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.

Sectioned – A Quick Review

Probably not the most in-depth review as I haven’t had a lot of time to process the programme shown on BBC 4 on Wednesday called ‘Sectioned’ as a part of the ‘Out of Mind’ season about mental illness.

The programme’s aim was to allow a greater insight into some (in this case three) patients who had or were being detained in hospital under a compulsory section of the Mental Health Act (known as being ‘sectioned’).

They followed three men – Anthony, Richard and Andrew and looked at the challenges they have and continue to face and the way they have experienced mental health services – particularly and exclusively (because of the nature of the scope of the programme) in-patient services.

Between them, they had experienced a number of hospital admissions and the programme certainly picked up on the cyclical nature of some of the experiences of mental illness. There isn’t necessarily a beginning and an end but more different ways of seeing things and different places along the scale of wellness and illness.

Rather than recount the experiences that were highlighted in the film, I think at least the film succeeded in presenting the stories of three individuals rather than three ‘patients’.

We had an understanding of who the subjects were and the effect that their illnesses had on them and their closest family.

The story was one of experiences rather than processes quite rightly and I think there is scope for programmes such as these to increase appreciation and understanding of the reality of mental health inpatient wards. There was no indication that any kind of support or process existed outside the wards but I suppose that wasn’t the point of the programme. There was a helplessness though that I was almost left with when I wanted to justify a little more hope than was presented but perhaps that wasn’t within the bounds of the programme makers remit.

One of the most striking things was the declaration that hospitalisation is and was crueller than imprisonment. There is no sentence though, just a revolving door and no crime that has been committed to lead to the sentence and the natural cycle of right and wrong.

It was a decent and sympathetic programme covering an aspect of mental health services that is often ignored. I wonder if Janet Street-Porter would benefit from a little time watching programmes such as these and coming to visit a psychiatric ward..

But then, as I explained to my tearful foster child last night, so long away from her family with no idea when or if she might be going home at all,  life isn’t about being fair.

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Officers or Nurses

I know I shouldn’t go to the Daily Mail website. It is a form of morbid curiosity but I saw this article headlined and couldn’t resist

Chief Constable Peter Fahy of Greater Manchester Police says that he needs ‘more mental health nurses as much as officers’ because, and I quote

‘there were so many disturbed patients being let out onto the streets by the NHS that officers were having to ‘pick up the slack’.

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‘Let out by the NHS’ – I wonder if that’s the new term for a hospital discharge. .

I don’t even know where to start with this. Of course, I don’t have the figures to hand and don’t know what the time spent on s135 and s136 is on Greater Manchester’s police force but it’s a valid use of police time.

s135 is the part of the Mental Health Act that allows an AMHP (who would have a warrant) with a police officer to enter a property to remove someone who is mentally unwell to a place of safety for an assessment to take place.

s136 allows the police to remove someone who they believe to have a mental disorder to a place of safety for an assessment to take place.

And the use of s135 and s136 powers is not about ‘apprehending criminals or ensuring no crimes are committed’ but rather an act taken for the safety of the patients and the general public to ensure that an assessment can take place.

Public safety, I thought that was what we were to expect from the police as much as ‘apprehending common criminals’.

I ponder at his comment that

‘We have to train our staff to a professional level of someone like a mental health nurse to enable them to deal with these cases.’

Seriously? He thinks he is training his staff to the level of a mental health nurse? I have to say I am fortunate to work in an area with some really wonderful police officers but it’s a bit like MPs saying they are social workers because they deal with a bit of paperwork every now and then. It denigrates the work that is done by professionals and that it should be acceptable to make an issue of it is a surprise. If it is acceptable.

The article goes on

He said: ‘Officers are very good at being able to detect the burglars, the car thieves, the hoodies, basically your common criminal.

‘But what we are talking about is a particular type of disturbed individual whose irrational behaviour is outside of the norm.’

He told the conference: ‘I really feel for my own staff who are sent to domestic violence or mental health cases, dealing with vulnerable people when that officer is trying to do his best and then a tragedy occurs.

‘Even if they have done their best, the Independent Police Complaints Commission will treat the officer as if they are responsible.’

Mr Fahy also called on magistrates to lock up suspects until proper risk assessments could be carried out.

So much to pull apart in those sentences. Firstly, I think he is underplaying the skill of his own officers. He distinguishes between ‘common criminals’ and somehow manages to put mental disorder as ‘outside of the norm’. I’d love to know what his idea of normal is. .. oh wait, I think it is very clear. The fact that he refers to ‘hoodies’ says it all really.

