Ann
Coffey: I understand the hon. Lady’s concerns, but
I cannot see how putting an exclusion in the Bill would prevent a
psychiatrist from falling below the standards to which they should
adhere in assessing people because of lack of knowledge and
understanding on their part. At the end of the day, we are asking
mental health professionals to assess individual situations. We cannot
prevent them from getting it wrong individually, as clinicians, by
having a clause in the Mental Health Bill, telling them that they are
not to get it wrong.
Sandra
Gidley: Would that life were that simple. It is not a case
of doing that, but a clear intention in the Bill would make clinicians
think twice. We should not lose sight of the fact that mental health
services areunder huge stress. It would be easy and perhaps
understandable in some cases for people to come to an obvious
conclusion. I happen to know that many people speak highly of the
services once they access them, because they find that time and
attention are given to them, but we should not necessarily take it for
granted that that will always be done. As I stressed earlier and as
cannot be said too often, it is not us asking for the provision that I
have described——it is the Royal College of Psychiatrists
itself.
Hywel
Williams: Does the hon. Lady accept that there is a wide
variety of practice—good and notso good—apart
from the obvious bad practice of someone sectioning someone entirely
inappropriately? Drawing the attention of officials of varying
standards of practice in respect of these inclusions can
onlybe
useful.
Sandra
Gidley: I am swayed by the fact that it is the health
professionals themselves who are asking for this
clarification——in some respects, this
protection——for their
profession. I wanted
to talk about the alcohol exemption. I still think that it is confused.
There seems to be a lack of clarity about misuse and the degree of
dependency that is necessary. The Minister may say that that has been
clarified, but Opposition Members are not entirelysure when
someone could be covered under ICD10—the
International Classification of Diseases, 10th revision—which is
not covered by the exemption. It still has not been
explained.
Ms
Winterton: May I explain the situation to the hon. Lady?
The amendment that was introduced in the House of Lords is the
provision that refers to “substance misuse”. We are
making the point that it is not entirely clear what is meant by it.
That is one reason why we think that it should be removed: it is not
clear; it is
confusing.
Sandra
Gidley: We shall not settle this issue here and now. We
all seem to be talking at cross-purposes. Perhaps we are all choosing
the bits of the legislation that we choose to
believe. With regard
to sexual identity or orientation, again I have some concerns, because
without this exclusion, people with gender dysphoria, transsexualism
and fetishistic sexual behaviour will be brought within the
legislation, because those behaviours are included in ICD10. Sexual
orientation would cover the fetish behaviour. However, the JCHR
reported
that “in
order for a non-emergency detention on grounds of unsoundness of mind
to conform to the requirements of Article 5(1)(e) ECHR, there must be
reliable evidence of a true mental disorder. We are concerned at the
possibility that a person with Gender Identity Dysphoria or transvestic
fetishism, which are recognised aspects of private life under Article
8, might be detained on grounds of mental disorder without any actual
mental disorder such as depression or actual personality
disorder.”
Mr.
Boswell: Does the hon. Lady acknowledge in that context
that the Government introduced the legislation on gender identity only
because of the intervention of the European Court of Human Rights, in
order to repair a defect in our interpretation of the
convention?
Sandra
Gidley: I thank the hon. Gentleman for that clarification,
which I was not aware of. He has had a longer association with the
issue. It would be useful for the Government to consider that aspect,
so as to prevent the necessity for, shall we say, new legislation after
the event. I shall
not go into the social control arguments, which have been raised a
number of times. However, there are also concerns in the black and
ethnic minority community about some of the implications of the
legislation. We all know that black and ethnic minority men are
committed at a higher rate for certain disorders than white males of a
similar cohort. However, we must be absolutely sure that there are no
cultural factors contributing to that—hence one of the
inclusions in the Lords amendments.
Mr.
