‘Beautifully masked’: hidden tragedies at the heart of Mental Health Act assessments in England

ABSTRACT

This article considers the difficulties faced by social workers and others who have concerns about the reliability of information provided by people they are assessing in England under the Mental Health Act 1983. The article is in two parts, the first part includes descriptions of case studies which highlight difficulties in assessments when assessors need to note what they are told and yet sometimes also fear that the truth of this information might be knowingly or unknowingly masked. The second part of the article argues that a understanding of Shakespeare and other creative writers can enhance and expand empathy and thereby promote more sensitive and aware social work practice. Advantages of allowing as much time as possible for conflicting realities to emerge throughout assessments are advocated along with acknowledgement of the essentially unseeable complexities of attempting to assess people at any one point in time.

KEYWORDS:

• Mental health assessments
• deception
• disguise
• performance

I give my soul now one face, now another,

According to which direction I turn it.

If I speak of myself in different ways,

That is because I look at myself in different ways,

All contradictions may be found in me. (Montaigne)

Part one

Preparing a face to meet the faces that you meet

Social workers have long held a pivotal role in multi-disciplinary mental health teams in England (Golightley & Goemans, 2020). One of their essential tasks is to function as Approved Mental Health Professionals (AMHPs). When working in this role social workers, usually along with two Doctors, will assess people who come to their attention, to determine whether they should be admitted, or detained under the Mental Health Act 1983. The AMHP plays a crucial part in this process as it is their decision whether or not to make an application under the act to detain people, against their expressed wishes, for assessment (up to 28 days) or treatment (up to six months). They will also contribute to a decision made, along with the doctors, as to whether or not a person could be discharged from the assessment or admitted informally rather than detained. They are obliged to follow the ‘least restrictive alternative’ available whenever thought possible. For more details of the role and powers of the AMHP and other professionals involved in the process, as well as safeguards available see Barcham (2016), Brown (2019) and Stone (2020). AMHPs are required to take into account ‘all the circumstances’ of a situation presented to them and make decisions in good faith and without negligence. When making assessments they need to be mindful of a person’s history and balance risks and safety factors, based on what they see and hear. As such, the words spoken and impression given to them at the time by the person being assessed are of crucial importance. I now go on to describe two cases which highlight practice dilemmas which can form part of the assessment process.

Case study 1

When working as an AMHP I was asked to assess a young woman, A, aged 22, along with two Doctors to ascertain whether we thought she needed to be admitted to psychiatric hospital. A had a history of sexual abuse, an eating disorder and self-harm. Aged sixteen she had been detained under the Mental Health Act 1983 for six months, despite this, she achieved good results at ‘A’ Levels after being discharged from hospital and subsequently went to University to study paediatric nursing. While at University she was detained under the Mental Health Act for a further two years. When I saw A, she had diagnoses of Emotionally Unstable Personality Disorder (borderline type), Anorexia, Obsessive Compulsive Disorder, Depression and Anxiety. She had been out of hospital and living at home with her mother for just over a year. Her mother told me she had been delighted with the progress that A had made since her discharge from hospital and they had recently celebrated the fact that she had been out of hospital for over a year. Since her discharge from hospital A had been seeing a psychologist for Cognitive Behavioural Therapy (CBT).

One morning A attended her appointment with the psychologist and told the psychologist she had been ‘seeing’ men outside the window of her home and she had been hearing the voices of these men telling her she should kill herself. She said she had made a plan to kill herself, as instructed, as, if she did not do so then her mother and sister would both die. She refused to disclose any details about the plan but said she would not be alive after the next few days. The psychologist alerted the police who contacted A’s mother and an assessment under The Mental Health Act was requested.

When I saw A with the Doctors, she repeated what she had told the psychologist – that she was ‘seeing’ men and hearing their voices telling her she should kill herself. She intended to kill herself so as to keep her mother and sister alive. She had a plan to follow but she would not tell us any details. A said she would not take any medication as this was poisonous. Nor would she agree to go into hospital voluntarily. When we asked A how we could help her she told us we could not. There were no prospects of anything improving for her and she just wanted to be dead. Because of A’s emphatic and uncompromising responses to us and the fact that no less restrictive alternative seemed feasible, we concluded we had no option but to complete papers for her detention under The Mental Health Act.

