DMH 141 Memorandum from Crewe and Nantwich
Mental Health Sector Planning Group
The following comment is to be considered as evidence
to the Committee.
Summary
The implied underpinning of the revised Bill is that
there should be a balance between the protection of society, protection
of the individual and the accessibility of treatment, and a greater
tolerance of individual behaviour hopefully leading to a tolerant
and just society. However, both the accessibility to treatment,
resources, and the greater degree of control placed in the agents
of state, the partial reversal of an individual's self-determination,
the reduction in state funded care on discharge from compulsory
treatment and the definition of mental disorder are matters of
great concern.
2. Severe Personality Disorder
2.1 Now that this syndrome is regarded as a severe
mental illness, people with this condition might expect appropriate
treatment. It is curious, therefore, that the government has dismantled
the residential provision in our locality, Webb House (administered
by Bolton, Trafford and Salford MR Trust), after setting it up
just a few years ago at great cost. The argument that such services
should be placed in the community is partly right, there should
be a range of modalities. Institutions — even very benign
ones, - are regarded as leading to institutionalisation, which
does not need to be the case (e.g. the special treatment units
in HM Prisons, where a change of culture massively changes the
success). Therapeutic communities require very high commitment
by its residents, and the behavioural outcomes are good (without
any drugs!).
2.2 Widening the criteria of the condition may
lead to greater secrecy and self-deception, making it more difficult
to acknowledge the possibility of a problem.
2.3 The idea that persons who self-harm (but
are not mentally ill) may be subject to compulsory measures is
generally not acceptable. Such patients need prolonged help in
taking control of their lives — within their own community
—rather than (enforced?) CBT etc. The Cochrane papers acknowledge
that
studies are of insufficient size to enable an evidence
base to be devised, and a meta study is not possible since the
small scale research is so diverse.
2.4 And where are the therapists for deliberate
self harm? In this area of Mid Cheshire (pop. C. 215,000) the
only resources are one or two voluntary organisations, grievously
under funded. Psychologists will no longer be having caseloads
of their own. Other professionals with the necessary skills are
few. Greatly increased resources for the non statutory sector
must accompany legal changes.
2.5 And where is the funding? Literally dozens
of frozen nursing posts because of the Trust overspend; wards
being declared unsafe to practice due to poor staffing levels
with consequent closure of a psychiatric intensive care unit to
boost staffing on other wards —
and the catalogue of resource problems could
go on.
2.6 The realistic solution is an eclectic mix
of resources and routes into services, but greater compulsion
is to be deplored. No matter how we wince at the thought, deliberate
self harm is a choice emanating from a distorted way of coping.
Help, yes. Compulsion (except in extreme circumstances and as
part of a frank mental disorder,) no.
2 Control
3.1 Professionals
of all kinds often have a profound difficulty in viewing the world
other than through their patriarchal eyes. If it were otherwise,
there would be no real need for a nominated person or mental health
advocates etc. If viewing other people from their own perspective,
(it used to be called empathy), was a reality, treatment would
be a (generally) cooperative process rather than the imposition
the Draft Bill implies.
3.2 Imposition would be arguably less of a problem
if the treatments only led to positive outcomes, or that the undesirable
outcomes were honestly acknowledged and the risk/harm ratio balanced.
But of course we have, in many respects, been led up the garden
path. The so-called atypicals with a lower risk of side effects,
have been comprehensively criticised by the ex editor of the BMJ,
Richard Smith. Prozac, Corticosteroids, the new generation of
anti depressants — the
list is considerable. So much for an evidence base.
3.3 And as for (implied?) ECT for young people,
even in an emergency, personally I, and I guess many other people,
will find that reminiscent of a gulag.
3.4 No matter how carefully and professionally
the new Act is implemented, the fact that the words could allow
detention of people whose beliefs or behaviour could be construed
as a manifestation of distorted brain functioning, poses political
and human rights problems. The definition(s) of what legitimately
constitutes grounds for an assessment must be much tighter, with
very rapid access to a Tribunal if the patient disagrees, and
not be seen to theoretically extend into old style Soviet catch-all
phraseology.
3 Patriarchy
4.1 The Royal College of Psychiatrists issued
advice, in the form of a booklet, some years ago advising patients
of the searching questions they should use when in consultation
with a psychiatrist. The underpinning philosophy was that patient
views count — as
do those of carers — which
seems largely lost on the civil servants who have drafted the
Bill.
4.2 Of course, some patients will have lost insight
(in our terms), but most will have insight when well, and can
make sensible comments about how best they can be helped when
mentally ill, and in particular what creates fear and dread, and
what makes them feel worse. More sensitive exploration of a service
users reflections when well, could probably shorten a later acute
phase, and hasten recovery.
4.3 There is the acceptance within the draft
Bill, that staff are only capable of uni dimensional functioning
— they
are unable to stand outside of themselves and examine their behaviour
from a patient's perspective. It used to be called empathy. Why
else would it be necessary to expand the numbers of mental health
advocates? While some patients may need help to express themselves
and be more assertive —
when advocates are invaluable —
the underlying empathic malaise is depressing.
In reality, the Bill is right to emphasise their importance, and
accreditation, but only as a result of professionals' limitations.
4.4 Advance directives should be valid unless
they imperil the patient to a life threatening degree.
5. Consent
5.1 The often dismissive attitude to consent
is deplorable. Professional staff should have an enabling or health
enhancing role, not the patriarchal 'do it my way', 'iron fist
in velvet glove' manner. Except in very tightly defined situations,
joint exploration should be the sine qua non. Consent should also
be regularly reviewed, not a once-for-all event, particularly
as the patient recovers and nascent abilities recovered.
6. Aftercare
6.1 With the increasing
amount of home treatment in the acute phase, aftercare becomes
a natural continuum . Nevertheless,
a package of care for all patients, free and comprehensive, must
be in place if costly recurrent breakdowns are to be avoided.
6.2 The fore shortened period of six weeks aftercare
(previously S. 117), is unacceptable, particularly for patients
whose hospitalisation has been prolonged.
7.Compulsion in the Community
7.1 Guardianship under previous legislation was
intended for use within a mental illness context (as well as in
learning disability), but was seldom implemented for a number
of reasons, particularly that of liability by local authorities.
The liability issue remains.
7.2 It was also impractical for the same reason
as in the draft Bill, because it is based on flawed reasoning.
7.3 If a person does need to be 'compelled' under
the Mental Health Act, it pre supposes that the patient is either
non compliant, unreliable, or unpredictable. Therefore, someone
within that circle is at risk, possibly life threatening risk.
Safety, therefore, has to be permanent and hospitalisation expedited.
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