Walker: I shall make this a micro-speech. I am sorry that
some hon. Members think that, in supporting the Lords amendment, we are
having a go at clinicians. I hope that I can put their minds at
restby reading a submission by the Royal College of
Psychiatrists, which
says: “We
warmly welcome the amendments made by the House of Lords and hope that
further improvements in the House of Commons will ensure that it is
more fit for purpose.” I
would like to think that we are singing from the same hymn sheet as the
professional clinicians and that it is Government Members who are on
the wrong page. I was
confused by the Minister’s assertion that the exclusions would
create a lawyer’s paradise. That is not a sufficient argument
for not having the exclusions, because it suggests that people with
mental illness value their liberty less than those who are not mentally
ill. I can assure hon. Members that if my status as a free person was
being reviewed and I faced being locked up, I would fight tooth and
nail for my liberty, and I would expect someone with a mental illness
to take very much the same view. Why we think that people who are
mentally ill should not be allowed to have legal representation, or
that such representation is somehow less valid than in other cases, I
do not know. In
arguing her corner, the Minister said that lawyers would be arguing on
behalf of some of the most dangerous offenders, which again suggests
that the Bill is not really a public health Bill, but a public order
Bill. The Minister’s focus on dangerous offenders in that
context, as opposed to people who are ill and may harm themselves,
suggests that we should perhaps have a Home Office Minister sitting
alongside her, making an argument for the public order aspects of the
Bill. I said that
this would be a short speech and it will be. You ruled me out of order
earlier, Lady Winterton,but I hope that this will be in order.
The British Psychological Society, which I have every reason to believe
is an august body, made a submission to the Committee that
said: “There
has been a long history of compulsory psychiatric treatment being used
against those who breach social and political conventions. The fact
that the 1983 Act excluded certain
categories of people has meant that this has been less of a concern in
the UK. However, we should not be complacent about the possibility that
this might happen were there to be no
exclusions.” With that,
Lady Winterton, I say thank you very
much. 6.30
pm
Chris
Bryant: On the face of it, it seems sensible to include
the exclusions that the House of Lords has put in place. They seem very
attractive. Many who remember Pinochet’s Chile or Russia under
Soviet rule will know how mental health services were used to
incarcerate people who were not of the right political opinion. Many
British gay people, and gay people across Europe, know how it has been
to be imprisoned, or for that matter executed, for their sexuality, so
it seems intrinsically a good idea for the Bill to say expressly that
one cannot be sectioned solely on the basis of one’s sexual
orientation. As the
Minister said in her reply earlier, and as I tried to tease out of her,
there is a significant issue in the way that many black Africans and
Caribbeans—males in particular—are treated under the
mental health system in the UK. Many are sectioned for psychotic
disorders beyond the extent that would be expected, although there is
probably not yet sufficient concrete evidence to be absolutely certain
of that. However, certain consultant psychiatrists in London have said
to me that they are aware of a fairly significant problem with London
mental health services whereby people from countries in Africa bring a
mentally disordered relative to Britain because they know that there
are no mental health services for the relative in the African country.
They do so knowing that their relative will receive mental health
services here, because no clinician would be able to allow him or her
to roam the streets.
I can see several reasons,
therefore, why it might seem intrinsically a good idea for the Bill to
contain the proposed exclusions. However, on sexual orientation in
particular, it seems bizarre that we would want to cover it in the
Bill. We should assume that nobody believes that somebody’s
homosexuality is a reason for them to be sectioned. We should make that
assumption, together with the assumption that nobody should be
sectioned for their political, religious or cultural
views. Of course there
will be complicated decisions, such as when someone says, “I am
God” rather than, “I believe in God.” Richard
Dawkins would say that both are equally delusional, but I think that
British society has a settled understanding of how religion and mental
health play together, and I do not believe that that needs to be put
expressly in the Bill.
That is why, despite
understanding the reasonswhy people might wish to include
them, I find the exclusions patronising and therefore inappropriate. I
also believe that they would be a legal nightmare. The person who does
not want to be sectioned, and whose lawyer says that his claim to be
God is a religious belief, will be able to advance that argument before
the courts. That gives a much more complicated set of decisions to the
courts than would be appropriate.
In the end, I suppose that I
believe that there should not be any exemptions. In particular, I have
a real concern about the exemption on alcohol and drug
abuse. As the hon. Member for Daventry mentioned earlier, several
conditions similar to alcohol dependency are conditions for which we
section people. Bulimia and anorexia nervosa are both eating disorders.
Many people believe that alcoholism is a similar type of disorder, and
many of the treatments that people undergo for each of them, such as
the 12-step treatment, would be very similar. Why, therefore, should we
choose in no circumstances whatever to section somebody who is
alcoholic yet be prepared to section people who might be a danger to
themselves for other reasons, when I would suggest that the conditions
are relatively
similar? On
alcoholism, my hon. Friend the Member for Bolton, South-East made an
important speech about dual diagnosis. Where somebody is an alcoholic,
there is often a chicken-and-egg debate: is the person an alcoholic
because they are depressed or are they depressed because they are an
alcoholic? That has not been genuinely resolved in any sense, and that
is why there is a worry about people being turned away from mental
health services when their primary mental disorder is alcoholism. I am
talking not about binge drinkers or people who drink on a regular
basis, but about people who would go into delirium tremens were they to
stop drinking. Such people would have fits and hallucinations, and
would not be able to get through the morning, afternoon or evening
without having a sufficient quantity of alcohol in their
bloodstream.
