The following post is from Gary Sidley. We asked Gary to write for us following his contributions to the Durham conference, especially on the subject of the Mental Health Act. Gary’s post speaks for itself. Readers will find it raises some profound and political questions. Please let us know your thoughts (by commenting on this post, which Gary will read). If you wish to respond to this post in a more detailed way, please ‘contact us’ to discuss that.
Gary has worked as a mental health nurse, a consultant clinical psychologist and has been a team manager. He has a perspective which spans over three decades of work in mental health services and has a PhD that explored the subject of predicting suicidal behaviour. You can find out more about Gary here. He is now a writer and has recently had a critical mental health book published through PCCS books. We feel that this book could not have arrived at a more serendipitous moment and we are looking for people to respond to it on this blog (please contact us if you are interested). We are extremely pleased to have his involvement in the Critical Mental Health Nurses Network.
As the Critical Mental Health Nurses Network (CMHNN) strives to find its raison d’etre, it is timely to ponder as to where this embryonic organisation might best focus its energies. Given the raft of current deficiencies in the way that Western psychiatry responds to human misery and suffering, there is no shortage of worthy endeavours. Possibilities include: challenging the prescriber/drug-industry alliance to stop its relentless misuse of psychotropic medications; ensuring that people in distress routinely receive compassionate and respectful responses from those employed to help them; confronting advocates of the ‘illness like any other’ approach with the stigmatising, passivity-inducing and hope-quashing consequences of their mantra; or highlighting the distorted way that risk is both perceived and addressed within the mental health arena.
But maybe there is one supra barrier that feeds a number of flaws inherent in the current psychiatric system and requires dismantling if we are to realise our aim of providing a more effective and enabling response to emotional pain and anguish: the Mental Health Act (MHA).
What’s wrong with the current MHA?
It is reasonable to propose that the MHA is a form of legalised discrimination that functions as a central generator for much that is awry in psychiatry. In a 21st century democratic society how can we justify a law that permits some of its citizens, who typically have committed no crime, to be incarcerated without trial (‘sectioned’) and to subsequently endure forced drug treatments? Clearly, this process infringes the fundamental tenet of Western democracies that a person is assumed innocent until guilt is established, as well as trampling over the sacred rights of any individual to decide whether or not to accept medical interventions. Even advance decisions – legally-binding instruments that allow all of us to formally highlight a specific treatment we do not wish to receive in the future should we lose the wherewithal to make our own choices – can be overridden by the ‘responsible clinician’ acting within the warped auspices of the MHA.
Since the 2007 revisions to the Mental Health Act, these coercive tentacles have extended beyond the walls of the psychiatric hospital. Community Treatment Orders (CTOs) allow patients who have been detained in hospital under particular sections to have restrictions applied to them upon discharge. Typically, their future freedom is made contingent upon their continuing to take psychotropic medication; non-compliance can lead to a forcible return to hospital. Furthermore, a wide-ranging review of the impact of CTOs concluded that these human-rights violations achieved no clinical benefits for those service users snared within them (1)
Coercion is on the increase
Statistical evidence indicates the deployment of coercion within mental health services is steadily increasing, year-on-year (2). At the end of the 2013/14 reporting period, 23,531 people in England and Wales were subjected to restricted freedoms under the MHA, a figure that represents a 6% rise on the previous year and a startling 32% increase compared to 2008/09, the year that CTOs were introduced.
‘Mental disorder’ and ‘high risk’: two dubious concepts
Measurement of the two fundamental criteria – the presence of a ‘mental disorder’ and significant risk – used to justify the deployment of compulsory treatment under the MHA are each riddled with weaknesses, particularly regarding their validity. Mental illness diagnoses have long been recognised as virtually meaningless, providing minimal information about the likely course of the problem or the interventions likely to be beneficial (3).
