Section 25 of Mental Health Act order admitting boy with OCD to CAMHS in-patient unit – 2023vol1#62

The Health Service Executive (HSE) applied to the Dublin Metropolitan District Court for an order under section 25 of the Mental Health Act 2001, in respect of a teenager with severe obsessive-compulsive disorder (OCD) to be admitted to and detained in a Child and Adolescent Mental Health Services (CAMHS) inpatient unit. The application was made by way of short notice and was heard by the court as a priority.

Both parents of the boy were present in court. While the boy’s mother was supportive of the application, his father, although not objecting to the application, was very concerned that the change in environment in being admitted to the CAMHS inpatient unit would be extremely difficult for his son.

The HSE lawyer explained to the judge that the boy suffered from an extreme form of OCD. He did not leave the house and would only eat a very restricted type of food. On the very rare occasions that the boy had left the house, he subsequently engaged in a cleaning ritual involving up to six to nine hours in a shower.

The boy had previously engaged in cognitive behavioural therapy (CBT) sessions between April 2019 and January 2020, which had helped him at the time, but his symptoms had subsequently returned and had become even worse. The boy had not complied with his medication regime since the end of 2022. The Child and Family Agency’s (CFA’s) lawyer said that a psychiatrist had engaged with the boy through his bedroom door. She had recommended a number of community-based steps for the boy to follow. However, it had proved impossible for the boy to do these.

The HSE’s lawyer said that in addition to the section 25 order, the HSE was also seeking a number of ancillary reliefs as follows:

  1. Permission for the HSE to engage a specialist service of trained nurses and medical specialists who would assist with the admission of a person who does not want to be admitted to hospital. This specialist admissions team would engage with the boy and his parents in order to effect the transfer with the least amount of distress;
  2. A number of standard reliefs that usually accompany section 25 orders and which enable the clinic team to treat a young person in their care;
  3. A general relief that allowed the boy to be transferred to a general hospital in the event he required any general medical care.

The judge spoke directly to the boy’s parents. She acknowledged that the court room environment was very intimidating and stressful and she encouraged them to ask any questions that they wished at any stage of the proceedings.

The consultant psychiatrist was then called to give her expert evidence to the court as to why the section 25 order was required. The consultant psychiatrist first confirmed the contents of her report and that she was not related to the boy. She went on to outline the background information and the boy’s circumstances at the time of the hearing.

She said that the boy first came to her clinic for treatment in 2018. He was suffering from quite severe OCD at the time. He had required 45 sessions of CBT before he began to respond well. It had taken a long time to engage the boy but he had done well following his discharge.

However, the boy had deteriorated during the second Covid lockdown. His OCD had become worse but he had been reluctant to do any more CBT. He had said that he was so stressed that he could not do the CBT therapy. In 2021 he had told her that he was not going to continue with his medication.

The psychiatrist told the court that the boy had not engaged as well with her the second time compared to the first time. She said that on the second occasion, he had completed 25 CBT sessions, but she admitted that the evidence was poor that more than 20 CBT sessions really worked. The boy had told her that he had found the sessions too scary and as a result he had not tried as much.

While on medication there had been occasions when the boy would leave the house, after which he would then need to shower for between two and four hours. However, now that he was off his medication, if the boy left the house he had to subsequently shower for up to nine hours. She said that the OCD had taken over all his life but he had not been willing to try medication again.

The psychiatrist said that the boy did not want to go to hospital, but he did want to meet his friends and to finish his education. She said that he believed that at some stage he would be able to do so. The psychiatrist told the court that the choice was either to let him stay in his own room or, as a last attempt, that they could bring him into hospital in order to treat him as an inpatient.

The psychiatrist confirmed that the boy definitely had severe OCD and that this condition was considered to be a mental disorder as per the section 25 requirements.

When asked by the judge if she was satisfied that there would be a significant deterioration in the boy’s illness if this order was not made, the psychiatrist responded that she could not be 100 per cent sure that the detention would help. However, she said that it was likely that he would improve. She noted that the medication the boy had been prescribed did not cause side effects, but that he just did not like the idea of taking it. However, she believed that he would work hard in order to get himself out of hospital.

When asked, she said that he was not at risk of causing harm to others. When on medication he actually improved when he left his room. She thought that the boy’s OCD was prompted by something linked to his bedroom. For example, when he had gone on a week’s summer camp, his condition had actually improved and he had not felt the need to take showers during that time.

The psychiatrist felt that getting the boy out of his room was key and that the room was linked to the complicated rituals of the OCD. She said that another possible way to deliver the treatment required was to go to the house, but that this was unusual and also intrusive. She said that when she had examined the boy via Zoom he had told her that he did not want to go to hospital. He also had agreed to go to his GP for a check-up and to have bloods done, but he told the team later that this had been too difficult.

The psychiatrist told the court that the boy believed that he could stop anytime, but that this belief did not match with what had actually been going on. She said that she was aware of the parents’ concerns regarding involuntary admission of their son. However, she said that in her experience, the specialist-assisted admissions team had never had to intervene physically with a young person. The team were very experienced and very good at what they did. She said that the process would not be easy, but it was a chance to break the rituals and to be a circuit breaker. She could not be 100 per cent sure, and there was a risk he might relapse, but if it were not done, the boy was at serious risk.

The judge noted that the HSE was requesting a section 25 order for 14 days and asked for the rationale for this. The psychiatrist replied that the rationale was because the parents were concerned about the boy and that he himself did not want to go into hospital. The time line was to allow them see how things were going. The psychiatrist told the court that it was her professional opinion that the section 25 application was appropriate and in the best interests of the boy.

The judge, relying on section 3(1)(b) of the Mental Health Act 2001 that the severity of the boy’s illness was such that a failure to admit him would likely lead to a serious deterioration in his condition, and that his treatment would be likely (albeit not guaranteed) to benefit or alleviate his condition to a material extent, granted the section 25 order for 14 days. She noted that the measure was the last treatment option on the table for the boy and that all other options had been exhausted.

The judge noted that the boy’s mother had consented to the application and that though the boy’s father was not objecting, he had expressed his worry about admitting his son against his will. The CFA’s lawyer asked the judge if she would consider appointing a guardian ad litem (GAL) to the boy. The judge agreed to this request.

Having heard the evidence of the consultant psychiatrist and considered the parents’ views, the judge granted the section 25 order for 14 days.

Addressing the boy’s parents, she said that she hoped that this would be the start of a better time for their son and that the treatment would give him a chance of recovery. She acknowledged the very long road that had been travelled to get to this point.