Events | 2009.12.08
The last resort
Deborah Orr spends a day with the mental health workers who routinely face the most challenging of decisions: when should a patient be sectioned?
Ten of us are hanging about on an inner-city street corner, waiting for Natasha Sloman to get off the phone. The bed she had lined up the day before has been taken by an emergency admission, and the matter in hand cannot be got on with unless she can secure another one. Natasha is used to this kind of setback. She is an "Amhp", an approved mental health professional, and it is her job to lead the interventions that decide whether people should be sectioned for their own safety, or for the safety of others, under the Mental Health Act.
It has taken her some days to put this team together. She has assembled two psychiatrists, four police officers, two ambulance men and one journalist (highly unusual). She has also assembled a pile of paperwork, which includes a warrant allowing us all to enter a home uninvited, and two "pink forms".
The pink form is one of the most powerful bits of paper in our world of powerful bits of paper. These two, one signed by the two psychiatrists who make medical recommendations, one signed by the Amhp who has the final say on whether to apply for a section, will confer awesome power on the team. They will be able forcibly to remove a man from his flat, place him in an ambulance against his wishes, then tuck him up in that elusive bed, on a closed psychiatric ward, for anything up to six months, while he receives medical treatment that he may quite decidedly not want. No one on this team has ever met him before, but in a few minutes they expect to gather in his sitting room, conduct an on-the-spot psychiatric and social assessment, then decide whether they should take his freedom.
Natasha tucks her phone into her bag, and confirms that she has found a bed, although it is unfortunately very far away. The police climb into their van, and the rest of us climb into the ambulance. Natasha offers a verbal brief to the two psychiatrists as we are driven to this man\'s address. Ideally the doctors should already have a relationship with the patient being assessed, but in this case, and quite often, this simply isn\'t possible. All the psychiatrists have to go on, except the evidence they hope shortly to gather during the assessment, is this back-of-the-van synopsis.
Jeremy is in early middle age, and has been sectioned a number of times before. He has a diagnosis of antisocial personality disorder dating back to an episode of acute psychosis – thought to have been cannabis-induced – when he was a young student. He more recently received a diagnosis of paranoid schizophrenia, and was last sectioned in 2005-2006. Since then, Jeremy has been living in supported accommodation, his medical and social care co-ordinated by a community mental health team. Until a few months back, he had been doing well.
But earlier in the year his surviving parent died, and he came into a good deal of money. His brother, a consultant surgeon like his late father, keeps in close touch with Jeremy, and thinks that the money has enticed his younger sibling back into street drug use, and away from taking his prescribed medication.
In telephone conversations with Natasha, Jeremy\'s brother says that he recognises a pattern of behaviour similar to those he has noticed before as Jeremy approaches a crisis. He fully supports the decision to assess him for a possible section three under the Mental Health Act. A section three allows a patient to be held on a ward for up to six months, although family members can object. A section two places a person under involuntary care for up to 28 days, with no right of objection for the nearest relative. The subject of a section, whether two or three, always has the right to appeal.
Jeremy\'s pattern of behaviour includes hostility, paranoia, aggression, violence and highly disinhibited sexual behaviour, all especially directed at those Jeremy perceives as being more vulnerable than he is. He is known to the local police, but is elaborately polite towards them. All who are involved with him, professionally or as family and friends, call his behaviour increasingly bizarre. Jeremy thinks that people come into his flat and take things. Yet when we pull up outside his flat, it is clear that his cracked, bulging windows have been bashed out, not in.
Natasha knocks on the door, and shouts, "Hello, Jeremy. Can we come in?" through the letterbox. No one answers. She jogs up to the warden\'s flat, and the warden comes down with a key. There is no one in the disordered flat, although the vacuum cleaner is switched on, and sucking away at the stifling atmosphere. A neighbour says that Jeremy went out half-an-hour ago. No one knows when he will be back.
One of the police officers, however, had noticed a man vaguely fitting Jeremy\'s description turning into the street a few minutes ago, then changing his mind and hurrying away again. Cursing his failure to act on his instinct, he consults his fellow officers. They agree that the object of their visit will not be back in a hurry, and leave. Natasha has a few words with the warden, and urges her to call 999 at the first sign of trouble. She will be back, she promises. But setting all this up again could take as long as a week.
Natasha and the psychiatrists start climbing back into the ambulance, which is returning to the local hospital where Natasha and her team have their office. A man approaches us, and asks very courteously who we have come to take away.