Risk in the mental health arena is perceived, and responded to, in an entirely different way as compared to the threats inherent in our society as a whole (4). Despite the recognition that mental health problems per se contribute very little to the overall level of violent crime (5), there seems to be underlying (and flawed) assumptions that our service users are inherently risky to others and that somehow professionals can accurately predict future risk, and intervene to prevent it, in a more effective way as compared to the risk posed by people outside the psychiatric system. Such distorted assumptions around risk are used to justify the discriminatory practices associated with the MHA. Pilgrim and Tomasini (4) pointedly highlight society’s double standards, arguing that, if risk reduction was the overarching determinant of government policy, a blanket weekend curfew would be imposed on all young adults – a draconian measure that would (unlike the MHA) markedly reduce the incidence of violent crime.
The perpetuation of stereotypes
Not only is the MHA blatantly discriminatory in denying people with mental health problems their fundamental rights of citizenship, but it also underpinned by the most pernicious stereotypes to afflict psychiatric service users. The implicit assumption about inflated risks to others (discussed above) gives weight to lurid tabloid headlines equating psychosis with gruesome murder and other violent crime. Furthermore, as the process to section someone requires no formal assessment of decision-making capacity, it colludes with the implicit notion that people identified with mental disorders must all be inherently defective, rendered incapable of making autonomous choices. Also, there are important negative consequences associated with the spurious view that mental health problems are caused by internal defects – the ‘illness like any other’ mantra – including increased stigma, hopelessness about recovery and overuse of medication (6).
And there are feasible alternatives to the MHA. For example, a ‘fusion law’ has been proposed (7) that is based solely on ‘capacity’ and ‘best interests’, with no specific reference to mental disorder. Importantly, under this amended legislation, any law-abiding citizen retaining the wherewithal to make his or her decisions would be immune to coercion.
Is rejection of the MHA a necessary precursor to meaningful change?
Is it realistic to expect radical change in the way we respond to human suffering while all professional mental health provision is obliged to operate within the discriminatory infrastructure of the MHA? Would progress in addressing prejudice and bigotry in other domains – for example around race, gender and sexuality – have been achieved without changes to statutory laws?
In the words of the inspirational Jacqui Dillon, ‘Fighting for the rights of people deemed mad, many who have already suffered more than enough, is the last great civil rights movement’ (8, p 156). But where are the collective screams of disapproval from mainstream psychiatric professionals, demanding radical revisions to the MHA? If they’re out there, I rarely hear them. Maybe the CMHNN, as the critical mouthpiece of the largest, and potentially most influential, professional grouping within the psychiatric system, might consider a radical revision of the MHA as a central goal?
- Churchill, R., Owen, G., Singh, S. & Hotopf, M. (2007). International Experience of Using Community Treatment Orders. Institute of Psychiatry: London.
- Health and Social Care Information Centre (2015). In-patients formally detained in hospitals under the Mental Health Act, 1983 and patients subject to supervised community treatment, Annual figures, England, 2013/14. http://www.hscic.gov.uk/searchcatalogue?productid=16329&q=title%3a%22Inpatients+formally+detained+in+hospitals+under+the+Mental+Health+Act%22+&sort=Most+recent&size=10&page=1#top
- Bentall, R.P. (2009). Doctoring the Mind: why psychiatric treatments fail, pp. 89 – 109. London, Penguin.
- Pilgrim, D. & Tomasini, F. (2013). Mental disorder and the socio-ethical challenge of reasonableness. In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 74 – 89). PCCS Books.
- Vinkers, D.J., De Beurs, E., Barendregt, M., Rinne, T. & Hoeck, H.W. (2012). Proportion of crimes attributable to mental disorders in the Netherlands. World Psychiatry, 11(2), 134.
- Sidley, G. (2015). Tales from the Madhouse: an insider critique of psychiatric services. PCCS Books.
- Szmukler, G. (2010). How mental health law discriminates unfairly against people with mental illness. http://www.gresham.ac.uk/lectures-and-events/how-mental- health-law-discriminates-unfairly-against-people-with-mental-illness
- Dillon, J. (2011). The personal is the political. In M. Rapley, J. Moncrieff & J. Dillon (Eds.), De-Medicalising Misery: Psychiatry, Psychology and the Human Condition (pp 141 – 57). Palgrave: Macmillan