Displacing the Nearest Relative

Not the right way to displace the nearest relative

The Mental Health Act 1959 first introduced the concept, role and statutory rights and duties of the Nearest Relative as applied to patients subject to the Act. The 1983 Act and the 2007 Act hardly made any changes. I have discussed the role of the Nearest Relative in a number of previous posts (just look up the Nearest Relative tag on the Blog).

In certain circumstances, the NR under the Mental Health Act can be displaced, and replaced with an acting NR.

The Code of Practice states (Para 8.6):

“An acting nearest relative can be appointed by the county court on the grounds that:

• the nearest relative is incapable of acting as such because of illness or mental disorder;
• the nearest relative has objected unreasonably to an application for admission for treatment or a guardianship application;
• the nearest relative has exercised the power to discharge a patient without due regard to the patient’s health or wellbeing or the safety of the public;
• the nearest relative is otherwise not a suitable person to act as such; or
• the patient has no nearest relative within the meaning of the Act, or it is not reasonably practicable to ascertain whether the patient has a nearest relative or who that nearest relative is.”

I was recently asked by an AMHP: Is there any guidance to the practicalities of executing the role of acting nearest relative for professionals?

This got me thinking. And searching. While displacing a patient’s NR and appointing an acting NR is not a very common procedure, it happens often enough that all local authorities have detailed written procedures for how AMHP’s may displace nearest relatives. However, none of them appear to give written guidance on exactly how an individual appointed to take on that role should discharge that duty.

The Code of Practice has nothing to say about how someone appointed to act as a nearest relative should act, and neither does the Reference Guide. The MHA itself makes the only reference to specific duties, and this is in Sec.116.

Sec.116(1) states:

“Where a patient to whom this section applies is admitted to a hospital ... the authority shall arrange for visits to be made to him on behalf of the authority, and shall take such other steps in relation to the patient while in the hospital as would be expected to be taken by his parents.”

Sec.116(2) defines to whom this section applies. It predominantly applies to children and young people, but it also includes “(c) a person the functions of whose nearest relative under this Act are for the time being transferred to a local social services authority.”

Richard Jones in the Mental Health Act Manual has little to add to the bare words of the MHA. However, David Hewitt, the author of The Nearest Relative Handbook, in an interesting and informative lecture I attended at a North West & North Wales AMHP Conference in 2013, observed that the acting nearest relative “must be treated as if they were the substantive nearest relative”. He interprets this to mean that they should exercise all the nearest relative rights, interestingly including the right to delegate nearest relative status.

David Hewitt, in The Nearest Relative Handbook, points out that to act as a patient’s representative is not the identified role of the NR. This means that the local authority appointed acting NR is a distinct role from that of the Independent Mental Health Advocate (IMHA). He acknowledges that the role of the acting NR is ill-defined, but also points out that this is also the case for a normal NR.

The NR has some wide ranging powers and duties. These include the right to be consulted regarding decisions being made by professionals concerning the patient, the right to make an application in their own right under Sec.2, 3, 4 or 7 MHA, and the right to request that an AMHP assess the patient under Sec.13(4) MHA.

If the acting NR is an AMHP employed by either the local authority or the local MH Trust, it is actually quite difficult to see how they might comfortably exercise some of these powers and functions.

Indeed, David Hewitt points out that there ais considerable scope for conflicts to arise with the role of the AMHP, the role of the IMHA, the wider advocacy role, and with the role of the Director of Adult Services. He has suggested that possible solutions to these conflicts could be by neighbouring local authorities having reciprocal arrangements to provide this role, or even to use some sort of external independent provider.

It seems to me that this is an issue that local authorities and Trusts need to address.

AM v SLAM: How to Decide between the Mental Capacity Act and the Mental Health Act

For some time I’ve been trying to get my head round the implications of the case of AM v South London & Maudsley NHSFoundation Trust (SLAM) and the Secretary of State for Health [2013] UKUT 0365(AAC), as it appears to both clarify and complicate the decision making process that an AMHP, a hospital or a Best Interests Assessor has to make when deciding between the Mental Health Act and the Mental Capacity Act.

The notorious Bournewood case in 1997, in which a mentally incapacitated man was held in a psychiatric hospital without any formal detention under the Mental Health Act, was one of the factors that led to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. But the MCA has never actually satisfactorily resolved the ethical and legal issues surrounding the keeping of a complaint mentally incapacitated person in hospital.

