Bedlam – Do we need stories to understand?

I watched Bedlam, a documentary based on the work done in the South London and Maudsley (SLaM) NHS Foundation Trust last week and this week. I was reassured by last weeks’ episode, titled “Anxiety” which followed some people who had obsessive compulsive disorder so I was looking forward to the episode broadcast last night titled “Crisis” which was based in an assessment ward (which they called a Triage ward) where, the programme makers told us, decisions were made about whether to admit over longer periods or discharged home.

The “story” aspect of the programme focussed particularly on four people – two men and two women who had found themselves in situations which had necessitated (or where they had chosen – in the case of informal patients) to be admitted to psychiatric inpatient wards.  Fashionable documentary style is very much in the ‘story-telling’ vein. We like stories. We like stories with ‘happy’ endings and as the programme finished, they made sure we had the resolution we required but I was left uncomfortable by a number of aspects and details in the programme. Maybe I was more critical this week because it was an area I had more experience of but I didn’t walk away from the programme thinking it had necessarily reduced stigma and instilled a greater understanding of the mental health system as it is. Of course, that’s not the purpose of TV programmes at 9pm. The purpose was entertainment and perhaps that’s where some of my discomfort lies.

I saw a lot of the positive waves of support for the programme, helpfully tweeted out by NHS Maudsley through the programme. Interesting (but of course, unsurprising) that they didn’t deal with some of the criticisms. I know the issue of capacity to consent to filming has been raised and the programme makers have addressed it.

The producers state

One of the complex questions for filming on the ward was that of patients’ capacity to consent. We’d agreed a rigorous consent protocol with the Trust which included getting an initial steer from a lead consultant in charge of the patients’ care before even approaching an individual. At times we just got a patients’ consent to film them, we had to return to them at a later date to get consent to broadcast the material. We filmed with one lady, M, for a number of days while she was on the ward and then when she was discharged home we met her for lunch and she decided not to be involved further. Central to the filming was a respect for people’s right to privacy and we respected M’s decision.

Clearly they have covered themselves legally but some of the situations presented made me wonder how much thought had been given to the future impact of the broadcast on recovery in the long term and a full understanding of the implications of being filmed at your most unwell “in the public domain” for perpetuity – and the effect on yourself and your family of this. Of course, I’m sure these issues were covered but I was uncomfortable in the same way that I was with the ‘much lauded’ Protecting Our Children series. I’m not sure that seeing people at their most unwell or disturbed is ‘entertainment’ and now ‘educational’ it is. Do we need to ‘see’ crisis? Do we need to see a psychiatrist telling a patient he is going to use section 5 (2) of the Mental Health Act to demand that he remains on the ward when he has asked to leave? Are some things necessary to film and show on the television with real people to understand?

Perhaps I’m too sensitive because I’m thinking that for me, the thought of being filmed if I were to be restrained and forceably medicated by a team of staff is abhorrent personally. And thinking about the shots of someone being ‘persuaded’ to take their medication and forceably injected, I wonder how much it was necessary to see it. It reminded me of Panorama where the abuse at Winterbourne View was shown – not because there was abuse, clearly, but because I wondered at that point too, how much needed to do shown on camera and whether we were indulging voyeurism too much. Of course, legally, the Trust and TV production company had consent tied up but I can’t say it didn’t leave me with unease at the way we view entertainment and couch it in ‘education’ and ‘attention raising’ to make us feel better.

My other discomfort, and I’ve been criticised for raising this, was some of the racial undertones and stereotypes that I felt were perpetuated by the ‘storytelling’. Dominic, the white middle class man who would be someone who could be ‘identified with’ by many at home, was a ‘danger to himself’. Rupert, a black man, was presented as having been a ‘danger to others’. I felt distinctly uncomfortable not with the people telling their own stories in the context of the programme but with the narrative of the documentary makers that ran over it. The sequence with Dominic and Rupert singing together, seemed particularly focused on the viewer ‘empathising’ with Dominic – possibly at Rupert’s expense. Dominic was someone who was ‘like us’ – at least, until he got his ‘new’ diagnosis of having a personality disorder which immediately ‘othered’ him. Rupert was presented differently. Perhaps I am too sensitive to these things but having worked in mental health services in central London, it’s hard not to attune to race as an issue – particularly when we look at compulsory admissions.

