WHAT IS STRESS
Stress is the & quote “wear and tear” our bodies experience as we adjust to our continually changing environment; it has physical and emotional effects on us and can create positive or negative feelings. As a positive influence, stress can help compel us to action; it can result in a new awareness and an exciting new perspective. As a negative influence, it can result in feelings of distrust, rejection, anger, and depression, which in turn can lead to health problems such as headaches, upset stomach, rashes, insomnia, ulcers, high blood pressure, heart disease, and stroke. With the death of a loved one, the birth of a child, a job promotion, or a new relationship, we experience stress as we re-adjust our lives. In so adjusting to different circumstances, stress will help or hinder us depending on how we react to it.
HOW CAN IT BE ELIMINATED
As we have seen, positive stress adds anticipation and excitement to life, and we all thrive under a certain amount of stress. Deadlines, competitions, confrontations, and even our frustrations and sorrows add depth and enrichment to our lives. Our goal is not to eliminate stress but to learn how to manage it and how to use it to help us. Insufficient stress acts as a depressant and may leave us feeling bored or dejected; on the other hand, excessive stress may leave us feeling & quoted “up in knots.” What we need to do is find the optimal level of stress, which will individually motivate but not overwhelm each of us.
HOW CAN I TELL IF I AM AT MY OPTIMAL LEVEL
There is no single level of stress that is optimal for all people. We are all individual creatures with unique requirements. As such, what is distressing to one may be a joy to another. And even when we agree that a particular event is distressing, we are likely to differ in our physiological and psychological responses to it.
The person who loves to arbitrate disputes and moves from job site to job site would be stressed in a job which was stable and routine, whereas the person who thrives under stable conditions would very likely be stressed on a job where duties were highly varied. Also, our personal stress requirements and the amount, which we can tolerate before we become distressed in changes throughout our ages.
It has been found that most illness is related to unrelieved stress. If you are experiencing stress symptoms, you have gone beyond your optimal stress level; you need to reduce the stress in your life and/or improve your ability to manage it.
HOW CAN I MANAGE STRESS BETTER
Identifying unrelieved stress and being aware of its effect on our lives is not sufficient for reducing its harmful effects. Just as there are many sources of stress, there are many possibilities for its management. However, all require effort toward change: changing the source of stress and/or changing your reaction to it. How do you proceed?
BECOME AWARE OF YOUR STRESSORS AND YOUR EMOTIONAL AND PHYSICAL REACTIONS.
Notice your distress. Don’t ignore it. Don’t gloss over your problems.
Determine what events distress you. What are you telling yourself about meaning of these events?
Determine how your body responds to the stress. Do you become nervous or physically upset? If so, in what specific ways?
RECOGNISE WHAT YOU CAN CHANGE.
Can you change your stressors by avoiding or eliminating them completely?
Can you reduce their intensity (manage them over a period of time instead of on a daily or weekly basis)?
Can you shorten your exposure to stress (take a break, leave the physical premises)?
Can you devote the time and energy necessary to making a change (goal setting, time management techniques, and delayed gratification strategies may be helpful here)?
REDUCE THE INTENSITY OF YOUR EMOTIONAL REACTIONS TO STRESS.
The stress reaction is triggered by your perception of danger…physical danger and/or emotional danger. Are you viewing your stressors in exaggerated terms and/or taking a difficult situation and making it a disaster?
Are you expecting to please everyone?
Are you overreacting and viewing things as absolutely critical and urgent? Do you feel you must always prevail in every situation?
Work at adopting more moderate views; try to see the stress as something you can cope with rather than something that overpowers you.
Try to temper your excess emotions. Put the situation in perspective. Do not labour on the negative aspects and the "e “what ifs.”
LEARN TO MODERATE YOUR PHYSICAL REACTIONS TO STRESS.
Slow, deep breathing will bring your heart rate and respiration back to normal.
Relaxation techniques can reduce muscle tension. Electronic biofeedback can help You gain voluntary control over such things as muscle tension, heart rate, and blood pressure.
Medications, when prescribed by a physician, can help in the short term in moderating your physical reactions. However, they alone are not the answer.
LEARNING TO MODERATE THESE REACTIONS ON YOUR OWN IS A PREFERABLE LONG-TERM SOLUTION.
BUILD YOUR PHYSICAL RESERVES.
