Preliminary Mental Health Examination - Essay Example

Part REQUEST FOR ASSESSMENT ANALYSIS OF CASE STUDY Introduction: The existing Mental Health Act s from 1983 (Morris et al, 2005: p.19). The New Mental Health Draft Bill of September 2004 has incorporated many changes, including new criteria for detaining patients (Department of Health 2004b)1, unlike the earlier compulsory order method. Some of the statutory changes: Approved Social Workers (ASW) to be replaced by Approved Mental Health Practitioners (AMHP), accepting service user’s experience as a significant and valid testimony, understanding mental life with an emphasis on the future: coping, recovery and claiming of a better quality of life, and the importance of empowerment as compared to restricting intervention to ‘treatment’ alone. These measures will help autonomy in psychiatry, as stated by Richardson (2007: p.71). The AMHP who could be from any discipline in the health care field, would be required to coordinate the ‘preliminary examination’ of a person liable to be treated under a compulsory order, and to provide a non-medical assessment alongside the assessment of two medical practitioners (Hannigan & Hannigan, 2003: p.38). Request for Assessment: An Analysis of the Case Study of KEITH BURROWS Preliminary Information: Name of the Subject: Keith Burrows. Date of birth: 19th July, 1977. Address: No.27, Osborne Street, Melchester. Appearance: The patient presented as very gaunt and of medium height, in his late twenties. He appeared unkempt, with evidence of self-neglect and poor personal hygiene. Details About Patient Being Brought to A & E: Keith Burrows was brought to the Melchester Mental Health and Social Care Trust’s A & E Department by the police at 4:20 am on a Section 136. He had banged on his neighbours’ door at about 2 am, demanding to see his mother. The elderly couple, both in their 70s, had called the police due to the disturbance caused by Keith. When he became aggressive towards the police, they used Section 136 on him, and brought him for assessment and evaluation to the A & E department. 2Section 136 enables a police officer to remove someone from a public place and take them to a Place of Safety for a duration of up to 72 hours. Section 136 states clearly that the purpose of being taken to the Place of Safety is to enable the person to be examined by a doctor and interviewed by an Approved Social Worker, and for the making of any necessary arrangements for treatment or care. He was seen by Dr. King, the duty psychiatrist at the A & E Department, who asked for a further consultation from Dr. Cullins, the consultant psychiatrist at the same department. Past History of Illness: Social work records show that Keith Burrows was admitted on a section in 2003. A Section 2 assessment had been done, as indicated in the social circumstances report prepared at that time. Section 2 provides the authority for someone to be detained in hospital for assessment. It requires an application which is based on two medical recommendations. (Nygel Turner’s Hyper Guide to the Mental Health Act). The social circumstances report indicates that Mr. Burrows was living alone in a housing association property. His sister Rosa Burrows had contacted the General Practitioner since she was concerned about his health and welfare. Their mother had died three months previously, after which Keith Burrows had become withdrawn and had not been eating properly. The doctor’s initial assessment was “psychotic depression following bereavement”. Personal Information About Keith Burrows: The following details were obtained from Mr. Burrow’s sister Rosa Burrows, at the time of the current A & E Assessment. She was his nearest relative (N.R.) since his elder brother was not present. Under Section 26 of the MHA: As the Nearest Relative has a number of specific rights and powers under the Act, it is vital to be able to determine which of a persons relatives is the Nearest Relative. The service user is the youngest of three children. They have an older brother Glen who emigrated to Canada over two years ago. Their father was a railway worker, who died when Mr. Burrows was fifteen years old; and his mother was a nursing assistant, who died in 2003 following a long illness. Keith had been a good student both at school and at Melchester University, he was also a keen sportsman, and had worked as a disc jockey while in college. Keith Burrows’ mother developed multiple sclerosis, soon after he completed his college education. The son worked part-time at a C.A.B. and was her carer. In the final stages of her illness, he left his job to look after his mother full-time. Burrows used to visit Rosa and her family once a week, but since the last three weeks, he had not visited them. Rosa recalled that her brother had never been aggressive or involved with the Police prior to the Section 136. She did not want him to be admitted in the hospital. Presenting Problems: Mental Status Examination (MSE): By