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MENTAL HEALTH (CARE AND TREATMENT) (SCOTLAND) ACT 2003
TRANSITIONAL TRAINING MATERIALS

INTRODUCTORY TRAINING FOR MENTAL HEALTH OFFICERS AND OTHER PRACTITIONERS
TRAINERS' GUIDE

Introduction

Welcome to this Trainers' Guide to the Transitional Materials. It is assumed that you fully understand the purpose and background of the Transitional Training materials. If you do not, we direct you to the foreword and introduction to Reader 1.

The purpose of the Guide is to enable you to implement the package of these materials. We propose a choice of two designs for the five study days. Set out and explained below, we call them Model A and Model B. However, there is as much scope within the overall design of the materials to bend them to your own style of delivery and your own particular use as you wish. We offer the materials in this way because there will be a range of trainers, who will exercise various preferences depending upon style of working and other factors such as demographic spread of the workforce. We also recognise that there will be a range of experience amongst the trainers, from those who feel as confident in the new legislation as any of us can be, to those who feel disadvantaged by lack of knowledge of it. Therefore, for example, some of you may already have designed your own package of training and may wish to use Readers 1 to 4 and the attached case studies in your own way.

This guide is written in anticipation that few of us are fully familiar with the words in the Act and none of us can yet know how it will work in practice. It is also written from the experience of having implemented a Pilot of the materials. The purpose of the Pilot was to:

Find out how the materials worked in practice and what required redrafting;
Find out the best ways in which the materials may be implemented; and
Obtain sample answers to the questions asked in the case studies, based upon the discussion of the cases by the participants in the Pilot. ¹

We therefore advise you that the following guide carries the weight of practical experience and that certain aspects of it should be adhered to very closely. We will flag these up as they occur.

Finally, by way of introduction, we acknowledge the complexity of the materials, this Guide included. This is because of the size, scope and complexity of the Mental Health (Care and Treatment) (Scotland) Act 2003, and the considerable task of putting it into action in the most effective and efficient way. The Pilot has demonstrated that the study of the Readers and the undertaking of the training are very taxing tasks for both participants and trainers alike.

1. Who should be a trainer?

The package of transitional materials is aimed primarily at MHOs. Therefore, from the experience of the Pilot, we are certain that it would not be possible for anyone who lacks extensive MHO practice experience to implement the training. It would also be impossible for anyone without extensive experience as a trainer to undertake the task. If your local authority lacks employees with these dual qualifications, we strongly recommend that you either buy them in or make partnership arrangements with another authority which has such employees.

We envisage the most appropriate group of people for the task of trainer to be tutors and co-ordinators of MHO training programmes as they have the joint expertise of MHO practice and training specifically focused upon the subject matter of Mental Health law.

It would be helpful to jointly undertake the implementation of the training. This would share the burden of understanding and introducing the materials and it would prove useful in managing group discussion and feedback (see below). In any case, we strongly advise that this training will not work unless you have a maximum relationship of one trainer to ten every participants.

2. What is required of trainers by way of preparation?

Obviously you will need to arrange the material circumstances of venue etc. You will need to co-ordinate numbers of attendees (and this may be complicated if session 1 is open to a wider group of multidisciplinary practitioners than the other sessions). The training is designed for fairly small optimum numbers, and this may require several runs of the event in larger, more populous areas.

However, perhaps the largest task for trainers is that they will have to be fully conversant with all the materials in the Transitional Package before they begin the training. We advise that you should make an early start on this task of reading and familiarising yourself with the didactic texts and the case studies well in advance of planning the training. It may be that you need to read core parts of the Readers more than once, in order to be at home with the content. You will need to pay particular attention to the case studies and consider the questions attached to them and the sample answers to them given in this guide. You will also have to read the Codes of Practice and the Act itself, if you have not already done so. You should approach this as a major piece of work.

We acknowledge that it has been impossible to devise a training of this scope and complexity without requiring you to make your own adjustments to it according to local need. It has been simply impossible to design an 'off the peg' product to meet so many specifications.

3. What is the optimum size of training group for the five-day event?

You will notice in the programme designs below that we speak of small group case study discussion and feedback to the larger group. This is in anticipation that, in most areas the complement of MHOs is so large that more would attend one 5-day event than could comfortably sit in a group and participate in the sort of detailed discussions that we expect our materials to generate. Therefore we suggest:

• Sessions 2 and 4 (for MHOs alone), 30 participants, forming up to 3 small groups of 10 each, for the small group discussion;

• Session 1, (general overview of the Act), 50 to 60 participants: the 30 MHOs plus 20 to 30 colleagues, drawn from multidisciplinary settings (3 small groups of up to 20); and

• Session 3, (to which medical colleagues are invited), 40 participants: the 30 MHOs plus up to 10 medical colleagues. (3 small groups of maximum 14)

As we stated above, we strongly advise you from our experience of the Pilot that you will need:

• One trainer for each small discussion group; and

• A maximum of 10 participants per small discussion group for sessions 2 and 4.