Exercise for cardiovascular fitness three to four times a week (moderate, prolonged rhythmic exercise is best, such as walking, swimming, cycling, or jogging).
Eat well-balanced, nutritious meals.
Maintain your ideal weight.
Avoid nicotine, excessive caffeine, and other stimulants.
Mix leisure with work. Take breaks and get away when you can.
Get enough sleep. Be as consistent with your sleep schedule as possible.
MAINTAIN YOUR EMOTIONAL RESERVES.
Develop some mutually supportive friendships/relationships.
Pursue realistic goals, which are meaningful to you, rather than goals others have for you that you do not share.
Expect some frustrations, failures, and sorrows.
Always be kind and gentle with yourself–be a friend to yourself.
AN EXAMPLE OF A GOOD WAY TO INTRODUCE THE SESSION AND SOOTHING WORDS TO GIVE MOVEMENT INSTRUCTION.
Please take off your shoes, glasses and ties, loosen any tight belts or clothing, and lie on your back. Get in a comfortable position and close your eyes.
Begin by trying to relax your body as far as possible. Concentrate on your breathing; try to establish a deep, slow, rhythmical pattern of “in” and “out”, using as much of your lungs as you find comfortable. As you breathe, try to imagine that with each strong, slow breathe in you take, every part of your body is getting an inflow of energy.
With each slow breathe out, your tensions are flowing from you. Feel yourselves pushing out the tension within the body as you breathe out.
Imagine that you are basking in the sun on the beach. You are on a long holiday.
There is no pressure to do anything and you feel good… Just lie and listen to the sound of the waves breaking. Listen to them coming in and out…in and out.
Concentrate on the waves. Now your thoughts are calm. Sink back on to the floor, let your limbs sag, keep your eyes closed, breathe deeply and we will begin relaxing.
RELAXATION, EACH SECTION CAN BE REPEATED AS NECESSARY.
Tighten your toes up as tight as you can… and relax.
Pull your feet up tight, push your heels down and relax.
Tighten your calf muscles, brace your kneecaps and thighs… and relax
Relax and let all the tension flow away. Be aware of how heavy you feel, feel your legs’ sinking into the floor, the tension is flowing away.
Make a tight fist, put all your effort into it… and relax.
Bend your elbows, tighten your biceps… and relax.
Let your arms feel heavy sinking into the floor. Spread open your palms, press your hands and arms into the floor… and relax.
You are feeling much more relaxed. Hunch your shoulders right up to your ears… and relax.
Press your back hard back into the floor… and relax.
All the stress that you could feel in your shoulders and back is flowing away with every breath. Your body is heavy, so heavy, and the tension is flowing away.
Slowly twist your head to the right, hold it and relax back again.
Your head is so heavy, raise it from the pillow… and relax.
Now the only tension left is all concentrated in your face. Clench your teeth and relax.
I am going to play some music to you, and when it fades away you will be awakened and refreshed, slowly rising from your rest. Take you time, move at your own pace, until you are ready to leave this session.
REFLEXOLOGY: ZONE THEORY
Zone Theory evolved from the research and writing of Dr. William Fitzgerald in the early 1900’s. He observed that direct pressure on certain areas of the body could produce an analgesic [anaesthetic] effect in a corresponding part. Just how one part “corresponds” to another is what zone theory is all about. Dr. Fitzgerald systematised the body into zones, which he used for his “anaesthetic” effect and which we now use for therapeutic application. [See illustration.] He was able to deduce that his patients had been “anaesthetising” themselves with direct pressure [e.g. clenching fists] or that, in some instances, an assistant had inadvertently applied pressure. In some cases he noted that no actual anaesthesia was needed before or during surgery. By exerting pressure on a specific part of the body he had learned to predict which other parts of the body would be affected, and he had taken the first major step in the development of zone theory.
Zone therapy became further popularised by Dr. Edwin Bowers. Working together with Dr. Fitzgerald, he developed a unique and startling method for convincing their colleagues about the validity of zone theory. He would apply pressure to the colleague’s hand and then stick a pin in the area of his face anaesthetised by the pressure. Such dramatic proof made believes of those who witnessed it. Zone therapy had other proponents, including Dr. George Starr White, who had a large practice in LOS ANGELES during the 1920’s. Joseph Shelby Riley was another who wrote a book on zone theory and continued to study it over the years.