"Oh, you must be Jeremy," says Natasha, very casually. "I think the warden has been looking for you." She starts propelling him gently towards the warden, but not before he explains that he has been doing some cleaning and has been looking for some gloves. "Do you have some gloves?" he inquires hopefully. The warden engages him in conversation about gloves and cleaning, while Natasha herself rings, under clearly defined protocols, the police events office, with the intention of asking for a call to be put out requesting the return of the four officers. The line is engaged each time she tries.
Jeremy makes his way back over to Natasha and asks her which hospital she works from. "Ah," he says when she tells him, "I like it there. They have table tennis, good dinners . . ." He says it wistfully, with yearning, and it seems clear that this man is riven with ambivalence, that part of him wants to be taken to a place of safety where he will be looked after. But without the officers, an attempt to conduct an assessment on this large, strong man, is too unpredictable. Nothing can be done for now, beyond hoping that this frustrating delay does not result in harm, to Jeremy or to any of the people who may come into contact with him.
While Natasha is deeply worried about Jeremy\'s situation, she is used to the fact that such charged interventions are often beyond the scope of her careful planning. Anyway, back at the office there is plenty to do. Natasha runs the Camden Approved Mental Health Professional Service. It sections the same proportion of assessed people as other comparable units. But it is situated in a part of London that attracts a highly volatile population, and is one of the busiest units in the country. There are four other assessments already slated for today and, back at the office, further requests for emergency intervention are already coming in. Along with three other Amhps – all women who have qualified as social workers and then completed further training in order to gain the authority to wield the pink forms – Natasha expects to conduct four to eight assessments in any one day.
The next planned assessment is led by Tracy Brown. The same four police officers and the same two ambulance drivers meet her on a different street with different psychiatrists. This time a locksmith has been hired as well, because Jennifer, the woman who is about to be assessed, has recently been barricading herself into her flat. The referral has come from her community mental health team, who say that she has not been co-operating with them, refusing to eat or take her medication, or allow support workers into her flat. Jennifer has been showing mildly psychotic and thought-disordered symptoms. Her diagnosis is of late-onset schizophrenia, and she was last formally admitted to psychiatric care in 2004.
Given a final brief on the street by Tracy – again a long, sad story going back many years and involving a painful narrative of gradual loss of family and friends – our large mob of 11 assorted people swarm up the stairs toward this lady\'s front door. Out on the landing, the mass of bodies seems impossibly large, and when Tracy\'s knock is answered almost immediately by a frail, pale, but well-groomed woman, it all seems tragically out-of-proportion.
Jennifer is not hostile, although she questions why there are so many people at her door. She agrees that Tracy and the two doctors can come in, and she is persuaded that the presence of one police officer won\'t hurt. Reasonably enough, she doesn\'t like the sound of playing host to a journalist as well.
A neighbour passes through the knot of people waiting outside, and inquires conversationally: "You\'ll be taking Jennifer in, will you?" He nods, in subdued approval, even though we explain that we cannot comment. He knows exactly what is happening, and appears to think it\'s for the best. After a long period of time, the five emerge. Jennifer has agreed to go into hospital as a voluntary admission. She has changed into a smart outfit, but she has declined to pack an overnight bag. In the ambulance, her conversation flits from lucid to rambling, from the practical to the paranoid. She remembers being on the ward she is being taken to before, and says how much she hated it last time.
On the ward, Tracy briefs the staff about Jennifer\'s history, the medication she is being prescribed at present, and hands over a sheaf of notes. A whiteboard displays the names of the 18 other patients. They are all under section. Jennifer is the only person who is here of her own volition, and Tracy is pleased that this assessment has not resulted in an involuntary admission.
However, from the Amhp and from the psychiatrists, there is a whiff of dissatisfaction about the whole situation. Tracy says that if her flat was as "ill-kept" as Jennifer\'s, then she\'d be very much more pleased with her housekeeping skills than she actually is. With more "creative" community support, they all quietly admit, Jennifer could stay at home. Yet these teams are under huge time pressure, and patients get only an hour or so of domestic attention each week. The smallest fissures in co-operative relationships soon turn into dangerous chasms of unpredictability and risk.
Back at the office, everyone is on the phone. Jeremy has been arrested, after assaulting two workers at a day centre. A new assessment must be urgently arranged.
A young man, thought to be Belgian, has been picked up by the police in a park, after various calls to the police reporting a trail of bizarre and frightening behaviour. He had been talking to vegetables in a supermarket. He had been trying to talk to children, via two soft toys he was handling as if they were mobile phones. He has been throwing off his clothing, and yelling at visitors to the park. He, too, needs to be assessed today, and this time a translator will have to be conjured up as well.