When we had finished talking with A her mother joined us. She was tearful and distraught, saying through her tears that when she had received the phone call saying that her daughter intended to kill herself, this had come completely ‘out of the blue’. A’s mother had no indication whatever that anything was amiss or different from the good progress that A had sustained over the last year. She kept returning to this point, as if still unable to take it in. She said when A had deteriorated previously this had been a slow process and she had seen A slipping slowly downhill. This time, despite her many years of caring intimately for A over seven years of serious mental illness, she had no reason whatever to suspect anything was wrong. She told us, ‘A must have kept what she felt beautifully masked, because I, as close as I am to her, had no idea that anything was wrong’.

I have reflected on the phrase used by A’s mother for some time since she said it. Her use of the word ‘beautifully’ struck me as interesting as people would usually use this word to describe something positive, that they liked or approved of, something that brought pleasure or enhancement. However, A’s mother did not seem to intend any of these conventional uses of the word when describing her daughter’s masking as ‘beautiful’. She said the phrase with a kind of awed respect that her daughter could be so clever, adept, and proficient in her deception. Her use of the word reminded me of WB Yeats’s (1916) poem ‘Easter 1916’ in which he uses the phrase, ‘a terrible beauty’ (www.poets.org). Reflecting on the capacity of people assessed in the context of Mental Health Act assessments to present in completely different ways brought to mind the tragedies that can result from hidden and powerful aspects of people later coming to light. This is also apparent in the next case study, now described.

Case study 2

B was a 21-year-old student gamer who presented to his University counsellor as disturbed and psychotic. Making the referral for an assessment under the Mental Health Act his counsellor said he was ‘all over the place, making no sense whatever’. B could speak English fluently but it was not his first language. Two doctors and I saw B in a hospital Accident and Emergency Department, in the company of a friend of his who also spoke the same first language as he did. The B we saw differed considerably from the B who had been described to us by the referrer. He denied any previous admissions to psychiatric hospital or involvement with mental health services. B was able to concentrate and respond appropriately and calmly throughout the hour-long interview. He seemed to understand the majority of what we said to him and we seemed to be able to interview him in a ‘suitable manner’ as required by The Mental Health Act. When there was any doubt, his friend clarified certain words and phrases for him until he did understand. His friend also acknowledged that the presentation we saw was far more calm and reasonable than how B had presented earlier in the day. It was as if the crisis had passed and B had calmed down. It seemed to us that B was sufficiently well to return home and, his friend agreed to keep an eye on him when they returned to their student accommodation.

However, because the impression given by the counsellor referring B differed so extremely from the B we saw we thought B should take some medication before discharge, so as to keep him calm and settled on his return home. B agreed to this and we requested the medication from an Accident and Emergency Doctor. When we returned with the medication, after some ten minutes, to give this to B we saw a completely different version of the same person.

B looked distraught and chaotic. His eyes were staring and wide and he looked as if he had seen something shocking. He was mumbling repeatedly to himself, and no longer talked in English but had reverted to talking in his first language. However, when we asked his friend what he was saying the friend said he was making no sense at all. He was extremely agitated and distressed and kept attempting to walk away but he seemed to have no particular idea of where he wanted to go. In the space of a few minutes, he had changed completely. It was now apparent to the assessing team why his counsellor had described him, when referring, as ‘all over the place and making no sense whatever’. We therefore reversed our original decision to allow him to return home and, instead, detained him under section 2 of the Mental Health Act. After a few days it had been possible to contact his family from his country or origin. They said they were worried about him and that he had a history of mental illness and detentions in psychiatric hospital. No one we spoke to in the UK had been aware of this.

Reflecting on the assessment of B I realised how fortunate it was that we had delayed our conclusion until after we had obtained the medication rather than just let him return home after the initial interview. We had seen two very different versions/aspects of B in a short time. A few days after seeing B I came across an article in The Daily Telegraph (2018) entitled, ‘Student gamer who hanged himself was “isolated and depressed” by life split from reality’. The article described how a 21 year-old student who spent hours playing computer games had killed himself. His father is quoted as saying, ‘We had absolutely no idea that he was anywhere near that state of mind’. His mother spoke to him two days before his death and said he sounded ‘tired and frustrated’ on the telephone, ‘There was nothing about the phone call that made me think he was desperate. Frustrated, yes, But not desperate’. The father’s words reminded me of what A’s mother had said about A – that she had no idea that her child (who she saw everyday) was thinking and feeling what she was. The student’s case closely resembled B’s circumstances. He was a similar age to B and engaging in the same hobby (which frequently, by its very nature, entails players adopting and discarding different identities). Had the assessing team not delayed reaching a conclusion about B, this could also have resulted in tragedy as it could also have been B who ended up dead.