The case of GJ v. A Foundation Trust in 2009 provided some clear guidelines concerning when to use the MHA and when to use the MCA, but the same Judge (Mr Justice Charles), in AM v SLAM, has now produced new guidelines.

Mr Justice Charles recently considered (well, in August 2013) the case of AM. AM was a 78 year old woman living with her daughter. The local mental health services were concerned about her wellbeing, and her daughter was preventing an assessment. An AMHP consequently obtained a Sec.135(1) warrant, and AM was admitted to hospital under Sec.2 MHA.

AM remained under Sec.2 MHA while an application was made for her daughter to be displaced as Nearest Relative. Two Tribunals considered the case, and both upheld her continuing detention. There was a consequent appeal against the second decision.

It was being argued on AM’s behalf that her stay in hospital could be covered by Sec.5 of the Mental Capacity Act, and that an authorisation under the Deprivation of Liberty Safeguards (DOLS) could be issued if it was considered that there was a deprivation of liberty.

The Judge had previously found in GJ v. A Foundation Trust that when there was a choice between the MCA and the MHA, then the MHA had primacy. My own view as an AMHP was that this was appropriate, as the MHA provided more legal safeguards, for instance, the right to appeal against detention, and the right to automatic referrals to a Tribunal if detention continued.

However, AM v SLAM has essentially displaced this judgment, and goes into extensive detail on how to decide between the MCA and the MHA in a range of different circumstances.

The judgment places all people who may be being considered for detention under Sec.2 or Sec.3 MHA into four categories. These are:

“i) The compliant capacitated.
ii) The compliant incapacitated.
iii) The non-compliant capacitated.
iv) The non-compliant incapacitated.”

The Judge goes on to state that:

“i) the MCA cannot apply in respect of any matter which the relevant person has the capacity to decide for himself or herself,
ii) a person with the capacity to do so can consent to a deprivation of his or her liberty, and
iii) a person with the relevant capacity who is refusing to be admitted to hospital or is demanding to leave hospital (so a category (iii) person) can only be detained there pursuant to the MHA.”

It is the view of the Judge that the entire process of deciding between the MCA or the MHA hinges on S.131 MHA – informal admission to hospital. The Judge states: “The application of s.131 MHA and ss.5 and 6 of the MCA to the assessment and treatment of a compliant incapacitated patient work together.” Here, the crucial factor is whether or not the patient has capacity.

The judgment goes on to outline the three stages in the decision making process:

1. Is there a need to admit the patient? And if so, does the patient have the capacity to consent to informal admission under S.131 MHA?

2. Can the hospital rely on the MCA alone to assess and treat the patient?
3.  If the MCA could be used, “How should the existence of a choice between reliance on the MHA and the MCA and its DOLS be taken into account?”

The Judge considers S.16A MCA and paragraph 17 of Schedule A1 to the MCA, relating to a patient who is considered to be “ineligible to be deprived of his liberty”. Essentially the judgment is saying that the MCA/DOLS can only apply to categories ii) & iv), so that in category i) one would rely on S.131 MHA, and for category iii) one would consider detention under S.2 or S.3.

I have attempted to visualise some of this process in the form of a flow chart:

 

Having reached a point in the assessment process when it can be considered that MCA/DOLS may apply, that is not yet the end. It is still necessary to consider whether, even so, it is more appropriate to use the powers of the MHA.

 

AM’s representatives argued that in her case MCA/DOLS should be used, but the Judge made it clear that “the correct position is that there may be cases in which a compliant incapacitated person may properly and lawfully be admitted, assessed or treated and detained under Part II MHA when he or she could be assessed or treated pursuant to s. 131 MHA and ss 5 and 6 MCA and be the subject of the DOLS.”

 

He points out that “examples of circumstances when this will be the case are found in paragraph 4.21 of the MHA Code of Practice and paragraph 4.48 of the Code of Practice to Supplement the Mental Capacity Act Code of Practice.”

 

To save you the onerous task of looking up these references, here they are.

Para 4.21 of the MHA CoP gives the following examples of when the MCA is not appropriate:

“• the patient’s lack of capacity to consent is fluctuating or temporary and the patient is not expected to consent when they regain capacity. This may be particularly relevant to patients having acute psychotic, manic or depressive episodes;

• a degree of restraint needs to be used which is justified by the risk to other people but which is not permissible under the MCA because, exceptionally, it cannot be said to be proportionate to the risk to the patient personally; and

• there is some other specific identifiable risk that the person might not receive the treatment they need if the MCA is relied on and that either the person or others might potentially suffer harm as a result.”

