support Allowance and placed on Jobseeker’s Allowance, even though they also been assessed, separately, and by the DWP, as being entitled to high levels of Disability Living Allowance.

I have never understood why a service user who has already been through an assessment of their disability, then has to go through a further assessment of their capability to work. Actually, I’m being disingenuous here: I think it is very likely that the reason for being put through these continuous assessment processes (they often seem to occur on an annual basis) is in order to remove them from ESA and hence to reduce their benefits.

The statement in the report that the assessments fail to account adequately for people with mental health conditions certainly chimes with my own experience of these assessments.

If you had a problem with your kidneys, for example, you might expect to see a specialist urologist. But when you go as someone with a mental illness to an ATOS assessment, it has been my experience that the assessors, who usually appear to be general nurses, have woefully little knowledge of the nature of the person’s psychiatric diagnosis, or how that disorder might affect their ability to work.

Their assessments are entirely geared up to assessing physical mobility, or the ability to bend or lift or stand for periods of time. They do not know how to assess the capacity for someone with chronic paranoid schizophrenia to hold down a job, or how to assess someone with agoraphobia, or depression, or even chronic fatigue syndrome.

Unless such people have a representative, who can describe in more detail how their condition affects them on a day to day basis, they inevitably find themselves on Jobseeker’s Allowance, having to attend work focused interviews – and also inevitably failing at these, and therefore risking being removed from benefits entirely.

It is therefore no surprise that the report finds that CAB’s have encountered an 83% increase in assisting with appeals, nor that over a third of those appeals are found in favour of the service user.

I am glad that that the committee have highlighted these scandalous issues. I hope that the Government will take heed.

When Service Users Seek to Deceive Part III

For about 15 years, from the early 1980’s to the late 1990’s, I used to do sessions on the Social Services Standby Team. You would cover nights and weekends, as well as doing your fulltime day job.

It always seemed to be that the oddest and most perplexing cases turned up outside normal working hours. Nigel was certainly one of those.

One Saturday afternoon, I received a call from the Charwood Samaritans. They needed the help of a social worker. However, it was not the sort of problem that the Samaritans usually dealt with.

Nigel had turned up at their offices out of the blue in some distress. It had taken them a while to coax the story out of him. They eventually gathered that Nigel had been living in some sort of residential facility in a county about 150 miles from Charwood. They thought he probably had learning difficulties. He told them that one of the staff had shouted at him, so he had decided to leave. He had packed a few belongings in a bag and had left.

He had then gone to the local coach station and had got on a random coach, which had eventually dropped him off at Charwood bus station. Lost and upset, he had found the first place that seemed to offer help.

My first step was to try and find out more about him. If he had left a residential care home, then he would have been reported as missing. I rang the standby social worker for the area he had apparently come from to see if they had an alert out on him. Unfortunately, he was unable to tell me one way or the other.

I decided I would have to see Nigel, and make an assessment of the situation. If he appeared to be a vulnerable person, I would then need either to arrange bed and breakfast for him through the local housing authority, or if necessary, try and find an emergency residential placement for him until we could return him to his home area.

When I arrived, one of the Samaritan volunteers took me through to a side room where Nigel was ensconced with a cup of tea, three sugars, and a sandwich.

Nigel appeared to be in his forties. He was wearing an anorak zipped up to his neck and had a round face and rosy cheeks.

“Hello,” I said to him gently, and told him my name. He peered up at me through the thick lenses of his glasses. “I Nigel, thank you” he replied.

I attempted to find out from him his full name, his address, and a contact phone number. He told me the place he had come from, but was unable to give me names of carers or a phone number.

“The bad man shouted at me,” he said. “I didn’t like it. So I wanted to leave. So I got a coach. I got off here. Here I am, thank you.”

I asked him if he had any sort of identification. He shook his head. I asked him if he had any medication with him. He took a bottle of pills out of his duffel bag and showed them to me. They were anticonvulsant tablets. They came from a pharmacy in the town where he said he had run away from.

