In psychiatry you have to cover the whole bio-psycho-social spectrum. This ugly word refers to the notion of not only understanding someone’s physical health but also the way they are thinking and feeling, who they live with and what they do. The simplest way of grasping those social conditions is to knock on the front door and see what is going on inside a patient’s home. If they don’t let us in, we try again, sometimes several times. If we become concerned enough, we turn up with a locksmith, a housing officer and the police. Such “domiciliary visits” (shortened, in the usual way of health professionals, to DVs) occur almost weekly. If you are going with the police and you plan to bring them (in front of you), the simpler term is “dawn raid”.
We went to see Mr P because of the concerns of the neighbours. He was making a lot of noise, banging on the ceiling, and the housing association wanted something done. He had been in hospital three months earlier, with TB, but someone had noticed (in between the X-rays and blood tests) that he said some strange things: that he was an undercover operator for the CIA and that he had done some rather special ops. He also believed he was owed at least £1m in back pay and that the judge in a recent court case, when he was charged with a rumpus in the back of a bus, was aware of his claim for compensation and would award him the money. On being asked about these things he quickly went quiet and got himself out of hospital.
The visit was nicely expository. While there is an unavoidable voyeurism in seeing people at home, once the door is open, often all is clear. In Mr P’s case, the door was only ajar, he was half-dressed, and he stared out distractedly. There was a smell of stale rice and body odour, the flat looked bare and disordered, and he was unwilling to talk at length.
There were hints of grandiosity when asked about the money he was owed. He advised that he was of royal descent but did not want to discuss that now. At times it was difficult to follow the logic of his statements, and he muttered to himself under his breath. “Would you like some help, Mr P?” we asked, “because we know you are short of money and may be able to discuss this with our social worker.” He looked briefly interested, but denied causing any nuisance, said the neighbours were shouting at him, not the other way round, and did not think he needed any medication. What to do?
The senior trainee, who came on the visit, thought that we should revisit to try to get a bit more detail. Like all good psychiatrists she also wanted a corroborative history, in which you don’t just take on what the patient tells you, but find out from an objective source what has actually been happening. She tried to follow some of Mr P’s logic. But I was quite clear in my own mind that I could not. As a consultant psychiatrist, if I can’t understand people, then (and this is the special delusion of Consultancy) the chances are they’re not thinking straight.
When we checked with the housing association, problems seemed to be both persistent and getting worse, so we decided to recommend detention under the Mental Health Act. This means the usual wheels start turning, and the approved mental health practitioners are contacted along with the police and ambulance service. It normally takes three to four days for them to arrive at the door. That’s acute psychiatry for you: DVs, doorway diagnosis and detention. In Mr P’s case, he was admitted, treated and got better.
Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity