89. Recent research has emphasised the high prevalence of substance misuse among acute in-patients - close to 50%. Alcohol is the major problem drug, with illicit substances second. Mental health service staff have to be aware of the tension between received social values, actual behaviour in the community, their own personal standards, and what is required of them professionally. These should not be confused when assessing risk and delivering care.
90. The Mental Welfare Commission commented in its 1996/97 Annual Report4 on a growing awareness, from carrying out its statutory duties, that illicit drug and substance misuse by in-patients in psychiatric units and hospitals was increasingly presenting problems to staff in maintaining acceptable and safe care environments. Many staff voiced concerns to the Commission about the appropriate course of action to take if they suspected or discovered that a patient had, or was using, an illegal substance. The patients described by staff to the Commission appeared to fall into 2 groups, those with a history of drug related problems, and a secondary diagnosis of psychotic breakdown, and those with a primary mental health problem who used drugs recreationally, or perhaps in an attempt to reduce their symptoms. In the first group there is the risk that substance misuse would worsen the mental health problem. In the second there is the danger that the misused substance would work against the treatment medication.
91. In all cases, staff reported problems in deciding how to act in the patient's best interests, being aware of their mental state at the time, while respecting confidentiality and protecting other vulnerable patients and minimising their own legal liability. A survey of Trusts in Scotland who provided mental health services showed a worrying variety of approaches, and failure to address some of the key issues. Inaction exposes both organisation and staff to risk in an unjustifiable way. Action which is going to be effective in dealing with the issues has to maintain a balance between individual rights to privacy and wider concerns.
92. Specialisation of psychiatric services has allowed the development of innovative and more effective ways of practice. However, it is clear that individuals with mental health problems do not fit easily and simply into just one category. Boundaries between specialist services can serve to obstruct integrated comprehensive and best care for individuals. Clinical improvement cannot be achieved in this area by putting one set of problems on "hold" while the other is dealt with.
93. Thus agencies that provide mental health services need to work out with the police and their own legal advisers, clear policies and guidance for staff on:
when it is appropriate to search in-patients and their belongings;
implications of the legal status of individuals and their civil liberties;
informing individuals of the harm done to their mental state by substance misuse;
mechanisms of informing service users of services of the dangers of substance misuse, the local policy regarding searching belongings for an individual's supply and what rights an individual has;
local agreement with police and the Procurator Fiscal about the steps to be taken if illicit substances are found;
disposal/transfer of surrendered/discovered illicit substances;
urine testing to screen for illicit substances;
training staff to perform these duties sensitively.
training which reflects the skills they need to practise there and then, updating and augmenting earlier training;
awareness of the policies and relevant operational guidance in existence.
".....clearly he was under the influence......"
94. The additional influence of intoxication, by drugs or alcohol, is a complicating factor in the assessment of the risk an individual poses to himself or others. About two-thirds of all episodes of deliberate self-harm take place under the influence of alcohol. Alcohol consumption and substance misuse add greatly to the potential for violence to self or others. Individuals present to general practitioners, A & E departments or to mental health crisis services seeking help, often admitting to suicidal thoughts but are unpredictable in behaviour and reaction. They have to receive assessment and care which is professional, humane and appropriate.
95. In a forensic context, intoxication is not a defence against conviction for a crime committed under the influence. In a mental health service context violence or damage should be dealt with by informing the police and pursuing redress. Personal responsibility continues. Yet there is a common law responsibility to care for someone temporarily "out of his mind". Also there are professional responsibilities to behave within expected limits to an individual defined as a patient. Intoxication alone is not a reason for refusal to see a person - instead, it is a reason for that person to be seen in the right environment with the right supports available for the safety of all concerned.
96. The staff member may be irritated and feel that time is being wasted, blame the individual for getting into that state, and feel anxious because of previous adverse experiences.
97. Individuals may be anxious about approaching services and use alcohol to calm themselves. A hidden physical injury or illness may be present, affecting behaviour adversely. Every effort has to be made to speak to any informant who can give an account of the previous few hours. Has there been a previous history of self-destructive behaviour? That day? What are the risk factors known to those around the individual? Particularly are there risks to others in the individual's circle who are at risk from his behaviour while intoxicated?
98. One of the paradoxes in service provision is that emergency out-of-hours psychiatric rota may leave decision making on such anxiety provoking matters to a junior, inexperienced doctor. The availability of supervision and willing support from senior colleagues is absolutely essential. It is questionable whether an individual should be seen by just one worker - good, safe practice demands 2 at least. Operational policies should be in place to plan for the risks found especially in this situation and managers should be closely involved in monitoring events.
99. When it is decided that an admission is appropriate, in-patient nursing staff deserve to receive the additional support required to provide the care the individual needs.
100. Sending an individual away to "cool off" may increase the potential risk without attendant safeguards, such as a reliable, unintoxicated companion alert to the dangers.