Therapy and counselling, mood stabilisers, mental health law

Question 1

What are the principles of psychotherapy?

Answer 1

Develop therapeutic relationship
Listen to patients concerns
Empathetic approach
Provide information support and advice
Allow expression of emotion
Encourage self-help

Question 2

What is psychotherapy?

Answer 2

A treatment based on psychological theory
Treat (mainly) mental and emotional disorders
Generally talking treatments but may also involve computers, books, art, dance and drama
Often at least as effective as biological treatments

Question 3

What are some IAPT/ NHS talking therapies?

Answer 3

Stepped care model
IAPT offer support at steps 2-3
Primary care psychotherapy service
GP or Self-referral
Range of approaches but mainly CBT based

Question 4

What are the different levels of psychotherapy?

Answer 4

1: GP – Assessment and recognitions
2: PWP - Supported self-help. Low intensity CBT / counselling
3: Psychotherapist – Structured high intensity therapy
4: Specialist Psychotherapy
5: Highly Specialised

Question 5

Aim of psychotherapy

Answer 5

support patients in changing the way they interact with and perceive
the world, to come to terms with past stressors and to cope more effectively with current and
future stressors.

Question 6

Psychotherapies used for what illnesses

Answer 6

mild to moderate
depressive illness, bipolar affective disorder, neurotic illness, schizophrenia, eating disorders and
personality disorders.
learning disabilities,
psychosexual problems, substance misuse disorders and chronic psychotic symptoms.

Question 7

What are the indications of CBT?

Answer 7

Mild–moderate depressive illness, eating disorders, anxiety disorders, BPAD,
substance misuse disorders, schizophrenia and other psychotic disorders as an adjunct to
pharmacotherapy, as well as chronic medical conditions (such as fibromyalgia, chronic fatigue
syndrome) or chronic pain.

Question 8

What are the multiple appraoches of CBT?

Answer 8

1st wave: Behavioural Therapies
2nd wave: Cognitive therapy
3rd wave: Combined approaches, integration of mindfulness and acceptance

CBT approaches are generally structured and fairly brief (12-20 sessions) but may be much longer in some cases

The focus is mainly on the here and now, and on problems in day-to-day life but acknowledges the impact of the past.

Question 9

Rationale behind CBT?

Answer 9

Treatment is based on the idea that the disorder is not caused by life events, but by
the way the patient views these events (Fig. 12.1.2). It is a short-term, collaborative therapy,
focused on the ‘here and now’, the goals of which are symptom relief and the development of
new skills to sustain recovery. Some people hold unhelpful core beliefs or ‘silent assumptions’
that they learn from early, traumatic life experiences. These people are more vulnerable to
depression. When exposed to stress at a later date, these core beliefs are activated and they
have negative automatic thoughts or cognitive distortions

Question 10

Example thought process of CBT

Answer 10

Friend didnt call when she said she would = CBT comes in =
Negative automatic thought: friend doesnt like me > Emotional response: sadness> Maladaptive behaviour: attempts to avoid friend > social isolation > worsening of mood

Question 11

Key features to look into with CBT?

Answer 11

Thoughts
Emotions
Behaviours
Bodily sensations

Question 12

What is selective abstraction

Answer 12

Focusing on one minor aspect rather than the bigger picture eg I failed an exam cuz I got 1 question wrong

Question 13

All or nothing thinking

Answer 13

Thinking of things in all or nothing terms eg If he doesnt see me today it means he hates me

Question 14

What is magnification/minimisation

Answer 14

Over-or under-estimating the importance of an event eg He didnt talk to at that meeting, so he must dislike me

Question 15

What is catastrophic thinking

Answer 15

Worst possible outcome of an event

Question 16

What is an overgeneralisation

Answer 16

If one thing is not going well, everything is going wrong

Question 17

What is arbitrary inference?

Answer 17

Coming to a conclusion in the absence of any evidence to support it eg No one likes me

Question 18

Aim of CBT

Answer 18

The aim of CBT is initially to help individuals to identify and challenge their automatic
negative thoughts and then to modify any abnormal underlying core beliefs. The latter is
important in reducing risk of relapse

Question 19

Modes of delivery of CBT

Answer 19

CBT can be delivered on an individual basis, in groups, or as self-help via
books or computer programmes (including online). It is usually fairly brief (6–20 sessions)

Question 20

What is relaxation training?

Answer 20

This is particularly useful for those with stress-related and anxiety disorders.
Here, the patient is asked to use techniques causing muscle relaxation during
times of stress or anxiety. The patient also learns to put themselves in
situations that they find relaxing, such as walking in the fields.

Question 21

What is systemic desensitisation?

Answer 21

This is often used for phobic anxiety disorders. In this therapy, an individual is
gradually exposed to a hierarchy of anxiety-producing situations (

Question 22

What is flooding>

Answer 22

Unlike systemic desensitization, flooding therapy involves the patient rapidly
being exposed to the phobic object without any attempt to reduce anxiety
beforehand. They are required to continue exposure until the associated
anxiety diminishes. It is not a technique commonly used.