In the meantime, another assessment has been planned. This one will be led by Rachel Busby. We are given a lift to another street corner, by the same two ambulance guys, who seem well-suited to this work and really know the ropes. One of them was a children\'s entertainer, a puppeteer, before he trained as a paramedic. Rachel explains that the regular crew is one of Natasha\'s innovations. She concentrates as many planned assessments as she can on Thursdays and Fridays, so that it is worthwhile to have a dedicated ambulance crew for those two days each week. This arrangement is apparently unusual, an innovation. But it makes perfect sense.
This time there are no police and there is no warrant. Most of the people who slowly gather on this latest street corner know Anna well. Her friend and neighbour, who looks after her and has a key to her flat, has agreed to be present; this lady – neat, coiffed, beautifully made-up and in her mid-80s – is such a brisk, no-nonsense Englishwoman that she could almost have stepped out of an Ealing comedy. Anna\'s young GP is in attendance, too, and so are a couple of the members of her community health team. They are all desperately concerned about Anna.
Anna is very deeply depressed and lies in bed all day, barely eating, and drinking spirits almost constantly. She stumbles about alone in her flat, and there are worries that she will end up having a terrible accident. She is suspected to be very close to liver failure.
It all went wrong for Anna, her doughty friend explains, when she lost the job as an arts administrator that she had held and loved for 40 years. She had recently been in hospital as a voluntary patient, but had discharged herself. She is plagued by paranoid thoughts and delirium tremens. She is, by all accounts, a sweet, gentle lady, who harms only herself. But the level at which she is harming herself is very high. "I like a drink myself, so I don\'t blame her," says her longstanding friend. "I always have liked a drink! But Anna never used to drink. She wasn\'t really interested in drink at all."
It is obvious that Anna trusts all the people she knows in this group, and is untroubled by the presence of an observing journalist. Yet it feels intrusive to be here all the same. Mental health professionals are wary of allowing journalistic access to their patients. They fear, understandably, that the temptation to file colourful copy about flamboyant insanity will add more heat to the debate than light. But there is also a feeling that the public ought to know and understand more about what goes on in their communities, under their noses. The word "section" is a fearful word to most people. The phrase "the men in white coats" is a gallows-humour shorthand, signifying a complex, cloistered little world of strange and tender brutality – one that everyone hopes they never have occasion to learn about from experience.
Anna sits on a hard-backed chair, and people perch on every flat surface in her pretty, dusty living room, looking at her. She weeps without inhibition, and says half-a-dozen times how very weary she feels. She just wants to go to sleep, she says again and again. She just wants to go to sleep and never wake up.
Her friend, rising to stand beside her, one arm over her shoulder, one hand grasping Anna\'s tightly, interjects: "It won\'t be like that though, will it? You\'ll fall over. Injure yourself. Lie for ages, waiting for help."
She has had a wonderful life, Anna says, but now it is all spoiled. She has a wonderful son, and wonderful grandchildren, she says.
"Your wonderful son hasn\'t managed to get back from Shropshire to see you in 18 months," says her friend, who is clearly an advocate of tough love.
Rachel quietly tells the group that she has been talking to the son on the telephone.
She has been lucky, Anna says, but she is very weary. Under the probing of the psychiatrist, she admits that she thinks the police are spying on her, because they suspect her of financial fraud. She thinks that people believe her to be a racist and an Islamophobe. "But I\'m not anti-racist," she insists. "I\'m not anti anti-Muslim. I\'ve never been anti-anyone."
Her friend, her doctor, her care-workers, they all try to soothe her, and reassure her that they do not think these things about her, that nobody does. She is particularly attached to Ben, her community nurse, and asks all the time for his reassurance. He tries to explain how certain everyone is that Anna is not a racist or an Islamophobe. But she will not be consoled.
Her friend asks Anna what it is all about. These are not fears that Anna has talked to her about before, and the steely old lady is clearly even more alarmed about Anna\'s condition than she previously was.
Very gradually, the idea that Anna has to go into hospital for a while is broached. She is adamant that she will not do this. "I have my right," she says, and hesitates. "As a . . . person." Anna appeals to the people who help her get through her day, and one by one they each tell her that they cannot do it any more.
Rachel, although leading the assessment, has been saying very little. Instead she has been unobtrusively concentrating on nudging and facilitating, gently patting the assessment back on course, when the main points are in danger of being lost. Eventually, she signals that she and the doctors should retreat into the hall.
