Wednesday, 23 May 2007

Kafka knocks

Martha “sectioned” a patient last week, which means that she conducted a formal examination under Section 2 of the Mental Health Act. As I mentioned before, in my experience the people involved always take things seriously because it is not a trivial thing to deprive someone of their liberty. This time it was a young man whom we know well. Sadly he has had quite severe paranoid schizophrenia since his teens and Martha and I have both “sectioned” him several times in the past. Martha takes up the story:
Then I went off to section poor old X, who couldn't tell at all the difference between his delusions and reality. It was one of the more coercive MHA assessments I have been to, as everyone including the family knew he had been ill for months and couldn't be persuaded to take his drugs. I was allowed to leave after signing the forms, so I don't know whether it was left to the four policemen loitering in the hallway to manhandle him into their car. It reminded me of the first line of Kafka's "The Trial" - "Someone must have been telling lies about Joseph K for without having done anything wrong he was arrested one fine morning".
As you may tell, she didn't enjoy it. But it is worthwhile doing, because one of the criteria laid down by the Mental Health Act is that the mental problem from which the patient suffers must be treatable. You are depriving them of their liberty temporarily so that they can be made better. But our illiberal and nannying Government has plans to change the law so that doctors will be both allowed and obliged to “section” people with untreatable problems like personality disorder. Imagine being deprived of your liberty by your doctor just because of the sort of person you are. You might indeed imagine that someone had been telling lies about you.


The Shrink said...

I completly agree that detention under the MHA 1983 is very serious and is only undertaken when the least restrictive options have been exhausted.

Although I'm a psychiatrist approved under section 12(2) and cover a large patch, review of my last year's activity showed that for 11 months there were no detentions under any section of the MHA 1983 for any of my patients. I firmly, firmly believe we have to try and manage folk informally if it's at all possible to do so.

Yet, we have a duty to provide tratment for folk who are unable to make meaningful, informed decisions about their care and that treatment is going to effect meaningful change.

With psychotic episodes, that's fine . . . hopefully when the chap's well he'll thank Martha for getting him back on track. Some do, some hate us, so it goes.

As to treating personality disorders, that's indeed contentious. I don't think mental health services should be detaining folk who don't feel ill and don't want treatment and pose no immediate high risk to self/property/others/health but society sees them as potentially risky and wants then simply contained.

Is personality disorder treatable? Technically, yes. Are outcomes good? If you admit them as an inpatient for a long term, then employ a full time therapist for them for 1:1 daily therapy, some will indeed improve. How much? Not much. Toss a coin and it's 50/50 if there's an improvement. After 4 years of 1:1 inpatient therapy. Ain't happening any time soon in the NHS then!

eryn said...

Interesting post Dr Brown,
In New Zealand we are able to detain patients under the MHA regardless of whether their condition is treatable. They need to have an abnormal state of mind which results in them posing a significant risk to themselves or others. We do section people with severe personality disorders. The only people we are not allowed to section are those whose state of mind is primarily due to alcohol or substance use. I think we do provide good inpatient treatment for most people who are sectioned but the main concern seems to be preservation of safety.

Dr Andrew Brown said...

Shrink and Eryn: thank you both for your helpful comments. It's interesting to hear how things are done in NZ.