Welcome to the first of what we hope will be several blog posts that are written in response to the Government’s independent Mental Health Act Review, Dec 2018.
This first post is a critique of a central underlying assumption of the review. In it, Jonathan Gadsby argues that by framing the debate in terms of autonomy vs protection rather than libertarian vs authoritarian, the review narrows the possible discussion in ways that are self-serving and anti-democratic. In other posts we hope to address two further issues – firstly, the ‘Alternative Review’ by the English Hearing Voices Network and secondly, to reflect upon the fact that in this 114000 word document, the word ‘nurse’ appears just three times. Considering that the MHA is implemented more by nurses than anyone else, that seems… well, interesting to say the least.
It is recommended that readers do view the Wessely report alongside this document. The report is written in refreshingly plain English and there will be much in it that mental health nurses relate to. It also feels right to recommend an anonymous posting to Mad In The UK this morning as something that could be read alongside this, too.
As ever, you are welcome to agree or disagree with the following. Please feel free to comment.
Autonomy versus protection:
a case of ‘meta-gaslighting’.
Instead of a point-by-point response to Wessely’s report, this first post will focus on its central argument: the mental health service must reside and pragmatically work within an area of political philosophy in which a single static solution is impossible. Services must contain a dynamic balancing of libertarian versus authoritarian views. To argue that all detention is de facto wrong because it offends the values of libertarianism is a position that requires one to take an uncritical position on libertarianism (and upon authoritarianism, too, although I write that with some trepidation). It is therefore probably true that it should remain a legal possibility to detain someone who has not committed a crime for reasons of risk to self and others because of mental state, or at least, the arguments for the abolition of such a law are probably not fully convincing yet. One expects to follow this understanding as the report does, with hopes to make the use of the Mental Health Act a rare occurrence. It is right that the report expresses deep concern that it is not increasingly rare but increasingly common. This is also probably a good moment to say that within the confines of a particular ideology, this report reads as well-intentioned, careful and moral. Also commendable is that service-users’ experiences of the use of the Mental Health Act are presented in full and sombre detail (although the efforts to work with service-users did not extend to recognising the expertise and perspectives of key survivor groups). To read this report is to be moved by both the apparent intentions of the author and the appalling nature of the experiences reported by service-users. It confirms that, sadly, mental health services are a horrible experience for a lot of people. That much is probably not contentious.
However, in a fundamental way I find I cannot accept the central argument made by the report. Actually, it never uses the language libertarian/authoritarian, preferring instead autonomy/protection. This is symptomatic of certain key assumptions and has a number of profound implications that will be explored below.
This reduction is made possible because the report fails to notice that key knowledges of psychiatry itself are deeply contested. The report attempts an apparently reasonable and heartfelt call for a rebalancing of an autonomy/protection seesaw, but all the while assuming that the grounds currently supplied for the authority of mental health law and mental health professions for this ‘protection’ are credibly valid. Wessely might reply that the report could not possibly solve the problems of diagnostic psychiatry at the same moment as considering the powers and uses of the MHA, but that is wrong. The MHA and diagnostic psychiatry support each other. Ultimately, the only explanation for the existence of either is the other and they cannot be reviewed or revised independently. The politics of Wessely et al. cannot see the discredited science of psychiatry and the discredited science enables their politics. Even though the report might be right in its assertion that autonomy/protection must always be held in balance, the kinds of conversation that one could have about that balance are utterly distorted into what I think of as a meta-gaslighting.
The racism that the authors movingly deplore is described as being caused by a ‘fallible’ mental health system (p19). This is the kind of stance that is only possible when there is an idealised ‘true’ psychiatry able to correctly identify ‘natural kinds’ illnesses, but one that sadly sometimes makes mistakes due to human error. In fact, as many critiques establish, that is not a good understanding of what psychiatry is. Psychiatry is rarely something that ‘carves nature at the joints’, but a complex system of cultural vectors and normalising narratives (even where it identifies embodied distress, even when it provides bodily relief). Therefore, this trope of continuing shame about the over-representation of BAME people (the report also very briefly mentions the prevalence of force upon women service-users but does not particularly discuss it) is unable to provide any hope except that clinicians must try harder. There is a hint at one of psychiatry’s favourite stories (p24) in regards to what is framed as the unwillingness of BAME communities to benefit from psychiatry: they don’t know we have changed. As Bonnie Burstow argues, psychiatrists have always looked about them at current mental health system violence and told themselves that it already belongs to the past.
De-politicised psychiatry will forever attribute more illness to minorities and the marginalised, who will always experience and embody more distress, whoever they happen to be. Such a psychiatry will always struggle to willingly engage the marginalised because they will rightly find its culturally-mediated categorisations a poor fit and within engagement are heavy prices for them to pay (to culture, history, identity, integrity, justice, etc.). Using its particular brand of circular logic/powers of projection, psychiatry will interpret this poor fit as proof of its own rightness and necessity. Psychiatry remains so often unaware of its own meaning and context. It is not the ‘fallible’ application of psychiatry that is the cause of an inadvertent racism (and sexism). The problem of racism within mental health practice will not be solved by a programme of individual competencies (no suggestions are made about combatting sexism). If psychiatry is a practice of normalisation and othering it therefore inherently holds marginalised people in suspicion and is part of the means of their further marginalisation. It is not an accidental feature of a stratified society that people are marginalised and feel its effects; it is not an accidental feature of psychiatry that the distress of marginalised people is considered to be their personal illness. These are very well-established ideas, Dr Wessely et al.!