I wonder how much he is just riding on the crest of Daily Mail readership but there’s some serious problems with what he says. The assumptions that he draws that mental illness = danger. That domestic violence is ‘just a drag’.

The police should be dealing with ‘common criminals’ rather than ‘domestic violence or mental health cases’. Interesting interpretation when he wants to pick and choose what help to give.

I would feel very sorry for any mental health nurses he did want to employ but I think it was just a matter of rabble rousing.

In the meantime it does nothing for the cause of working together and combatting assumptions and stigma against those who suffer from mental illnesses and need the support of services, including the police force, at some of the most difficult moments.

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Why Did You Kill My Dad? 9pm BBC2

Tonight, BBC2 is airing a documentary called ‘Why did you kill my Dad?’. It is made by Julian Hendy, whose father was fatally stabbed by a man with long term mental health problems. He did, as a result of this, do some research about the levels of homicides carried out by those who are mentally ill and presents his findings for the programme – focussing on the failings of the British mental health systems.

His research is said to show that homicides are much higher than ‘official’ figures. The reasons, perhaps, for some of this ‘underplaying’ is explained by Louis Appleby, the ‘Mental Health Tsar who states

“If somebody were responsible for a homicide in which there were multiple victims that would count as one incident from our statistics – so the 50 cases a year are perpetrators, not victims. And, of course, there are a small number of cases where a person commits homicide and then commits suicide so there is no conviction, and those cases aren’t included.”

So this seems to be the way of judging – I don’t think it is an active and deliberate attempt to obfuscate but rather than that the method of gathering information is for different purposes – looking at the perpetrator rather than the victims. If the ‘gathering’ is done for the reasons of delivering and providing services rather than for public protection and/or information.

Paul Jenkins, Chief Executive of Rethink, made the following statement on their website.

Julian Hendy’s documentary raises important issues.  No-one can watch the families talking about their grief without feeling immense sympathy.   However, it only tells a handful of stories, which cannot explain the reality of life for the 630, 000 people with a severe mental illness across the country.  The vast majority are not only normal law-abiding citizens but are more likely to be a victim of violence than a perpetrator.
“We must ask what we can do to prevent these cases, which cause immense trauma to everyone involved. The answer lies not in scaremongering about the likelihood of being attacked, which remains extremely rare. Instead we must design a mental health system that responds when people and their families ask for help and is proactive if people disengage in treatment. A decent system would help our entire society, including the 1 in 4 of us who will experience a mental problem at some point in our lives.

“The documentary comes at an important time. Political parties need to explain now what they will do to give Britain a health system that provides the right treatment for people with severe mental illness at the right time.”

The statement seems to strike a balance between acknowledging the pain and poor service delivery that can lead to homicides while noting the rarity and the much higher propensity to be a victim of violence that those with severe mental illnesses face.

I think there are two aspects that to need to be highlighted there – active engagement and responded to families who raise concerns themselves. Both of these – as everything – require more resources – which requires more money.

I don’t have any doubt that there will be huge gaps in service provision and quality of care highlighted. Because there are huge gaps. Services are limited by finances and not everyone receives a quality of care that they should. I don’t want to defend poor practice by any means but in a world of limited resources choices are made and they are not always the right ones.

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I am not sure if I’ll watch the programme tonight just due to other external factors but will try and catch it on the iPlayer and review it later in the week. In the meantime, I’d be interested in hearing responses to it.

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The GJ judgement and DoLs

I’m coming back to Best Interests Assessments and DoLs for a while now so excuse my indulgence but it is something that has and is creeping back into my workload after a few ‘dormant’ months and a part of the reason has been the impact of the ‘GJ’ judgement which has been winging it’s way around various communication channels in our Trust.

I found a good summary of the GJ v Foundation Trust, PCT (Primary Care Trust) and Secretary of State for Health case in Family Law Week.

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It clarifies a lot of the questions that existed about the ‘eligibility’ assessment part of procedure to determine the authorisation or otherwise of a ‘deprivation of liberty’ under the framework of the Mental Capacity Act as opposed to the Mental Health Act.

When assessing people who are being deprived of their liberty and who lack capacity, in a hospital setting, the eligibility assessment has always been crucial. The eligibility assessment disbars the authorisation if the patient would otherwise meet the criteria of an assessment under the Mental Health Act.

