Being assessed under the mental health act

[fluffydressinggown]

It is looking likely that prior to discharge from the hospital I am in my community team will request that I am formally assessed under the mental health act.

They are concerned about the risk to myself, I am not psychotic. I feel unable to stop myself and although I am aware of the consequences I am unable to stop myself despite them. For example my wrist is badly burned at the moment, I am really upset about this but feel unable to stop myself from doing it despite risks. I feel a strong urge to cut in a life ending way - I know it might kill me and sometimes I want to die (and think about hanging myself a lot) and sometimes I am scared that I have to die.

What will actually happen in a formal assessment? I am pretty sure I will not be put onto a section because I have had 11 weeks as an informal patient but the request is coming because the community team feel I am too much of a risk to myself to be allowed home.

Thanks for any advice.

just bumping for you and giving you a big ((((((((((((virtual hug))))))))))))

Thank you.

Anyone?

Two Drs and an Approved Mental Health Practitioner will conduct an assessment and make a judgement as to whether you should be detained in hospital.

Do you still feel like killing yourself?

Yes and no.

I think on discharge on of these will happen -

• I won't cut in a dangerous way
• I will cut enough to die because I am fixed on cutting an artery to bleed enough - death will be 'accidental' but I am willing to take that risk to do my cutting right
• I will cut and cut in order to get to enough and end up back in hospital because of the risk (see above)
• I won't be able to manage my feelings, I will be exhausted by cutting and hang myself/jump off a bridge (clear plans for both)
• I will accidentally kill myself with a ligature - not sure about this, when I use them I know that death might happen and I kind of don't mind if it does, takes the responsibility off me choosing to hang myself

So death features highly, I think about killing myself here but have managed to stay safe(r)

I feel unable to stop myself and I know what I need/have to do. With direct interventions I can be stopped though - eg if I was on constant obs here I would not SI here, I have a care plan based around a specific SI and it has significantly reduced the risk here

What exactly happens in the assessment? I am seeing an AMHP tomorrow for a pre-assessment to see if she thinks a full assessment is worth while.

The likelyhood of me not cutting is very very small btw but I know I have to acknowledge that as a possibility.

I was admitted initally because my SI was too risky - all my cuts were very deep and into muscle and A&E were muttering about needing plastics to fix me instead of them and I had taken a sizeable OD. The OD risk is still there as well. I was readmitted very quickly after discharge because of the risk. Both times I was admitted it was on the understanding that I went in informally or I would be sectioned. I have also had periods in hospital where they have said as long as I stay in I am ok but if I want to leave they will section me for my own safety.

My working diagnosis is BDP traits with OCD traits and depression (but who wouldn't be depressed by all this). I am not psychotic and I am not manic.

Are you trying to/requesting to leave hospital against medical advice? What do your inpatient team say? It's unusual for a mental health act assessment to happen if you are already an informal inpatient unless your inpatient consultant psychiatrist has made a medical recommendation for you to stay in hospital.

It is a bit weird i know.

I am informal and inpatient and have been for 11 weeks.

My consultant psych here wants to discharge me following a plan made 4 weeks ago to discharge after 4 weeks.

The community team I am being discharged to are concerned that I am not ready and the risk is too great to manage and so they are asking for me to be assessed to see if the risk is too great. I think if I do cut when I go home I will be sectioned then and have been told that this is a significant possibility because the community team feel I am not well enough to make decisions to keep myself safe. I think they are asking for it because they want to make the Dr discharging me responsible and 100% aware for the risk they feel I am at (if that makes any sense?).

Sections have been discussed during my time here and I have been told that I would go straight onto a 3 with the compulsary treatment being psychotherapy.

I do engage and I am compliant(ish) I do SI here and I have brought things in to SI with.

All that happens is that the 2 doctors and the AMHP will talk to you (sometimes separately, sometimes 2 or all of them together) and ask questions about how you are feeling, risks, care options, support networks etc. They will then try and work out whether detaining you in hospital is the best or only way of treating/caring for you at present.

The doctors consider your clinical presentation and if they feel it meets the threshold for compulsory detention in hospital will make medical recommendations for that to happen. If both doctors make recommendations, the AMHP will think about your social circumstances and will decide whether or not to make the application for you to stay in hospital, considering "all circumstances of the case" and with a duty to consider any less restrictive options for treatment/care (ie informal admission, home treatment).

The AMHP will also need to consult your nearest relative if it is a section 3 assessment- this is the section that allows you to be treated in hospital rather than a section 2, which allows you to be assessed. If you've been in hospital for 11 weeks already you should already have been assessed and have a treatment plan so it's more likely to be a section 3. If your nearest relative objects to you being detained in hospital the AMHP cannot make the application.

Mind has some good info.

Hope you feel better soon and are getting helpful treatment. Sorry you are so unwell and going through this very hard time.