Question 23

What is Exposure and
response
prevention
(ERP)?

Answer 23

This therapy can be used for a variety of anxiety disorders but is particularly
useful for OCD and phobias. Patients are repeatedly exposed to the situation
which causes them anxiety (e.g. exposure to dirt) and are prevented from
performing the compulsive actions which lessens that anxiety (e.g. washing
their hands). After initial anxiety on exposure, the levels of anxiety gradually
habituate and decline.

Question 24

What is behavioural action?

Answer 24

This therapy is used for depressive illness. The rationale behind it is that
patients avoid doing certain things as they feel they will not enjoy them or fear
failure in completing them. Behavioural activation involves making realistic and
achievable plans to carry out activities and then gradually increasing the
amount of activity.

Question 25

What are the features of psychodynamic therapy?

Answer 25

Freud’s original model focused on therapy as a process of uncovering past trauma to resolve present day symptoms (originally ‘hysterical’ symptoms, such as dissociative paralysis)

Modern day psychoanalytic approaches are still founded on Freud’s theory but the focus is more broadly on making connections between past and present

Helping the person to become more aware of the unconscious processes which are giving rise to symptoms or to difficult repeating patterns

Helping the person construct a narrative of their life and give meaning to symptoms

Question 26

What is important in psychodynamic therapy?

Answer 26

The therapeutic relationship with the therapist is seen as part of the focus of the work, with the idea that patterns of relating to others in everyday life will come up in therapy, where they are worked on safely

In the NHS psychodynamic therapy typically takes around a year (may be longer) and involves weekly sessions

NICE Guidelines – Depression in young people and adults

Question 27

Indications of psychodynamic therapy?

Answer 27

Dissociative disorders, somatoform disorders, psychosexual disorders, certain
personality disorders, chronic dysthymia, recurrent depression

Question 28

What is the rationale behind psychodynamic therapy?

Answer 28

It is based upon the idea that childhood experiences, past unresolved conflicts and
previous relationships significantly influence an individual’s current situation. It is based on
psychoanalytic principles

Question 29

What is the aim of psychodynamic therapy?

Answer 29

The unconscious is explored using free association (the client says whatever comes to their
mind) and the therapist then interprets these statements. Conflicts and defence mechanisms
220
(e.g. denial, projection) are explored and the client subsequently develops insight in order to
change their maladaptive behaviour.
There is much emphasis on the relationship between the therapist and patient. Therapies can be
offered on an individual, couples, group or residential community basis.
Key therapeutic tools:
1. Transference: The patient re-experiences the strong emotions from early important
relationships, in their relationship with the therapist. When the current emotions are positive
it is said to be positive transference and vice versa for negative emotions.
2. Counter-transference: The therapist is affected by powerful emotions felt by the patient
during therapy and reflects what the patient is feeling.

Question 30

What is the mode of delivery for psychodynamic therapy?

Answer 30

Psychoanalysis is an intense therapy that usually involves between one and
five 50-minute sessions per week, possibly for a number of years. This is a much longer duration
than in CBT.

Question 31

What is psychoeducation?

Answer 31

Psychoeducation (PE) is the delivery of information to people in order to help them understand
and cope with their mental illness.
It is usual to inform the patient of: 1) the name and nature of their illness; 2) likely causes of the
illness, in their particular case; 3) what the health services can do to help them; and 4) what they
can do to help themselves (self-help). PE may take place individually or in groups, and will
usually take the person’s own strengths and coping strategies into account.

Question 32

What is counselling?

Answer 32

Counselling is a form of relieving distress and is undertaken by means of active dialogue
between the counsellor and the client. It is less technically complicated than other forms of
psychotherapy and can range from sympathetic listening to active advice on problem solving

Question 33

Indications of counselling?

Answer 33

Adjustment disorder; mild depressive illness; normal and pathological grief;
childhood sexual abuse; other forms of trauma (e.g. rape, postnatal depression, pregnancy loss
and stillbirth); substance misuse; chronic medical conditions; and prior to decision making, e.g.
genetic testing or HIV testing.

Question 34

Rationale of counselling?

Answer 34

Behaviour and emotional life are shaped by previous experience, the current
environment, and the relationships that individuals have. People have the tendency towards
positive change and fulfilment which can be halted by ‘life problems’. A collaborative relationship
with a counsellor is one method of addressing these issues

Question 35

Aim of counselling

Answer 35

To help the client or patient find their own solutions to problems, while being supported to
do so and being guided by appropriate advice.

Question 36

What is supportive psychotherapy and what does it involve?

