Newcomers to care, especially mental health care often believe that they not only can but actually will ‘save the world’. They genuinely expect that their winning personality, supported only by a nice smile, a cup of tea and a chocolate digestive will solve every psychological problem there is. They’re the saviours and their naivety puts everyone at risk.
Most of us grow out of such expectations early on in our careers. We may have begun wanting to save the world but now we just want the world to go away and leave us alone. We’ve had the naivety of inexperience kicked, beaten or otherwise drummed out of us in no uncertain terms and we’ve learned that we can only do so much in our little corner of the system. We knuckle down, get good at our particular task or set of tasks and keep that original, positive spark of enthusiasm alive with realistic expectations and the ability to take delight in smaller successes.
But some people never grow out of their saviour fantasy. They never overcome the innocence that may well have led them into the job but that also makes them beat themselves up every day because they haven’t yet fixed everything. They may not show it often but these overgrown saviours are racked with guilt because of the impossible task they set themselves. If you’re one of these saviours please read on…
It’s pension day and Mary, a kindly octogenarian toddles out of her local post office clutching a wad of notes in her gloved hand. She never did manage to catch up with all that modern internet banking nonsense and has always been a little suspicious of computers managing her affairs. ‘That’s what cheque books and cash are for’, she reasons. Her handbag hangs nonchalantly from her elbow as she fishes in the apparently inexhaustible, portable cavern for her purse.
Suddenly – two young thugs come dashing toward her. One snatches the cash, knocking Mary to the ground as he does so. The second stamps on her head for good measure, causing bright red blood to stream from her ear onto the pavement.
You run to her, screaming at passers-by to call an ambulance as you cradle the unconscious old lady in your arms. You feel helpless and angry as she breathes her last, still held tight in your embrace. You’re angry but you’re not guilty. You tried to help, after all. You never caused this and at least you had a go, unlike the rest of society who seem only able to cross the road and look the other way.
Mental health care’s like that. We didn’t cause the problems our patients have developed. Often it took them years to become this ill. That’s not your fault and you’re not to blame. At least you’re trying to help!
By Caroline Spencer-Boulton, NALP Licenced Paralegal, 24:7 Criminal Defence
There has never been a better time for the legal profession to ask itself if it properly serving clients with mental health issues, with mental health firmly on the agenda and more people suffering as a result of Covid-19 and lockdown,
I believe there has been a distinct failure by the legal profession, over the years, in obtaining proper and full assessments of clients suffering from one or more mental health issues. This means the profession is letting down its clients and acting without the highest standards in mind. Even where there are clearly issues for concern, there has been a failure in many cases, to obtain appropriate psychiatric or psychological assessments. This needs to change.
I have specialised in the field of Criminal Defence for 14 years, the last eight years operating as a licenced paralegal preparing cases for my own clients both within solicitor firms and more recently on a privately funded client basis, I have been involved in the preparation of defence cases for a considerable number of clients with mental health issues.
The onus must be on the authorities and legal professionals throughout the UK to thoroughly consider a client’s potential mental health state from the outset. This should start at the police station interview stage. For example, adverse behaviour as a child or teenager growing up in care, or within a dysfunctional or disadvantaged family is currently deemed to be not enough of a concern for many legal representatives to consider further investigation or expert reports.
Such incidents have led to miscarriages of justice in the past, yet still today not enough consideration is given to those with mental health issues who get caught up within the criminal justice system.
As a police station accredited representative, I have attended at police stations, and other venues, to advise and assist clients who are being interviewed by police. At the police station when a client has been arrested and is being booked in to the custody suite they are asked if they suffer from mental health issues as part of the welfare check. Many will not divulge that information due to a perceived stigma associated with mental health.
One client, whose mental health issues were known to exist and a mental health nurse was on hand to determine whether the client was fit to be detained and fit to be interviewed, was declared fit by the nurse. I arrived, and in consultation with my client it was clear that they were unfit, because they were talking about angels and the devil, and clearly did not understand the reason for their arrest or where they were. Having made representations to the mental health nurse and the custody sergeant I was advised that despite my concerns and representations the interview would proceed! Within a minute of that interview commencing the police officer agreed that the client was not fit to be interviewed nor detained. The client was subsequently released into the care of their carer. Clearly there had been a significant error on the part of the police force and mental health nurse. Thus, it is imperative that police station accredited representatives and solicitors take the time to assess a client and perhaps, more importantly, make suitable representations to the police and mental health professionals if there are concerns.