 

Para 4.48 of the DOLS CoP basically repeats the MHA CoP guidance:

“Even where a person does not object and a deprivation of liberty authorisation is possible, it should not be assumed that such an authorisation is invariably the correct course. There may be other factors that suggest that the Mental Health Act 1983 should be used (for example, where it is thought likely that the person will recover relevant capacity and will then refuse to consent to treatment, or where it is important for the hospital managers to have a formal power to retake a person who goes absent without leave).”

 

The Judge suggests that there will be a need to take “a fact sensitive approach, having regard to all the relevant circumstances, to the determination of the “necessity test” and thus in the search for and identification of the least restrictive way of best achieving the proposed assessment or treatment”. This will need to include “the practical / actual availability of the MCA regime”.

Is that all clear?

 

Mills & Reeve’s helpful analysis of this case may be able to elucidate. They suggest:

 

“When applying the “necessity test”, the decision maker is looking for the alternative that best achieves the objective of assessment or treatment in the least restrictive way, whether this is under ss2 or 3 MHA. This requires consideration of the MCA/DOLS against the MHA detention to ensure that deprivation of liberty is lawful and governed by a statutory regime.

 

The decision maker needs to consider the theoretical and practical availability of the MCA/DOLS authorisation, as well as the overall impact of each statutory regime in best achieving the desired outcome.”

 

Overall, I’m not sure whether this Judgment helps or hinders an AMHP, hospital or other decision maker, in reaching a decision about whether to use the MCA or the MHA in these circumstances. It still seems to boil down to a matter of individual professional judgment.



Let’s Play Big Society Jenga!

 

For those unfamiliar with the game of Jenga, it consists of a tower of wooden blocks. During the game, players take turns to remove a block from this tower and balance it on the top. The structure becomes increasingly unstable as the blocks supporting the structure from lower down are removed.

The Coalition Government are currently playing their very own version of this game, which I call Big Society Jenga. They are seeing how many basic elements of the structure that supports British Society can be removed before the entire edifice collapses.

Let’s take out Disability Living Allowance, which permits disabled people, who are unable to work, to have something approaching a decent quality of life, and see what happens!

Nothing! No wobbles yet!

Let’s penalise poor and disabled people in social housing for having too many bedrooms!

Look! Nothing’s happened. The tower’s still standing!

Let’s impose ridiculous and perverse capability for work tests! Then we can reduce the income to sick people, who can’t actually get into work in any case!

Still nothing! This is a great game!

What’s next? I know, we’ll reorganise the NHS and in the process reduce funding to make it even more difficult for it to function! We’ll make it so that they have to sack doctors and nurses, reduce the pay of NHS staff and at the same time give them higher work loads. That should be a good one!

Hmmm. Extra pressures on A&E. More old and sick people dying. Wobbling a bit. Still, let’s impose a few targets. That should sort it. And the old and sick can always be looked after by the local authorities.

That gives me an idea! Let’s reduce funding to local authorities!

Well, the tower hasn’t fallen down yet! It’s a bit shaky, don’t breathe too closely to it.

We could always divert attention from the instability by demonising those dreadful economic migrants and health tourists. Everyone hates them any way. Easy target.

The object of this game is to undermine Society. You win if the entire structure doesn’t collapse before the General Election in 2015. And even if it does collapse, then you win anyway, because you can blame it on the previous evil Labour Government, and then privatise what’s left.

Happy New Year!

Essential Christmas Gifts for Mentalists!

The Masked AMHP™ produced some indispensable products for AMHP’s a couple of years ago. He’s now introducing a range especially for people with mental health issues! He’s called it the Mentalist Collection.

AMHP Detector

Carry this handy device with you at all times, and you need no longer live in fear of that unexpected knock on the door heralding the arrival of an evil AMHP and his or her Sec.12 doctor henchmen. It will detect an AMHP in the vicinity anywhere within 100 metres, and give you those essential extra minutes in order to make your escape through the back door.