Sorry, x-post. Sounds like the CMHT and inpatient team need to agree on the careplan together, really. A mental health act assessment will not solve the problem of them disagreeing about your risk level and care needs. Even if you were detained, which sounds a bit unlikely if you are agreeing to be an informal patient and engaging with treatment, the consultant on your ward could rescind your section and discharge you any time.

I think they are wanting to push the consultant here to properly consider the risks. I have had input from the community psychologist here and the consultant has almost washed his hands of me - saying things like 'I am only here to talk about your medication' and 'your treatment is all down to the psychologist.' And as a result of this he has not engaged with the risk I present with.

He has commented that if I really wanted to do it I would have done it here, but actually I feel safer here where I have a lot of support ot manage my risks. I am also OCD about cutting and it has to be in absolute privacy and in a certain way to make it a right cut and here obviously there is no opportunity because I am on hourly obs and I would have to stop/move around to find the right place and then the cut would be wrong.

The team here think I would benefit from a slightly longer admission and that in recent weeks I have begun to make lots of progress.

I am also worried about the risk of a section if I go home, my care co-ordinator has said that she feels this would be appropriate and I suppose I would like to avoid that! I want to go home but I want to go home and be safe and at the moment I feel very risky and suicidal but I can see how, with the work I am doing here there will be a point in the near(ish) future where I can go home and be safer.

I also know that I have to go home at some point and so I think the consultant here has a point but it is hard when the community team you are going home to are so worried they are wanting as assessment for a section. Does that make sense? Like they know me enough and are worried enough for that and I don't think they are wrong to be so worried. I do do risky things, repetedly and compulsively and I am unable to stop myself from that despite not wanting to.

Hasn't the ward invited the community team in for ward round so that a treatment/discharge plan can be thrashed out and agreed? I am quite surprised to hear that the CMHT and ward are openly disagreeing in this way. And I am also surprised that people think that use of the mental health act will be helpful in this situation, based on what you have said. It is very important that the mental health act is used only in a last resort, particularly in illnesses such as yours when it is even more important than usual (and it is always important) to avoid a coercive approach if at all possible. I hope that another way will be found. And that you will continue in your recovery no matter what is decided.

fluffy - re: the Psychiatrist's attitude - mine is similar.
I have BPD & Depression too but unlike you I do have irrational thoughts & short psychotic episodes when i feel very suicidal, & he knows this.
I don't see reality in the same way when i get those episodes; & he acknowledges that.
But i think he doesn't want to section me because half the month i'm not depressed or irrational at all - PMT & anxiety are triggers for my problems.
That's fine by me; i don't want to BE sectioned. So i minimise the risks by not keeping sharp knives, & have put notes to myself in the house (& cutlery drawer) for when i do get psychotic or irrational episodes.

Personally it sounds to me like you do need to stay in hospital, or have someone stay in your home.
Psychology would really help you but you need to be more well for it to work.

My Psychologist has helped me to recognise the warning signs & triggers for when i get unwell so that i can 'take control' of my condition.
Returning to work after 5 months helps because i'm focusing on other people's problems & it's grounding me in reality more.
I work 2 days a week now which is ideal because I can focus on patient care which is important to me (i'm a nurse) & be sociable with my colleagues.
I'm not there often enough to get dragged into the staff politics & bitching, which has made me very paranoid before.
Plus my managers know my problems & are looking out for me - they were the first people to realise i was ill in the past.

Re: your self harm - i have done that obsessively at times but nothing as bad as what you have done.
Ironically being a nurse means that i'm conscious of wanting to avoid A&E at all costs; plus i have that knowledge in my mind of consequences (eg. i've cared for people who OD & got liver failure but lived long enough to regret their suicide attempt - so tragic & a waste.)
Also i know the risks re: infection - i've seen amputations due to infection.
The only way i would suicide is by cutting my wrists so i avoid sharp knives - i tried it but the scissors were quite blunt then before i did it anyway my stupid cat jumping onto my stomach wanting a fuss which made me laugh - my cat saved my life which sounds quite funny actually!
I know you have OCD but seriously - when you get home you need a cat - when i'm depressed i get paranoid that mine will get hurt outside, so i have to keep her indoors then. & she then goes out of her way to be annoying which is hilarious. I feed my cat even when i don't feed myself, & brush her daily even if i can't be motivated to get showered & dressed (well she gets sick with furballs if i don't brush her - yep i got a 'cute' Persian & they are hard work & demanding - oops).

If A&E wanted plastics involved (eg skin grafting) then your wounds must be pretty bad.
You have to stop & you know this. Or you WILL get nerve damage & could lose the sensation in your hands.
Killing yourself is not so easy either. Once you cut an artery you DO have time to regret what you've done - i've helped to treat arterial bleeds.
Jumping off somewhere - well you could break your neck & end up paralysed, or break both legs & need bedpans for months.
Hanging has deeply unpleasant consequences (not spelling them out) - & again, if you slowly strangle there's plenty of time to regret it.
OD's don't always kill you. You could go blind or damage your organs.

