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Why is it important to have an amendment like this? The joint scrutiny committee concluded that the wider the definition of “mental disorder”, the greater the need for exclusions. I am sure that the Minister will talk about the need for clinicians to have scope to employ their judgment. I do not believe that these amendments will in any way compromise that. The Mental Health Commission, in its evidence to the joint scrutiny committee, said:
“For the law to be of value—to patients, State administrators, mental health professionals, the police, the courts or the Tribunal—its meaning cannot rest upon the discretion of those working within its framework. We do not find it difficult to envisage the inappropriate use, however well meant, of mental health legislation for non-medical purposes of social control”.
Therefore, it is important, in these very difficult areas of sexual behaviour, illegal or disorderly acts or cultural, religious or political beliefs, that we, as Parliament, set boundaries within which we expect
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Baroness Murphy: A subtext runs beneath many of the Government’s proposals. I say, “Mind the gap”. In trying to change the 1983 Act, the Government, in almost every single clause, are concerned to try to include patients who have been excluded from the 1983 Act as a result of poor psychiatric practice. That is the subtext of much of the Bill. In trying to close those gaps they have forgotten that the law has been used only as an excuse.
Take, for example, a 20-bed unit with 110 per cent occupancy. When one considers whether to admit someone who has a mental disorder, one will consider whether he can be treated, whether he will be out again in 48 hours and whether he can be supported in the community. One could also consider admitting a rather challenging, difficult Mr Smith who is persistently drunk, never takes his medication, and about whom it is unsure whether he can be dealt with over the next two to three months, so he will be in the bed longer. When someone asks why one did not admit this or that person, the answer is that the law did not allow it. That is repeated over and over again. I cannot tell you how often it happens. That is what lies behind the very wise amendment of the noble Lord, Lord Adebowale, who sees people excluded from care every day of the week.
Is the answer to put such a matter in legislation, widening the scope of the Act to include many people who would not otherwise be considered for detention? For various reasons the answer is no. The answer is training, resources, better understanding of what is possible and better understanding of how to help people with difficult and challenging problems such as substance misuse and paedophilia, but one cannot include them all.
The amendment is about stopping detention creep. In this country it is quite difficult to get people to take it seriously because since the 1959 Act we have had a tradition of using psychiatric hospitals and units almost exclusively, but not entirely, for the care of people with mental disorder. But that exclusiveness is a relatively recent phenomenon. Mental hospitals and asylums in the 19th century and before and after the First World War became repositories for all kinds of socially excluded people when there did not seem to be anywhere else to put them. In those days if one were in a mental hospital, one was detained by default. The destitute unmarried mother, the epileptic, the merely eccentric and the socially incompetent all tumbled into the asylums. They were a social inconvenience but everyone colluded in saying that there was nowhere else for them to go. In the 1970s, when I first worked in psychiatric hospitals outside the great fringe around London—what we call the Epsom archipelago—the place was full in the back wards of people whom we had enormous difficulty diagnosing with anything.
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Society does not know what to do with other social misfits. One group is those who are persistently addle-headed on drink and drugs. They are very difficult to help. Of course, there are ways to help them, but it is not easy. Paedophiles form another group; the religious fanatics who belong to the Moonie loonies and the like is another. We know that those people are not as we would like them to be; they are not like us; they probably need some help, but how we should help them is rather obscure. No doubt a significant percentage of them suffer, from time to time, with mental disorder which would bring them properly under the scope of the Act, but it is a profound mistake to include all categories of people behaving badly simply because we do not have any other answers.
The Mental Health Act is designed, as we keep saying, to provide a check on clinical discretion and to give clear boundaries to protect against improper use. The Government believe that society in general is happy to leave decisions, such as the scope of the Act, in the hands of professional experts. I find that quite astonishing. They obviously do not know as many professionals as I do. I regret that I do not find it difficult to envisage the inappropriate use, perhaps well meant, of mental health legislation for non-medical purposes, for social convenience and control—“Get the paedophiles off the streets”. The pressure on services to find solutions to the presently insoluble problems will be massive. Exclusions ensure that practitioners carefully consider the basis for compulsory treatment. If there is an underlying mental health diagnosis, a person is covered by the Act; if there is no diagnosis, it is unhelpful and inappropriate for the mental health services to manage that person.