Zone theory is the basis of foot Reflexology. Reflexology has become a more refined system but zone theory is still a useful adjunct to it. An understanding of it is essential to an understanding of Reflexology.
Zones are a system for organising relationships between various parts of the body. They can be thought of as guidelines or markers, which link one part to another.
There are ten equal longitudinal zones running the length of the body from the top of the head to the tips of the toes.
The number “ten” corresponds to the number of fingers and toes. And therefore provides a convenient numbering.
Each finger and each toe falls into one zone, with the left thumb, for example, occurring in the same zone as the left big toe, and so on.
Each big toe corresponds to half of the head area, even though it also represents one specific zone as well.
But each big toe represents the four smaller toes, in that the little toes occupy the remaining zones, which represent the head/neck region in finer terms.
Like an arrow passing through, the reflex points are considered to pass all the way through the body within the same zones. The same point, for instance, can be found on the front as well as the back of the body, the top as well as the bottom of the foot.
Congestion or tension in any part of a zone will affect the entire zone running through the whole length of the body. Like a river that has been dammed up, the areas on either side of the “dam” [blocked] in the zone are affected.
If the area remains blocked, areas to either side can become affected. Sensitivity in a specific part of the foot signals the Reflexologist that there is something going on in that zone or zones somewhere in the body.
DIRECT PRESSURE APPLIED TO ANY PART OF A ZONE WILL AFFECT THE ENTIRE ZONE.
This is the basis of zone theory. It is also the basis of foot Reflexology. Because not only are the feet functional parts of the body with representation in each of the zones, they are direct reiteration of the body itself.
They actually mirror the body however; working the entire foot affects the entire body. Because of the myriad of zonal relationships it is always valuable to work the entire foot.
Therefore, Reflexology is a study of the reflexes in the feet corresponding to all parts of the body.
Deposits build up in the feet and are broken down by ‘working’ or massaging the feet in a particular way. The reaction following the massage would be described as relaxation.
The aim of Reflexology is to stimulate the ‘whole body’ to heal it’s self by removing
STRESS and TENSION.
It could be said that STRESS is the greatest threat to the body’s well-being.
Diabetes Mellitus is not a single disease but a variety of minor to severe disorders in which there is deficiency of insulin action in the pancreas.
As insulin is responsible for the metabolism of glucose, the deficiency results in the increase in blood glucose resulting in the following problems:
AETIOLOGY (Or causative factors)
There are two proven factors, these being over – nutrition and a form of hereditary tendency.
That is: Some 40 – 80% of patients developing diabetes over the age of 40 are, or have been, obese.
The hereditary factor has been indicated by studies of patients and their families.
TYPES OR ONSET
Diabetics fall into one of two main categories; Juvenile onset or Maturity onset.
These shall now be discussed individually as separate illnesses which, essentially, they are
SIGNS AND SYMPTOMS
- Weight loss
- Hypoglycaemia ( See later )
- Dehydration ( And constipation )
- Glycosuria ( Sugar in urine )
These symptoms are usually of a rapid onset in childhood. The child tends to be thin and small, but this is only a tendency not a rule.
Normally control can only be maintained with insulin, injections and diet.
Oral diabetics are not usually any good as the lack of body insulin is so severe; the oral drug cannot make up the difference.
SIGNS AND SYMPTOMS:
The symptoms are as for juveniles, however they are milder and have a slower onset – Known as INSIDIOUS. The patient is usually middle age or older and tends to be fatter.
Depends on severity of illness, but is very rarely needs insulin therapy. Therefore control is achieved by balancing diet with oral diabetic drugs or by diets alone – See Treatment.
URINE TESTING: -
Using a Clinitest, Acetest, or Ketostix, glucose in the urine can be detected. (See signs and symptoms).
A positive result indicates that some reducing agent is present – Not necessarily glucose as some drugs such as aspirin, ascorbic acid and anti-convulsants can do this.
The amount of glucose in the blood can be tested. This result when compared with a blood glucose curve can indicate illness and severity.
TREATMENT OF DIABETES
As previously discussed, there are 3 forms of treatment: –
- Diet alone
- Diet and oral drugs – known as Hypoglycaemic agents.
- Diet and Insulin.