Then consider other people. Nurses, doctors, paramedics & police may act jokey, hard, even uncaring but actually it's all an act.
When we see someone badly wounded (like with your self harm) it's very upsettting obviously.

I have friends in the 999 services who deal with suicides, a little bit of themselves dies with each one. They do get badly affected by what they see, & often drink heavily to hide it. Some won't admit it - even i did develop a hard shell when i was a student nurse & saw too many deaths - but when that shell breaks that's when healthcare & 999 staff can get ill too.
Think of how they will feel to see a person like themselves dead (& trust me it's very very final) & in a disgusting mess - dead bodies decompose very quickly & it is horrible. You learn to live with what you see, but your case could be the one that destroys the person who has to see you - that is one bad legacy to leave, & that is why i don't want to kill myself ultimately.

You need to develop strategies to stop the self-harm.
You are obsessive, so am i. You can't stop being obsessive until you have therapy for that - so just get an obsession or two that take up your time & energy but cause no harm or distress to you or to anyone else. Eg. some kind of hobby, study or exercise that will get you connecting with others.
You can connect well with others - your post shows that you have empathy & are intelligent. So do that.
Make sure you are referred for therapy - ask for DBT.
Listen to the Psychologist that you will get (if you don't have one now) & also phone the CMHT Crisis team every time you need to.

If you are anything like me then you will think others are more important than you. For example if my Mum was suicidal or self-harming then i would make her live with me! But i keep forgetting how she must feel when i do it, when i'm suicidal i just want to end the pain, or i just feel that i must do it, or i feel like i will be doing everyone a favour.
Well that's NOT the case (currently i'm much more well so i can see that) - you WILL begin to see that as well when you start to recover.

Until You start to recover - write down this & stick it up in each room of your home:

I do not really want to kill myself.
My thoughts that i must kill myself are totally irrational & caused by underlying anxiety.
Death is disgusting.
Cutting & burning will give me dangerous infections & irreversible nerve damage.
Suicide will cause severe distress to others including professionals & i do not want to cause distress to others.
(Write down a list of activities that will then distract you - both in your home & outside - even just going to sleep for a bit may help)
(Also write down - 'call the Crisis Team - they want to help me even though i don't think i'm important because they would not have jobs if people like me didn't phone them' - 'I must phone them before i self-harm because they would prefer me to phone them & not self harm').

Finally get a shoebox - call it your 'happy box' (yes sounds daft i know).
Fill it with your favourite photos; any positive notes / cards etc from others; funny jokes or funny books; funny DVDs; CDs that are uplifting & you can dance around to. When you feel depressed then look through it.

And keep a reminder to eat healthy low sugar, snacks - because food can really help to lift your mood.

PM if you like. Take care & remember you will get well.

Ps. think of stopping self-harm like stopping smoking. It's very difficult but it has to stop & you CAN stop, because self-harm causes so many problems.

This does seem an unusual situation to be in, for all the reasons that scummymummy says.
It must be difficult to have two teams to deal with, and all the potential for miscommunication that goes with that. Have you had a chance to discuss this situation eg the mental health act assessment and what has led to it with your psychologist?

I have no advice, only sympathy for how you must be feeling. Can I just recommend everything Latara said, she has a real insight into OCD and have so much admiration for her honesty. I hope it is of help to you.
(((( ))))

Thinking of you fluffy, sorry I don't have anything to add, but I hope you get the right treatment.

Thank you for the replies. It is difficult and there does seem to be a bit of a clash between the inpatient and the community team.

I do see a psychologist and have therapy based around DBT.

Hope things are working out for you today.

I wanted to update this.

They had a big MDT about me and it was decided to give me two more weeks inpatient with lots of leave alone at home, on discharge home treatment team (crisis team) will be involved with planned daily visits and if my self harm is similar to how it was prior to discharge they will be looking for a PICU admission to keep me totally safe (as I have been able to self harm while inpatient). So lots of people looking to keep me safe.

I was seen by an AMP who felt I would be appropriate for a section 3 but as I am here and willing no further action was taken.

I had unaccompanied leave yesterday and cut my leg which needed stitches so not a great start but we shall see.

I'm glad you've got a plan now fluffy that people are agreed on. I hope it all goes well for you.

yes glad they are looking after you.

I do self-harm; skin picking (yuck, i know). Recently found out it's called Dermotillomania (i think). It's addictive & so hard to stop. I have had infections & needed oral antibiotics / antibiotic cream as a result - but not near as bad as what you do, fluffy.

I think with the self-harm you need to try to reduce it & make things as least risky for yourself as possible - eg if you really feel the urge to self-harm then keep the damage superficial - avoid arteries, deep tissue, areas that show like face & arms, & minimise the risk of infection.

You will recover one day, & so it's best to avoid getting any more scarring & damage to your body than you have got already.
The ideal is obviously to stop totally but it's definitely not easy.

Good luck with trying.
I will try my best to stop what i do too.