Working as a specialist mental health social worker and Approved Mental Health Practitioner for over 30 years I have long been interested in ways in which Literature and the Arts can articulate and illuminate the tragedies, ambiguities and complexities of our human condition (Chamberlayne & Smith, 2009; England, 1986). As early as 1905 Freud was drawing heavily on the works of Shakespeare and other novelists to illustrate how these writers could usefully illuminate distressing and disturbing states of mind (Freud, 1988). In ‘Shakespeare comes to Broadmoor’ Cox (1992) provides extended examples and applications of how insights can be gained from the works of Shakespeare and applied to attempts to understand minds in distress and turmoil. This recognition of the contributions from Shakespeare and other novelists is also conveyed in Adshead and Horne’s (2022) recent collection of case studies which continue and update the work of Cox (1992) in describing therapeutic attempts to help those who have demonstrated extremely disturbed behaviours. Jamison (2000) also demonstrates repeated applications of the work of creative writers in promoting a deeper understanding and appreciation of suicidal and potentially suicidal states of mind. ‘The Journal of Social Work Practice’ has published articles over several years which describe and illustrate ways in which an imaginative understanding of the works of Shakespeare and other poets and novelists can help to extend and expand empathy, thereby enhancing more sensitive and aware social practice (see, for example, Smith, 1996, 2008, 2012, 2017, 2019, 2021). I now go on to provide some examples of these claims.

Part two

To thine own self be true

The words of Polonius to his son, Laertes, in Shakespeare’s Hamlet rank among the most well-known and often cited of quotations from Shakespeare, “This above all – to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man “(Act 1, scene iii, lines 78–80, Alexander, 1964).

This quotation seems to resonate with many people as it speaks of a kind of ‘authenticity’ a fundamental sense of honesty with and about oneself from which good and beneficial things will necessarily (albeit, perhaps eventually) follow. This sense of authenticity or ‘congruence’ is a core condition of helping others in a therapeutic relationship, as defined by Carl Rogers (1979) in his ground-breaking and still essential text ‘On Becoming a Person’. In this work Rogers also has a chapter entitled, ‘To Be That Self Which One Truly Is’ and this again, speaks to the notion of a fundamental self and/or sense of self that one can discover and ‘be true to’. Other people will recognise when one is being true to this (sense of) self, i.e. sincere, and when one is not, i.e. fake or phoney.

However, on further examination this quotation is less straightforward than it first appears. Firstly, it appears in a play which is famous for presenting one person – Hamlet – as having so many facets, aspects and versions of himself that it is impossible to pin him down to being any one thing. (‘What a piece of work is a man!’ (Act II, scene ii, line 303, Alexander, 1964). This accounts in part for the play’s reputation, success and countless re-interpretations over the years because Hamlet is capable of being portrayed in so many different ways. His multiplicity defies neat, straightforward categorisation – the same individual is comprised of many different, various and multi-faceted aspects. There is no one sense of self he can be true to. Secondly, Shakespeare gives the words that are quoted by so many as being so wise to Polonius who is often portrayed as an out of touch, over-wordy, lugubrious, figure of fun in the play. Later on the play Hamlet describes him as a ‘wretched, rash, intruding fool’ and ‘a foolish prating knave’ (III, iv, 31, 215, Alexander, 1964). So, might it be that Shakespeare is actually teasing us about having one ‘self’ we can be true to, as he knows this to be impossible because, in reality, we are comprised of many different selves?

Elsewhere in Hamlet Shakespeare conveys how people often like to portray themselves as different to how they really (truly) are, ‘God hath given you one face and you make yourselves another’ (III, i, 142, Alexander, 1964). Here, people are described as not being true to themselves but in creating a (made up) version of themselves that they find more acceptable and pleasing. They furthermore expect others to also favour the created rather than the ‘natural’ self. The similarities between this and manufactured and created identities presented on social media is also apparent.