Lots happens on admissions ward but in terms of staff, we only saw doctors and nurses. It’s a shame that there was a missed opportunity to see some of the multi-disciplinary work that happens on inpatient wards constantly especially as people move towards discharge but perhaps that’s an unfair criticism, after all, it isn’t an ‘entertaining’ as seeing people in distress. The ‘follow ups’ we got intimated that hospital admissions were successful. If that’s the case (and it isn’t always although obviously, we hope it is), I’d have liked to have seen some of the ‘why’ that we saw last week. Apart from seeing someone medicated, what other ‘tools’ are used to help prepare someone to move out of crisis. In my view, that’s an opportunity that was missed.

Early in the programme, I heard the documentary makers mention that patients who were ‘informal’ needed to see the doctor before they could leave the ward. This, I have to admit made me bristle. I hope it was a misunderstanding on the part of the documentary makers as it is veering dangerously close to ‘de facto detention’ on the part of the Trust. Someone asked me, during the programme to explain this better so I’ll give it a go. An ‘informal’ patient is a patient who chooses, willingly and with capacity understanding the implications of their actions, to admit themselves to a psychiatric ward. They are free to leave whenever they like. They are not under any compulsion to stay. If staff feel they are making a clinical decision that there is a need for someone to  remain on the ward, or ‘see a doctor before they leave’ they have to ensure they have the legal authority to do so so as not to breach article 5 of the Human Rights Act – either by a detention under the Mental Health Act (known as ‘sectioning’) or by using immediate short term holding powers under section 5 of the Mental Health Act (5(2) is where a doctor can compel someone to stay on the ward until an assessment is carried out and 5(4) is where a nurse can do so for a much shorter period). Leave cannot by restricted for an informal patient. If they need to stay, or if their leave needs to be restricted there are legal processes which need to kick into place. Detaining someone is a massive infringement of human rights and needs to be considered carefully. It cannot be a flippant comment by a member of staff on a ward about ‘staying to see the doctor’.

So Bedlam this week, definitely not leaving me feeling that it was waving the flag for stigma busting. It’s a shame as the opportunity was there but the need for stories and entertainment were paramount. Personally, it compounded my view that fly-on-the-wall wouldn’t be my personal format of preference for gaining insights into worlds that might not be apparent to others. I am of the view, and I am aware I’m probably in a minority on this, who thinks that created drama without ‘real’ people on camera – at least during their moments of crisis – would be a better way to achieve this. Drama created by people who have understanding and experience, absolutely,  but I’m not sure how much seeing the ‘real time’ distress and illness is a help to those who are experiencing it. Is that my inherent paternalist nature creeping out? Perhaps it is. Perhaps I overthink things and should let people get on with it but frankly, after last week, I was disappointed with last nights’ episode – as a rather sad epilogue, I am also thinking, thank goodness the Trust I worked in didn’t agree to TV cameras. Stories are good. Stories are necessary. But do we need every part of a story to understand? Do we need to see the needle being injected, the distress and confusion, do we need to see all that in ‘real time’ to understand? Maybe we do now. I accept I probably don’t  hold the majority view on this, judging by the waves of praise for the Trust and the TV production company  but it doesn’t shake off my general unease.

What does a Mental Health Social Worker do?

I think there’s a lot of misunderstandings about what I actually do at work. What do social workers who are in mental health services do? What do social workers who work in adult services do?

I hope by reading, some people get to learn a little of my day to day role but I also thought it might be useful to set it out more explicitly.

I’ve worked in adult services and I’ve worked, as I do now, in mental health services but I’ve never worked in childrens’ services so I can’t comment at all about the work that is done there. This is my attempt, not to explain social work as a whole, but to explain the bit of social work that I’m familiar with.

I work in a multidisciplinary Community Mental Health Team. We have a consultant psychiatrist attached to the team as well as a few (the amount fluctuates!) other doctors. We have occupational therapists, clinical psychologists, assistant psychologists, community psychiatric nurses and of course, social workers. We always seem to have students around, whether psychology trainees, OT students, nursing students or social work students (and even some medical students pop in occasionally).  I sit opposite a psychologist and between an OT and a nurse.