Diet alone patients, as discussed, are of maturity onset and therefore have mild symptoms, as their level of insulin is not too low in the pancreas. The diet should generally be of low calorific value designed to reduce the sugar intake but still maintain nutritional benefits. See Diabetic Diet File.
SIGNS AND SYMPTOMS
Also known as Diabetic coma in extreme cases.
- Slower onset than hypo, symptoms developing over days or even weeks:
- Hyperventilation (Deep)
- Tongue (Dry and inelastic)
- Breath smells of acetone
- Circulatory symptoms (Tachycardia, low B.P)
- Dry Skin
MAY BE CAUSED BY: -
- Omission/reduction in insulin
- Undiagnosed diabetes
- Intercurrent illness
- Unknown factors
- Fluid and electrolyte replacement
LOSS OF CONTROL
Usually results from patient not adhering to diet or drug regime. Therefore it is generally the patients fault though in some circumstances it can be due to inaccurate prescribing of medication.
This condition should be rectified as soon as possible. It may result in an increase or decrease in blood sugar, depending on the cause of the problem.
MANAGEMENT OF ILLNESS
Unlike people without diabetes, when our client is suffering from an inter-current illness there is a need to assess the diet and treatment.
This is because a persons calorific intake is necessarily either increased or decreased depending on the illness.
Therefore the treatment should be adjusted accordingly.
COMPLICATIONS OF DIABETES
There are several problems that can arise from either severe or mild diabetes. As they are so numerous they shall be listed after this short introduction.
Most of these conditions are treated symptomatically as they arise, but the best form of treatment is to control the diabetes. (As described in the first passage).
- Retinopathy (Common)
- Lens opacities
- Glomerulo-sclerosis (Loss of protein in urine)
This is quite a serious illness in itself and is the second largest cause of death.
- Peripheral neuropathy (Legs + + +)
- Diarrhoea and loss of bladder sensation caused by;
- Automatic system neuropathy.
- Coronary artery disease (Largest cause of death, as in non-diabetic)
- Peripheral arterial disease
- Cerebral-Vascular disease
- Maybe listed under four headings;
- Septic (Infectious)
There are two drug groups available; SULPHONYLUREAS and BIGUANIDES.
These act by promoting the release of insulin and action in the Beta cells of the
Islets of Langerhans, which are in the pancreas.
Drugs in Use and Doses: –
Tolbutamide – Rastinon > 0.5-1g tds
Chlorpropramide – Diabinese > 750mg od
Glibenclamide – Daonil > 2.5-20mg mane
N.B: These drugs depend on there being some action in the pancreas.
These act by inhibiting the absorption of glucose in the gut and enhancing passage of insulin into muscle cells.
Drugs in use and Doses: –
Metformin – Glucophage > 0.5-1g tds
Phenformin – Diguanil > 25-50mg tds
The insulin dependant person is treated, long-term, and with adequate diet there are certain objectives, which are as follows;
Maintain quality of life i.e. earn a living, enjoy ordinary activities etc.
Keep free from any symptoms of their illness, other than mild attacks of hypoglycaemia.
Keep blood glucose as near to normal limits as possible.
USE OF INSULIN
Insulin is destroyed by gastric secretions and can only be given by injection.
Usually the root is subcutaneous, but it can be given intra-muscularly and intra-venously in the case of an emergency.
SOURCE OF INSULIN
Insulin is made from extracts of pig or cow pancreas. There are different preparations and their functions vary in length of action.
Short acting tend to be used in crisis and long acting for maintenance. A few years ago, insulin used to be available in different strengths and it was a complex task to calculate doses. Now available is 100 strength insulin which means, there are 100 units of insulin per 1ml of injection.
Two types of special syringe are used: –
0.5ml (50 units)
1.0ml (100 units)
Therefore, it is a simple task to calculate dose.
As an example, if a patient is prescribed a dose of 16 units then 0.16 of a mil is measured.
Some patients need constant reviews of doses to maintain adequate control, where as others can remain on doses for long periods.
A diabetic diet, as described before, must be taken in conjunction with the insulin. There is a slight change in the diet and that is that carbohydrate intake must not exceed 200grms daily.
There are some crisis’ that may arise: –
- Hypoglycaemia (Low blood sugar)
- Hyperglycaemia (High blood sugar)
- Loss of control (Tolerance management of illness)
SIGNS AND SYMPTOMS: -
- Fast onset
- Sense of apprehension
These can progress to unconsciousness, coma, and convulsions.