Dr. Cullis, consultant psychiatrist. The information about the patient’s problems were as follows: Mr. Burrows had an unkempt, look due to self-neglect and poor personal hygiene. He was very gaunt. Mood: His appearance of quiet reserve and preoccupation belied his words that his mood was fine. The objective assessment of the psychiatrist was that he was in a withdrawn and apathetic mood. But his unstable and emotional feelings were evident when he started weeping on being questioned about the police action. Thoughts: When the Approved Social Worker interviewed Mr. Burrows, she brought up the matter about his neighbours who had phoned the police when he had disturbed them by banging on their door in the wee hours of the morning, demanding to see his mother. Burrows stated that his neighbours had never liked his family and had always been causing trouble. With respect to his concept of his mother as still living, and the neighbours, some indication of delusional and passivity phenomena are evident in the patient. Delusional phenomena are characterized by false or arbitrary ideas developed without adequate proof. These phenomena, each of psychopathological form, include delusional mood and ideas of reference, primary and secondary delusional ideas and delusional perceptions (Taylor, 1981) as quoted in Hales (1985: p.114). Delusional phenomena are frequently observed in severely ill psychiatric patients, and are frequently found in patients with affective disorder. According to Kingdon; Turkington (2005: p.128), passivity phenomena and thought interference are specific forms of disorder of thought content (delusions). Formal thought disorder involves changes in the way thoughts are expressed. Speech: Keith Burrows gave very short one-word answers to most questions. Only when the neighbours were mentioned, did he respond in a disordered manner, showing that he could not think clearly and calmy about the matter. Depression, disinterest, and impatience at being held up indefinitely, interspersed with a turbulent mental condition were indicated through his speech. Behaviour: The patient showed blunted affect. He did not establish eye-contact, and spent part of the interview curled up in a ball on the floor. Emotion refers to the inner somatic expression of feeling, whereas affect refers to the outward behaviour engendered by emotion (Kolb and Brodie, 1982) as quoted in Davies; Janosik (1991: p.156). Affective alterations are distancing or protective actions taken to isolate or overcome painful emotions. These can manifest as blunted affect or apathy. Blunted affect is the extreme decrease in the client’s response to any person, idea or experience. Their reactions are unemotional, flat and dull, regardless of the nature of their experiences (p.157). The patient’s action of remaining in a curled up position on the floor strengthens the view that he was trying to isolate himself, and was unwilling to respond to the questions asked by the ASW, in the interview. Mr. Burrows was aggressive when questioned about his mother. According to Coccaro (2003: p.89) for some individuals, their anger is totally externalised and hence justified, leaving their sense of self untouched. This appears to be true for Keith Burrows. Drugs/ Alcohol: The client showed no evidence that he had been drinking. This fact was confirmed by Dr.King, the duty psychiatrist at the A & E Department, who had seen him first, and also confirmed by the police. He used cannabis occassionally, and there was no evidence of the patient using any other street drugs. The role of the psychiatrist includes ruling out other causes of abnormal behaviour, such as use of drugs or alcohol. Conclusion and Plan: Dr. Cullis, the consultant psychiatrist summed up the case: relapse of psychotic illness since the last two months. Keith Burrows was not amenable to voluntary admission. He was a risk to self and to others, particularly to neighbours. The psychiatrist ordered MHA Section 3 Admission. After the general practitioner and social worker also reviewed the case, the patient had to start on Olanzapine, an anti-psychotic and sedative drug immediately. Section 3 provides the authority for someone to be detained in hospital for treatment. It requires an application which is based on two medical recommendations. The duration is upto two months initially. This Section may be renewed for a further 6 months and then for a year at a time3. ASW’s INTERVIEW WITH KEITH BURROWS: Similar to the experience of the consultant psychiatrist in interviewing the client, the Approved Social Worker was able to elicit only monosyllabic answers from him. On the whole, he was slightly warmer in his demeanor, though he continued to avoid eye contact during the interview. He expressed his view that the police had blown the incident out of proportion. One important fact that emerged from the interview is that the client was extremely worried about his substantial rent arrears, since he had not been working for six months. This