Although no week is typical, I’ll give a few examples both of the generic role and the way that social work fits into a mental health setting, in England, at least (because I’m not sure if there are differences in Scotland, Wales and Northern Ireland).

Work is allocated for ‘care co-ordination’. Care co-ordination is akin to what we would have called ‘care management’ in Adult Services although there are some differences and responsibilities under the Care Programme Approach.  It basically means we take responsibility as a kind of ‘key worker’ for individuals who are ‘taken on’ by our service.

Allocation should be done on the basis of appropriate professional expertise so for some issues that have a more ‘social work’ tilt about dynamics, organising personal budgets or residential placements might be preferred as allocated to social workers, some that are more rehabilitation orientated might be allocated to an Occupational Therapist and more medical or medication management might be allocated to a CPN but that is a very broad brush to paint and in practice – most people are a mixture of all the different needs and so are allocated generically. If I have need a of specific OT assessment for one of the people that I am care coordinating, I will ask one of our OTs and similarly, I care coordinate one person who receives a monthly depot injection from one of my nursing colleagues.

So what is care coordination/care management about? Well, we start by working with and on a care plan and this should be led by the user of the service. If there is a carer involved it would also involve them and we put together plans. In my service which works predominantly with older adults, there may well be care services needed and this is now all delivered through personal budgets so I would take someone through the supported self assessment questionnaire, the resource allocation system and develop with them and/or their carers, depending on capacity issues on a support plan and way that services would be delivered. This would be reviewed and implemented in partnership.

I will also arrange respite placements  and services when they are needed and review services as they are delivered.

Alongside this, I would also be responsible for monitoring any changes in mental state and might provide some brief therapeutic interventions mainly through basic CBT type models according to additional training which has been given in the NHS Trust I work in as they are trying to ‘skill up’ all care coordinators!  When I meet with someone, my discussion ranges for more broadly than about their care needs specifically. Sometimes it is about sourcing and finding ideas, services and people that might be able to help, namely through group work which is run across the service or through referrals to specific psychologists attached to the team. Sometimes it is much more difficulty to quantify – and log – and record.

I work with carers and work through carers’ assessments and services such as they are. Often I feel one of the most important aspects of my work is carer support as we rely so heavily on some carers. I might liaise with different organisations on peoples’ behalf if they can’t manage or need some assistance. Sometimes I help with Attendance Allowance or Disability Living Allowance claims but there are council teams that do that so it would only be in circumstances when I might know someone particularly well and be concerned that someone who doesn’t know them that well might ‘underplay’ some of their needs.

Sometimes it is about liaising with creditors, gas and electricity companies, housing etc with various degrees of success. I like to think of myself as an advocate at times.

Although at times, I am very far from an advocate. I am subject to specific ‘terms of reference’ of my job and have no control over things like budgets that can be assigned to various people with various needs. I would ‘present’ the needs of service users I work with to various internal funding panels so on that basis I need to advocate clearly.

We have to review the services that are in place regularly. I would attend meetings at day hospitals and on wards when I am allocated to people who currently attend or are inpatients.

I work to plan and organise discharges from hospitals both the psychiatric hospitals and the general hospitals when people whom I am allocated to are inpatients. There are some very obvious time limitations on these pieces of work and no-one wants anyone to be in hospital any longer than they have to – but equally no-one wants someone to be discharged from hospital before they are well enough to be – which is another very important consideration.

I conduct safeguarding investigations as well. Alerts come up with what can be surprising frequency and there are prescribed procedures through which we approach these investigations. It’s hard to generalise as they can be very different. Interestingly most of my recent ones have involved residential services in some way or another. I think I’ll come back to the process of investigating abuse in another post as it is altogether a subject in its own right. We tend to get more of these investigations in older adults services than occur in the working age adult services.

I am an Approved Mental Health Professional (AMHP). That means that I am on a rota to carry out Mental Health Act (MHA) Assessments . There is an important difference between a Mental Health Assessment which is a more generic term for an assessment of someone’s mental health and a specific ‘Mental Health Act Assessment’ which is a formal assessment under the 1983 Mental Health Act which can result in a compulsory admission to hospital without consent.