 

Disappearing ink

Left it a bit late to get away from that pesky interfering AMHP? Well, there’s another crafty ruse! When they’re about to fill in those pink forms, show you’re cooperating by giving them this innocent looking pen. What they don’t know is that within 2 hours the ink will evaporate leaving no trace! So by the time you get to the hospital, they’ll be presented with nothing but blank forms!

Escape kit

So, despite your AMHP detector and disappearing ink, they’ve still somehow managed to get you into hospital. Don’t despair! This amazing lightweight rope ladder folds away and can be concealed inside a toothbrush holder! Then, after lights out, it’s a simple matter to make a clean getaway through your bedroom window!

Tin foil hat kit

Everyone knows that the ESA and GCHQ are monitoring the entire nation’s thoughts with undetectable microwaves. A great way to protect yourself from this intrusion is with a tin foil hat! This kit contains everything you need to make your own! Will also prevent aliens from employing their nefarious mind control techniques!

Electromagnetic mind shield

Concerned that even a tin foil hat may not protect you from external thought wave interference? This unobtrusive headgear is guaranteed not only to shield your brain from any remote sensing equipment, but will also stop your thoughts from being broadcast on local TV stations and prevent persons unknown from taking thoughts out of your head! Comes in three colours: Men-in Black, Paranoid Paisley, and Lucy-in-the-Sky Tangerine!

Pull Yourself Together and Snap Out Of It DVD

You know the saying “There’s always someone else worse off than yourself?” Well, the Masked AMHP Blog team have tracked that person down and have interviewed him for a special mood boosting DVD!

Feeling down in the dumps? Watching this DVD is guaranteed to cheer you up! There really is someone worse off than yourself!

Comes with a special bonus DVD consisting of someone who’s never had any mental health problems saying motivational things designed to make you feel better! Examples include such classic lines as:

• “It’s like you’re not even trying.”
• “Try having a nice long bath.”
• “Go for a walk.”
• “There’s no such thing as mental illness.”
• “It’s all in the mind.”
• “You’ve no reason to feel depressed.”
• “Try thinking positively.”
• “It’s as if you don’t want to get better.”
• “Try smiling once in a while.”
• And of course the classic “Just snap out of it!”

Please note: The Masked AMHP has now gone for a nice long lie down in a darkened room. He might then go for a walk in the countryside, followed a long bath surrounded by scented candles. It is hoped that normal service will be resumed on the Blog after Christmas.

A Christmas Eve Mental Health Act Assessment

Don’t you just hate it when you’re on AMHP duty on the day before Christmas, and just as you think you can go home, you get a call?

It was an elderly man. The GP had visited Nicholas at home and was very concerned. He said that he was displaying marked delusional thinking and was also hoarding. The GP said that he appeared to have been buying large quantities of children’s toys, which he was storing in his house, and when questioned about this said that he was going to give them all away.

On the face of it, there appeared to be a number of risk factors, including self neglect and spending money he could ill afford on inappropriate goods.

I obtained a medical recommendation for a Sec.2 for assessment from the GP, and arranged to visit with a Sec.12 doctor. I also took my AMHP trainee with me.

Nicholas lived in a remote house on the outskirts of a village outside Charwood. It was a large rambling farmhouse, set in several acres of garden and paddock. As far as we knew, he lived alone.

I knocked on the door, and after a moment, the door creaked open and a large elderly man with a long flowing unkempt white beard answered the door.

“Hello, Nicholas,” I said, “Could we come in and speak to you?”

He looked distracted. “Do you think you could come back after Christmas?” he asked. “Only I’ve got a lot on just at the moment.”

Peering past him, I could see that the hallway and the room beyond were piled high with boxes and objects of all sizes, all wrapped in Christmas paper. It did indeed look as if Nicolas was a hoarder. Diogenes Syndrome? Obsessive Compulsive Disorder? It was too soon to tell.

“I’m an Approved Mental Health Professional. Your doctor is worried about you. We do need to see you today.”

He looked resigned. “Very well,” he sighed. “But not too long. I’ve got a lot to do before the night’s out.”

We entered the large, heavily beamed hallway, festooned with holly, ivy, and other traditional Christmas decorations, and he led us through into a huge farmhouse kitchen. The table and most of the surfaces were all piled high with parcels of all shapes and sizes. An Aga on one wall kept the room cosy and warm.

This was most unusual. I had never come across a case of hoarding quite like this before. Although it appeared chaotic, all the parcels looked new and were all immaculately wrapped and tied with ribbons and bows.