‘Drunk-like’ behaviour, aggression, emotional upsets may be caused by: –
Too large a dose of drug
- Missing a meal
- Excessive exercise
- Change of insulin
- Combination of above
Take sugar in a quickly digested form i.e. Glucose. If unconscious, give an injection of it in special solution
MENTAL HEALTH ACT 1983
PART 1: DEFINITIONS
Means Mental Illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind.
Not defined in the Act, and its operational definition is a matter of clinical judgement in each case.
SEVERE MENTAL IMPAIRMENT
Means a state of arrested or incomplete development of mind, which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct.
Means a state of arrested or incomplete development of mind, which includes significant impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct.
Means a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct.
EXCLUSIONS FROM THE DEFINITIONS OF MENTAL DISORDER
A person may not be dealt with under the Act as suffering from a mental disorder purely by reason of promiscuity, other immoral conduct, sexual deviancy or dependence on alcohol or drugs.
Footnote: MEDICAL TREATMENT
Includes nursing and also includes care, habilitation and rehabilitation under medical supervision. (5.145 1)
COMPULSORY ADMISSION TO HOSPITAL & GUARDIANSHIP
ADMISSION FOR ASSESSMENT
Duration: Up to 28 days
Application by the nearest relative or approved social worker. Medical recommendation: by two medical practitioners (one of them must be approved) in writing.
The patient is suffering from a mental disorder which in the interests of his own health or safety or with a view to the protection of other persons, warrants his detention in hospital for assessment (or assessment followed by medical treatment) for at least a limited period.
- The period of detention commences from the day of admission.
- The patient must be admitted within 14 days of the signing of the last medical recommendation. Not more than 5 days must have elapsed between the two medical examinations.
- The person making the application must have seen the patient within a period of 14 days ending with the date of signing the application.
- If the application form is signed by the nearest relative it is the duty of the hospital managers to inform the Social Services Department of the admission.
- It is the responsibility of the Approved Social Worker to consult the nearest relative or, if impractical, to inform the nearest relative of the admission and his rights under this Act.
- It is the responsibility of the hospital managers to inform the patient, in writing, of his rights under the Act.
- Any patient detained under Section 2 has the right to appeal to the Mental Health Review Tribunal once within the first 14 days of detention.
- One period of detention under Section 2 must not immediately follow another.
The patient can be discharged at the instigation of:
- The responsible medical officer (RMO) (Sec.23)
- The managers (Sec.23)
- The nearest relative (must give 72 hours notice) (Sec.23)
- Mental Health Review Tribunal (MHRT) (Sec.72)
- After expiry of the period of detention if absent without leave. (Sec.18)
The managers may bar the relative’s application for discharge if the RMO indicates that the patient, if discharged, is likely to act in a manner dangerous to other persons or himself. If a barring certificate is issued, the relative does not have the right to apply to a M.H.R.T., but the patient may do so during the first 14 days of his detention (Sec.25)
ADMISSION FOR TREATMENT
Duration: Six months, can be extended for a further six months, after review – can then be extended for periods of one year at a time after appropriate review.
Application by the nearest relative or approved social worker. Medical recommendation: by two medical practitioners (one of them must be approved) in writing.
The patient is suffering from mental illness, severe mental impairment, psychopathic disorder or mental impairment that makes it appropriate for him to receive treatment in hospital; and:
In the case of psychopathic disorder or mental impairment, such treatment is likely to alleviate or prevent deterioration of his condition; and:
It is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment, and it cannot be provided unless he is detained under this section.
The patient must be admitted within 14 days of the signing of the last medical recommendation. Not more than five days must have elapsed between the two medical examinations.
The two medical recommendations must state that in the opinion of both medical practitioners, the patient is suffering from one or more of the four forms of mental disorder set out in Section 1.
The medical recommendations must include at least one form of disorder in common and the reason must be given why the patient cannot be suitably cared for outside hospital or be admitted as an informal patient.
In the case of psychopathic disorder or mental impairment, the medical recommendations must state that the treatment is likely to alleviate or prevent deterioration in his condition.
The person making the application must have seen the patient within a period 14 days ending with the date of signing the application.
If the application form is signed by the nearest relative it is the duty of the hospital managers to inform the Social Services Department of the admission as soon as practical (5.14).