would mean in all probability that he was experiencing a financial crisis in all respects, and may be the basis for his anxiety, depression, blunt affect and anger. Ethically, the ASW would not be able to maintain confidentiality, since under Section 26 of the MHA, she would have to speak to the Nearest Relative without his consent. The ASW was also aware of the risk factor involved, since he had been in the Place of Safety for a few hours already, and gone through interviews with other members of the Multidisciplinary Team. ASSESSMENT BY ASW and RECOMMENDATION OF SUITABLE INTERVENTION PLAN: The ASW’s assessment of the case is that Keith Burrows needs help and support in starting a new life. He has sacrificed a lot of his time after leaving college, in care-giving for his sick mother. He gave up his part-time job towards the end of her illness, when his help was required. By detaining him and putting him on an anti-psychotic drug he would be restrained in hospital conditions for maybe a lifetime, with no way out to a normal life. Sectioning would also cause him difficulty in finding a job even if he managed to come out of detention. The better option would be to help him find living support until he is able to regain his health and normalcy. Then he would be in a better condition to find a good job to support himself, to lead a normal life, and to repay his rent arrears. Hence, the recommendation is to have the following support network in place: the LSSA or Local Social Service Agency should be able to find Burrows temporary accommodation and welfare support, and to get his debts stayed until he would be able to repay them. Conclusion: If the scenario was written with Keith Burrows as a black male: older or younger, or as a female, the assessment may have been different or it may have been the same, depending on the ASW, who has a lot of power and can control the outcome regarding intervention. Since health care should be rightfully available to all equally and without bias, it would be well if health care professionals kept up the high values of their profession, and treated all without discrimination (Article 14 of the Human Rights Act 1998), Morris (2005: p.43). Their pioneering efforts of working towards a better society, would be followed in time by others. REFERENCES Article 14 of the Human Rights Act 1998: Morris, Zoe Slote; Chang, Linda Rosenstrom; Dawson, Sandra; Garside, Pam (Eds.), (2005). Policy Futures for U.K. Health. United Kingdom: Radcliffe Publishing. Coccaro, Emil F. (2003). Aggression: Psychiatric Assessment and Treatment. New York: Informa Health Care. Davies, Janet L; Janosik, Ellen H.(1991: p.157). Mental Health and Psychiatric Nursing: A Caring Approach. United Kingdom: Jones and Bartlett Publishers. Hales, Robert E. (1985). Psychiatry Update: American Psychiatric Association Annual Review. Washington: American Psychiatric Publishers. Hannigan, Ben; Hannigan, Ben. (2003). The Handbook of Community Mental Health Nursing. London: Routledge. Kingdon, David G; Turkington, Douglas. (2005) Cognitive Therapy of Schizophrenia. New York: Guilford Press. Morris, Zoe Slote; Chang, Linda Rosenstrom; Dawson, Sandra; Garside, Pam (Eds.), (2005). Policy Futures for U.K. Health. United Kingdom: Radcliffe Publishing. Richardson, G. (2007). “Balancing Autonomy and Risk: A Failure of Nerve in England and Wales?” International Journal of Law Psychiatry. 2007 Jan-Feb, Vol.30, Issue 1, pp.71-80. Part 2. FOR MENTAL HEALTH REVIEW TRIBUNAL (MHRT) SOCIAL CIRCUMSTANCES REPORT ON CASE STUDY 2 Patient’s Name: Ms HELEN SMITH Date of Birth: 6th December, 1982. Address: No. 15, Osborne Street, Melchester. ANNEX B: Part 2. FOR MENTAL HEALTH REVIEW TRIBUNAL (MHRT) SOCIAL CIRCUMSTANCES REPORT ON CASE STUDY 2 Dated…….................Day of…............................2007 Name of Author of Report: ……………………………… PATIENT Date of birth: 6th December, 1982. Date of current formal detention/ section: 18th February, 2007. Nature of section: Section 3 Mental Health Act (1983) Hospital: Owen Unit at Melchester Infirmary Ward: Cambridge Ward Address of patient at time of admission: No.15, Osborne Street, Melchester. INTRODUCTION: Relevant Statutory Events: Article 5 of the Human Rights Act 1998, which states that the right to liberty and security of a person will directly affect the detention provisions of mental health legislation4. Legal processes prior to admission: MHA assessment with the General Practitioner and Duty Approved Social Worker. Agencies involved e.g. police, out of hours team, Outreach: None. Source of referral to hospital: Consultant psychiatrist Dr. Adams. Route of referral: Ms. Smith has been treated as an inpatient on two previous occassions in the last three years. The last admission was a short voluntary one over nine months ago. Since her discharge, she has been treated as an outpatient by the consultant psychiatrist. Date of admission to hospital: 18th February, 2007. Identity of Professionals Concerned in the Case: Name and status of key worker/ care co-ordinator: Approved Social Worker. Name of person or persons with the responsibility of aftercare of the patient on discharge: The Local Social Service Agency (LSSA); Housing Association; Financial Assessment Team. Sources of Information and the Author’s Personal Knowledge of the Patient: Basis of report and named sources: Persons interviewed: 1. Patient: Ms Helen Smith, interviewed on March 10th, 2007 at her room in the hospital ward. 2. RMO: Dr. Adams, the consultant psychiatrist, interviewed on March 10th, 2007 at his office in the hospital. 