As I looked around, I could hear rustling noises among the parcels, and movement. It must be rats, I thought with a shiver.

“What’s moving about in the room here, among these, er, parcels?”

“They’re my helpers,” the old man replied, with a kindly smile on his face.

Mental alarms started to ring. “Helpers? Can you tell me a little more about these helpers?”

“They’re mainly elves,” he said. “Do you think I could wrap all these presents on my own?”

“Elves?” I said carefully. Just this brief conversation was confirming my suspicion that Nicolas had dementia and was hallucinating.

“Oh yes,” he said happily. “They’re always so helpful. They help me get everything ready.”

“And what are you planning to do?” I asked.

“Why, I’ve got to deliver all these parcels tonight.”

I looked around. There appeared to be literally thousands of parcels. And this was just what I could see in one room. How could he possibly deliver all of these, even if he did have “elves” to help him?

“So who will you be delivering all these parcels to?” I asked.

“Why, all the children, of course.”

My worst suspicions were confirmed. Nicolas appeared to be planning to give these “presents” to children, children whom he could not possibly know, and to whom he had no legitimate business giving presents. As well as the risks to himself, he was clearly also potentially dangerous to the wider community.

“And how will you be distributing these presents?” I asked.

“I’ve got a sleigh round the back. Do you want to see it?”

“We’d love to,” I said.

He led us out of the kitchen back door into a yard. In the middle of the yard was a large wooden sleigh, complete with runners.

“But there’s no snow,” I said gently. “This sleigh wouldn’t work, would it?” I was trying to see if he still had even the slightest grasp on reality.

Oh, that’s not a problem,” he announced proudly. “My sleigh doesn’t need snow, because it will fly through the air!”

“Fly through the air?” I repeated.

“Why yes! You see, it’s a magic sleigh! Magic will allow me to fly all around the world, giving out presents to every child!”

I had heard enough. We made our excuses and retired to my car, where the doctor completed his recommendation and I filled in my application.

When I told them about his plans to visit children in their homes, the police were very obliging and turned out to ensure that Nicolas went into the ambulance without a fuss.

“But what about all the children?” Nicolas cried mournfully as he was assisted into the back of the ambulance.

“What about all the children indeed,” I thought to myself. While the distraught look on his face made me feel a little sad, I knew that I had done the right thing.

I made sure the house was secure, and looked around outside. I saw a large stable on the other side of the yard, and peeped inside. “Uh oh,” I thought, my heart sinking. Then I had an idea.

“Here’s a job for you,” I said to my AMHP trainee. “Under the Protection of Property regulations, we’re going to have to accommodate nine reindeer! And judging by the condition of its nose, one of them is going to need checking out by a vet!”

Why Social Care is Different from Double Glazing

I'm glad we've got that sorted out

(This is reblogged from the 1st issue of Care to Share Magazine)

There is a school of thought, which has its origins in some fuzzy concept of “Victorian values”, that there is something inherently wrong with the State intervening in health and social care. This reaches its apotheosis in the USA, where the Republicans regard Obama’s idea of ensuring that there is some basic form of health care accessible to even the poorest as little less than Satanic in conception.

Real Victorian concepts of philanthropy encompassed the idea that doing good was not only inherently virtuous, but was also a pragmatic and utilitarian solution to the problems that impacted on society. When large numbers of the populace are poor or sick, this affects everyone, even the rich. One of the factors that drove the development of National Insurance and improvements to social housing after the First World War was the discovery that many of the men seeking to enlist in the Armed Services were in very poor physical health. You couldn’t fight a war with unhealthy men.

There have been efforts to introduce market forces into the provision of health and social care for many years. The first Thatcher Government introduced the NHS & Community Care Act in 1990. One of the changes it introduced was the concept of the “purchaser/provider split”: this created an internal market, and essentially meant that those who “purchased” social care services should not be the same people that provided them. Until then, nearly all home care services were provided by the local authority. After that, at least 80% of services had to be purchased from private of voluntary providers

I was working in a local authority social services department when these changes came into effect in the early 1990’s.

This is how it worked before the Act. As a generic social worker, I would receive a referral for an elderly person living alone who wasn’t managing very well. I would go out and assess them and establish whether or not they needed a service: a home help to assist with cleaning or preparing meals; aids and adaptations to their home; or residential care.