The role of the AMHP could be a post all of its own and it probably should be so I’ll condense here for clarity because it has increasingly become a part of my day to day role. I organise and arrange these assessments by arranging for ambulance service and doctors attendance (there have to be two medical recommendations written by doctors – one should know the patient (usually their own psychiatrist or GP along with an independent doctor who has had additional training). I also attend a magistrates’ court to obtain a warrant to enter if it is likely that we would not be allowed access to a property. I  arrange police support if necessary and would also organise a hospital bed if necessary.

There are legal forms to complete and I have an obligation to be mindful and respectful of legal rights and human rights when involved in these processes.  I am obliged to attend a specified amount of ‘legal updates’ every year to maintain my approval as an AMHP and every five years I have to be ‘reapproved’ which involved me taking a legal test and submitting some reflective pieces and examples of my work as well as carrying out a set number of assessments per year (no problem with the numbers – I’ve done the requisite annual number in the past week!).

I’m also a BIA (Best Interests Assessor). This means I have specific duties and responsibilities to carry out assessments under the ‘Deprivation of Liberty Safeguards’. Again, that probably demands a post or two of its own. Suffice to say that every so often I am called out to do a specific type of assessment on this basis.  I had to attend additional training to be able to do this and have to attend update workshops and training to retain my approval.

Apart from the things I’ve listed, my job involves other pieces of work. I write social circumstances reports for tribunals. I occasionally have been involved in assessments and writing reports for Guardianships and in taking part in the process of approving or extending a Community Treatment Orders. I frequently carry out Capacity Assessments for various reasons.

I’m a practice assessor too so when I have a student, well, I have a student to supervise. I tend to enjoy having students around. It does create more work though and there’s no recompense in terms of reduction of caseloads! And the universities and local authorities wonder why we can’t offer as many statutory placements!

My work is often one of juggling and trying to prioritise and reprioritise on the basis of risk management. What is more important for me to complete on any given day.

I haven’t even mentioned data input or writing case notes but takes a fair bit of time. We have regular audits of our ‘productivity’ – we have to input our ‘outcome measures’ and re-input them regularly so our management overlords accept that we are actually spending our time at work, working effectively and not just twiddling our thumbs and playing Facebook games.

The amount that we have to ‘report back’ is, of course, growing at an exponential rate.

So that is my job – as briefly as I could manage and I have missed out some of the million subtleties that might change on a day to day basis.

I generally enjoy it. I love the variety that is thrown my way on any given day. Some days it frustrates me and there are rarely enough hours in the day to get what I want done, done. This may explain some of my frustration with the bodies who all say they ‘speak for social work’.  Have they explained the role of social work outside child protection? Would you know, if you are not involved in the ‘system’ what a mental  health social worker actually does?

But really, that’s another fight for another day. For now, well, I need to go to work!

But I had over to you, dear reader. Is there anything that surprises you? What you expect? What have I left out – as I’m sure I have missed a lot of things!

Sadness, Sympathy and Self

Sometimes, some days feel filled with sadness. I had one of those days this week. I don’t like to use the word ‘hardened’ but to put it this way, in over 10 years of frontline social work practice in some of the most deprived areas of the country and in the inner city, I’ve seen a fair bit of what society has to throw in terms of crumbs to those who are some of the most vulnerable members of it.

I look at the high rises that skirt around the cities and I see hundreds of lives being lived, families existing and stories being told. Some with hope and pride. Some with desperation and despair. All different, all a part of this community and society we live in. Poverty is real. Despair is real. The two don’t have to go hand in hand though.

I have a strong stomach and don’t bat an eyelid at all sorts of things when I walk into a house. I’ve probably seen worse.

In some ways, human misery is a part of my trade. Not always, of course, because there are the wonderfully reassuring smatterings of hope but difficult social circumstances and social deprivation run a theme through my career.

Although I often emphasis that mental ill-health is certainly no respecter of social class or financial assets, it is sometimes the level of deprivation and the difficulty and shame of poverty that I see that reminds me of the way that this political class intentionally ignores and isolates some members of the community.

