Compassion and empathy, or we are all “buggered”.

By CKMG (AMHP and lecturer)

I was heartened recently to see an article in The Independent which highlighted the significant issue occurring in A&E departments across the country where people who require mental health assessment and possible admission under the Mental Health Act are left waiting for days and sometimes weeks without any legal safeguards (Thomas, 2022). As an AMHP, I was impressed that this issue had been covered by a national newspaper and highlighted the human rights issues for many people in mental health crisis who are left waiting in A&E. Unfortunately, my feelings changed upon reading a comment underneath the article where a commentator expressed the view: “if they want to leave, just let them” (since removed). This comment showed ignorance at best and at worst, a complete lack of compassion or understanding for people in acute distress. On recounting this to a friend, also an AMHP colleague, her comment struck me given her usual positive outlook and faith in human nature; she stated “well in that case we're all buggered aren’t we”. This gave me the inspiration for this article. I wanted to explore whether or not this was the case based on my own professional experiences as an AMHP.

I have completed two recent assessments in A&E departments. In both situations the person had been brought there by family members (who later, it turned out were Nearest Relatives) and who were at the end of their ability to provide care for their loved one. They expressed being unable to cope with the level of care required despite daily support from local crisis services. They had done what they thought was the only option, to bring their family member to hospital given the risks for them of remaining at home. I want to give some context to this to help others understand what this might be like. In one situation the person with mental health problems had a long-standing diagnosis of bi-polar affective disorder which was usually something that did not impact on their independence - they had a full-time and responsible job and led a full and active life. Over the past few weeks this had changed significantly. They had not been sleeping, been unable to work, had been distracted when doing day-to-day things such as cooking or even eating and had been causing risk, such as lighting candles to help them feel safe but which had led to a minor fire in their bedroom. Understandably their relative felt unable to relax or leave them for any period of time due to care being required both day and night. 

On reading the other blogs on this site, a recurring theme has been to highlight the role of advocacy that the AMHP can bring to their role and practice. I could not agree more but also think that advocacy needs to extend to the family members and carers who provide the vast majority of support to people with mental health problems. Often they have to juggle their caring responsibilities alongside work, caring roles for others and other responsibilities they have. I cannot begin to imagine how even basic tasks such as shopping and meal preparation are undertaken when providing the level of care sometimes required.

When undertaking these assessments in A&E I was concerned that staff across the different teams involved would express frustration with the family members for having brought the person to hospital. I could not have been more wrong. In neither case did staff look to blame the carers or express negative attitudes regarding them, instead they showed compassion and understanding that these carers could no longer continue.

For both people I assessed the outcome following assessment was that admission under Section 2 of the Mental Health Act for further assessment and possible treatment was required. Neither person was able to consent to this, due to the level of mental health distress they were experiencing, as they were unable to use and weigh information about their care and treatment. There did not appear to be a viable lesser restrictive option to the use of Section 2 and I felt confident in my decision. This is where things should be simple but started to become quite the opposite as the bed managers were unable to identify a bed in in a mental health hospital. An application under Section 2 could therefore not take place and instead leading to both people having to remain in A&E until an application could be made. For one person this was twenty-four hours after the assessment, for the other it was around forty-eight hours later. During this time there were no legal safeguards in place to support the people when waiting.  

What struck me about this was the bizarre role I had as the AMHP in explaining to the nearest relative that whilst we wanted to admit their relative under Section 2, this wasn't going to be possible as we could only do so once a bed was identified. The outcome instead was the person would have to wait in A&E for an unspecified amount of time. One of the nearest relatives paused and said in a somewhat concerned manner, “you don't mean they could just walk out do you?”. As the AMHP I had to explain that this was the case, that there are no powers to keep the person at A&E, although should they try to leave staff would encourage them stay. The alarm expressed by the nearest relative in this circumstance was difficult to hear and echoed my own anxieties. For this situation the nearest relative said they would also remain in A&E as well despite the impacts on their own job security by taking yet more time off work.

Unfortunately, this unsatisfactory outcome is becoming ever more common following assessments under the Mental Health Act. My own thoughts around this were confirmed as I fed back to the nurse in charge at A&E. She commented, “would it be the usual procedure then?” and went on to reel off in a well-practiced manner that the crisis team would continue to support and provide updates about bed availability, that if the person tried to leave that staff should try to support them to stay, should they leave police should be alerted. Whilst it was reassuring in some ways that the nursing in charge was confident in the arrangements, this only further demonstrated how common this outcome is at the end of a Mental Health Act assessment. In fact, what should be expected is that the nurse would be up in arms about the person remaining in such an unsuitable place, not that this was business as usual.

It is important that we consider the impacts on the person's dignity as a result of being in an A&E department when so acutely mentally distressed. This included the person struggling to remain in their room, shouting and using abusive language and at times trying to grab other people. I am unsure how many other people came through A&E in the hours in which those people were waiting for beds. This was difficult for both the staff and other patients, some of whom were young children who were visibly shaken by seeing or hearing the person so distressed. My concern as an AMHP is how this might impact on their ability to re-join and integrate within their community following assessment and treatment, given the number of people who have seen them at their lowest in A&E. This ‘exposure’ will only add to the stigma and shame the person may experience internally as well as how others might treat them.

I want to return to the theme of compassion and empathy, as during these assessments, I worried that A&E staff would express frustration towards the person and blame them for how they were behaving. Yet again, my fears were completely unjustified with one staff member (who, I should add, had been shouted at by the person), stopping me in the corridor and commenting on how awful it was for the person to be waiting in A&E. I could not agree more and was moved by the level of compassion shown. It is clearly not the fault of any staff member, the person with mental health problems, their carer, the AMHP or any other professional that the person is unable to be admitted to an appropriate setting. The situation which is clearly occurring regularly is that people are remaining in A&E without any legal safeguards or the appropriate care. This must be highlighted until all people receive the level of care needed to support them at a time of crisis.

I wanted to end by considering the often-cited view, ‘how a society treats its most vulnerable is always the measure of its humanity’. In writing this article I wanted to highlight the number of responses shown in these A&E assessments where compassion and empathy were demonstrated. This is important at an individual level when promoting human rights, dignity and respect for the person. Unfortunately, without services and structures of support for people in mental health crisis, the pressure at the individual level will only increase. This does not lead to good outcomes for staff or service users. Whilst we must continue to demonstrate compassion and empathy, we must continue to advocate for change at a structural level, or as my friend said, we are buggered. Holding those in power to account is becoming increasingly important in society as we see waves of strike action across the country. We as AMHPs and others who are aware of the Cinderella services in mental health must raise awareness of this serious issue and advocate for change. Without this we cannot uphold people’s rights to dignity or respect when we know that the provision of support is beyond our power.

Reference:

Thomas, R. (2022, November 08). Mental health patients held ‘unlawfully’ in A&Es across the country, experts warn. The Independent. https://www.independent.co.uk/news/health/patients-unlawful-held-a-e-uk-b2219739.html