We advise this because the newly acquired knowledge of the 2003 Act in conjunction with the practice experience of the participants will generate highly complicated and detailed discussion in the context of the case studies. This discussion must be carefully managed to keep it on track, being mindful of the purpose of the training:

• To give good understanding of how the 2003 Act will work in practice;

• To gather together questions and issues for continuing professional development and future training in working under the new Act; and

• To collect matters for policy and service development within the service as a whole.

This will not be achievable in larger groups or with less than one trainer per group.

4. General features common to Models A and B

Both models extend over a 5-day period.

Both models are complicated by our wish to build into the actual 5 days training as much Guided Study time as possible. This is to allow participants to:

• Read, reflect upon and assimilate the didactic texts;

• Undertake the self assessed questionnaires;

• Read and consider the case studies before small group discussion;

• To achieve all of this without having to find space in very pressurised work time or to have to do it in the participant's own spare time. ²; and

• It is also so that the trainers may be reasonably assured that all participants will have read the materials before beginning to discuss the case study exercises.

Both models are also complicated by factors relating to the purpose of the training. The core purpose of getting MHOs up to speed for the implementation of the Act has been added to by the awareness that the general introductory session could benefit a broader multidisciplinary audience and that RMOs could benefit from the session in which CTOs are discussed. This also has obvious benefits for MHO participants. If the 2003 Act is underpinned by strong multidisciplinary work, then the wider invitations to attend selected parts of the training will enhance the experience for everyone.

Therefore, in both models:

• Session 1 is a general introductory day on the 2003 Act, open to all relevant multidisciplinary colleagues;

• Session 2 is exclusively for MHOs, on making inquiries, applying for warrants and considering consent to Emergency and Short-term detention;

• Session 3 is for MHOs and RMOs, on Compulsory Treatment Orders; and

• Session 4 is for MHOs on SCRs and matters relating to Criminal Procedures.

In summary, there are four sessions extending over 5 days. Each session lasts for a working day, the fifth day being given to the guided study of the texts. In both models, the only part of the reading we were unable to include in the allocation of guided study is the study of the text of the Reader 1 in advance of session 1.

Note: In inviting participants to the training, the letter will have to contain explicit instructions to arrive having read Reader 1. This letter should also ask participants to bring Codes of Practice and copies of the Act with them. All MHOs should have copies of these documents.

The difference in the models is in how the 5 days are broken up. The models are explained below and the relative merits of each discussed.

MODEL A

This model integrates the guided study into the four sessions. Therefore, the sessions do not fit comfortably over the allotted 5 days.

Day 1: Session 1:

Day 2: Session 2

Day 3: Session 2

Day 3: Session 3

Day 4: Session 3

Day 5: Session 4

Merits of Model A:

This model allows for guided study to be undertaken in smaller chunks which some trainers may feel is more manageable and easier for participants to digest than model B, which contains a day-long period of guided study. The shorter periods of study also mean that the participants are not confronted with such a daunting pile of reading and that they approach each section of the study unburdened with the knowledge that is required for subsequent sessions. In this model, the knowledge base is acquired incrementally and this may be more conducive to reflection upon it.

The problems with model A:

The model is slightly complicated and unwieldy in that session 2 is broken over two days and the second half of the session may feel light in content. There may also be difficulties in restarting the session after an over-night gap.

MODEL B

This model separates out the guided study from the four sessions and places it in a unified day of its own. Therefore the sessions fit comfortably, each into one of the remaining 4 days.

Day 1: Session 1

Day 2

Day 3: Session 2

Day 4: Session 3

Day 5: Session 4

Merits of Model B:

Clearly, in the already complicated design of the entire package, this model has the comfort of relative simplicity. It avoids the complications of splitting Session 2 over two days. It gives a unified study day to all of the reading and this then allows participants to get on with the discussion of cases in an unimpeded fashion.

In rural areas or areas where participants may be travelling over wide distances to get to the training, it avoids the problem of asking them to make the effort of coming to the third day which may be perceived as light in content in Model A.

While we advise you to convene the study day in a centralised setting, in dispersed rural areas it may be more economical to allow participants to undertake the guided study in their own locality.

As will be seen in 'Ways of delivering the 5-days' below, if your preference is to split the 5-days into smaller units, Model B is more easily devisable into stand-alone one-day units than is Model A.

The problems with Model B:

These are all the converse of the merits of Model A:

It does not allow for assimilation of learning incrementally. It burdens the reader with all the material at once and with carrying all the knowledge through the 3 days of discussion.