Answer 36

Is used to describe the psychological support given by mental health professionals to patients
with chronic and disabling mental illnesses.
It does not aim to produce change, but rather to help people cope with adversity or unsolved
problems over a sustained period.
Key elements include active listening, providing reassurance, providing explanation of the
patient’s illness, providing guidance and possible solutions to difficulties they are faced with, as
well as enabling the patient to express themselves in a safe environment.

Question 37

What is problem-solving therapy and what does it involve

Answer 37

Consists of a structured combination of counselling and CBT. It facilitates individuals to learn to
deal actively with their life problems by selecting an option for tackling each one, trialling out
solutions and reviewing their effect.
Indications are mild anxiety and depressive disorders.

Question 38

What is Interpersonal therapy (IPT)

Answer 38

IPT is used to treat depression and eating disorders.
The focus is on an interpersonal problem such as a complicated bereavement, relationship
difficulties or interpersonal deficit, adopting techniques from different psychotherapies. The
therapy focuses on the difficulties that arise in relationships and the impact on the individual.
It has some overlap with CBT and psychodynamic therapy and deals with four interpersonal
problems (grief at the loss of relationships, role disputes within relationships, managing changes
in relationships and interpersonal deficits) which may be causing difficulty in initiating or
maintaining relationships.

Question 39

What is eye movement desensitisation and reprocessing (EMDR)

Answer 39

EMDR is a psychotherapy treatment that aims to help patients access and process traumatic
memories with the goal of emotionally resolving them.
It is an effective treatment for PTSD.
It involves the client recalling emotionally traumatic material while focusing on an external
stimulus. The stimulus usually involves the therapist directing the patient’s lateral eye
movements by asking them to look one way and then another or follow their finger.

Question 40

Psychotherapy indications

Answer 40

Adverse life events PE, counselling, relaxation training.
Depression PE, counselling, CBT, psychodynamic therapy, IPT, behavioural
activation.
PTSD PE, CBT (trauma focused), EMDR.
Schizophrenia PE, CBT, family therapy.
Eating disorders PE, CBT, IPT, family therapy, CAT.
Anxiety disorders PE, CBT, behavioural therapies.
Substance misuse PE, CBT, motivational interviewing, group therapy.
Borderline personality
disorder
PE, DBT, psychodynamic therapy, CAT.

Question 41

Features of Family/ systemic therapy

Answer 41

NICE guidance – Psychosis, Depression, Perinatal difficulties, substance use, eating disorders

Family attend together. Interactions are observed by other therapists to help therapists and family reflect.

Works with a family’s strengths to help family members think about (and try) different ways of behaving with each other.

Question 42

What is Dialectical behavioural therapy? (DBT)

Answer 42

DBT is used for individuals with borderline PD.
The therapy adopts components of CBT and also provides group skills training to provide the
individual with alternative coping strategies (rather than deliberate self-harm) when faced with
emotional instability

Question 43

Features of DBT

Answer 43

NICE Guidelines – Borderline Personality disorder, Self-harm & Suicidality
Emotion dysregulation, interpersonal difficulties, repeat self-harm / impulsivity

Intensive therapy
1-hour individual therapy weekly
2 hours group skills training weekly
12-18 months total

Learn and apply skills to understand and regulate emotions, manage interpersonal difficulties and tolerate distress.

Question 44

What does DBT mean?

Answer 44

‘Dialectics’ means trying to balance seemingly contradictory positions

Balancing acceptance (yourself and your experiences as you are) and change (making positive changes in your life)

Question 45

What is cognitive analytic therapy (CAT)

Answer 45

Combines cognitive theories and psychoanalytic approaches into an integrated therapy.
It is based on various areas of analysis including analysing problems and difficulties, how they
began and how they affect everyday life as well as analysing the reasons behind symptoms.
Can be used for a range of psychiatric problems such as eating and personality disorders.

Question 46

What are mood stabilisers?

Answer 46

Mood stabilizers are drugs that are used to prevent depression and mania in bipolar affective
disorder and schizoaffective disorder.

Question 47

Examples of mood stabilisers?

Answer 47

Lithium
Topiramate
Gabapentin

Question 48

Treatment of acute mania

Answer 48

Stop antidepressant > Is patient taking antimanic medication >
No: Consider antipsychotic or mood stabiliser - consider short term benzodiazepine for all patients
Yes: If taking antipsycho check compliance and dose or add mood stabiliser - if taking mood stabiliser only check levels and consider antipsychotic - consider short term benzo

Question 49

Indications of Lithium treatment

Answer 49

First-line prophylaxis in bipolar affective disorder. Also effective in an acute
manic episode (if an atypical antipsychotic is ineffective) and as an
adjunctive treatment for depression (to prevent antidepressant-induced
hypomania).