This, then, is the effect of transforming ‘authoritarianism/libertarianism’ into ‘autonomy/protection’. Under the former, it is clear that the right kind of mental health service would have to be a democratic mental health service, noting the ideological nature of all positions and that, despite the reality of personal suffering, individual pathology is a value judgement more than it is a natural fact. The role of democratic psychiatry within society might be one in which the structural injustices of society are challenged as well as the suffering of individuals recognised and provided for. Yet with the de-politicised version enters the expert with the casting vote and ‘best interests’ and the important democratic questions of whose best interests are fading away or being twisted by what amounts to the ability to give some people a trump card in the conversation. Thus the role of psychiatry is to further disempower those already subject to deficits of democracy and, painful though it is to admit, there exists a clear and well-explored argument that the more ‘successful’ psychiatry is at its job the more societal justice is delayed. It may be that some of these highly politicised perspectives on psychiatry are overly simple, in some ways reductive just as biomedical depoliticised perspectives are, but should they be missing?
Order and diversity
To alter the terms back from autonomy/protection to authoritarian/libertarian would, I believe, actually be a very positive move for the survival of psychiatry, mired as it is in its failures to show itself to be a natural science. It would, however, be hugely changed, as would society as a whole. I have tested this idea out on psychiatrists I have taught. They agree with me that to describe psychiatry as imbued with value judgements does not render it wrong of itself. Yes, it has (and always has had) authoritarian leanings, but that also is not wrong of itself. Every society makes value judgements and has many institutions that are normalising. Order (a key value of authoritarianism) is always at the expense of diversity (a key value of libertarianism) and vice-versa. The spread of values in which psychiatry is located is a legitimate diversity of values. People are generally not surprised that more libertarian governments encourage schools to teach values of creative self-expression and values of individual freedom, nor are they surprised when more authoritarian governments insist that national standards and competencies should be tested through the relative conformity of exams. Few teachers or parents (and probably, few children) think that one should be wholly endorsed at the expense of the other. We think of them as a legitimate diversity of values to be debated, thus showing that we view education as inseparable from political thought. Of course every different government ‘fiddles’ with education! The debate is never-ending and that is exactly how it should be.
As with education, governments also seek to alter psychiatric practice. The context of our increase in the use of the MHA is not the hand-wringing mystery Wessely makes it out to be. For nearly 40 years (arguably with a slight blip in the early Blair years) we have had an increasingly authoritarian UK government that believes it has a mandate to push back against a number of diversities in order to place more emphasis upon order. As the report shows (but does not notice the relationship), the increased use of the Mental Health Act has mirrored this (also with a slight blip in the early Blair years). Successive UK governments have sought to narrow the diversity of reasons that may excuse a person from paid employment and home ownership. As a result, the diversity of society is driving more distress and services are encouraged to meet it with individualised approaches that push people to take responsibility, regulate and ‘recover’ (become an orderly conforming citizen in the workplace). As every decent critique of the recovery model of services over the last six years or so has argued, mental health services have been a conduit for this politics. This is precisely because of devices such as the ‘autonomy/protection’ narrow focus. It might be fair to say that during this period teachers have tended to be more generally libertarian and have been unhappy about the imposition of greater testing, national standards, SATS etc., whereas mental health services have a long-standing weakness for aggressively authoritarian tendencies. Where mental health staff have retained some libertarian views, the Work Capacity Assessment has taken over, quite literally over-riding those views. These are not the ravings of an extreme libertarian (I hope I have demonstrated that I believe liberty is not the only good in society although I would not want to be misquoted on that, it is certainly one of the best); they are some of the most established and scholarly critiques of psychiatry in 2018.
Good intentions are the only substance
Despite detailing some factors that have probably contributed to the rise and rise of coercion and force within mental health services, good intentions are really the only substance in Wessely’s report. For example, Advance Choice Documents are “to be honoured unless there are compelling reasons why not”. Within five minutes, in will come the consultant with his/her ‘nature’ and ‘degree’ arguments and bingo, you have your reason for compulsion, a loophole even a person forced to take a haloperidol depot could drive a bus through. Will it matter if that argument is presented at one tribunal or two tribunals? Will it matter if the tribunal was requested by the service-user or triggered automatically on their behalf? By the time the report has argued that should an Advance Choice Document request a treatment “known to be harmful or ineffective” then it would be “documented but not implemented” (page 22) the feeling is once again that sanity is simply what the doctor tells you it is and your only ‘choice’ is to agree. Expect such Advanced Choice Documents to be kept in the notes until such time as they become irrelevant. To me, the deep regret expressed throughout the report seems to suggest that on a certain level, the authors already know this. Likewise, what is the value of threatening the CTO (weirdly saying it is “in the last chance saloon”, p27) but with no real recommendations other than we all try harder not to use them for more than two years unless once again there is a “compelling” reason? These are not recommendations, they are tomorrow’s excuses. They look rather similar to today’s.
To summarise, this report is undermined by a depoliticised view of psychiatry that takes the debate properly known as authoritarian/libertarian and alters it to merely autonomy/protection. In doing so, power imbalances (such as racism and sexism) cannot be explained and democratic dialogue is made impossible. Poor political philosophy is not the genesis of good practice, and there is no hope of good practice when the report contains a credulous acceptance of the validity of what is, in reality, a highly contested narrative of medical diagnosis and treatment for distress/overwhelming mental states/unshared beliefs/abuse/trauma/oppression. The result of these assumptions is that the recommendations are not much more that a re-stating of good intentions and asking for more resources to see them through, leaving psychiatry as the final arbiter. I am left with questions of whether this report is better than nothing at all, because if this kind of reasoning does attract more resources it will be of very doubtful benefit.