The revised definition of mental disorder is deliberately simplified and free of diagnostic categories in the Bill, so it is all the more important to be clear about the exclusions, which, after all, are a feature of the legislation in all comparable jurisdictions in the common law world, including our near neighbours Ireland and Scotland.
I turn to sexual behaviour. When I was a trainee psychiatrist, we were obliged to learn all the ways to treat homosexuality, even though at the time many of us were horrified that it came within the scope of what we were meant to learn. Until recently, it was included in ICD 10. There is still a wide range of sexual behaviours in ICD 10 and so are many other mental phenomena which by themselves would not necessarily fall into the category of mental disorder; for example, excessive gambling and grief. Just because something is in ICD 10 does not mean that it should necessarily fall within the Act. We know that people whose sexual behaviour departs from socially acceptable norms are likely to be stigmatised. They may or may not have a mental disorder. Their behaviour may or may not be contrary to criminal law. Without this exclusion, however, people with gender dysphoria or transsexualism and, indeed, your everyday rubber fetishist will be brought within the Act as well as paedophiles.
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Forensic scientists tell us that the current exclusion criteria are important in enabling them to distinguish between those who are truly amenable to help and would warrant a detention because they have an additional mental disorder, and those who do not. From a psychiatric point of view, there is no necessity to remove the exclusion of pure disorders of sexual preference from the definition of mental disorder. As I say, the Government are obsessed with folk who do not get into treatment. This is not the right way to approach that.
On illegal or disorderly acts and political beliefs, there should be a clear distinction between people who have a mental disorder and those whose behaviours and practices are simply unacceptable to society in general. There are, after all, lots of people who say that those young British Muslim terrorists who blew themselves and others up were mad—not a far step from thinking that all people who want to see an Islamic state in Britain should be locked up in a mental hospital. It has been done elsewhere in the world, as the noble Earl, Lord Howe, pointed out. Psychiatry has been abused in Nazi Germany and many other countries and, in the 1960s and 1970s, in the Soviet Union.
I spoke to many colleagues in the Soviet Union during that time, when I was a young trainee psychiatrist and the Soviet Union’s psychiatrists were excluded from the World Psychiatric Association. Most of the psychiatrists working in the Soviet Union at that time believed that they were doing the right thing—there were of course those brave dissidents, many of whom managed to come here and other parts of western Europe. Most of the psychiatrists did it with the best of intentions. We must remember that. That is why they were excluded from the World Psychiatric Association; it was not imposed on them by their Government.
The effect of not having exclusions further confuses the role of psychiatry and mental health services in the public mind, moving it from its proper aim of the assessment and treatment of mental disorder into social control. It further reduces the acceptability and, therefore, effectiveness of the services. That will have a serious impact on people from black and minority-ethnic communities, as we have already heard. I have covered the third exclusion of cultural, religious or political beliefs, and the joint scrutiny committee agreed.
The Government are concerned with the exclusion of people with mental disorders who have unusual cultural beliefs. I cannot think why they feel that there is a risk that they will not be included, since minority cultures tend to be over-represented in those compulsorily detained. If there is a misunderstanding, it is, rather, the inverse of what the Government fear. What is their evidence on this? In their response to the scrutiny committee, the Government made the extraordinary statement that,
- “cultural, religious and political beliefs do not constitute mental disorders, but may sometimes be symptoms of a clinically recognised mental disorder”.
In other words, it is possible that you could have no delusions, hallucinations, thinking disorder, speech
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These amendments are to protect against inappropriate detention, and to protect professionals from being used inappropriately by society. With good training and better resources to treat people with a wide variety of disorders and ancillary problems—including those the noble Lord, Lord Adebowale, is talking about—we should certainly be able to solve this problem. Widening the definition, however, is not the answer.