The importance of the face in conveying ‘truth’ or deception also features in Shakespeare’s Macbeth. When Lady Macbeth and Macbeth are discussing the possibility of murdering the (then) current king, Duncan, so that Macbeth can become king in his place it is as if the extent of what they are contemplating dawns on Macbeth and he shows this in his face. His wife says to him, ‘Your face, my thane, is a book where men may read strange matters’ (1.v.58, Alexander, 1964). This is the idea of the face as an ‘open book’ which others can read and thus discover what it is truly going on in the mind. Lady Macbeth chides her husband not to be so naive, as, if he shows his intention so clearly in his face, others will know what he is planning and hold him to account for it. She tells him, ‘To beguile the time (i.e. deceive those around you), Look like the time (i.e. show conformity with what is expected). Bear welcome in your eye, your hand, your tongue; look like the innocent flower, but be the serpent under it’ (1.v.60–63, Alexander, 1964). Relating Lady Macbeth’s advice to those subject to assessments under The Mental Health Act, if people assessed have made a serious suicide attempt and intend to make another, they often know it won’t help them to carry out their plan and attempt suicide again, if their face is ‘an open book’ which reveals their true intention. If they want to avoid being admitted to hospital they need to ‘beguile the time’ (assessing team) and give them assurances that they regretted what they did, they no longer feel this way, and they will accept appropriate support going forward. They need to look as if they are ‘innocent’ of any further intention to harm or kill themselves, and, if this helps them get away from the assessing team and the prospect of admission, they will then be free to make another attempt.

Later in Hamlet, Hamlet says to his mother, ‘Assume a virtue, if you have it not’ (IV,i,160). The notion behind this statement is that if you are lacking something you should act as if you have it and then the attribute you seek may follow from the outward expression of it. Hence, putting on a brave, or happy face, even when you don’t feel brave or happy. This notion has become a part of contemporary self-help advice, ‘Act as if, and so become’, ‘Fake it, to make it’. In this marvellous play with so many references to different types and aspects of acting, Shakespeare works in an understanding of ways in which acting can infiltrate the smaller nuances of everyday life as well as performing for the ‘big’ occasions. He shows awareness that there is far more than one aspect of the self to be true to.

In As You Like It, Shakespeare writes, ‘All the world’s a stage and all the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts, His acts being seven ages’, (II, vii, 140–143, Alexander, 1964). The ‘parts’ Shakespeare writes of can also be sub-divided into different aspects whereby the self is presented differently. A self could go through seven stages in a day, let alone a lifetime. For the purposes of this article the crucial focus is not on what the self ‘really’ or ‘truly’ is, but how it is presented at different times. This presentation involves staging a performance.

The presentation of self in everyday life

In a seminal text the sociologist, Erving Goffman, writes of the central importance of performance in day to day living in his book, The Presentation of Self in Everyday Life (Goffman, 1978). The title of this book is instructive as it speaks to both a sense of self and then (also) how this self is presented which can vary from day to day, hour to hour, minute to minute.

Goffman begins his book by establishing, ‘The perspective employed in this report is that of theatrical performance; the principles derived are dramaturgical’ (Goffman, 1978, p. 9). He goes on to write about ‘impression management’ and states, ‘when an individual appears before others he will have many motives for trying to control the impression they receive of the situation’ (Goffman, 1978, p. 26). This will particularly be the case when the stakes of the encounter are high and when there is a lot to gain or lose as a consequence. In the case of Mental Health Act Assessments an individual’s freedom will be affected.

Goffman quotes from Park, ‘It is probably no mere historical accident that the word person, in its first meaning, is a mask. It is a recognition of the fact that everyone is always and everywhere, more or less consciously, playing a role … It is in these roles that we know each other; it is in these roles that we know ourselves’ (Goffman, 1978, p. 30). The concept of the mask that is employed to create the desired impression rather than the ‘true self’ is also described by Jung, ‘The process of civilising the human being leads to a compromise between himself and society as to what he should appear to be, and to the formation of the mask behind which most people live. Jung calls this mask the persona, the name given to the masks once worn by the actors of antiquity to signify the role they played. But it is not only actors who fill a role; a man who takes up a business or a profession, a woman who marries or chooses a career, all adopt to some extent the characteristics expected of them in their chosen position’ (Fordham, 1966, pp. 46,47). Again, the extent to which people use masks to perform different roles at different times and thereby present a different version of themself is apparent.

Eric Berne, in his theory of Transactional Analysis also draws on concepts of role, masks and performance, when writing of ‘Script Theory’. The title of his book, ‘What do you say after you say hello?’ poses the question of how do people spend their time, interacting with one another? He answers this question, in part, by claiming people have a script they follow and this script contains lines they should deliver from the character they are enacting. He writes, ‘Each person, has a preconscious life plan or script, by which he structures longer periods of time … which further the script while giving him immediate satisfaction, usually interrupted by periods of withdrawal and sometimes by episodes of intimacy. Scripts are usually based on childlike illusions which may persist through a whole lifetime … ’ (Berne, 1972, pp. 25,26). Once again, there is the concept of an individual playing a part in a dramatic performance. Berne claims that people often cast themselves in certain roles that come with a life script to follow. Some people see themselves in starring roles, others, walk on parts, some give themselves a happy ending, others, tragic. Updating Berne’s ideas Stewart and Jones comment, ‘Like all stories, your life-story has a beginning, a middle, and an end. It has its heroes, heroines, villains, stooges and walk-on characters. It has its main theme and its sub-plots. It may be comic or tragic, enthralling or boring, inspiring and inglorious’ (Stewart & Jones, 2002, p. 99). different attributes are closely woven into many life scripts.

