According to medical folklore, most mental health crises occur on Friday afternoons. I am not sure that this is actually the case but I couldn’t help noticing that it was exactly one minute past noon on the day before the weekend when the call from the approved social worker was put through. “It’s about your patient Maggie Halliwell,” he explained. “I’m convening a section assessment. What time might you be available?”
Committal under the Mental Health Act (MHA) is one of the most weighty responsibilities a doctor can have: admitting someone, against their will, to a psychiatric hospital, where they will be detained, potentially for months, while their condition is evaluated. The deprivation of liberty and the power to enforce treatment are subject to numerous safeguards, beginning with the obligation that two doctors – one an experienced psychiatrist, the other, whenever possible, the patient’s GP – have recommended committal.
MHA assessments are also notorious for taking a heck of a long time to complete. I looked at my schedule for the afternoon: admin for hospital correspondence, phone calls, prescriptions and laboratory results; then a tutorial with my registrar, followed by evening surgery. Nowhere were there two minutes, let alone two hours, waiting for some work to come along to fill them. Nevertheless, having known Maggie for many years, I felt that I would have a valuable perspective. So something had to give.
The team assembled on the pavement near Maggie’s house and her community psychiatric nurse (CPN) briefed us on recent events. Maggie’s schizophrenia is usually well controlled on antipsychotic medication but periodically she decides that she no longer needs to take it, with predictable results. The CPN had been coming daily to supervise Maggie taking her tablets but yesterday she hadn’t been able to get in.
Maggie’s sister had come down from Birmingham, so access to the house wasn’t a problem today. Maggie elected to see us in her bedroom. MHA assessments are awkward: there’s no way that a small herd of health-care professionals can descend on someone’s home in such circumstances and not be intimidating. Maggie remained recumbent throughout, chain-smoking, while the five of us stood in an uncomfortable arc around her bed.
To section someone, you have to believe that they are suffering from a treatable psychiatric condition that endangers their health and safety and/or the safety of others. You also have to consider whether community treatment or a voluntary admission might be viable alternatives. The crucial features are insight and capacity. When people are severely unwell, they often can’t see it and lack the ability to consent to and co-operate with the help on offer.
Maggie was certainly behaving erratically and expressing odd views but it quickly became clear to me that she was far from sectionable. Over the years, I had seen her considerably worse and I had become familiar with her idiosyncratic beliefs. (The most endearing is her delusion that she suffers from anorexia nervosa, because she once read that when anorexics look in the mirror, they perceive themselves to be grossly overweight. This is what Maggie experiences, too, whenever she observes her reflection. She remains stubbornly resistant to any suggestion that a body mass index of 35, which puts her comfortably in the “obese” category, in any way undermines the diagnosis.)
After a lengthy interview, we adjourned downstairs to arrive at a collective view. Maggie has been sectioned several times in the past: a couple of summers ago, for example, when police were called to find her sitting partially clothed in her front garden with a plastic bag over her head. While some of the team were minded to admit her, I resisted. Maggie stayed at home and gradually stabilised. The assessment might have trashed my timetable but it was an afternoon well spent.
This article appears in the 25 Nov 2015 issue of the New Statesman, Terror vs the State