It was apparent to me that Social Services would have to look after him until he could be returned to his home county. He seemed far too vulnerable just to arrange bed and breakfast.

Being many years before cheap mobile phones were available, I was reliant on the Samaritans to let me use their phone. They were kind and accommodating. One of them showed me into a small cubicle which contained a small desk, a phone, and a chair. It was one of the cubicles the volunteers used when they were manning the Samaritans’ helpline.

I started to make calls to the social services residential homes that specialised in learning difficulties. I then had to wait while staff talked to managers and managers talked to staff.

After a wait, one of the care homes rang me to confirm that they could accommodate Nigel on an emergency basis over the weekend, until further enquiries could be made.

I went to see Nigel and explained to him what was happening. He seemed a bit apprehensive.

“They won’t hurt me? They won’t hurt me? I don’t like it when they hurt me!”

He suddenly stood up and picked up his duffel bag.

“I go to the bus station. I get a bus, thank you.”

“It’s OK, Nigel, nothing’s going to happen. You’ll be safe.”

He eventually calmed down and allowed me to take him to the care home.

The next day being Sunday, I rang the next social worker on duty and explained the situation to them. They would chase up the local authority where he came from and get some more information, and hopefully arrange for his safe return. And that was the end of my involvement.

I happened to see my standby colleague a week or two later.

“Remember Nigel?” he said. “I got through to his local authority. I managed to speak to someone who knew him. They knew him all right. He’s not from any of their care homes – but they did accommodate him in one a few weeks ago when he turned up on their patch one weekend saying that he’d run off from somewhere in another county a long way away. That is, until they made their own enquiries – and got the same story. Then they sent him on his way! Once we found this out, we confronted him with it and he left, rather quickly. I wonder where he is now?”

There is a postscript to this story.

I was speaking to a social worker in a neighbouring county a couple of years later. I told him the story of Nigel. He immediately recognised him.

“We put Nigel up in one of our mental health care homes for about 6 months,” he said. “Then we had a full psychological assessment done, and it turned out that he had a completely normal IQ and everything. Then he mysteriously disappeared.”

From time to time I think of Nigel, traveling the country, turning up in distress, like a lost person with learning difficulties, in need of care and shelter, being taken in and looked after, at least until the truth about him was found out, then moving on again. What drives someone to live their life like that?

He’s not the only one who does it. I knew of another case which happened in our county, of a young girl, apparently in her early teens, who presented herself one day, wearing a nightie and clutching a teddy bear, claiming to have been abandoned. She was placed with foster carers for several months, until it was discovered that she was actually 25 and had the tenancy of a flat in another part of the country.

Does it constitute a mental disorder, or is it simply a means to an end, a way of being looked after without any responsibilities? How many are there like Nigel and the “little lost girl”? And how many are so successful that they’re never found out?

When Service Users Seek to Deceive Part II

Borrowed from the excellent Little People Blog

 

Warning: this post may contain triggers for abuse.

 

During the more than 20 years that I have been based in a CMHT, I have worked with literally hundreds of women and men who have been the victims of childhood sexual abuse, rape and domestic violence.

 

One of the greatest fears that abuse survivors have when they disclose their abuse is that they will not be believed. That is one of the reasons why, as a matter of basic practice, I always believe what service users tell me. After all, I often tell them, why would anyone want to make up those sorts of stories?

 

I also often say to those people that out of the hundreds whose stories I have heard, there has only ever been one who did not tell the truth.

 

Trudy was 25 years old when I first met her. She already had a considerable psychiatric history, including depression, anxiety, and bulimia, and had recently had a spell as an inpatient. She also had dependency problems with amphetamines and other drugs. As a result of all this, she had split up from her husband, and he had got custody of their two children.

 

When I assessed her, she told me, without going into any detail, that at the age of 16 she had gone to live with an older man whom she described as a gangster. While she lived with him, she was terrorised by him, and had to endure nameless sadistic practices, until she had eventually managed to escape his clutches and move to another part of the country.