I would then consult with our Occupational Therapist, who would assess for aids and adaptations, or the Home Help Organiser, who could assess precisely the level of home care services required, and then arrange for one of her Home Helps, who was employed by the local authority, to deliver that service. Some of these home helps could even be neighbours, who might be employed specifically to provide a service for that individual.

This is how it worked after the Act. The social worker would assess the person. They would then have to decide themselves exactly how much time in a week that person required a cleaning service, or preparation of meals, or someone to shop for them, or someone to help them get up in the morning or go to bed at night. The social worker would then go to the Home Care Manager, as they were suddenly called, and tell them what was required, and the Home Care Manager would then have to work out how to provide that service, using a combination of “in house” staff and external agencies.

Since then, this process has accelerated, to the point that more and more local authorities have sold off or out sourced all of their care services, and many are actively looking at how they might out source social workers, too.

The recent reforms in the NHS, centring on the GP led Clinical Commissioning Groups, are creating a culture in which it becomes imperative to provide health services via private service providers. The premise, behind the smokescreen of the mantra of “customer led” service, is that private providers can deliver cheaper and more efficient services.

There is a basic fallacy in all this: health and social services are inherently and fundamentally different from the manufacturing or service industries. You cannot apply models of the private market to the public sector.

This is what might happen if it really were the case that the health or social care service user was the “customer”.

Jeremy’s windows are draughty and let in water. He decides he needs double-glazing. He gets several companies to give him quotations for replacement windows, then makes a decision based on price and quality.

A few months after his new windows have been installed, Jeremy starts to worry about pains in his lower back. He looks these up on the Internet and decides that he must have problems with his kidneys. So he contacts the Renal Department of the local hospital, sees the consultant, and insists that he needs a kidney transplant.

The second scenario is clearly absurd. It is necessarily the role of specialist doctors to assess a patient’s health problems, and it is ultimately their decision as to what treatment the patient requires. Equally absurdly, if we were to apply this to the first scenario, then Jeremy would simply be told what sort of double glazing he needed by the expert double-glazing salesman.

Because in reality users of public services are not “customers”: it is the GP’s, via their CCG’s, who are the real customers. They are the ones who want specific services for their patients, and they choose what service they will go with.

The concept of “Payment by Results” and “clustering” currently being implemented as a means of service delivery in national mental health services is, in the words of the Department of Health, “a major change in the way that mental health care is currently funded, a shift from block grants to Payment by Results currencies which are associated with individual service users and their interactions with mental health services.”

And there is revealed the true state of affairs: in this brave new world, users of public services are not “customers”, they are “currency”.

Case Study 1: Greg and The Wicker Man

(Greg has given me permission to tell his story on my blog.)

Greg is one of the people on my case list. I’ve been seeing him for about two years.

Greg is in his 50’s. For the last 40 years, he has been experiencing vivid and terrifying visual and auditory hallucinations. However, he has been under the radar of secondary mental health services for most of that time. That is, until 2 years ago, when he stabbed himself and was admitted to a medical ward.

Why did he stab himself? Because he could no longer tolerate his hallucinations. He would have spells, sometimes lasting days, sometimes just a few hours, of exceptionally vivid hallucinations, when he could both hear and see a number of menacing men, who would threaten to kill him in horrible ways. Most of the time, these figures would stand outside his window, looking in at him. Sometimes, they insinuate themselves into his house.

So one day, after a number of hours of enduring the threats and taunts of these figures, who were telling him they were going to burn him alive like The Wicker Man, he decided that the only way of escaping this awful fate was by killing himself. So he went into the kitchen, inserted a knife into his ribcage, and leaned against the wall, using his weight to push the knife deep inside.

Fortunately, his wife found him in time, called an ambulance, and was able to get him to hospital.

But although they were able to patched Greg up and saved his life, he was still experiencing the hallucinations, and the ward appropriately asked for a psychiatric assessment.

It nearly unravelled at that point. This is because Greg had been self medicating with alcohol for many years. The psychiatrist who assessed him noted his history, diagnosed alcoholic hallucinosis, and decided that no further involvement was necessary from mental health services.

When he was discharged, however, his supportive GP made a referral to the Community Mental Health Team. I started to look through his records, such as they were. This is when I found that he had had a brief psychiatric admission 15 years previously. And unfortunately his history of alcohol use was held against him, and he was discharged with no follow up.