Other Considerations:

You will see from Model B that it results in a half day of extra time on the final day. This time is given over to gathering unanswered questions and matters to take forward for policy and service development and for further training requirements for the body of MHOs. This lighter half day, to which the facilitator may wish to invite the manager responsible for MHO services, may also be of advantage as a catch all, to clarify any issues arising out of the training.

In Model A these issues would have to be gathered by trainers as they progress through the programme, rather than in one unified session at the end of the training. This may either perceived as an advantage or a disadvantage, depending on your perspective and your style as a trainer.

Ways of delivering the 5-days:

The programme can be delivered in a unified block. This has advantages:

• It would be easy to arrange; and

• It takes participants away from work considerations for a unified period of time and allows them to give full attention to the training.

It, however, has disadvantages:

• There may be problems in delivering MHO and other services if large numbers of key mental health staff are taken out of practice for an entire working week;

• The programme is very condensed and intense and a wider spread of study days may make the study easier to assimilate; and

• For similar reasons, spread out delivery may allow for reflection time, which the 5-day block configuration does not.

We advise you to determine how to configure the study days in consultation with MHOs and their managers, as the problem is a mixture of operational, workload management and training-led considerations.

A broader spread configuration of the days would most easily be achieved for both Models A and B as follows:

In this way the first and last days become detached from a core 3-day block. There may be ways of further dispersing the days, for example, by using Model B above and making each day stand alone. However you resolve the matter we strongly recommend that the material is presented in the sequence of Readers 1, 2, 3 & 4.

5. Special use of Session 1

It is possible to uncouple this general introductory day from the other three sessions and use it broadly, for multidisciplinary groups as induction into the Act. This option may be of particular interest to trainers who are devising training along with colleagues from Health Care and other agencies, in line with Joint Local Implementation Plans. This session may then take on the function of ' awareness training' for a much wider audience, reflecting the larger numbers of staff for whom it is applicable.

6. Who might attend Session 1?

Whether used in conjunction with the rest of the 5-days or delivered in its own right, session 1 would be of relevance to a wide group:

• Care Management Staff;

• Other Local Authority Staff, Non-MHO Mental Health Social Workers etc;

• General Nurse Managers (particularly in A & E settings);

• Psychiatric Nurse Managers;

• Psychiatric Nurses;

• GPs;

• Approved Medical Practitioners;

• Police;

• OTs, Physiotherapists, Speech and Language Therapists;

• Psychologists;

• Health Care and Local Authority Managers;

• Medical Records staff; and

• Health Centre Practice Managers.

This list is by no means inclusive. For example, while the materials are obviously focussed upon the statutory duties (principally of the local authority), they may be of use for voluntary organisation staff and those developing Advocacy services for the Act.

It would be most helpful for the person co-ordinating the training to encourage any RMOs who intend to come to session 3 on CTOs to also attend session 1. In this way they will be oriented to the format of the training and they will have received the general introduction in preparation for the more in-depth discussion of session 3.

7. Discussion of case the studies

To give you the necessary advantage as trainer, we will replicate the questions asked in each case study and summarise some matters of significance by way of answers. However, throughout the case studies of Session 1 and those of other sessions you should bare in mind our instruction to participants: These discussions may generate questions to which we can have no answers as yet. These sorts of questions have a particular importance of focusing us on aspects of practice yet to be developed.

We would like to note some general matters:

• In reference to some issues/questions, these are by no means definitive answers. Nor can trainers anticipate the range of responses that will be generated in discussion amongst participants of the training.

• While we have advised participants not to be too restricted by the questions, there are several ways in which diversion from the questions may be unhelpful.

• Some questions may seem to invite divergence into discussion about the interface with the Adults with Incapacity (Scotland) Act 2000. While we accept the importance of developing this understanding, the purpose of this training is the narrower understanding of the 2003 Act. We therefore advise you to discourage such discussion.

• While much is made in these materials of the comparison of the 1984 and 2003 Acts, we would advise you to discourage too much discussion of the former Act, comfortable though knowledge of it may seem at this juncture.

• Various agendas may accrue to the advent of the new Act. For example, some practitioners may bring matters to the discussion in relation their workloads and the impossibility of undertaking the new MHO role in their current situation. While we have addressed such matters in the Briefing Paper for Health Service and Local Authority Managers, we worry that this will detract form this training, which is anyway a forum in which such issues cannot be answered. We therefore advise you to steer away from any such discussion.

• The experience of the Pilot is that a certain type of discussion is inevitable if you place like-minded MHO practitioners together. They tend to enthusiastically generate discussion of ethical matters in relation to practice. This is to their credit as it seems indicative of their shared interest in a very challenging area of practice. While some measure of it is inevitable and even desirable in the discussion of these case studies, we advise that it requires careful facilitation by the trainer to keep to the point of each case study. It is for this reason that we advise you to have one trainer per group.