It is the responsibility of the approved social worker to inform the nearest relative of the admission and of his rights under this Act.
It is the responsibility of the hospital managers to inform the patient, orally and in writing, of his rights under the Act (5.132)
Any patient detained under Section 3 has the right to appeal to the Mental Health Review Tribunal once within the first six months of detention. If he does not do so, the managers must refer the case to the tribunal if he is detained for a second six months.
List of nearest relatives (in order of precedence, the older of the two taking priority but there are further qualifications in the A
husband or wife
son or daughter
father or mother
brother or sister
uncle or aunt
nephew or niece (Sec.26)
The patient can be discharged by:
- The responsible medical officer (Sec 23)
- The managers (Sec.23)
- The “nearest relative” (Sec.23)
- A Mental Health Review Tribunal (Sec.72) or:
- After 28 days absence without leave (Sec.18) or:
- After six months continuous absence with leave (Sec.17)
- The responsible medical officer can bar the nearest relative” discharging the patient. In this case, however, the relative can apply to a Mental Health Review Tribunal within 28 days.(Sec 25)
ADMISSION TO HOSPITAL FOR ASSESSMENT IN AN EMERGENCY
Duration: Up to 72 Hours
One medical recommendation plus application by the nearest relative or an approved social worker.
The person making the application must have personally seen the patient in the previous 24 hours.
The practitioner supplying the medical recommendation must have seen the patient within the previous 24 hours and should preferably be a practitioner who has had previous acquaintance with the patient.
The recommendations should make clear the circumstances of the emergency. Grounds:
It is of urgent necessity that the patient should be admitted and detained for assessment, and compliance with the normal procedure would involve undesirable delay.
If a second medical recommendation is received within the period of detention, the patient may be detained for 28 days from admission as if originally admitted under Section 2, and the rights and conditions of that section then apply.
APPLICATION IN RESPECT OF A PATIENT ALREADY IN HOSPITAL
Up to 72 hours (To include any period during which nurses’ holding power was used).
The practitioner currently in charge of the treatment of the patient (or his nominated deputy).
That it appears that an application for admission to a hospital should be made.
The medical practitioner in charge of a patient’s treatment may nominate one, but only one, other medical practitioner on the staff of the same hospital to act on his behalf under the section, in his absence.
This report should be given immediately to an officer authorised to receive such reports on behalf of the managers.
The 72-hour period begins to run from the time the report is furnished.
Applications under Section 5 may be made in respect of an in-patient in any part of any hospital, including a general hospital, even if he is not being treated for mental disorder at the time.
NURSES HOLDING POWER
Duration: Up to six hours
By a registered nurse (RMN or RMNS) only.
The patient is suffering from a 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 hospital.
It is not practicable to secure the immediate attendance of a practitioner for the purpose of furnishing a report under Section 5(2).
The holding power starts after the nurse has recorded his opinion on the prescribed form.(No.13)
This must be deliver to the hospital managers as soon as possible.
The nurses should let the hospital managers know as soon as the holding power has lapsed, on the prescribed form (No.16).
MISCELLANEOUS AND SUPPLEMENTARY PROVISIONS
The mentally disorder patient found in a public place
Police constables have the power under this section to remove to a place of safety* a person whom they find in a public place who appears to be suffering from a mental disorder and to be in need of care and control in his own interests or for the protection of others.
The patient should be taken to the nearest convenient place of safety* where he/she can be detained for a period not exceeding 72 hours for the purpose of being medically examined to be interviewed by an approved social worker and suitable arrangements to be made for his or her care.
A ‘place of safety’ is a hospital, police station or other appropriate place.
MENTAL HEALTH REVIEW TRIBUNALS
A separate Mental Health Review Tribunal covers each of the Regional Health Authorities in England. The Lord Chancellor appoints members. The president is always a lawyer (and for restricted cases must be a barrister or Queen’s Counsel of judicial standing) and the other two members are a registered medical practitioner and a layman. The tribunals are administered from three regional offices, in London, Liverpool and Nottingham.
Hospital managers’ duty to refer.
Any patient who has been detained for more than six months under Section 3 and has not applied for a Tribunal or had an application made on his behalf by the nearest relative, or had his case referred by the Secretary of State, must be referred to a Tribunal by the hospital managers.