I discovered that Greg had actually stopped drinking completely a few months before he stabbed himself. But there had been no reduction in his experience of hallucinations. So alcohol abuse could not have been the cause. Speaking to Greg, it became clear that he had been using alcohol in an attempt to manage the hallucinations, rather than the hallucinations being a consequence of his alcohol use.

I was allocated as his care coordinator, and the team psychiatrist prescribed him an antipsychotic.

I began to visit Greg regularly, and got to know him well.

Greg is a fiercely intelligent man, who despite suffering from these tormenting hallucinations, succeeded in a variety of jobs, ranging from car salesman, to wine merchant, to a care worker rehabilitating offenders. He is very creative, and had at one point won £5000 in a national poetry competition. But since the breakdown that precipitated his hospital admission 15 years previously, he had not worked.

It was hard to know what to make of his hallucinations. They were exceptionally vivid, but Greg did not present with other symptoms of psychosis. He also had full insight – he knew that the voices and images weren’t real, although that did not reduce the horror for him. Neither did the hallucinations appear to be depressive in origin.

So it was difficult to make a formal diagnosis of schizophrenia, and it was also difficult to diagnose psychotic depression.

Greg revealed that he had been sexually abused by a teacher when he was a child. Did this give a clue? Hallucinations, often very vivid, can certainly be a feature of Borderline Personality Disorder. But these hallucinations usually centre around hearing or seeing the abuser, and again the nature of Greg’s hallucinations did not fit this formulation.

Whatever the origin, the antipsychotic he was taking, while taking the edge off these experiences, did not stop them occurring.

One day, Greg described having a sense of when the hallucinations were going to begin. The quality of the light changed, and he always smelled coffee.

Could this be a clue? Could Greg be describing the aura some people experience immediately prior to having a seizure? Could Greg have a neurological disorder, such as temporal lobe epilepsy?

There were other clues. One day, I took a detailed life history from him. Greg described a life of transience, moving frequently, and never staying in the same job for more than a year or so. He also said that he always threw himself completely into any job he took, aiming to be the best he could, but getting bored quickly. He also described long periods when he would be intensely active and creative. I had also become aware of occasions when I visited when he would be calm, polite and friendly, while at other times he would be agitated and extremely irritable.

Could Greg have a mood disorder, such as bipolar affective disorder?

Greg had an EEG, but this was inconclusive. Nevertheless, the psychiatrist decided to prescribe carbamazepine, which is both a mood stabiliser and anticonvulsant.

Although here was no immediate change, over a period of months, the intensity and duration of Greg’s hallucinations reduced markedly. At the same time, his mood became much more stable, and he was always cheerful and affable during my visits.

I discussed with him ways in which he might manage the hallucinatory episodes. The commonest hallucination was seeing people peering in through his living room window. He did not have any curtains on this window. I asked him if it might help if he put a blind on the window, so that he could shut the images out.

He tried this simple expedient, and reported delightedly the next time I saw him that it had worked! If he begins to see anything outside, he closes the blind, and although he can then still hear voices, the intensity is much more manageable.

With these improvements, his creativity returned. He began to write poetry again. This poetry was accepted and published in a range of poetry magazines. He began to write a children’s book. When he finished it and sent it to a publisher, it was accepted and published.

Writing serves two purposes for him. He found that the act of writing could distract him sufficiently from the hallucinations that he could exclude them entirely from his awareness. He therefore took to writing if he was ever troubled by the voices or images. The success he achieved in writing also improved his self esteem, and provided a shape to his day. He began to look forward to getting up in the morning, so that he could get on with his writing.

In order to prepare himself for his writing day, he spontaneously began jogging first thing in the morning. This improved his fitness, and set him up for the rest of the day.

From being adrift in a sea of hopelessness, with no motivation to do anything, and dreading the day ahead, Greg now has days full of anticipation and achievement.

I do not know to what extent Greg’s improvement is due to the change in his medication, and what is due to my regular visits and support. I suspect it is a combination of the two. I also still do not know what diagnostic label to give Greg.

Which is probably just as well. Greg after all is a person first. The important thing is that, with some assistance from mental health services, who are at last supporting him rather than ignoring him, Greg is leading a life full of meaning and enjoyment. He no longer thinks about killing himself. His “symptoms” have not gone away completely, but Greg now knows how to accommodate them within his life rather than them being his life.