We will clearly articulate the specific purpose of each case study in our discussion below. In some cases we will advise you of specific outcomes to which we wish you to direct the group discussion. To these ends we advise you to be open with the group and that you articulate the aims of each case study.

8. Small group discussion and large group feedback

This device was introduced to enable you to hold larger training sessions than the level of group participation requires. The idea is that a number of small groups can simultaneously enter into detailed discussion of the case study and that they can then add to the learning process by giving condensed feedback of their discussions to the larger group of participants.

It may be that you are undertaking training of MHOs in insufficient numbers to warrant this strategy. If so, then you would have more time for small group discussion. However, assuming feedback to a larger group is required; you will have to consider how to manage it.

In collecting large group feedback we advise you to collect points of significance and unanswerable questions, and to undertake to circulate them after the training, as a means of reminding participants of the discussion. If some of the issues do relate to organisational or operational matters, it may be of help to undertake to address these to the lead manager for MHOs.

Since the experience of implementing the Pilot suggested that facilitating the small group discussion involves intense concentration on the task, we advise you to appoint a note taker in each group so as not to burden the facilitator with the added task of thinking, talking and writing at the same time.

9. Session 1

Introduction:

While the design of this package is prescriptive, we hope that, as a trainer, you will be able to deliver it in your own style. This begins with the session in which you introduce the materials. Therefore, we wish to give you some pointers and ideas which you may chose to adopt or which you may reject in favour of your own introduction:

Our proposed timetable is very tight (allowing one hour for introduction, from 9.30 to 10.30). You may wish to experiment with the timings, giving yourself more time for individual presentation if that is your style. By way of introduction to the first session we recommend a presentation that:

• Sets out the material for the day, in the context of the 5 days;

• Conveys the difficulty of the task with enthusiasm;

• Draws out the potential benefits of the 2003 Act; and

• Introduces the key themes of the Act.

Some of those key themes are:

• A set of principles by which people given formal powers under the Act must go about their duties;

• A more focused regard for the needs of children and young people affected by serious mental disorder;

• The creation of the Mental Health Tribunal for Scotland, which largely replaces the function of the Sheriff Court in civil procedures of granting powers to detain and provide care and treatment on a compulsory basis;

• Expanded duties upon the local authority to provide a range of services for people affected by mental disorder in their area;

• Expanded roles and duties for other bodies such as the Mental Welfare Commission for Scotland;

• A revised framework of compulsory powers of detention in hospital for assessment, care and treatment of mental disorder;

• New powers to compel some individuals affected by serious mental disorder to receive care and treatment services in the community;

• Revision of the relationship between the criminal justice system, mentally disordered offenders and the powers to detain, treat and compel people to receive care;

• A better reflection of the Human Rights of people with mental disorder in relation to the Act;

• Statutory right of access to Advocacy Services for all people affected by mental disorder;

• Revision of the treatments that may be given to people without their consent and the conditions in which they may be given;

• Introduction of 'advance statements' whereby people may register the care and treatment they wish to receive should they become unwell; and

• Addition of new roles in support of people with mental disorder who require compulsion.

The Scottish Executive has made available a set of core PowerPoint slides for use in introducing the Act, which are available on their website at: www.scotland.gov.uk/health/mentalhealthdivision. These were developed by Karen Wiles, Principal Solicitor, the Moray Council. NES has also developed web-based learning which can be viewed at: www.nes.scot.nhs.uk/mha These may be of help in the introductions to all of the training days. We also draw your attention to the DVD/Video made by the Highland User Group (HUG), which serves very well as a means of communicating the voice of service users speaking about their experiences and their hopes for the Act, particularly in relation to the principles. This introduction might be a good place to air this voice.

Discussion of case study 1:

We have produced some guidance on the purpose of the case studies so that you may keep discussion in the small groups on track, and some sample responses to the questions, so that you are fore-armed with likely points of discussion and so that you may re-energise any flagging or off-beam discussion in the groups. To enable you to distinguish these insertions, we have added them in coloured type :

Case study 1: How may the Principles inform a case for Short-term Detention?

It has to be borne in mind that this introductory day is for a broader audience than MHOs alone. This is one of the reasons that we begin with discussion of some issues that may seem self-evident to experienced MHOs. The intention here is not to patronise this body of practitioners, but to involve them in discussion with other colleagues to develop multidisciplinary discussion. Another reason that such matters are contained here is that questions such as 'how best to take account of a person's age, gender, cultural background etc' previously arose out of concern for good practice. MHOs must understand that these matters are now embodied in the Principles and that their elevation from 'good practice' to 'legally competent practice' changes the way that they are approached. This is a core point of significance that trainers ought to indicate through facilitation of the small groups.