Question 50

Mechanism of action of lithium

Answer 50

Lithium is an element in the body that is handled in a similar way to sodium.
There is some evidence that bipolar patients have an ↑ intracellular
concentration of sodium and calcium, and that lithium can ↓ these. With
lithium, a decreased activity of sodium-dependent intracellular secondary
messenger systems has been shown, as well as modulation of dopamine
and serotonin neurotransmitter pathways, ↓ activity of protein kinase C and ↓
turnover of arachidonic acid. Lithium may also have neuroprotective effects
mediated through its effects on N-methyl-D-aspartate (NMDA).

Question 51

SE of lithium

Answer 51

GI & LITHIUM
Leucocytosis, Impaired renal function, Tremor
(fine)/Teratogenic, Thirst (polydipsia), Hypothyroidism/Hair loss, Increased
weight and fluid retention, Urine ↑ (polyuria), Metallic taste. In toxicity
(‘TOXIC’): Tremor (coarse), Oliguric renal failure, AtaXia, Increased reflexes,
Convulsions/Coma/Consciousness

Question 52

Contraindications and cautions of lithium

Answer 52

Avoid in renal failure, pregnancy (teratogenic) and breast feeding. Caution
with QT prolongation (including concomitant use of drugs that ↑ QT interval),
epilepsy (↓ seizure threshold), diuretic therapy. Lithium is contraindicated in
untreated hypothyroidism, Addison’s disease and Brugada syndrome (heart
disease with ↑ risk of sudden cardiac death).

Question 53

How do we monitor for lithium

Answer 53

Before lithium treatment is started U&Es and eGFR (lithium has renal
excretion and is nephrotoxic), TFTs, pregnancy status and baseline
ECG should be checked. Drug levels should be closely monitored and
patients should be informed of potential side effects and toxicity.
Lithium levels should be monitored 12 hours following the first dose,
then weekly until therapeutic level (0.4–1.0 mmol/L) has been stable for
4 weeks. Once stable check every 3 months.
U&Es should be checked every 6 months.
TFTs should be checked every 12 months.

Question 54

Dosage of lithium

Answer 54

Usually given as lithium carbonate. Must be given for at least 18 months for
clear benefit. Starting dose 400 mg at night. Titrate dose (400–1200 mg/day)
to keep plasma levels between 0.5 and 1.0 mmol/L.

Question 55

What do you do for lithium therapy?

Answer 55

Check lithium levels (12 hours post dose), at least every
three months and during any intercurrent illness (can ↑
causing toxicity).
At each consultation, ask about any signs of toxicity or
signs of hypothyroidism.
Check thyroid function, U&Es, calcium and creatinine
every 6–12 months.
Inform patients: of potential toxicity and symptoms of this;
the need for contraceptives in women of child bearing
age; the need for regular fluid intake; the need for
compliance in taking medication; of the dangers of crash
diets; to avoid NSAIDs; not to exceed more than 1–2 units
of alcohol per day; that it takes 3–6 months to be
established on lithium, and that lithium cards are available
from pharmacists.

Question 56

What do you not do in Lithium therapy

Answer 56

Prescribe if you are not a
specialist.
Give lithium to women of
child bearing age. Lithium
is teratogenic and can
cause congenital heart
defects.
Give in severe renal
failure.
Prescribe NSAIDs,
diuretics (particularly
thiazides) or ACE
inhibitors without careful
thought.
Prescribe lithium if you
feel that adherence to
treatment will be a
problem.
Withdraw lithium abruptly.
Abrupt withdrawal (either
because of poor
compliance or rapid
change in dose) can
precipitate relapse.
Withdraw lithium slowly
over several weeks,
monitoring for signs of
relapse

Question 57

How do we manage lithium toxicity>

Answer 57

Lithium toxicity is a medical emergency which can lead to seizures, coma and death.
Lithium toxicity is enhanced by the 4 D’s: Dehydration, Drugs (ACE inhibitors, NSAIDs),
Diuretics (thiazide), Depletion of sodium.
If signs of toxicity are identified, lithium should be stopped immediately.
A high intake of fluid should be provided including intravenous sodium chloride therapy, to
stimulate osmo tic diuresis. In the most severe cases, renal dialysis may be needed.

Question 58

Indication of sodium valproate (valproic acid) treatment

Answer 58

Comparable efficacy to lithium as a mood stabilizer. If lithium (and an atypical
antipsychotic) is ineffective or unsuitable in acute mania. Used in
combination with lithium for rapid cycling bipolar affective disorder

Question 59

Mechanism of action of sodium valproate

Answer 59

Valproate is a simple branched-chain fatty acid. It is thought to inhibit the
catabolism of GABA, ↓ turnover of arachidonic acid and activate extracellular
signal-regulated kinase. This alters synaptic plasticity, interferes with
intracellular signalling, promotes brain-derived neurotrophic factor (BDNF)
expression and ↓ levels of protein kinase C.

Question 60

SEs of Sodium Valproate

Answer 60

GI and VALPROATE
GI disturbances, Very fat (↑ weight), Aggression, LFTs ↑, Platelets low
(thrombocytopenia), Reversible hair loss (in 10%), Oedema (peripheral),
Ataxia, Tremor/Tiredness/Teratogenic, Emesis.