Perhaps the most difficult part of  my job is wrapped up in the AMHP (Approved Mental Health Practitioner) role. It is a mirror into my ethical compass and while I enjoy the aspects that were involved in training and the support and development and even community feeling I have with other AMHPs, the process of making a decision about someone’s forced detention in hospital or a forced medication regime is never one that can be taken lightly and I don’t think it is one that should ever be ‘enjoyed’.  It is power, writ large. It is control.

Sometimes people thank you retrospectively for ‘making the right decision for me at the time’ but more likely that isn’t going to happen.

This week, I carried out a Mental Health Act Assessment in a hospital. That is very far from unusual. When I read the background and the circumstances, when I conducted the assessment and made the application for detention, which I did, I was overcome with a feeling of sadness for the action that I had taken and for the life that it predominantly affected.

For obvious reasons  I won’t go into details – anyway, even if I did they would possibly sound fanciful and unrealistic. To people who think that I have a ‘difficult’ job, I would say I  have had a walk-on part among some fine and very strong people who have had to contend with sickness, pain and family circumstances that have rolled all the dice against them in the lottery of life.

And when I sign the papers and write up the report, I don’t forget. I think, I reflect and I try to learn. What could we have done to prevent this situation from having occurred? Sometimes the answer is nothing but sometimes there might have been a different path, a different action or different guidance that might have led to a different outcome.

Sometimes, some days, I just feel overcome with sadness. Sadness at the injustices that are meted out by life, fate and circumstance. Sadness at the way that this society perpetuates and builds on those injustices of circumstance. Sadness at my role my own complacency in accepting that we have created such an unequal and unfair society.

In a community where people who live on state benefits are treated with an intention to humiliate and scorn and where the government not only condones and supports this, it tries to create further barriers between the ‘haves’ (with ‘have’ meaning working tax-payer) and the ‘have-nots’ (meaning those who depend on the state for income) it sickens me as I know that the rhetoric of ‘choice’ and  ‘community capacity building’  are empty words which mean nothing without the world of privilege. By privilege I don’t mean money, necessarily, but include the privilege of having family or friends around, the privilege of being well enough to build up networks of support, the privilege of being a part of a community. There is so much more to privilege that cash assets or income.

Sometimes I want to shout against the system that I am a part of. The social care system in this country is not ‘fair’ – it reeks desperately of unfairness and the pushing of ‘choice’ in very narrow terms onto a wide range of people who in reality have no choice whatsoever further marginalises and discriminates against poverty, incapacity and isolation.

But I continue in my job. I go into work and ‘buy into’ the system. In my own defence, I fight as hard as I can from the inside and I don’t forget the names, the faces and the stories of those whose lives touch mine.

I remember, I note and I learn and sometimes, that just fills me with sadness – but when I stop feeling that sadness, I stop learning, growing and trying to create a better world. One person at a time. In spite of the system I work in and with rather than because of it.

Rising Admission Rates

Yesterday, via Twitter, I was alerted to the publication of the ‘Mental Health Bulletin  – Fourth Report from Mental Health Minimum Dataset (MHMD) returns 2010’. I know it’s a bit of a mouthful but briefly, it means statistics about admission, treatment and care by Mental Health Trusts around England.

There are a few tidbits of information that are worthy of comment and commentary.

The most obvious ‘headline’ figure presented is that there has been a 30.1% rise in people held in hospital under the Mental Health Act between 2008/9 and 2009/10

‘from 32,649 in 2008/9 to 42,479 in 2009/10’.

That’s a staggering initial figure for a change in a one-year period so I wanted to look at some of the possible reasons for this.

The survey itself indicates a large part of the change – being that

Some part of this increase was due to improved recording between 2008/09 and 2009/10, because a small number of trusts failed to provide MHA information in 2008/09. On a like for like basis, excluding the data for trusts that failed to return information in 2008/09, there was an estimated increase of about 17.5 per cent in the number of people being detained under the MHA – from 32,649 to 38,369

I’m not entirely confident I understand the baseline statistics but taking advice from those who know better, I’m happy to stick with that 17.5% increase.

My initial gut feeling and certainly the situation that tallies with my own practice experience is that the influence of the Mental Capacity Act has been crucial in leading to an increase in detentions that I, personally, have signed over the last year.