Another client with mental health issues who was already serving a significantly long sentence advised me that they became involved in bad behaviour as they believed that they would be killed if they were not segregated. That client had received no mental health care in the, approximately, 10 years they had been incarcerated. Due to my concerns, a full psychiatric and psychological assessment and expert report was obtained. It transpired that one of the experts believed that the client’s original case was unfair due to the client’s mental health issues and that the client should consider appointing a legal professional to look at their original case with a view to submitting a fresh application to appeal. That client, with the diagnosis, evidence and advice submitted in the expert reports, was finally given mental health care and treatment in the prison.
These are just two examples of many I have dealt with, some in relation to submitting applications for leave to appeal, where I firmly believe a miscarriage of justice has taken place.
So, what needs to be done to address the issue? Here is what I believe needs to happen in order for the legal profession to better serve people with mental health challenges:
An in-depth assessment by the Crown instructed expert psychiatrists and psychologists. Often these people are only given the defence expert report and prosecution evidence. The Crown’s experts should be given sight of the medical records of those they are assessing, and they should provide a full assessment and report on the person’s ability to understand the trial process and take part in it. They should not be asked simply to provide a report aimed solely at a continuation of prosecuting a defendant. Often the full mental health issues are not covered in these Crown instructed reports.
Start at the police station
Full and proper consideration/assessment by mental health nurses at the police station stage. The aim is to determine, where a client suffers from mental health issues, their real ability to understand and give instructions and/or an interview. All too often clients are deemed fit for interview at the police station, when clearly, they are not.
The use of intermediaries in court proceedings appears to be a rarity. In a world where there is a significant trend towards those with mental health issues facing proceedings before the Courts, intermediaries should be instructed to assist the client during trials and other hearings/conferences where necessary. This intermediary service is currently heavily overlooked.
Education of legal professionals
This applies to both defence and prosecution, to help them understand mental health issues and the treatment options. Further educating legal professionals to note and consider these issues if they have concerns when dealing with a client. Encouraging them to obtain those vital expert reports, from psychiatrists and psychologists, as to their client’s mental health. More often than not those assessments prove vital to the outcome for the client.
Deeper consideration and use of Hospital Orders. Utilising the help available from the Probation Services and ensuring that the most vulnerable are protected by the courts.
Prisons should revert to proper rehabilitation techniques. These appear to have waned over the past 10 years or so. This should include suitable assessment of those with suspected mental health issues particularly within the Autism range, ADHD and PTSD; all of which can be complex. Appropriate treatment should be given to those serving custodial sentences. Those with significant learning difficulties and/or low IQ should be provided with approved courses and treatment to help with coping and progression, as well as obtaining employment once released. The government should put in place a service for those released from prison who suffer from mental health issues so that they may continue to be provided with assistance and treatment, in order to reduce reoffending behaviours.
Full expert reports should be obtained by defence solicitors/firms on their client’s behalf where and when possible. Legal aid funding is available for these expert reports where clients are legally aided. For those clients who are privately funding their defence case, their defence team should advise them about the importance of obtaining expert reports on a client’s mental health issues – albeit that this can be at a significant cost to the privately funded client.
On a positive note, there appears to be a very gradual roll out of psychiatrists being available at the Courts to assess defendants facing sentencing. A very tiny step, but certainly one in the right direction. However, my concern is that there are not enough hours in a day at the court for a full and proper assessment to be carried out. Therefore, in my opinion, without a full assessment, defendants will not be offered appropriate treatment or sentencing plans.
Mental Health is a wide-ranging condition which is all too often either not fully considered by legal professionals and related authorities or considered at all. This attitude and lack of proper consideration must change for future generations.