I am aware that this may seem a little dry to those coming in from the ‘outside’ but it is absolutely fundamental to the legislation and the legislative tools that we engage with.

The situation of GJ, as highlighted in the case law, relates to himself, as a 65 year old man suffering from Korsakoff’s syndrome and vascular dementia as well as diabetes. His partner had assisted him in managing his diabetes prior to her death however following this, he had suffered from two hypoglycaemic attacks with obvious consequences for his physical health.

The discussion in the judgement published by the Court seems to centre around the question as to whether the treatment in hospital is on physical health grounds in which case, it would seem that a DoLs authorisation may be appropriate however if there is any part of the treatment process which relates to a mental health need, then GJ would move into the ‘ineligible’

The judgement summarises that there are two strands to this case – namely whether GJ is being detained and treated in hospital and thus being deprived of his liberty on the basis of his physical treatment regime and the only reason for this detention was on the basis of his ‘package of physical treatment’. In which case, he would not be a ‘mental health patient’ and an authorisation could be granted to deprive him of his liberty to receive this treatment under the Mental Capacity Act.

However, if the mental disorder existing were to be treated in a hospital setting, that seems that the eligibility requirement for the Mental Capacity Act would be ‘failed’ and the Mental Health Act assumes it’s primacy in this situation.

The other crucial point that can be gleaned from the judgement is as follows

58. In my judgment, the MHA 1983 has primacy in the sense that the relevant decision makers under both the MHA 1983 and the MCA should approach the questions they have to answer relating to the application of the MHA 1983 on the basis of an assumption that an alternative solution is not available under the MCA.

59. As appears later, in my view this does not mean that the two regimes are necessarily always mutually exclusive. But it does mean, as mentioned earlier, that it is not lawful for the medical practitioners referred to in ss.2 and 3 of the MHA 1983, decision makers under the MCA, treating doctors, social workers or anyone else to proceed on the basis that they can pick and choose between the two statutory regimes as they think fit having regard to general considerations (e.g. the preservation or promotion of a therapeutic relationship with P) that they consider render one regime preferable to the other in the circumstances of the given case.

So the Deprivation of Liberty Safeguards cannot be used as an alternative to use of the Mental Health Act as the eligibility criteria still need to be met in order for the assessments to continue. I’ve underlined for greater emphasis as much for my own benefit as anyone elses’ as I know personally of consultants who have favoured referring patients for the DoLs framework rather than using the Mental Health Act as it seems ‘least restrictive’ (an argument that doesn’t really exist in my view as the effect, namely someone being in hospital against their volition is the same in both regimes and in fact, there is a much more robust appeals procedure available under the Mental Health Act).

I’m sure there are many more qualified to sift through the case law which is coming from the Court of Protection, than I but it is a relevant judgement that has a significant impact on my work as a Best Interests Assessor and as an AMHP, eligibility assessor under the DoLs framework.

Schizophrenia – on film

Time to Change, the campaign being run by a partnership of mental health charity, which is working towards challenging stigma which is faced by people with mental illnesses, is today launching a couple of films which are intended to work on some of the prejudices and preconceptions held.

The videos can be seen on the Time to Change website and are also going to be available on various other websites to be, according to the BBC, played in cinemas later in the year.

image atomicjeep at Flickr

Challenging some of the preconceptions that surround mental illness is certainly a positive as the preconceptions are invariably negative. I doubt there will be much measured effect but if it makes it easier for people to speak about mental illness and for the distress to be recognised, that can only be a good thing.

The BBC quotes a Yougov survey that indicates a third of people questioned thought that people suffering from schizophrenia were violent. It’s unsurprising and in some ways, I’m surprised it isn’t a higher figure.

The films will help I imagine, but the real stigma needs to be fought in some of the media reporting which tends to define people by their mental illnesses because it is an ‘easier’ explanation rather than display any kind of sensitivities or understanding of other factors that might come into play.

The actor in the films, Stuart Baker-Brow, has himself been diagnosed with schizophrenia and is quoted as saying he wanted to be involved in the filming in order to allay some of the assumptions and stigma that he faces, as he says to the BBC

“Helping to make the film has been part of a journey to take control of my life,” he said.

“Rather than giving up I made a decision to change my life, which was borne out of a necessity to prove not only to myself and to all those around me, that a good level of both physical and mental recovery from schizophrenia is possible.”

I don’t doubt that having these films is better than not having them. I hope they will make some difference, but there is probably a deeper level of understanding that needs to be reached for a difference truly to be made.