Question 61

Contraindications of sodium valproate

Answer 61

Avoid in pregnancy (can cause neural tube defects in the fetus and result in
spina bifida), hepatic dysfunction and porphyria.

Question 62

Monitoring of sodium valproate

Answer 62

FBC (to check platelets) before therapy and before any surgery. Monitor
LFTs and prothrombin time (PT) before therapy and during first 6 months.
Pregnancy test and weight/BMI before commencing. Check LFTs, FBC and
weight again after 6 months then annually.

Question 63

Dosage of sodium valproate

Answer 63

Dose started at 250–500 mg daily, and subsequently titrated upwards.
Oral. IV only used for epilepsy.

Question 64

Indications for carbamazepine

Answer 64

Mania (not first-line), prophylaxis of bipolar affective disorder unresponsive to
lithium. Alcohol withdrawal.

Question 65

Mechanism of action for carbamazepine

Answer 65

Carbamazepine blocks voltage-dependent sodium channels, and therefore
inhibits repetitive neuronal firing. It ↓ glutamate release and ↓ turnover of
dopamine and noradrenaline.

Question 66

SE of Carbamazepine

Answer 66

GI disturbances, dermatitis, dizziness, hyponatraemia, blood disorders e.g.
leucopenia, thrombocytopenia.

Question 67

Contraindications of carbamazepine

Answer 67

Caution in cardiac disease and blood disorders. Contraindicated in AV
conduction abnormalities and acute porphyria. Avoid in pregnancy (can
cause neural tube defects in the fetus).
NOTE: Is a potent enzyme inducer so drugs such as COCPs will be
metabolized faster. If the COCP is being used as a contraceptive, other
methods should be considered.

Question 68

Monitoring of carbamazepine

Answer 68

Check WCC after a week. Measure plasma carbamazepine levels if signs of
toxicity. LFTs and U&Es (hyponatraemia). Baseline measure of weight is
desirable

Question 69

Dosage of carbamazepine

Answer 69

Start at 400 mg daily in divided doses. Build up (max 1.6 g/day).
Oral.

Question 70

Indications of lamotrigine

Answer 70

Used to treat bipolar depression. It is less teratogenic than the other mood
stabilizers and therefore usually the drug of choice in women of child bearing
age. Lamotrigine does not treat or prevent manic episodes.

Question 71

Mechanism of action of lamotrigine

Answer 71

Lamotrigine is thought to work by inhibition of sodium and calcium channels
in presynaptic neurons and subsequent stabilization of the neuronal
membrane.

Question 72

SEs of lamotrigine

Answer 72

GI disturbances, rash (in around 5% of patients), headache and tremor

Question 73

Contraindications of lamotrigine

Answer 73

A combination of lamotrigine and carbamazepine may cause neurotoxicity

Question 74

Monitoring of lamotrigine

Answer 74

LFTs, FBC and U&Es prior to starting. Do not routinely measure plasma
lamotrigine levels unless there is evidence of ineffectiveness, poor
adherence or toxicity.
NOTE: Inform patients to see doctor if signs of hypersensitivity e.g. severe
rash, fever, lymphadenopathy (antiepileptic hypersensitivity syndrome)

Question 75

Dosage of lamotrigine

Answer 75

Must be initiated very gradually beginning at 25 mg daily.
NOTE: Avoid abrupt withdrawal (unless serious Stevens–Johnson rash).
Oral.

Question 76

What is a fundamental principle of medical care

Answer 76

for treatment to be given to the patient, consent
should be gained, i.e. the patient has a right to decide for themselves which treatment to undergo
and which treatments to refuse.

Question 77

What is mental capacity defined by?

Answer 77

one’s ability to make decisions. Capacity can involve consent about
personal welfare, healthcare and financial decisions.

Question 78

What is time specific mental capacity?

Answer 78

Person may lack capacity at one point in time but may have capacity at
another point in time. If the lack of capacity is likely to be temporary, e.g. delirium, it may be
possible to delay the decision until the person has recovered.

Question 79

What is decision specific mental capacity?

Answer 79

May have capacity to consent for one decision but not for another (e.g.
may have capacity to consent for a simple endoscopy but not for a more complex surgical
procedure which poses greater risks, such as a hemicolectomy).

Question 80

What are the situations where treatment can take place without consent?

Answer 80

1. Treatment under the Mental Capacity Act.
2. Treatment under the Mental Health Act.
3. Treatment authorized by a court.

Question 81

What is common law

Answer 81

Common law is the law based on previous court rulings, which differ from laws that are created
by acts of parliament such as the Mental Health Act and the Mental Capacity Act.