ABOUT THE AUTHOR
Caroline Spencer-Boulton is a NALP Licenced Paralegal from 24:7 Criminal Defence.
The National Association of Licenced Paralegals (NALP) is a non-profit Membership Body and the only Paralegal body that is recognised as an awarding organisation by Ofqual (the regulator of qualifications in England). http://www.nationalparalegals.co.uk
I’ve always thought of myself as a face to face, engage with a live cohort/audience sort of trainer/speaker until…
I asked yesterday for volunteers to do tutorials with as a form of content marketing. The very first contact I had was for group training over zoom. A little thought later I agreed. I’m about to start a whole new voyage of discovery into online training.
If you’ve been wondering how to get decent quality, interactive training on mental health and social care in these days of lockdown, look no further.
Saffron Cordery is the deputy chief executive of NHS Providers, the membership organisation for NHS hospitals, mental health, community and ambulance services. These guys really do know what they’re talking about.
According to Cordery, writing in The Independent just after the general election, Boris’ government, for all its fine words is setting the NHS up to fail. Not that this comes as any great surprise to those of us who’ve been watching developments since 2010. The Tories, with the help of their LibDem enablers, have been stitching up our NHS, ready to sell it off to the highest bidder for years.
“Although quality of care once you’re in the system has held up remarkably well, timely access to treatment in the NHS has been slipping for years, despite frontline staff working harder than ever – so hard, in fact, that they’re in danger of burning out. Demand has been steadily outstripping supply; gaps in the workforce have widened substantially; our assets have deteriorated; and financial investment has been lower in the past decade than at any point in the NHS’s 70-year history.”
For all his fine words, Mr. Johnson is well aware that his promise of funding falls way short of the amount currently provided to our country’s flagship health service. Even if he restored funding to previous levels the backlog of neglect and decay, of equipment and buildings upgrades would mean a significant cut in comparative terms. The Tories may be promising money but they’re hardly making much of an effort.
Of course they can’t make too big an effort because the money’s already earmarked for tax cuts and perks for big corporations. Which is why the health, mental health and social care sectors are to be left to pick up the slack.
If you thought the last 10 years were bad, just watch this space. There’s far worse to come.
On October 25th 2007 22 year old EG gave birth to twins at the Royal Shrewsbury Hospital. A few hours later she was dead because she refused to accept a blood transfusion. EG was a devout Jehovah’s witness. She suffered a sudden haemorrhage and bled to death following a natural delivery. EG had already signed a form before the birth refusing blood in such an event.
According to newspaper reports staff at the hospital tried to get EG’s husband and wider family to consent to the blood transfusion on her behalf but they would not.
Is this ‘valid and applicable’ as an advance decision to refuse treatment?
What about the notion that ‘decision-makers should not be motivated by a desire to bring about the person’s death’?
What do you make of the staff asking EG’s family to overrule her decision?
If the family had consented would the transfusion have been legal?
If not – would the family have been liable or the staff who gave it?
Who was the legal decision-maker in this situation?
Last night I had an interesting conversation with a stranger in the car park of my local supermarket. We’d exchanged a few pleasantries in the queue for the checkout – like me he refuses to use automated checkouts because, also like me, he’d much prefer that people keep their jobs.
We happened to have parked our cars next to each other on the way in and so the conversation continued in the car park, this time the subject was cars, driving and the rather nasty bump he’d had to the front of his vehicle. That conversation reminded me of today’s topic on anxiety.
Some time ago, one dark winter morning I found myself driving to work down unlit country roads in the rain. Visibility was poor and so I wasn’t going particularly fast which turned out to be a really good idea.
Also on the road on that dark, wet morning was a cyclist. A cyclist who was dressed in dark clothing with no lights and no helmet. To be honest I don’t even know how this guy might possibly have seen where he was going without lights – it really was that dark. However, presumably he could. I couldn’t see him though.
As I approached this invisible cyclist he pulled out into the middle of the road intending to turn right. You can guess what happened next. That’s why it’s such a good job I wasn’t going very fast. If I’d been driving at the legal speed limit instead of to the actual conditions I’d probably have killed him.