I understand that I might have a slightly non-representative view as I am a specialist in older adults’ mental health and primarily carry out Mental Health Act Assessments for Older Adults therefore I may see a disproportionately high number of people who may lack capacity due to organic mental ill-health (e.g. dementia).

However, the impact of DoLs (Deprivation of Liberty Safeguards) has led, through something of a drip-drip process and through caselaw – particularly GJ v Foundation Trust which established that there can be no ‘choice of law’ between the use of the Mental Capacity Act and the Mental Health Act for a ‘mental health patient’ in a ‘mental health hospital’, to an increase in admissions under the Act.  Actually, I genuinely believe it allows a far far greater protection than the DoLs process allows but I might be getting over-technical. Suffice to say that there has been a substantial increase in the amount of people on the older adults wards who are now detained ‘under section’ – who may well have, last year, been informal patients.

Of course, the issue of capacity or lack of it doesn’t solely relate to older adults but the examples I give are from my direct experience.

I’ve turned down a couple of Eligibility Assessments under the DoLs framework, suggesting the people whom I have assessed have been ineligible for a Deprivation of Liberty Order because they would otherwise be eligible for detention under the Mental Health Act. I’m just one person, I know,  but I know of other people in my Trust who have made similar decisions.

It may be a reason for some of the increase in detentions.

I’m not sure if the  cuts agenda has had a significant impact on status of admissions yet save the generalised increased levels of distress and higher potential levels of mental illness that may occur when the economy is in a depressed state.

In  our Trust there have been a massive reduction in the amount of inpatient beds available. Does that mean people who  might have been brought into hospital earlier are not? Possibly.  It may mean fewer  informal admissions take place due to the lack of beds and therefore situations deteriorate so an admission has to be on a compulsory basis. That may also explain why the length of time of stays has increased.

The other unsurprisingly depressing point made from the data is that

Whilst the number of people using services rose across all ethnic groups, the percentage rise was noticeably larger for the Mixed ethnic group (a rise of 17.7 per cent). The Mixed and the Black and Black British groups now both have rates of access to services that are over 40 per cent higher than for the majority White group (at approximately 3,800 per 100,000 population compared with about 2,700 for the White group).

The most obvious explanation of this relates to institutional (and overt) racism and a differentiation of the way the treatment and treatment decisions are made on the basis of cultural backgrounds.

If anything needs to be actively addressed it is this inherent difference in the system and services that seem to allow such disparity to exist.

Another interesting point that was in the main document was that

The number of women detained under the MHA who came into hospital via the prison or the courts rose by more than 85% since 2008/9 ….  The number of men in this category rose by 48.1% since the previous year’.

Again, staggeringly high figures. I wonder what significance changes to prison services has and will have on admissions to psychiatric hospitals via the court system. It’s not an area I have more than perfunctory experience of so I can’t comment in detail, except that it’s an interesting aside.

In fact, looking at the bare figures, it seems that these increases have made up a good proportion of the overall rise in compulsory admissions under the Act across the board.

As I’ve been reading through the document I came to the conclusion that I could easily cover about 10,000 words worth of analysis of the information provided!

What I would say though it that it’s worth checking the entire document because the information contained on the breakdown of admissions on the basis of gender, age and race make for lots of potential analysis and interest in the nature of work and how it is changing in mental health services in England.

Rising Detentions

Community Care have a short report about figures were published yesterday by the NHS which indicate that there has been an increase in detentions under the Mental Health Act over the last year.

As the article says

The numbers of people being detained under the Mental Health Act rose by 1,692 in the last financial year according to figures published by the NHS information centre.

The 3.5% increase brings the total people detained under the act to just under 50,000 in one year and represents the largest increase in three years.

The total numbers admitted to hospital also increased to 30,774 in 2009-10, a 7.3% increase from 2008-9. The rise was attributed to an increase in admissions to NHS hospitals, while previous increases have been driven by private sector treatment.

I thought it would be an interesting point to consider as, on an incredibly unscientific basis, I can say that I have been personally busier as regards making applications for detentions under the Mental Health Act in the last year than I was in the previous year.

It’s ironic considering we’ve had a number of wards closing in our Trust and the number of beds available has decreased.