Question 82

What is the mental capacity act (2005)

Answer 82

A person may lack capacity to make a decision for a variety of reasons, e.g. dementia, delirium,
intellectual disability, neurological disorder.
The Mental Capacity Act (MCA) aims to identify those people who may lack capacity to consent
to or refuse treatment (see OSCE tips 1 and Fig. 12.7.1) and to protect them. The MCA applies
to England and Wales only and failures to comply with the Act are potentially criminal offences.

Question 83

What is the mental capacity assessment

Answer 83

Look at page 252 of susmit das book

Question 84

When do we suspect a lack of capacity?

Answer 84

CARD
Cognitive impairment, e.g. dementia.
Abnormal behaviour.
Refusing treatment.
Delirium.

Question 85

What are the 5 key principles of the Mental Capacity Act (2005)

Answer 85

1. Best Interests: Decisions made on behalf of the patient must be in their best interests.
2. Help to make decisions: People must be given all appropriate help before anyone concludes
   that they cannot make their own decisions, e.g. use of interpreters and multiple times (as
   capacity may fluctuate).
3. Eccentric or unwise decisions are allowed: Capacity is determined by the way in which a
   decision is made and not the decision itself. Therefore, it does not matter how unwise the
   decision is.
4. Least restrictive intervention: Decisions made on the patient’s behalf should be the least
   restrictive option.
5. Presumption of capacity: Capacity is assumed to be present until proven otherwise

Question 86

What is a lasting power of attorney?

Answer 86

This allows a person with capacity to appoint an attorney (usually a relative or close friend) to
make future decisions on their behalf if they lose capacity.
There are two types of lasting power of attorney:
1. Property and affairs deals with property and financial affairs.
2. Personal welfare deals with decisions about healthcare, living conditions and location.

Question 87

What is advance care planning?

Answer 87

process that allows patients to make decisions about their future
care. It takes the form of making an advance statement or an advance decision to refuse
treatment, or appointing a lasting power of attorney.

Question 88

What is an advance decision or advance directive?

Answer 88

legal document with a specific refusal of treatment
in a predefined future situation (where the person would have lost capacity) that is signed by the
patient and witnessed. Advance decisions permit a person to refuse treatment but not demand it.

They do not allow patients to refuse basic care needs such as food and drink by mouth or basic
hygiene. Persons writing an advance decision should have capacity at the point of writing it

advance decision only concerns refusing certain treatments. An advance statement can
also be used to express other wishes and preferences not directly related to care, e.g. stating food
preferences. Advance statements are not legally binding like advance decisions

Question 89

What is an advance statement?

Answer 89

(made verbally or written) allows the patients to make general statements
about their wishes and preferences for the future, if they were to lose capacity.

Question 90

What is the Deprivation of Liberty Safeguard (DoLS)

Answer 90

The aim of DoLS is to make sure that people in care homes, hospitals and supported living, who
lack capacity, are looked after in a way that does not inappropriately restrict their freedom.
When a hospital or care home identifies that a person who lacks capacity is being, or risks being
deprived of their liberty, they must apply for an authorization of deprivation of liberty

Question 91

What is Independent Mental Capacity Advocate (IMCA)

Answer 91

An IMCA is someone appointed to support a person who lacks capacity but has no one to speak
on their behalf (i.e. no next of kin or lasting power of attorney).
The IMCA makes representations about the person’s wishes, feelings, beliefs and values, while
bringing to the attention of the decision maker all factors that are relevant to the decision.

Question 92

What is the Mental Health Act 1983 Amended in 2007

Answer 92

The Mental Health Act (MHA) (1983, amended in 2007) is the law in England and Wales that
allows people with a ‘mental disorder’ (see Key facts 2 for definition) to be sectioned, i.e.
admitted to hospital, detained and treated without their consent – either for their own health and
safety, or for the protection of other people.
This is used for individuals who will not consent to be admitted voluntarily, or who lack capacity to
consent to admission and treatment.
Patients who are only under the influence of alcohol or drugs are specifically excluded.

Question 93

When do we decide when to use the MHA 1983

Answer 93

Page 255 Susmit Das book

Question 94

Common abbreviations related to the Mental Health Act (MHA)

Answer 94

MHAC: Mental Health Act Commission (MHA is supervised by this commission).
AMHP: Approved mental health professional (they make an application for the patient to be
sectioned. They may be social workers, nurses, psychologists or OTs, but not doctors).
AC: Approved clinician (almost always doctors but can be other professionals. If they are
section 12, it means they are approved by the Secretary of State as having expertise in the
assessment and treatment of mental disorders as described in Section 12 of the MHA).
NR: Nearest relative.
CTO: Community treatment order

Question 95

What is the definition of a mental disorder?

Answer 95

A mental disorder is defined as any disorder or disability of the mind. It includes mental illness,
personality disorder, learning disability and disorders of sexual preference (e.g. paedophilia), but
NOT dependence on alcohol or drugs.