3. Ward Staff: Jo Tucker, the key Nurse. Interviewed on March 15th, at the ward in the hospital. 4. Nearest Relative: Mrs. Smith, Helen Smith’s mother, interviewed at her home on March 16th. 5. Other relatives: Mr. Smith, Helen Smith’s father, interviewed at their home on March 16th.. 6. Other members of care team: The General Practitioner, interviewed on March 15th, Office. 7. Representatives of other support agencies: The Local Social Service Agency for aftercare, Housing Association/ Supported Accommodation for initial help with supported living after discharge from detention, Financial Assessment Team: to ensure that she receives all the benefits that she is entitled to. The Patient’s credit card debt which ran up due to her illness, could be written off if possible. The representatives were all interviewed at their offices on March 17th. 8. Any other person who has a particular knowledge of or concern for the patient: Access to critical records: The multidisciplinary healthcare staff need access to critical records relating to the following facts: Ms Helen Smith’s diagnosis is: bi-polar disorder. Her treatment as an inpatient on two previous occassions, over the past three years. The last admission was a short voluntary one nine months ago, after which she was treated as an outpatient. Events leading to admission: Precipitating factors: Loss of job, and subsequent expensive purchases on credit card led to financial difficulty, and inability to renew the lease for her flat, which is to expire in five weeks. Also, addiction to amphetamines and cocaine. Brief summary of events leading to psychiatric involvement and admission: Ms Smith had to give up her earlier job as legal executive in a solicitor’s office because of poor health related to late-night study. Her next job at the bookshop in which she worked overtime to save money for travelling, also came to an end due to a disagreement with the owner. After a month of unemployment, she was hospitalized, suffering from depression and loneliness. Her loss of job, drug problem, debts and housing situation resulted in relapse of bi-polar disorder. Factors in the patient’s behaviour indicating the need for formal detention: The patient started phoning her parents in the early hours of the morning, and sounded extremely distressed on the third occasion. Her mother visited her later in the morning, and found the house unlocked and the rooms in disarray. A number of expensive new items had been bought, but there was no food in the flat. Mrs. Smith was concerned at the changes. When Helen Smith returned, she was agitated and also excited about a supposed move to London for a new job. She was not worried that she had left the flat unlocked when she went out to celebrate the good news. Ms.Smith’s parents contacted Dr. Adams since they were worried about her behaviour, her history of bipolar disorder, and her avoiding outpatient appointments. Brief personal history: Place of birth: Former places or countries of residence: Developmental milestones: Home and family circumstances: Nearest Relative within the Act and relationship: Mrs. Smith, the patient’s mother. Cultural background: Ms. Smith came from a close family who continue to maintain the family bonds. Her parents held stable and respectable jobs, and she was given a good education. Composition of family: Ms. Helen Smith is the youngest of three children. Her elder siblings stay close to the parental home, and have families of their own. Relevant family dynamics: It appears that the family is very close, and Helen Smith stays in touch with her parents, though she refuses to move in with them. She also has a close relationship with her neices and nephew. Other significant relationships: The patient shares an abiding friendship with an old schoolfriend, whom she was saving up to visit in Australia after quitting her bookshop job. Relevance of and quality of the relationship to the patient’s ongoing care: Close relationships with parents, although the patient does not confide her personal problems to them, will support and help her to pull through the difficult time, and she can always depend on them to help her. The level of the support available to the patient on eventual discharge: The parents want her to live with them, but she is unwilling to accept their offer. The carer’s ability to support the patient: The parents if they were allowed to care for