At different times in my social work career, I have noticed that the same people can sometimes repeatedly present for Mental Health Act Assessments within a short time frame. Frequently these people have been diagnosed with Emotionally Unstable Personality Disorder and they have sometimes been referred several times within a few days (in extreme cases even within the same day!). Because of this frequency of presentation, the person being assessed and the assessing team get to know one another and there can be a sense of familiarity as we each adopt our roles, play our parts and recite our lines. In many ways it can feel like returning to another performance of a play one has got to know quite well, and yet which also is capable of re-interpretation at different times.

I now move from the notion of a person playing ‘many parts’ to the idea that these many parts can essentially be distilled into two.

Not truly one but truly two (or more?)

In his archetype-creating novella ‘The Strange Case of Dr.Jekyll and Mr. Hyde’ Stevenson writes, ‘man is not truly one, but truly two’ (Stevenson, 1974, p. 102). This concept can be seen in everyday phrases such as, ‘I am not myself today’ and ‘I don’t know what came over me’ where the same self is referred to as having two aspects, the ‘I’ and the ‘me’. The notion has long been applied in psychological texts, beginning with William James, who has a chapter entitled, ‘The Divided Self’ in his work ‘The Varieties of Religious Experience’ (James, 1984), first published in 1902. The phrase was later employed by Laing (1971) as the title of his existential study in sanity and madness. Laing claims that the divide is between those who have a basic existential position of ontological security and those who do not and who, therefore, experience ontological insecurity (Laing, 1971, p. 39). He writes of the division between an embodied and un-embodied self, ‘Instead of being the core of his true self, the body is felt as the core of a false self, which a detached, disembodied, “inner”, “true” self looks on at with tenderness, amusement, or hatred as the case may be’ (Laing, 1971, p. 69) (Italics in original).

Laing also wrote about the use of masks, a primary theme of this article. He writes, “’A man without a mask’ is indeed very rare. One even doubts the possibility of such a man. Everyone in some measure wears a mask, and there are many things we do not put ourselves into fully. In ‘ordinary’ life it seems hardly possible for it to be otherwise” (Laing, 1971, p. 95). He describes ‘Peter’ who experienced an acute sense of a ‘false self’, ‘the central issue for him had crystallized in terms of being sincere or being a hypocrite; being genuine or playing a part. For himself, he knew he was a hypocrite, a liar, a sham, a pretence, and it was largely a matter of how long he could kid people before he would be found out … His apparent normality was the consequence of deliberate intensification of the split between his “inner” true self and outer “false” self … ’ (Laing, 1971, p. 124).

The concept of the self being divided into ‘true and false’ has also been described by the psychoanalyst, D.W. Winnicott. He considers attempts at suicide might be the result of a conflict between the true and false selves and a failure to find a resolution, ‘When suicide is the only defence left against betrayal of the True Self, then it becomes the lot of the False Self to organize the suicide’ (Winnicott, 1990, p. 143). The idea of the false self organising the suicide rings true to me. As I explained above, at the beginning of this article, some people when interviewed about a suicide attempt and who want to get away in order to make another attempt, know that their best chance of doing so is to show ‘disguised compliance’ and employ their false self to put on a convincing performance which distracts and diverts from the true self’s true intention.

In Analysis Terminable and Interminable, first published in 1937 and bringing together some of his most profound observations on Human existence Freud writes, ‘It is not a question of an antithesis between an optimistic and a pessimistic theory of life. Only by the concurrent or mutually opposing action of the two primal instincts – Eros and the death-instinct – never by one or the other alone, can we explain the rich multiplicity of the phenomena of life’ (Sandler, 1991, p. 30). Here again, is the divided self. Divided by, a desire for pleasure, Eros, life on the one hand and destruction, Thanatos, death, on the other. Freud argued that the life and death instinct are continually engaged in a kind of dance or fight throughout the life of an individual and both need to be taken into account and given due recognition at any one time.