Question 96

When to use Mental Health Act 1983/2007

Answer 96

Revise Our Mental Health Act
Refusal of voluntary treatment.
Other options have been considered but are not appropriate.
Mental disorder: The behaviour must be the result of a known or suspected mental disorder.
Harm (risk of): The person must be at significant risk of self-harm, self-neglect or harm to
others.
Appropriate treatment: There must be an appropriate treatment option available to the patient.

Question 97

Purpose and recommendations for Section 2 and 3 under MHA

Answer 97

Purpose: Section 2 (s2) allows for an admission, for assessment and response to treatment. It
lasts up to 28 days. The purpose of section 3 (s3) is for the treatment of a mental disorder.
Patients can be detained under s3 if they are well known to mental health services or following
an admission under s2. For s3, patients can be detained for up to 6 months, but may be
discharged before this. Detention under s3 can be renewed for a further 6 months. After that,
detention can be renewed for further periods of one year at a time.
Recommendations: For s2 and 3, an AMHP or rarely the NR makes the application on the

Question 98

Patients rights in section 2 and 3 under MHA

Answer 98

A patient under s2 can appeal against the section to a tribunal during the first 14 days and to
hospital managers at any time.
For s3, patients have the right to appeal against detention to a tribunal (only one time)
during the first 6 months of detention. If the s3 is renewed, an appeal can be made once
during the second 6 months. Then an appeal can be made once during each one-year
period.
Patients have the right to apply for discharge to the Mental Health Act managers at any time
whilst they are detained and an Independent Mental Health Advocate can be sought to raise
any issues patients have with their care and treatment.
Under s2 and s3, patients can’t refuse treatment. Under s3, patients can be treated against
their will for 3 months, but after this time they are seen by a second opinion appointed
doctor (SOAD) if they lack capacity to consent or are refusing treatment. A SOAD carries
out an assessment to see if they think that the treatment is needed.
Some treatments can’t be given without consent unless certain criteria are met. These
treatments include ECT.

Question 99

After care for section 2 and 3 under MHA?

Answer 99

Free aftercare is provided for patients when discharged from s3. This is known as
section 117 aftercare.

Question 100

What are the emergency sections

Answer 100

Section 4
Section 5(2)
Section 5(4)
Section 135
Section 136
All last up to 72 hours apart from section 5(4) which is up to 6 hours

Question 101

What is section 4

Answer 101

Used as an emergency, when s2 would involve an unacceptable delay. Often
changed to a section 2 upon arrival at hospital. It can be done by one doctor with an AMHP or
nearest relative (NR). There is no right to appeal.

Question 102

What is section 5(2)

Answer 102

Is the urgent detention of inpatients on any ward excluding A&E, by an AC.
Patients on s5(2) must then be assessed for s2 or s3 or discharge from s5(2) to become an
informal patient. There is no right to appeal.

Question 103

What is section 5(4)

Answer 103

Allows urgent detention for up to 6 hours of an inpatient already receiving
treatment for a mental disorder in hospital. It is carried out by a registered mental health nurse
when a doctor is unable to attend immediately. There is no right to appeal.

Question 104

What is section 135

Answer 104

Allows a police officer or authorized person with a magistrate’s warrant to enter a
person’s premises, who is suspected of suffering from a mental disorder, and remove them to a
place of safety.

Question 105

What is section 136

Answer 105

Allows a police officer to remove an individual, who appears to suffer from a mental
disorder, from a public place to a place of safety for assessment.

Question 106

What is a community treatment order

Answer 106

A community treatment order (CTO) allows patients on s3 who are well enough, to leave the
hospital for treatment in the community.
The decision is made by the responsible clinician (RC) with the agreement of the AMHP.
The patient can be recalled to hospital if they do not comply with treatment or attend
appointments. Once recalled they may be detained for up to 72 hours for assessment.

Question 107

Other notable sections

Answer 107

Section 117: Deals with aftercare responsibilities after a patient has been detained under s3.
Sections 35–38: Used by a court to send offenders to hospital for psychiatric assessment.
Section 7 (guardianship): Gives power to specify where the patient lives and requires them to
give professionals involved in their care, access to their home.
Sections 58 and 59: Deal with treatments requiring consent or second opinion and consent and
second opinion, respectively.
Section 62: Concerns urgent treatments such as ECT for life-threatening depression.

