Threat from the voice within


Practitioner: John Gatefield, approved social worker, formerly with Halton Council.
Field: Mental health and emergency duty social work.
Location: Cheshire.
Client: Stephen, 29, is well known to his local mental health outreach team and to the community mental health team.

Case History: Stephen has been a diagnosed schizophrenic for several years, during which time there have been many incidents of actual and attempted self-harm. He lives alone, while his family live locally and are supportive. One afternoon Stephen turned up at a local hospital asking for help. He recognised that his illness was resurfacing and he was becoming frightened of the internal voices giving him orders to self-harm. He was seen by a consultant psychiatrist, who had no hesitation in completing a section 3 (Mental Health Act 1983) medical recommendation – that treatment in hospital was required. A second doctor, Stephen’s GP, agreed. But the duty approved social worker was not so sure.

Dilemma: Stephen had the presence of mind to seek help and would agree to voluntary admission into hospital, but not if it wasn’t a local hospital. But no local beds were available. So should he be compulsorily admitted?

Risk Factor: By choosing not to compulsorily detain Stephen, might he become a danger to himself and others?

Outcome: The duty approved social worker found a local hospital bed and Stephen agreed to be admitted. He was back in the community with support after a few days.

As an approved social worker, someone with “appropriate competence in dealing with persons who are suffering from mental disorder”, John Gatefield often found himself interviewing patients who were “most unwell”.

“I would usually attempt to tell them that, although they feel they are all right, they are in fact suffering from a mental illness, which is endangering them, or the public and they will have to be detained within a hospital until they recover,” he says.

However, a case earlier this year provided Gatefield with an unexpected set of moral and ethical dilemmas.

Having presented himself at hospital asking for help with voices telling him to self-harm, 29-year-old Stephen was interviewed by a consultant psychiatrist who recommended that he needed treatment – and if necessary he ought to be compulsorily detained under section 3 of the Mental Health Act 1983. However, a second medical recommendation was also required. It was at this point that Gatefield, as duty ASW, arrived with Stephen’s GP to jointly interview Stephen to complete the formal assessment process.

“Although he could recognise these voices as being internal, Stephen identified the grave danger of succumbing to their persuasive arguments,” says Gatefield. “At one point he actually held an argument with his voices as to whether or not they were real. A part of this dialogue included the inevitable logic from the voices that they had to be real in order to argue with him!”

Without entering into the argument and potentially joining Stephen’s delusional state, Gatefield sought to encourage Stephen to retain a grip on (Gatefield’s) reality without challenging the validity of Stephen’s. “This had to be done in a sensitive fashion and without responding to the prompts which came from the voices,” he says.

After the joint examination, the GP completed the medical recommendation. “We agreed that Stephen was suffering from a mental illness and that he potentially posed a threat to himself and others.”

This risk was increased with Stephen’s admission that he had taken an unknown number of health-threatening doses of his oral medication.

Gatefield says: “The issue then for me as the ASW was how to deal with the situation in the ‘least restrictive manner’, as required by law. Stephen was clearly sectionable under the act, yet was asking for help and therefore showing a degree of self-control.”

However, if Gatefield made the application for a section 3 it would result in Stephen being detained in a hospital some miles away as no local psychiatric beds were available.

“Stephen was firmly opposed to leaving the locality because of his close links with friends and family, all of whom were dependent on public transport,” says Gatefield. “He also presented the additional argument that he would not be able to co-operate with ‘strange’ doctors.”

Faced with this possibility, Stephen withdrew his consent to an informal (or voluntary) admission. Gatefield – who would need to make the recommendation for detainment based on the medical advice – decided to explore a different solution.

He says: “An alternative was for Stephen to return to live with his family but none of them were able to offer a stable environment. They recognised the warning signs of his deteriorating mental health and had become afraid of him. There had been previous violent incidents when Stephen had been ill.”

Gatefield was reluctant to make the application and sought guidance from the principles of the Mental Capacity Act 2005, which, although not law at the time, proved helpful. “Despite clearly deteriorating in his mental health, Stephen had not been formally assessed as having lost his capacity,” he says. “Although two medical recommendations had been completed, this was only indicative of his recurring mental illness, despite which he had been able to attend the hospital and ask for help. This act of self-determination therefore had to be protected as far as possible.”

Stephen was, however, seeking protection from himself. Although Gatefield felt ethically justified in using the act, it felt restrictive to do so, especially as this would result in treatment in an unfamiliar hospital, by unfamiliar doctors several miles from home, with little family contact.

Gatefield concluded that the minimum acceptable level of safety was within a ­hospital setting, and preferably locally. “I entered into intense discussions with the hospital managers who agreed to admit to a ‘leave bed’ (a bed designated to a patient but who had temporarily vacated it) and we arranged the informal admission ­immediately.”

Even so, the medical recommendations were stored on the ward in case of a rapid deterioration and another ASW assessment was required. Stephen was safely discharged after a few days and is now supported in the community by the outreach team.


Arguments for risk

 Gatefield reasoned that Stephen had insight into his behaviour and this proved a crucial factor. Gatefield drew on three of the key principles of the Mental Capacity Act 2005 (although it wasn’t the law at the time).

 Key principle 1: “It should always be assumed that a person has capacity to make decisions unless there has been a formal assessment which shows this is not the case.” Stephen’s assessments related to his recurring illness – not his capacity.

 Key principle 2: “People have the right to be supported to make their own decisions.” Stephen wanted protecting from himself and thus Gatefield could have used the act – ethically – to section Stephen. But this felt too restrictive, given that key principle 5 states that “all decisions must be made in a way that is least restrictive of an individual’s freedom”. A hospital placement in an unfamiliar place, with unfamiliar medical staff and little chance of family contact, would have been counter-productive.

Arguments against risk

 Stephen was delusional. His voices were telling him to harm himself. He has a medical history of self-harm – and indeed violence against his family has been known when he gets unwell. He was clearly in need of being protected and in a safe environment – he needed to be in a psychiatric hospital.

 The consultant psychiatrist was in no doubt that Stephen should receive hospital treatment under section 3 of the Mental Health Act 1983. This could mean compulsory detainment. Stephen’s GP agreed.

 The fact that Stephen would not agree to treatment in a hospital outside his locality is neither here nor there. He needed treatment and he should have been compulsorily admitted to the nearest hospital.


The five principles of the Mental Capacity Act shouldn’t prove difficult for ASWs as they are not very far removed from good practice, writes Gordon Kennedy.

Section 13(2) of the Mental Health Act says the ASW must be satisfied that detention is in all circumstances the best way to provide care and treatment. For John Gatefield this was the dilemma.

It is not uncommon for people to try to negotiate around an informal admission for example, saying they will come into hospital but not accept any medication. This could be considered a refusal.

The difference in this case was the reasoned argument put forward by Stephen something the ASW had to consider when assessing the risk. Stephen was not refusing any part of the care on offer, only where it might be.

The ASW must explore alternatives to hospital. With more community resources, such as home treatment teams, it might have been possible to care for Stephen in the community, but he was asking for admission. Consulting the nearest relative about treatment in the community, and considering the code of practice advice regarding informal admission might clarify the situation.

If no “leave” bed had been available, was the risk too great to manage in the community? Gatefield may have had little option but to detain Stephen.

Gordon Kennedy is an ASW, community mental health team manager and out-of-hours manager for adults in Flintshire, north Wales

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