 

Through copious tears, she described a range of symptoms of post traumatic stress disorder, including nightmares, flashbacks and intrusive thoughts and memories.

 

She decided that she needed to disclose the details of the abuse she had suffered at the hands of this man.

 

However, she was very avoidant. She would cancel appointments, or forget to come, or find other reasons why she could not attend. This pattern continued for over two years, with far more cancellations and DNA’s than actual sessions.

 

When we actually did have a session, she would frequently become so distressed and tearful that she was unable to speak.

 

Eventually, we devised a plan in which Trudy would write about specific incidents at home, and she would then bring the printed account to the session. I would then read it through, and it became possible for her to begin to debrief these events. His abuse of her, according to these exceptionally graphic and lurid accounts, was almost unimaginably sadistic. It was not surprising that she had been traumatised by this relationship, and that she now found it so hard to deal with it.

 

However, she reported that things were gradually improving as a result of these sessions. The trouble was, we would have one or two good sessions, then there would be a series of cancellations or no shows.

 

During this time Trudy had a number of acute psychiatric admissions. Various sorts of medication were tried, with little success. At the time, the CMHT did not have a clinical psychologist, but a psychologist from another team showed me how to practice EMDR (Eye Movement Desensitisation and Reprocessing), a technique in which the subject recalls a traumatic event while the therapist moves a pen or other object from left to right in front of their eyes. The technique is supposed to disconnect the emotion from the event, and hence to reduce the traumatic recall.

 

I tried this technique with Trudy, with quite remarkable results. She reported an improvement in her emotional response immediately. We therefore did several sessions, and the improvement continued.

 

Trudy worked hard to regain control over her life. She stopped abusing amphetamines. She started to do volunteer work, she went on a diving course, she began to address her weight problem, and on our last session she told me she was planning to take an HGV course. She was discharged from the CMHT.

 

It was very gratifying to see the change in Trudy, and to feel that I had in some way helped her.

 

Then a few months later, she unexpectedly turned up at the CMHT asking to see me urgently.

 

I took her into an interview room. She presented in a way I had never seen her before. She seemed agitated, but also almost elated.

 

“Masked AMHP,” she said to me, “There’s something I need to tell you. You know all that stuff I told you about, about that relationship? None of it was true. I made it all up. None of it happened. And when I went into hospital? I just pretended to have those symptoms.”

 

I didn’t know quite how to respond. I didn’t know quite how I felt. How could she have deceived me so well? And not just me – how could she have pulled the wool over the eyes of all the inpatient nursing staff and psychiatrists?

 

“Why do you think I did that?” she asked me imploringly. “Why did I make all that stuff up?” She seemed desperately eager for my response.

 

"Well,” I said at last. “There is a mental disorder called Munchausen’s Syndrome. That is when someone pretends to have an illness, and feigns the symptoms, and often convinces medics that they are really ill. It’s more usually about physical illness. Such people often end up having many operations and courses of treatment.”

 

“I see,” she said, as if this was a remarkable revelation. “That sounds like me, doesn’t it?”

 

“Then there’s Munchausen by proxy, where a parent pretends their child is ill, or even feeds them poison to make them ill, and then seeks medical help.”

 

Her eyes lit up.

 

“But I used to do that!”

 

“What?” I said.

 

“I pretended that my son was having epileptic fits. He had all sorts of tests, he was even admitted to hospital for a while. He was on medication. Of course, there was nothing really wrong with him.”

 

These revelations were even more difficult to process. Although her children were no longer in her custody, I knew I would have to report what she had told me to Children’s Services.

 

“You need to help me,” she continued. “I need help. You see, even though the other stuff wasn’t true, what is true is that my Dad sexually abused me when I was a little girl.”

 

“What was the nature of the abuse?” I asked her.

 

“I can’t actually remember anything. But I know he abused me, and I need help.” But her presentation was incongruent with what she was saying. Her eyes were wide. They glittered. She was excited.