The reason? Again, I repeat this is completely based on my own experience but I’d put it down to the impact of the Mental Capacity Act 2005 and particularly the provision of the Deprivation of Liberty Safeguards. This has led to a massive increase in the amounts of assessments I’ve been asked to complete for people who might previously have been informal patients in psychiatric wards who lack capacity to consent to admission or treatment.

Of course, this group of people should probably have been brought under the auspices of the Mental Health Act previously, on the basis of meeting the criteria for detention and despite all the perceptions and stigma associated with ‘being sectioned’, personally, I think the legal processes allow for much better protection of the individual than ‘being an informal patient’. There are various issues about how ‘voluntary’ an admission can be if someone has the threat of a potential compulsory detention hanging over their head but if there is a question of them being stopped from leaving, it has to be a strong consideration.

There is a greater awareness of issues of capacity now and that one doesn’t have to be rattling the door down and repeating ‘I want to go home’ every five minutes to be objecting to ones detention on a psychiatric ward.

There is also the sticky s117 issue which had allowed some consultants and Trusts to ‘dodge the bullet’ on making recommendations for compulsory detentions when really they might have.

s117 of the Mental Health Act ensures that the NHS remains responsible for any aftercare services provided. That may include residential and/or nursing care costs which can rack up to thousands of pounds fairly quickly.

Guidance has changed over the past few years (due to case law clarifications) and we are told that we cannot now discharge the s117 responsibility if someone has dementia as it is not likely to improve and therefore the aftercare is provided free for life.

Now, I’m not saying that these potential high costs might have prevented some informal patients being admitted formally to wards but it is a massive potential cost.

The DoLs (Deprivation of Liberty Safeguards) have led to greater awareness and training on the wards in relation to the interaction of the Mental Health Act and the Mental Capacity Act. I’m not saying that is the sole reason for an increase in compulsory admissions on the wards as I am aware my experience, being particularly in the field of older adults, is an area where this matter is much more relevant to those who might work with adults of working age,  but for me, it has been the key factor in the increase in applications for compulsory detentions that I, personally, have made.

To Section – as a verb

Is ‘to section’ a verb we should be using? My understanding and instruction was always that we should try, if at all possible, not to refer to ‘sectioning’ someone.

It seems a bit flippant. It seems to imply a decision made. I know these are values I am attributing to the words  but I can’t escape the discomfort I feel. Then, on the other hand, it is a word that describes a process in a way that is understood.

I know that is not a rational response to reject a word out of hand but I feel quite strongly about the process and having seen regularly, the distress it causes at close quarters, trivialisation is the last thing that should ever come to mind.

This occurred to me yesterday following a discussion with a nearest relative when I was explaining about the assessment I was going to be undertaking.

Just for the record, none of the pieces of conversation below quite matched the way the ‘real’ conversation went yesterday, but they are parts of conversations I’ve had with a variety of people over the past couple of years.

It’s one of the  tasks that I have as an AMHP (Approved Mental Health Professional) – and on a human level, it can be difficult. I am obliged as a part of my duties in setting up Mental Health Act Assessments to consult the relevant nearest relative in the case of an application for admission under Section 2 of the Mental Health Act and to consult and  ensure that they do not object in case of an assessment under Section 3 of the Mental Health Act.

There’s that ‘section’ word again.

Depending a little on the situation and whether it might be a person’s first assessment under the Mental Health Act and how close the family member actually is, you can judge how to pace the conversation.

‘I’m going to be carrying out a Mental Health Act Assessment of your mother’ Notice the difference between ‘mental health assessment'(which could be any type of more generic assessment carried out)  and ‘mental health ACT assessment’ (which is very specifically an assessment carried out in order to make a decision about compulsory detention in hospital). That’s the key difference and often it needs to be clarified.

That may be enough

‘Oh, is she going to be sectioned?’ may be a response if this has happened before.

‘Well,’ I might say ‘it’s an assessment so we don’t always know the result in advance’

Except some times it is a lot clearer than others.

That would depend on the circumstances and the lead up to the assessment.

We don’t consider Mental Health Act Assessments until all other possibilities have been expended but sometimes it might be someone we don’t know well or something might come up as a part of an assessment that we hadn’t known about in advance or it might just be a wholly inappropriate referral where some of the information given by a panicky care coordinator or family member isn’t quite what we see when we turn up on the doorstep.