Question 108

Section 2

Answer 108

Admission for assessment
– not renewable.
Assessment
An AMHP or rarely the NR
makes the application on the
recommendation of two doctors.
One of the doctors should be
‘approved’ under Section 12 of
the MHA (usually a consultant
psychiatrist).
28 days
Duration: 28 days
Renewal: No
Purpose: Assessment +/- treatment (with or without consent)
Professionals involved: 2 doctors (one S12 approved), 1 AMHP
Evidence required:
The patient is suffering from a mental disorder that is…
Of a nature or degree that warrants detention in hospital for assessment; and
The patient ought to be detained for his or her own health or safety, or the protection of others
Tribunal: Yes

Question 109

Section 3

Answer 109

Admission for treatment –
renewable.
Treatment Same as section 2.
6 month
Duration: 6 months
Renewal: Yes, each renewal then lasts 12 months
Purpose: Treatment
Professionals involved: 2 doctors (one S12 approved); 1 AMHP; Nearest Relative
Evidence required:
The patient is suffering from mental disorder that is…
of a nature or degree which makes it appropriate for the patient to receive medical treatment in a hospital; and
The treatment is in the interests of his or her health and safety and the protection of others; and
Appropriate treatment must be available for the patient
Tribunal: Yes; also, more significant role of Nearest Relative

Question 110

Section 4

Answer 110

Used as an emergency,
when a section 2 would
involve an unacceptable
delay. Often changed to a
section 2 upon arrival at
hospital.
Emergency GP and AMHP or NR. 72
hours
Duration: 72 hrs
Purposes: Admission for assessment when there is an “urgent necessity” in which waiting for a second doctor would lead to “undesirable delay”
Professionals required: 1 doctor; 1 AMHP or Nearest Relative
Evidence required:
The patient is suffering from a mental disorder that is…
of a nature or degree that warrants detention in hospital for assessment; and
The patient ought to be detained for his or her own health or safety, or the protection of others; and
There is not enough time for 2nd doctor to attend (risk)

Question 111

Section 5(2)

Answer 111

A patient who is a voluntary
patient in hospital can be
legally detained by a doctor.
Holding Doctor. 72
hours
For a patient already admitted (can be psychiatric or general hospital) but wanting to leave
Duration: 72 hours
Renewal: No
Purpose: Allows time to convene MHA assessment
Treatment: Cannot be coercively treated
Evidence required:
It appears to the registered medical practitioner that an application ought to be made [under the Act] for the admission of the patient to hospital
Tribunal: No

Question 112

Section 5(4)

Answer 112

Similar to section 5(2) but
completed by nursing staff.
Holding Nurse. 6 hours

For a patient already admitted to hospital (psychiatric or general) but wanting to leave
Duration: 6 hours
Renewal: No
Purpose: Allows time for MHA assessment
Treatment: Cannot be coercively treated
Evidence required:
It appears that the patient is suffering from mental disorder…
to such a degree that it is
necessary for his health or safety or for the protection of others for him to be immediately restrained from leaving the hospital
Tribunal: No

Question 113

Section 135

Answer 113

A court order can be
obtained to allow the police
to break into a property to
remove a person to a place
of safety.
Police Magistrate/Police officer. 72
hours
Allows police to legally enter a private dwelling and remove someone to a place of safety
Duration: 24 hours
Professionals involved: AMHP
Needs a court order (Magistrate)
Renewal: No
Evidence Required:
Reasonable cause to suspect that a person believed to be suffering from mental disorder; and
Is being ill-treated; or
Is living alone and is unable to care for themselves

Question 114

What is a private dwelling??

Answer 114

What is a private dwelling?

Any house, flat or room where that person, or any other person, is living; or

Any yard, garden, garage or outhouse that is used in connection with the house, flat or room, other than one that is also used in connection with one or more other houses, flats or rooms.

Question 115

Section 136

Answer 115

Allows police to legally detain (not arrest) someone in a public place without a warrant and remove them to a place of safety
Duration: 24 hours
Professionals involved: Police
Renewal: No
Evidence Required:
A person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control

Question 116

What is needed for someone to have a mental disorder?

Answer 116

Mental Disorder
What’s included? What’s excluded?
Nature / Degree
Section 12 Approved Doctor
“Special experience in the diagnosis or treatment of mental disorder”
Approved Mental Health Professional (AMHP)
Social worker, Psychiatric Nurse, OT, Psychologist
Nearest Relative
Section 26 MHA
Listed in terms of priorities
Has certain powers and responsibilities
Place of Safety
ED
Police Cell
Psychiatric Hospital (‘136 Suite’)

Question 117

Who does the mental health disorder exclude?

Answer 117

Disorder:
“Any disorder or disability of the mind” – Ch 1, MHA
Excludes
Acute intoxication
Autism / ID alone unless accompanied by “abnormally aggressive or seriously irresponsible conduct” (MHA CoP 2.15)

Question 118

What are the guiding principles of the mental health law?

Answer 118

Least Restrictive Option
Empowerment and Involvement
Respect and Dignity
Purpose and Effectiveness
Efficiency and Equality

Question 119

What are the guiding principles of the mental health law? (2)

Answer 119

Respect for patients’ past and present wishes and feelings
Respect for diversity
Avoidance of unlawful discrimination
Involvement of patients, carers, and other interested parties in planning, developing, and delivering care and treatment appropriate to them
Effectiveness of treatment
Patient wellbeing and safety
Public safety
Minimising restrictions on liberty