her, would welcome the opportunity, and they have the physical and financial ability to support the patient. Any specific or relevant circumstances which may be a relevant factor: The patient’s low conditions of health and financial problems are the circumstances which should compel her to accept her parents’ offer, and then overcome her hurdles in order to start a fresh new life. Social networks: The patient’s depression, sense of isolation and loneliness indicate that she did not have a support system of friends, but she can gain strenth from strong family support. Accommodation: Home circumstances and housing facilities available on discharge: 5Since the patient was detained under Section 3, she will be entitled to Section 117 aftercare, which gives the statutory authorities a duty to make arrangements for continuing support and care. Suitability of such housing facilities: Suitable, since the accommodation will be required only temporarily, until the patient can improve her health and find a new job. Alternative resources available: For supported accommodation, the patient may have to give some compensation, which may not be possible for her. Relationship with neighbours: It is not clear whether she maintained a good relationship with her neighbours. Ability to cope with community living: After experiencing hospitalizations three times, and a bleak future of detention, the patient would welcome changes towards a normal community life. Opportunties for employment or occupation: The patient has to overcome personal hurdles first, of getting off the drug habit, improving her health, and learning to budget and live within her means. With improved circumstances, she would be able find employment as she has significant skills. She is university educated, and has worked in a solicitor’s office as a legal executive, and in a bookshop. Access to patient’s needs for daytime activities or leisure activities may have to be sacrificed temporarily. Current financial circumstances and ability to manage financial affairs: The patient’s current situation is of credit card debts of 8,000 pounds. Ms Smith needs help from a financial assessment team to work out her finances. Psychiatric history: The patient was admitted on two previous occassions. The hospital stays were relatively short. Reason for re-admission was recurrence of bipolar disorder. The patient was a hard worker, as her previous working life showed. But she could not spend her money judiciously. It is recommended that she should be given basic training in financial management. Forensic history and current assessment of risk: Ms Smith has not been involved in any violence or offences as a drug user. But she will be vulnerable on discharge, unless she makes basic life style changes for a more holistic and balanced life. The current admission: On admission, the patient’s level of distress and depression was high. She slowly calmed down, and showed compliance with the care plan in the hospital. Ms Smith was quiet and maintained a good relationship with the staff. She was performing her daily living functions normally. She seemed vulnerable because of the threat she perceived from the health care professionals. There was no need for seclusion or restraint. Insight is that this time round, the patient will not forget her experiences, and will go all out to improve her conditions. The patient’s attitude to treatment: The patient’s attitude to treatment is so far not positive, as she wishes to be released with only some short-term benefits advice, and does not think she needs any support from social work staff. Her level of insight, willingness to comply with medication and community supports, potential for self-care and financial management on discharge and good social skills for forming and maintaining relationships with others: are all areas that need working on. Dedicated social workers should take her case as a challenge and teach her to improve her own conditions. Aftercare: Community support in the form of temporary accommodation arranged for by the local social service authorities, or supported living provided by housing associations would meet her requirement for independent living. The patient should continue detention and treatment in the hospital first, to be able to understand why changes had to be made in her own attitudes and activities. The Nearest Relative’ suggestion should be considered. Author’s Recommendations: I am recommending for Ms Smith to: 1. Continue detention, with a special social worker on her case. The patient has to be made to understand the actions which would be in her best interests. Her cooperation is vital. Cognitive therapy classes and art classes may help. 2. Arrange for the patient to get sound financial management advice. 3. Plan aftercare, with referral to welfare advice and referral to housing. 4. Stress on holistic and healthy lifestyle can be taught, for progress towards good health. Signature: Professional Status: Date: Qualifications: Read More