Sometimes the prospect of being forcibly admitted to hospital is enough to ‘encourage’ someone who might otherwise be reluctant to engage with services.

If it is a first assessment or someone who hasn’t had any knowledge of the jargon and the way we things might work, I’ll explain in more depth the workings of the Mental Health Act and the bases by which we assess and what the implications are and may be. It depends on level of distress and what some of the precipitating factors might have been and how closely that person was involved – if it’s been possible to have some of these ‘lead-in’ conversations beforehand or not.

So this may have been discussed in great detail before this point arrives – but sometimes it would be someone who had been unknown to our services and with whom we had not had previous contact.

‘So you mean you’re going to section my mother?’

I try to reassure and often will tell the family member not to be frightened of the word itself. ‘Sectioning’. Being admitted to a psychiatric hospital for detention or rather admission, assessment and/or treatment under the Mental Health Act. It is scary. The thought of not being able to leave may be frightening but the stigma attached to ‘being sectioned’ is also frightening.

There are a lot of perceptions of what psychiatric hospitals may be like – and some may be exactly as they are perceived to be but most of the wards I admit to, I know the staff and I know the quality of the nursing care that will be administered. It’s easy to reassure someone of this but it’s hard to break through the preconceptions – understandably.

We also know the stories, we know the general perceptions of what ‘being sectioned’ might mean and the labels that might be attached.

I explain that the word holds all sorts of connotations but sometimes it is about legalities and above all it would be to ensure that we can provide the best care possible for the individual in question.

I explain that we conduct an assessment and that we do this in as humane and thoughtful a way as possible, always respecting the person and not making the situation any more distressing than it need be.

But sometimes it does need to be distressing. Sometimes the thought of ‘sectioning’ brings some of those images – as exist in general media perceptions – of someone being dragged off into the night to a hospital.

And you know, sometimes things do happen that way, I can’t deny it. Well, I don’t work at night as a rule (only if something from the day has dragged on) and there are  few times when I’ve personally been involved when the police have had to actually put hands upon someone during the process. It can happen though.

Usually the police are very sensitive. We have some excellent, sensitive and extremely professional police in our borough who are, for the most part, a joy to work with.

Duty of care. It comes back to that. It would be wonderful if everything we did could be done with consent but the nature of the job is that it is not.

‘So you’re going to section XXX?’

Not necessarily, I might respond – we are going to conduct a Mental Health Act Assessment and make a decision as to whether she needs to be admitted to hospital or not.

It sometimes feels like fighting a losing battle.

‘This is the social worker. She sections people’ One of my colleagues introduced me to one of the nursing students.

‘Well, I organise Mental Health Act Assessments where they are needed and make the applications for compulsory admissions’ I try, but that’s seen as me being a bit pedantic. I’m rowing against a tide

‘Yeah, that’s what I meant, she sections people’.

When I was a student, one of my practice teachers was a (as then) ASW. It seemed a faintly mythical task to me – and more than a little scary.

It’s less mythical now of course, as I’m carrying out the same role myself, in a slightly different incarnation. But it’s still scary. There’s still a thought that this assessment, this moment is something that will have a profound impact on the course of this individuals’ life.

‘When I was sectioned.. ‘

And the shame and distress that will cause to everyone involved.

It’s easy to reassure that it is nothing to be ashamed about and that we are ultimately concerned with our duty of care towards the patient and to ensure that the best possible treatment can be administered.

Or sometimes it isn’t as easy to provide that reassurance.

That word again – sectioned.

I see why we were told to try not to use it. It has so much weight to it. So many assumptions and fears attached to it.

But we also need to say it as it is sometimes.

‘Does that mean my mother might be sectioned?’

‘Well, people do refer to it as that sometimes, yes, but it is an assessment’.

And afterwards, when I report back

‘did you section her?’

‘She was admitted under Section 2 of the Mental Health Act’

‘So you sectioned her?’

‘Yes’. Sometimes it is just best to be clear.

You would explain the reasons, the rights and responsibilities of those involved and of the nearest relative. I don’t always get it right.  I try to put as much empathy into these conversations as possible.

But sometimes, often, the grief and distress, it cuts like a knife.