Applying Freud’s concept of the life instinct and the death instinct to people who feel suicidal, Stengel writes, ‘Most people who commit suicidal acts do not either want to die or to live; they want to do both at the same time, usually the one more, or much more, than the other’. (Stengel, 1980, p. 87). Part of the purpose of an assessment of a person who has threatened or attempted suicide under The Mental Health Act is to reach a conclusion about whether or not they are likely to try to kill themselves if not admitted to hospital. Applying the theories of Freud and Stengel to such assessments presents social workers and others with a particular dilemma – if the answer to the question of possible future self-harm or suicide is not yes or no (either or) but quite possibly both, how can those assessing reach a safe decision and help prevent a tragic outcome?

The poet Walt Whitman (1986, pp. 84,85) sees no difficulty in recognising that people are comprised of many different parts and aspects, some known to themselves, others not, frequently contradictory, ‘There is that in me … . I do not know what it is … but I know it is in me … Do I contradict myself? Very well then … I contradict myself; I am large … . I contain multitudes’. This thought is also articulated by John Banville (1990, p. 95), “I had somehow got myself trapped inside a body not my own. But no, that’s not it, exactly. For the person that was inside was also strange to me, stranger by far, indeed than the familiar, physical creature. This is not clear, I know. I say the one within was strange to me, but which version of me do I mean? No, not clear at all “. The idea of the self being multiple and not entirely known by anybody is an interesting one which presents a challenge to anyone attempting to accurately assess someone else.

Implications for practice. ‘When thou hast done, thou hast not done’

I had been thinking about writing this article for some years but found my interest in it re-ignited when reading an article in The Times (Sanderson, 2023, p. 24) which described a mental health charity working with a television programme to publicise issues faced by people who had killed themselves and those they left behind, ‘Fifty portraits of smiling people were unveiled on London’s Southbank. Two days later the programme revealed that they were the last photographs of people who had taken their own lives’, The chief executive of the television station described the project as ‘harrowing’. Beautifully masked; again.

It is difficult to know what to conclude from these reflections. The case of B above shows that it can be advantageous to conduct assessments over a long time which then allows for the possibility of other/additional aspects of a self to emerge. On several occasions I have known patients to ‘hold things together’ for a period of time, only for this to be followed by an ‘eruption’ of an illness which seems to then break free into the room from any attempts to confine it. However, giving people time can be problematic when legislation and organisations expect assessments to be completed as quickly as possible within tightly defined time scales and targets. Further, many patients and those close to them frequently report they are kept waiting too long for assessments in difficult, stressful and sometimes potentially dangerous circumstances.

The consequences and aftermath of people killing themselves shortly after being assessed can remain with practitioners for years and even decades afterwards (Adshead & Horne, 2022). Adshead and Horne entitle their collection of powerful examples of working therapeutically with some of the most disturbed and disturbing forensic patients, ‘The Devil You Know’. The reason for this is that while encountering some aspects of ourselves and others might be uncomfortable, even frightening, it is better that we uncover these (Devil we get to know) than to remain in ignorance about them (Devil we don’t know). Adshead refers to the tragedy of King Lear (Act 1, scene 1, 293) in which Lear’s daughter Regan says, ‘He hath ever but slenderly known himself’ (Alexander, 1964) and it is this lack of self-knowledge and self-awareness that is responsible, at least in part, for the tragedies which unfold throughout the play.

A question I am left with concerns the extent to which people being assessed intentionally plan to deceive assessors by masking the truly destructive aspects of themselves. Do people know of these impulses ‘all along’ or do they emerge, suddenly, with a power and force which takes the assessed person by surprise as much as it does the assessor? Do people who go on to kill themselves shortly after being assessed intend this at the time of the assessment or does the intention come to them ‘out of the blue’ after the assessment has been completed? There is no way of asking or knowing this.

I do believe there can be value in assessors getting to know as much as possible about the ‘multitudes’ within themselves and others but also to recognise and accept that however much it is possible to know there is yet more that remains unknowable. What John Donne (1633) wrote about forgiveness speaks also for attempts to discover the ‘true self’ in Mental Health Act assessments in England, ‘When thou hast done, thou hast not done, For I have more … ’.

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Notes on contributors

Martin Stuart Smith

Having worked as a front-line mental health social worker for 36 years, Martin Smith has now retired. He remains interested in the dilemmas faced by mental health professionals and ways in which an appreciation of the Arts can help to understand and process these.