I took my mother through DTs on
several occasions, so I know how horrible such situations are. I
understand why many clinicians will not want to have to enforce
detoxification or rehab, but for some people the dependency on alcohol
is the mental disorder that needs to be addressed, and all too often,
people have not received the medical and psychiatric support that they
need. Because such people often have chaotic lifestyles, they may be
dependent not only on alcohol but on other drugs—in many cases,
such people are dependent on anti-depressants. As a result, it is all
too easy for the mental health services to say, “I am sorry, but
we just don’t think that we can really help
you.”
Dr.
Iddon: Does my hon. Friend agree that in the past people
with co-morbidity have been told to get rid of their substance misuse
before they proceed to be treated for their mental illness? We should
treat people holistically, as is best
practice.
Chris
Bryant: My hon. Friend makes an important point. One of my
worries about the provision of mental health services around the
country relates to the fact that not every person is the same. There
needs to be a wide range of treatment methods and locations. Some
people need to be treated at home, whereas others need to be treated
away from home. Some people need to go through the 12-step process,
although I should point out that because reference is always made to a
higher power, many people have difficulty in subscribing to it. I am
keen to see genuine diversity and people being treated in a holistic
way, as my hon. Friend suggests. That is why I worry about the
exemption in respect of drug and alcohol dependency.
I concede the Minister’s
point on alcohol misuse. The Royal College of Psychiatrists’
definition of misuse of alcohol is being drunk. Someone who is drunk
has misused alcohol, although they will subsequently recuperate. But
just because somebody is drunk does not mean that they should
necessarily enter into the mental health system and be
detained. I want to
make one other point about alcoholism. I worry that, by keeping the
exemption about alcohol and drug dependency in the Bill, we are not
preparing ourselves for the future. I simply do not believe that we
know everything that there is to know about alcohol dependency. In 20,
30 or 40 years’ time, I think that we will have a much better
understanding of how to treat alcoholism. I hold that as a passionate
belief, even though I have no substantive evidence for it. By including
an exemption in the Bill when the matter should be left to
clinicians’ independent judgment, we might be disabling the Bill
for the future. I also
want to refer to the issue of sexual identity and sexual orientation
and the exemption that exists in the House of Lords version of the
Bill. Incidentally, I shall try to elucidate the precise position in
respect of the row that I had with the hon. Member for East Worthing
and Shoreham earlier about whether homosexuality is in the ICD10 list.
It is true to say that homosexuality is in the ICD10 list, but so is
heterosexuality, so that does not take us very far forward. The fact
that something is in the ICD10 list does not necessarily mean that
anybody should consider certain people to have a mental disorder. That
is the point of the Bill. Several other hurdles have to be clambered
over. It is not just the fact of a mental disorder that is considered
but its nature and degree and whether a person will be a danger to
themselves and/or others. That has to be overcome before detention is
considered. The mere fact that something is listed in ICD10 as a mental
disorder is not sufficient. ICD10 does not state that homosexuality is
a mental disorder; it is a more complicated
measurement. It
is also true that paedophilia is not listed under a category called
“Sexual identity or orientation”, because there is no
such category in ICD10. It is listed under “Disorders of sexual
preference”, alongside fetishism, fetishistic transvestism,
voyeurism, sadomasochism, exhibitionism and various other minor
disorders. The Government need to be clear about precisely what they
expect clinicians to do about paedophilia. I hope that, if somebody
presented to a clinician and said that they had significant sexual
fantasies relating to pre-pubertal children, the clinician would want
to take action on that basis. If that mental disorder were of a nature
and degree that was significant enough, and if it was likely to lead to
danger to children, the clinician should be free to make the judgment
that the person should be detained. I should be grateful if the
Minister replied on that issue, because the exemption supported by
Government Members would make that
impossible. I shall
end by saying that I should prefer it if there were no exemptions.
Unfortunately, every psychiatristI know says, “I
don’t want my ward filled with alcoholics.” That is not a
good enough argument, but I understand why the Minister is supporting
that
position. Nevertheless, it is important that the issue of using
“solely” or “alone” should be added into
her amendment on
Report. | 
