Was he right to refuse?

Case notes
John Gatefield, professional development co-ordinator and approved social worker; Jane Thompson, social worker.
Field: Mental health and physical disability.
Location: Halton, Cheshire
Client: Matthew Hollins, 22, lives alone and has a severe hearing impairment and a diagnosis of schizophrenia.
Case history: A psychiatrist, based at a specialist unit for young people with hearing impairment, carried out a routine visit to Hollins. During the consultation she became concerned that he had stopped taking his medication and was drinking heavily. There had also been allegations of violence while under the influence of alcohol. Such was the concern that she completed a medical recommendation asking for a section three Mental Health Act 1983, which would allow for Hollins to be compulsorily detained in hospital for treatment for up to six months. Another medical recommendation and that of an approved social worker would be required.
Dilemma: Everybody agreed that Hollins should be sectioned but his father withdrew his consent at the last minute because he only wanted his son to be treated in a specialist unit.
Risk factor: By leaving Hollins in the care of his parents, his drinking may lead to further deterioration of his mental illness and place him at risk.
Outcome: Upon his return home with the exception of a couple of relapses, Hollins has maintained himself in the community with parental support.

The name of the service user has been changed

Given the recent controversy surrounding the government’s proposals to introduce 90-day detentions without charge for suspected terrorists, it’s worth remembering that we already have a law that grants detention for up to twice as long: the Mental Health Act 1983.

In essence, should a person’s mental illness put their own or others’ health and safety in danger then under section three of the Act they can be detained for up to six months in order to receive treatment. However, it does require the written recommendation of two doctors and, crucially, that of an approved social worker, whose duty it is to interview “the patient in a suitable manner” and take into account the wishes of relatives and relevant circumstances.

Sometimes the approved social worker will oppose the section. Sometimes, however, they may agree but changing circumstances and family intervention muddies the waters; as happened in the case of 22-year-old Matthew Hollins.

“This was a really complex assessment,” recalls approved social worker John Gatefield. “Because of Matthew’s hearing disability I needed an interpreter to sign in order to interview him in an appropriate manner. I also arranged for the GP to attend for the second medical recommendation, along with Matthew’s social worker, Jane Thompson. However, a number of problems arose with the assessment.”

It certainly didn’t have an auspicious start. “Matthew’s estate is a real warren of side-streets with numerous entrances and exits,” says Gatefield. “There was no direct parking outside the flats. Everybody went to different places.”

Thompson adds: “It got to the ridiculous situation where we took it in turns to stay with Matthew while the other acted as a search party to try and locate the others on the estate!” Eventually everybody found the flat. However, the GP did not want to phone the consultant psychiatrist. Says Gatefield: “I had to urge the GP quite strenuously to consult with the psychiatrist; which is what he should have been doing. It’s another example of doctors not knowing the part they have to play in the Mental Health Act.”

Reluctantly, the GP spoke to the consultant and then agreed to make his recommendation; it was then left to Gatefield to complete the section. “Considering we can keep someone in hospital against their wishes for up to six months and receive treatment against their wishes, this is serious,” he says. “It is heavy duty.”

Nonetheless Gatefield was prepared to do so but after two hours, the interpreter had to leave for another appointment: “With no one else available and with Matthew’s very complex communication difficulties this was a major issue. But through spending time we were able to get answers to my questions. His medication for his schizophrenia was being nullified by alcohol. There were empty bottles around the flat and a fridge-full of beer. It was clear that he had been drinking quite heavily, losing his insight and was in danger; so he had to be admitted. However, I explained I would prefer this to happen informally.”

Just as Gatefield was finishing the assessment, Matthew’s father arrived. He was, at first, all in favour of the section. However, upon realising that his son was being taken to the mainstream mental health community resource, rather than the specialist unit which specifically caters for people with hearing impairment, he withdrew his consent.

“He said in the absence of ‘us doing our job properly’ Matthew would not be leaving and the parents would care for him over the weekend,” says Gatefield. “This was interesting because the nearest relative either gives their consent or they don’t. They can’t say ‘yes – if’. But we took the view that he had legally withdrawn his consent. This meant without taking matters to court we had to stop there and then.”

Matthew’s parents stayed with him all weekend, but couldn’t stop him from drinking and the father contacted social services. “We completed the application for a section three,” says Gatefield. “Matthew was admitted temporarily to the mainstream unit and then transferred to the specialist unit as soon as a bed became available.”

A few months later, upon his return home, Hollins was back on his medication, had stopped drinking and apart from a couple of relapses has been maintained successfully in the community. “His parents are far more co-operative now,” adds Gatefield. “It’s difficult for relatives who don’t want to be signatories to having somebody incarcerated. But realistically they aren’t able to provide 24/7 care.”

Arguments for risk

  • Matthew’s father withdrew his consent to the application for a section three when he realised that his son was going to be placed in a mainstream unit rather than a specialist one that could meet his hearing disability needs. Hollins has schizophrenia and easily becomes frightened. If staff are unable to communicate with him effectively they won’t be able to reassure him, calm him or persuade him to take his medication.
  • The parents know their son. They realise he needs help but it must be the right help: help that meets his complex needs.
  • Gatefield realised the benefits of bringing along Thompson – Matthew’s social worker. She knew the family and would be able to say if they could cope or not. As Gatefield observes: “Ultimately I was the ASW and I was the one who would make the decision – for Hollins and the family this separates out the ongoing work and the role of the ASW.”

    Arguments against risk
  • Everyone agreed that Hollins needed to be sectioned: even his father – at first. Gatefield says that his reaction was: “Thank goodness you’re here to take him away to help him – great, that’s what we want”. The issue was where he would be detained not should he be.
  • Hollins wouldn’t go voluntarily so he had to be detained by law. He needed to be made safe and while the mainstream unit would not be ideal – it was, as Gatefield says, “the lesser of two evils. He had to be brought in and treated – no option.”
  • If the nearest relative objects there is recourse to legal action that social work staff can pursue. The court has the power to displace the objector as the nearest relative and have somebody else, such as the director of social services, appointed as the new legal nearest relative. However, despite there being “no option” for the section Gatefield felt that this was unwarranted at that time.

    Independent comment

    The vast majority of mentally ill people are not likely to become violent. But misuse of alcohol, as in Hollins’ case, heightens the risk of violence, writes Glen Williams.

    Risk assessment is an inexact science based on judgement, but its accuracy can definitely be improved by knowledge of the risk factors.

    In Hollins’ case these risk factors were: a history of violence; high levels of anger (possibly caused by frustrated communication); clinical diagnosis (schizophrenia) and active symptoms; non-compliance with medication; and the situational risk factor, namely the threat of being removed.

    One finding that is clear in the research is that the most common victim of violence by mentally ill people is a family member. The dilemma for the ASW is one of balancing Hollins’ rights to liberty against the safety of his community. This is complicated by his family’s right to object to the application being made. Put simply, Hollins was a high risk to his family, who objected to the low risk ASW application and wanted to try a high risk strategy of coping alone.

    Risks of violence might have been reduced by increased support to the family, reduction in Hollins’ alcohol intake, addressing social isolation and communication issues, possible anger management and a stabilisation of medication. The “hidden” risk is the absence of any of these options out of hours! Risk assessment is simultaneously art and science located in resources.

    Dr Glen Williams is EDT manager-practitioner, Sefton Council, Merseyside, and is chair of the Emergency Social Services Association

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