Joint Committee on the Draft Mental Health Bill Written Evidence


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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