As mentioned above, a presentation including a number of slides that will be useful are available form www.scotland.gov.uk/health/mentalhealthdivision. At the Pilot it was suggested that the appropriate ones for any given case discussion could be displayed on the wall. Amongst them is the abbreviated list of principles.

Please consider the principles in relation to the situation that is portrayed. In this scenario, take the conditions of detention to be given. This should not discount discussion of matters raised by the principles (having regard for the 'range of options available' for example) that may lead you to consider that detention is not the only course available. The specific purpose of the exercise is to get you to think about the principles in relation to the functions of considering whether to grant/give consent to Short-term Detention: a sort of amalgamated approved Medical Practitioner/MHO role. As this is the first exercise, we have listed principles we think are of significant relevance to help you answer the questions. You are also reminded of the abbreviated list of principles found at the start of the Reader.

Michael's parents say that they need him to be removed from the home, at least temporarily. What Michael's father describes as 'the last straw' was the moment when he broke down his younger sister's bedroom door and stood there, screaming at Rebecca and her two terrified school friends who were doing homework. As a result Rebecca is tearfully refusing to go to school tomorrow. She says that it took her long enough to pluck up the courage to invite her friends round to her home where she had a 'crazy brother'.

Michael has just turned seventeen. He has had psychiatric involvement for a year now and in that time, he has scarcely attended school. Michael's psychiatrist is reluctant to pronounce any lasting diagnosis upon his condition but Michael says that he has heard voices since he was about six years old, the age at which he was traumatised in a house fire. Since adolescence Michael's behaviour has become markedly less predictable and more upsetting and difficult for his family to manage. Always a loner, he now spends most of his time in his room. From behind the door he can be heard talking, shouting and laughing through the night. He sometimes goes out late at night, and stands in the back garden, staring at the sky.

Michael's mother is now signed off her work as a travel agent. She is being prescribed anti-depressants and is in a state of anguish over his condition. She worries that he seldom seems to eat anything and that he has no relationship with any other members of the household, walking zombie-like past them should he ever encounter them in the house.

Michael's father, a bus driver, alternates between rage and pleading despair at Michael's behaviour. He seems to have more difficulty than Michael's mother has in understanding the psychiatrist's explanation that this behaviour is not wilful. However, the family has managed to keep a lid on things until very recently.

Michael has not been very compliant with services so far. He had reluctantly allowed his parents to take him to psychiatric appointments, refusing all other offers of services. He had reluctantly taken oral anti-psychotic medication, but he has recently becoming less and less compliant with this too. When he refused to attend his outpatient appointment last week, his psychiatrist suggested that he be admitted for the first time. Michael responded by barricading himself in his room and, while his father thought admission was a good idea and would give them all a break, his mother tearfully pleaded for it not to happen. And so Michael stayed at home for one more tense week, until the incident in his sister's room.

(a) How best to interpret and take account of Michael's present and past wishes and feelings?

We do not have full enough information from the case study to allow us to deduce Michael's past wishes and feelings. Therefore any practitioner engaging with him would have a responsibility to find out as much as possible by establishing a relationship with him. However, Michael does seem to be closed in and blunted by his illness. Therefore, such information may have to be obtained from third parties.

Michael is certainly expressing some feelings which seem hard to interpret. For example, while he seems to feel the need to be left alone, he did attempt to communicate something to his sister and her friends. His present wishes are manifested in his reluctance to attend medical appointments and to take medication, but it must be noted that he has been persuaded to comply recently. Therefore, there may be some ambiguity in his wishes, or between his wishes and his feelings. Such ambiguity may be seen in the person who has feelings of fear of the dentist, but manages to overcome them in his wishes to get a sore tooth fixed.

Were this the case, it may be possible to reassure Michael that the frightening and isolating experience of his illness may be ameliorated with care and treatment. At the other extreme, we may acknowledge with Michael a divergence between what he wishes and the opinions of others in relation to what may be of benefit to him.

(b) How best to have regard for the views of Michael's named person and carer?

Michael's mother is currently his named person, in the absence of his having competently nominated one. (Being over 16, Michael is entitled to nominate his own named person.) His mother is expressing anxiety about how to cope, about Michael's wellbeing and about her family as a unit. She seems to be wavering between not wishing to hurt and betray Michael by securing treatment for him against his will and leaving him in what she sees as an intolerable situation.

(c) How you would enable Michael to participate as fully as possible in the discharge of the function? (Function in this regard is the consideration of granting/consenting to Short-term Detention).

What seems to be required is skilled imparting of clear information, given as carefully as possible and in a manner, which enables Michael to hear and understand. Facilitating Michael's right to access advocacy services may also be invaluable in this regard. It must also be remembered that there are a broader set of rights in respect of Short-term Detention (rights to apply to the Tribunal to have the certificate revoked) and Emergency Detention (right to general information, as encapsulated in the principles).