 

“We can’t do any more today,” I told her. “You were discharged from us months ago. You’ll have to get your GP to refer you again.”

 

However, she moved out of the area shortly afterwards. I never saw her again.



The Masked AMHP Featured in guerillapolicy.org

 

The Masked AMHP was recently featured on guerillapolicy.org's site in the Frontline series. Banging on about clustering and Payment by Results again. Here is the post in full. It can also be found here

 

I am a mental health social worker and Approved Mental Health Professional working in a community mental health team. My AMHP role means that I have the power to apply for the compulsory detention under the Mental Health Act of people with mental disorder. However, this is a power I do not take lightly, and indeed, most of the time I am advocating for people with mental health problems and attempting to keep them out of hospital.

 

I’ve been writing the Masked AMHP blog for the last 4 years. Having been involved in the training of social workers for many years, I thought that writing about the reality of the job of social work in mental health was a good way of giving an insight for those interested in the nature of my job. I wanted to be both informative and entertaining. I hope I have achieved that.

 

The knowledge that mental health practitioners, and the service users with whom they work, have of the day to day experience of having a mental health problem could and should be used to inform policy in this area. We know the effect that mental illness has on people’s life opportunities; we see and experience on a daily basis the positive and negative effects of social policy. Imaginative and joined up social policy initiatives can have a profound effect on the ability of people with chronic mental disorder to live full and productive lives and to contribute to their communities.

 

The move away from hospital based mental health provision to community services in the 1980’s and 1990’s was immensely important. It placed a wide range of mental health professionals, including doctors, social workers, nurses, psychologists and occupational therapists together in teams which were focused on providing efficient and cost effective services within the communities in which service users lived. And when it was adequately funded, it worked very well.

 

However, in recent years, policy changes focused on reducing expenditure at whatever social cost, and based on the ideology of the Private Sector being best, threatens to destroy the best aspects of community based mental health services.

 

The radical refocusing of the NHS, which fully comes into effect this April, has already had a disastrous effect on service provision, with Mental Health Trusts being forced to redesign their services according to year on year swingeing cuts in funding. Not only are many hospital beds being closed, but frontline clinical staff are also being cut to an alarming extent: typically, 20% of frontline staff, the people who actually work face to face with people with mental health problems, are being axed.

 

An integral part of this redesign is the concept of Payment by Results. Although this was apparently designed and approved by the Royal College of Psychiatrists, it does not obviously bear the signs of having been constructed by people with first hand experience of mental illness. Rather than focusing on how mental illness affects people in their daily lives, it concentrates on identifying their symptoms and then designating them to “clusters” of symptoms. These then define the treatment package that they should receive.

 

Although that sounds superficially patient centred, in fact the true reason for clustering service users is so that these clusters can be used as a “currency” for the allocation of financial resources. This is an explicit intention of the policy.

 

And once you have defined individuals in terms of their “clusters”, then it becomes possible for agencies and organisations outside of the NHS to bid to provide the treatment packages defined by these clusters. This lays the NHS open to piecemeal privatisation of services, leaving only the most difficult patients to be treated by an impoverished rump of the NHS. This is exactly what is currently being proposed in changes to the Probation Service.

 

At the same time that these finance led, rather than needs led, changes in mental health service provision are being made, the reductions in welfare benefits will be implemented.

 

In an article published in the Guardian on 09.01.13. Aydin Djemal, the chief executive of the Disability Law Service, which provides legal advice to disabled people, says "Austerity is already hurting the most vulnerable, but in truth the greatest impact is yet to be felt." The article goes on to say “Local authority cuts will start to kick in after April, hitting social care services and charities which support disabled people. Legal aid funding will be drastically cut back, and more benefit reforms will kick in. ‘We expect to hear more and more cases of disabled people having their basic dignity taken away from them,’ says Djemal.”

 

It is a depressing prospect for both mental health services users and those professionals still trying to help them.