Rachel checks that there is still a bed for Anna, and the GP starts filling out the first pink form. If he has filled out such a piece of paperwork before, it doesn\'t show, and Rachel offers him a succinct tutorial on what is needed and expected. In the middle of this hurried, whispered, doleful flurry of makeshift administration, Anna comes to the door of her flat. "No. I don\'t want to go into hospital. I\'m not going into hospital. I want to stay here. I want Ben – or someone – to look after me regularly. I really don\'t want to go into hospital any more. Please. Please. Please, Ben. Let me stay here."
But the group is resolute. Rachel explains that if Anna doesn\'t come with them, then the police will have to be called. Anna\'s own delusion is being used to entice her co-operation, and it works. The friend seizes her chance, once again, to drive home to Anna the reality of her situation. "You don\'t want the police coming here, dragging you off, do you? Because you don\'t like them. Much nicer to go now, off your own bat, with some dignity, eh?"
Anna is defeated. She has no allies. Ben takes her hand. He will come to the hospital with her. He will help her settle in. Anna, Ben, Rachel and I, a sad and sorry crew, get into the back of the ambulance and take this broken lady to the accident and emergency department of a large teaching hospital, where we find her a chair and some water, then stand around her as she quietly cries, awaiting attention she does not wish for. Anna has been brought here so that an assessment of her physical health can be made, prior to the start of psychiatric treatment. Ben does what he can to console her, but she is inconsolable.
I\'m meeting Tracy again at 3pm, at the same hospital, to observe the emergency assessment she is leading of the man who was arrested earlier in the park. The Amhps have been busy, and have, through the Belgian embassy, identified François and spoken to his parents. He had come to London with some friends, on holiday and to learn English. Diagnosed a few years back with bipolar disorder, he had been well for some time, and had been withdrawing slowly from his medication, under medical supervision.
Now, hours after his arrest, he is still reported to be incoherent, physically hard to contain, and convinced that if he presses a certain button in the room he is being held in, the world will end. He thinks that British children are far too exposed to sexual imagery, through advertising, and that British parents are not firm enough with their kids. It\'s a respectable enough viewpoint, when not made directly to children in a supermarket, through the agency of soft-toy mobiles.
This hospital\'s policy is to deny journalists access to patients unless they are accompanied by one of the hospital\'s press officers. There is not one available, so I wait outside. It is a respected, almost a sacred, convention that Amhps and doctors make no assumptions about their assessments until they have been completed. But this young man cannot say where he is staying or how his travelling companions can be contacted. The embassy has already undertaken to fly him home tomorrow. If he does not spend the night on a secure ward, it is hard to see what the alternative is.
It is no great surprise then, when, 45 minutes, later I meet Tracy and her charge on the ward she has arranged for him. The facility is very well organised, bright and modern. All of the patients have their own small and comfortable room. François seems as delighted with his billet as he could possibly be, under the circumstances. He had admitted to one of the psychiatrists that he had smoked dope – Thai sticks – four days before his eventual arrest and, since then, had not slept at all. Tracy, meanwhile, is relating all that she knows to the staff on the ward and filling out the necessary paperwork.
Yet neat and well-appointed as this facility is, it remains a closed mental ward. Some of the patients are very ill indeed, angry, abusive, restless, suspicious, paranoid. The staff are calm and efficient. But the patients are not.
Natasha comes into the office. She, too, has ended her day in this place, conducting an emergency assessment of a man in his early 20s who will have spent 28 days on the ward tomorrow, the longest possible time that his section two could have secured his treatment. His mother had requested a further section. Her son says he will kill her, and she is frightened of him. He marches into the office, agitated, and asks Natasha if and how he can appeal. She assures him that he can, and that she will help him to set the process in motion. Through the window of the office I see Karen leading poor Anna to a room. She has ended her day here, too. This seems like a shockingly inappropriate environment for her. She will most likely, say Natasha and Tracy, be moved to an all-female facility as soon as possible. But they cannot say how soon that will be, as beds there are always at a premium.
The three women, all looking shattered, fill out their paperwork, and talk urgently with various members of the staff who have already undertaken the care of these patients. Natasha\'s last task of the day is to brief the Amhp on night duty about Jeremy. He is being held at a police station and an assessment is being arranged for later tonight. He, too, it turns out, ends his day on a closed mental ward. What, when it comes right down to it, is the alternative?
The names of patients and some of their personal details have been changed to protect their privacy.
For more information, please visit
http://www.guardian.co.uk/society/2009/d[...]ay-mental-health-professionals