While these matters are examples of things that may be self-evident to experienced MHOs, it is worth reminding them of something that they may have forgotten: It is a very challenging task to explain complicated legal rights to mentally disordered people in crisis. At one time it was probably even more difficult for any MHO to perform this task, when they were less familiar with the 1984 Act. They will now have to become as familiar with the 2003 Act to be able to perform the same task with the same comfortable skill.

(d) What is the range of options available in the Michael's case?

There are many options including attempting to introduce services into Michael's life at home on a voluntary basis. However, while that seems not to have been seriously tried so far, it may also be a bit late for it. Therefore, the following all seem to be worthy of consideration:

• Doing nothing;

• Considering Emergency Detention;

• Considering Short-term Detention; or

• Making an application for a Compulsory Treatment Order with powers to compel receipt of services at home or in hospital.

(e) What is 'benefit' in Michael's regard, in respect of the importance of providing the maximum benefit to the patient?

Serious consideration of 'benefit' here would seem to preclude doing nothing. Of justifiable benefit would be securing treatment:

• Because he seems to be at risk to health, safety and welfare; and

• Because Michael's support system, his family, is collapsing under the strain, which would exacerbate the above risks, especially the welfare risks. If the group do not pick up on this it may be advisable to ask them what the welfare risks might be for Michael, as welfare is a new condition for detention.

(f) How can the functions of the Medical Practitioner and the MHO be discharged in a manner that involves the minimum restriction on Michael's freedom that appears to be necessary in the circumstances?

Assuming the conditions for the various options of compulsion may be fulfilled, doing nothing may ultimately prove of greater restriction on Michael's freedom than taking action to compel him to receive treatment. It may also be the case that Emergency Detention proves to be more restricting than Short-term Detention. This is because Emergency Detention has severely limited rights and a lack of treatment powers. It also may proceed without the expert judgement of an Approved Medical Practitioner. Therefore, Short-term Detention would most likely have to follow the imposition of an Emergency Detention Certificate.

It may be that a CTO is of greater restriction at the moment because the need for its longer duration and more intrusive powers has not yet been demonstrated. Short-term Detention appears to be the best means of assessing the need for the more restrictive CTO.

(g) What regard should be had in relation to the importance of Michael's background and characteristics, including age, sex, etc?

Here, we may see how the principles have added strength in their interlocking design. The important regard for Michael's age is echoed in the principle of primacy of the welfare of the young person. It also relates to section 23, which places a duty on Health providers to provide appropriate services for people of Michael's age. It may further relate to interviewing Michael in an age, gender and culture appropriate manner.

(h) What are the needs and circumstances of Michael's mother as his carer and how may they best be addressed?

Michael's mother appears to need support, advice and information in the first instance. In the longer term she probably needs a carer's assessment of need and respite services.

(i) Most importantly, how can the function be discharged in a manner that best secures Michael's welfare? (From section 2: 'Welfare of the child.')

In many ways we have already answered this question above. However, we have yet to acknowledge the duties of section 278, to 'mitigate adverse effects of compulsory measures on parental relations'.

Discussion of Case Study 2: Reflecting on the Principles in relation to the Named Person and Primary Carer:

As in the previous case studies, please consider the principles in relation to the situation that is portrayed. In this scenario, take the conditions of detention to be given. Beyond the fact that it would be unlikely that a Compulsory Treatment Order would be considered in such a situation, it is not anticipated that the context of detention (Emergency or Short-term) is a question relevant to the exercise.

It is important to note these points: At this stage in the training we need to focus on how the principles shape decision making, not upon the sort of decisions being made. There is ample opportunity for MHOs to consider the appropriateness of the conditions of detention and other matters later in the training sessions.

The question has two parts to it, the second part introducing complicating factors in relation to the role of the named person. The specific purpose of the exercise is to get you to think about the principles in relation to the patient and the functions of the primary carer in the first instance and, in the second component of the question, the named person.

While some of the questions between parts 1 and 2 may seem repetitive, it is worth asking them, because subtle shades of difference may come out in the answers, as the situation develops in the case study.

In your discussion, make sure that you allow time for both parts.

Reem Jiheli is a 29 year-old woman with a history of anxiety and depression dating back to her mid-teens. Reem describes herself as Scottish-Palestinian. She lives with her parents and, when well, has helped out in her father's business, a small Arabic printing service for local businesses. While she has managed reasonably well with CPN support and medication, she has also had severe stress-related bouts of illness in the past, during which Reem's mother has been identified as her main carer. She has required informal inpatient treatment on some of these occasions.

Within the family, Reem complains that both her parent's fuss too much over her and attempt to cushion her from any of life's potential hazards. Reem feels that they restrict her opportunities to form any adult relationships and she has consequently developed a close friendship with a man of her age without her parents' knowledge.