Fortunately, amazingly even he was OK apart from a few bruises. The ambulance came and took him to hospital where he was checked over. The police arrived and took my details, including my negative breath/alcohol test and I called in to work to explain that I wouldn’t be in that day. What happened next was revealing, especially about anxiety, phobias, avoidance and the ease with which normal freeze, flight or fight responses can become pathologies if we’re not careful.
My plan had been to return to work the following day. However within an hour or two of getting back to my accommodation I’d started to think. I actually believe that it would have been much easier to deal with the anxiety that followed if the accident had been my fault. If I’d done something wrong I could just decide to correct the flaw in my driving and make sure that nothing like this happened again. But that’s not what happened.
No matter how hard I tried I couldn’t think of any aspect of my driving that morning that I can change for the better. I hadn’t been drinking, I wasn’t going particularly fast, I was awake and alert, I was certainly concentrating due to the poor conditions, my car was in good condition and roadworthy and I was correctly positioned on the road. There was nothing I could think of to do that might prevent something like this happening again and if it does the next one might be fatal. That’s a really scary prospect.
It’s interesting that even though this is the first such accident I’ve had in over 30 years of driving all across UK, all that evidence of safe driving paled into insignificance against this one event. That’s because of a particular mental shortcut, an heuristic we know as the availability heuristic. I mentioned heuristics in an earlier video as part of my evolutionary psychology series. Click the link at the top of the screen for more information.
The availability heuristic is an evolved mental strategy that gives precedence to recent events. In a changing environment it’s useful – it allowed our ancestors to recall and give weight to the location of food, of predators and a whole host of other, changing environmental and behavioural artefacts. In the modern world it’s still extremely valuable but it has its drawbacks. One such drawback is the over-emphasis we give recent events. Here’s how it can turn useful anxiety into pathological disorders.
My emphasis on this single, recent memory caused me to work hard to find a way to avoid similar problems in the future. So far so good – we can all see the benefit of that. Unfortunately, the only thing I could come up with to avoid a repetition of this awful event is to stop driving. That’s rather less positive – especially in the light of the odds, bearing in mind my years, even decades of driving without hitting anyone, cyclist or not. But recent memories are the thing and that’s why I seriously considered not driving, giving up my job because I’d have no way to get to work without my car and I even spent time trying to rework my finances to allow me to retire early, all because I didn’t want to drive.
Now think about this. If I’d actually stopped driving that day what would my most recent driving memory be? Obviously it would be the traumatic memory of hitting, and initially thinking I’d seriously injured or even killed a cyclist. If that’s the result of the availability heuristic, the result of my most recent memory then my anxiety about driving will never dissipate. Not only that, the sense of fear I’d feel when contemplating driving, coupled with the relief I feel when deciding not to constantly reinforces the heuristic every time I think about getting back into the car.
Even though I know all this it took me three more days to pluck up the courage to drive my car again. I chose a quiet, sunny afternoon in broad daylight and drove around quiet country roads and literally had to force myself to turn the key and start the engine. That gave me a new memory but not enough to overcome the power of the traumatic heuristic. Powerful, traumatic memories take a lot of subsequent memories to take away the fear they generate. And the longer we avoid the issue the harder the trauma is to overcome. And that’s the point of this little video.
If you have an anxiety state that doesn’t seem rational, regardless of the emotion you feel, it’s important to ignore the emotion. Do this as soon as you can to build up new memories that can take advantage of the availability heuristic. That’s what people mean when they tell people to get back on the horse. Don’t let anxiety overcome rationality or you might find that your life choices become governed by fear to such an extent that avoidance shrinks your world, your opportunities and your options over time until there’s almost nothing left.
And it all begins when we give in to traumatic memories because of the availability heuristic.
When dealing with people whose behaviours are challenging it’s important to acknowledge that those behaviours may well be based upon some very deep-seated beliefs. Whilst we don’t need to agree with or even support beliefs that cause problems it is vital that we acknowledge the person’s right to hold them – even if we deny their assumed right to act upon them. It’s one thing to object to behaviours – it’s quite another to dismiss the person who holds those beliefs.