Reem met Duncan at a local mental health social-support drop-in service that her parents occasionally reluctantly allow her to attend. Duncan also has a history of mental illness. Reem and Duncan would eventually like to live together and he had been pressurising her to tell her parents about their relationship. Her CPN had offered to support Reem in the task. However, the pressure seems to have been too much for Reem's fragile mental health to endure. Superficially in agreement with the plan to tell her parents about Duncan, she had been more worried about it than she let on.

The current situation is that Reem has rapidly become increasingly anxious and depressed. Unable to tell any of those who support her of her deteriorating condition, she masked it as best she could until it was already profound. Once it was recognised by her parents, Reem's mother took on her customary, rather smothering caring role under which Reem has deteriorated to the point where she is mute and not eating. As she is now unable to consent to the hospital care that her CPN considers necessary, the CPN has advised her psychiatrist of a potential need for detention. An MHO has been advised accordingly.

The views of others:

While recognising from past experience that Reem ought to be in hospital, her mother is anxious that her daughter will not receive the personal care and attention she would receive at home. Reem's father is also anxious about her mixing with other mentally ill people in hospital.

Reem's CPN is concerned that Mr and Mrs Jiheli should not find out about Duncan's existence, as Reem was clearly more reluctant to let them know about him than she let on. Duncan, on the other hand, is angry about how Reem is smothered by her parents and he thinks this is the cause of all her mental health problems. He sees this as the perfect opportunity to confront Mr and Mrs Jiheli.

At first glance, Reem's situation appears to be sub-acute. At least, it does not appear to be a situation meriting consideration of compulsory powers, until the case study has developed to the point where Reem is profoundly depressed.

(a) How can you best interpret and take account of Reem's present and past wishes and feelings?

Reem's past wishes and feelings have been expressed ambiguously, in the fear of going against her parents' wishes on the one hand and in her own wish to assert her independence on the other. Her present wishes and feelings appear to be increasingly submerged in her depression and are therefore beyond expression.

(b) How best to have regard for the views of Mrs Jiheli, as Reem's carer?

There are complicated cultural issues attendant upon this. Mrs Jiheli seems to express her role as carer in a way that Reem finds smothering. As the case study develops, it also becomes apparent that Mrs Jiheli is mistrustful of the quality of care her daughter may receive elsewhere. It may be that she shares her husband's view that this care is culturally inappropriate or insensitive.

(c) Given Reem's condition, is there any merit in attempting to engage her in participating as fully as possible in the discharge of the function?

Even with severely depressed people, it is always worth attempting to engage them, if for no other reason than that they sometimes remember and appreciate the human contact in their mute state. It is also a duty of the MHO and others to communicate information about compulsory measures and one should therefore never assume that it is not worth while. Timing and the use of repeated and/or joint interviews with key others may assist.

(d) What is the range of options available in the Reem's case not just in relation to the potential detention itself, but also in relation to the issues discussed above?

These do not vary significantly from the options in Michael's case above, including attempting to introduce services into the home on a voluntary basis. However, while that seems not to have been seriously tried so far, it is also evidently too late for it. Therefore, the following all seem to be worthy of consideration.

• Doing nothing.

• Considering Emergency Detention.

• Considering Short-term Detention.

• Making an application for a Compulsory Treatment Order with powers to compel receipt of services at home or in hospital.

As with Michael, Short-term Detention probably comes out most favourably, with 'doing nothing' as the least justifiable option. It also seems evident that community based treatment is not viable at this stage.

(e) How might you interpret the word 'benefit' in Reem's situation, in respect of 'the importance of providing the maximum benefit to the patient'?

Reem's condition is life-threatening and this focuses benefit on providing services to prevent a deterioration. However, 'benefit' also may be interpreted not just in terms of what you do (for example securing urgent treatment if need be by compulsion), but also in terms of how you do it. In this sense, preserving confidentiality about Reem's boy friend would be of benefit to her.

(f) How can the functions of the Medical Practitioner and the MHO best be discharged in a manner that involves 'the minimum restriction on the patient's (Reem's) freedom that appears to be necessary in the circumstances'?

The question may be answered very much in terms of the response in Michael's situation above. However, it is also not just a question of what you do, but of how you do it. Again, breaking confidentiality about Duncan would be more intrusive than necessary.

(g) What regard should be had in relation to the importance of Reem's background and characteristics, including age, sex, sexual orientation, religious persuasion, racial origin, cultural and linguistic background and membership of any ethnic group?

Taking account of this reflects the problems of Reem's age, sex and sexuality, all of which seem to clash with her cultural background, ethnicity and (it may be implied) her religious background. Very careful regard should be had for all of this.

(h) What are the needs and circumstances of Reem's mother as her carer? Given that, at least in Reem's eyes, she appears to be a rather smothering carer, is your consideration of Mrs Jehali's needs diminished?

Clearly Mrs Jihali also requires the offer of a carer's assessment of need. She requires information and support and she needs to be listened to. Her views of services need to be accommodated and it needs to be borne in mind that considerations of culture reflected in the above principle should also be reflected in the provision of culturally sensitive services.

Case Study, continued….

The Named Person:

Let us now complicate matters by adding a more challenging dynamic to the case: Before Reem became ill, she and Duncan attended a workshop for service users on the 2003 Act. Inspired by this, the couple resolved to make each other their respective named persons. This was competently done, witnessed by Reem's CPN, who had discussed the potential implications of their choice with the couple and now their respective choices of named persons have legal standing.

In securing treatment for Reem, clearly the multi-disciplinary team has to negotiate these difficulties. In doing this, it is important to consider the following facts: Sections 1(3)(b) (i) and (ii) require regard to be had for the views of the named person and carer. On top of these requirements, Emergency and Short-term Detention carry duties on the hospital managers to inform the nearest relative (in the case of Emergency Detention only) i.e Reem's father, and the named person (i.e. Duncan), of the detention. Short-term Detention also requires that the Medical Practitioner who is considering granting it must consult the patient's named person unless it is impracticable to do so. There is no duty upon anyone to notify the nearest relative or the carer of the existence of the named person. However, in thinking this through, it is possible that Reem's father will find out about Duncan. For example, the named person has rights of appeal against Short-term Detention and Mr Jiheli may find out about Duncan and his role, should he choose to exercise these rights.

The Draft Code of Practice enjoins the Medical Practitioner and MHO to undertake as much joint assessment and consultation as possible. It asks the MHO to 'find out as much as is possible under the circumstances about the person's personal and social situation…. Where practicable and where it would not cause undue pressure or concern to the patient, it would also be best practice for the MHO to discuss the situation with the family/carers etc independently of the patient.'

The purpose of the insertion of the second part of the case study is to focus thinking on the role, purpose and implications of 'the Named Person' in relation to the principles and to relatives and carers. The introduction of Duncan as named person is a deliberate strategy to complicate the situation so that a stark contrast is created between the roles of named person and carer. It is also there in order for participants to consider that, even when 'the patient' exercises a competent and reasonable judgement in proposing a named person, it may create complications for them. On the other hand, the intention here is not to place a negative slant on the role of named person.

Questions for case study 2, part 2: Does this information impact upon any of the following questions that we have already asked you above?

(i) How may you best interpret and take account of Reem's present and past wishes and feelings?

In a sense, the revelation of Reem's nomination of Duncan as her named person only serves to emphasise her dilemma: whether to opt for independence while fearing to offend her parents, or to remain loyal to her parents' wishes. However, she has now elevated her boyfriend's status to one of legal standing and as such, it cannot be ignored.

(j) How may you best have regard for the views of Reem's carer (and now her named person)?

Mrs Jihali's views remain unchanged by events, as long as she does not know about Duncan. And, while one cannot realistically prevent Duncan from disclosing his relationship with Reem to her parents, his 'named person' status does not give him a right to do so. Therefore, while taking account of Duncan's views, it may be appropriate to point out to him that they represent his and not necessarily Reem's best interests, and that he may be actually harming her by his preferred course of action now.

Note, however, that there is no requirement in the Act for the named person to operate in a way that reflects the best interests of the patient. Free as they are from the binding principles, the onus is upon the patient to exercise judgement in nominating a person whose actions will be of benefit.

(k) What is the range of options available in the Reem's case, not just to detention itself, but in relation to the issues discussed above?

We have largely addressed this. Reem would seem best served by the immediate securing of Short-term Detention and thereby, obtaining treatment in the absence of Reem's ability to consent.

Other options are to consider that, while not being able to exercise a capacity to consent, Reem does not appear to be objecting to treatment and therefore her situation may be resolved with recourse to treatment under the Adults with Incapacity Act. Such issues may come up in discussion but they are needlessly complicating of our purpose here, the Adults with Incapacity Act better serves the needs of those who have physical treatment requirements and informality does not offer sufficient rights and safeguards. Therefore, paradoxically, it arguably may be seen as more restrictive of freedom.

Any discussion of treatment options risks going beyond the parameters of session 1. It would require more in depth understanding of Part 16 of the Act than participants yet have. For example, to give ECT without Reem's consent, but while she does not object or resist, would require a certificate from her Responsible Medical Officer or a Designated Medical Practitioner stating that she lacks capacity to understand the effects etc of the treatment but that it would be in her best interests as it is likely to alleviate or prevent deterioration of her condition (section 239).

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