7.45 pm
Lord Adebowale: I speak to Amendment No. 5 in my name. The Bill rightly clarifies that dependence on alcohol or drugs is not a mental disorder that justifies compulsory treatment. By making this clear, however, it could inadvertently mean that a person with a dual diagnosis of a mental disorder and dependence on alcohol or drugs might not get the help they need under the Act. Before I go on, I must once again declare an interest: Turning Point is probably the largest provider of services to people with alcohol and drug problems outside the NHS. I thank the noble Baroness, Lady Murphy, for her kind words on my amendment before she had heard me speak. That is quite nice.
My amendment is complementary to Amendment No. 4. In the United Kingdom, it is estimated that half the people in drug or alcohol services also have a mental health challenge. Around one third of patients in mental health services also have a drug or alcohol problem. My organisation works with many people who have multiple needs. We estimate that at least one in five people we support—at last count we provided a service to 136,000 people—with mental health challenges also need help with serious substance misuse.
All too often, the presence of a drug or alcohol problem alongside a mental disorder is used as grounds not to treat people. They are turned away, as has been pointed out, from mental health services when they are in the greatest possible need. From our experience, people with a so-called dual diagnosis of mental health and substance misuse problems have been turned away from mental health services in the past due to the current exclusions. Consequently, people are not receiving the help they urgently need. This has consequences across the social care system. Their mental health deteriorates even further and community services endeavour to help, despite being ill equipped to do so.
I offer an example. The Bill is often given colour when we talk about its effects on human beings. Sarah is 38 and has a diagnosis of depression and borderline personality disorder. She also has long-standing drug and alcohol difficulties and self-injures on a regular basis. When admitted for in-patient treatment, she is often put on a contract stating that she will be discharged if she self-injures or uses drugs or alcohol. These are her coping strategies; the use of alcohol or
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Simply educating mental health staff about substance misuse will not be enough to solve this problem. While I agree with the comments about resources and training, it is not enough. The reasons why people use drugs and alcohol are complex and often misunderstood. Sometimes it can be to self-medicate and treat the symptoms of mental illness but is often interpreted as resistance to treatment or to engagement with services. It is important, if we are going to have a Mental Health Act and spend time engaged in ensuring that those in need receive treatment, that we pay attention to this group, which is a growing challenge to mental health services throughout the country. That has already eloquently been pointed out by the noble Baroness, Lady Murphy.
I want to comment on the race issue, without repeating what has been said already here or in the joint scrutiny committee. There is considerable evidence that BME groups, particularly those from Afro-Caribbean backgrounds, are more likely to be diagnosed with a severe mental disorder. Simplified definitions where exclusions are removed increase the degree to which diagnosis of mental disorder depends on the subjective judgment of clinicians, which the literature now states with ample evidence is sometimes subject to quite racist interpretation. I am sure that my noble friend Lord Patel of Bradford can give chapter and verse on this, as chair of the Mental Health Act Commission.
Given the evidence that racial stereotypes are significant factors underpinning notions of mental disorder, that is likely to amplify the extent to which race is a factor in defining such disorder, in effect widening the pool of people to whom legislation could be applied and who will be affected by the existing skew toward black and minority-ethnic groups, a situation made worse by amendments.
Baroness Masham of Ilton: I support Amendment No. 5. It would be wrong to prevent the treatment of someone suffering from alcohol or drug abuse if they had a co-existing mental disorder. It is well-known that alcohol or drug abuse, or both, can exacerbate a mental illness such as schizophrenia.
Some years ago, I was involved with an alcoholic man who would suddenly lapse into a schizophrenic state when he had been drinking alcohol, becoming a dangerous and different person. There were several frightening incidents; once, he threatened a friend of mine with a knife. It would be wrong to make alcohol or drugs an excuse for not treating the mental illness.
Far too many people residing in Her Majesty’s prisons suffer from schizophrenia and do not get the treatment they need. That is of great concern to many, including prison governors. Will the Bill address that dilemma?
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Lord Alderdice: It seems to me that this group brings us to the heart of some real difficulties in applying legislation, and the law in general, to mental illness. It is not like physical illness; it is about the very essence of people and what they are, which is a very difficult issue.
The issues of diagnosis, management and practical reality all come to ground in this group, as the Government have recognised by introducing a specific exclusion. Nothing in the provision says that the exclusion is on a point of principle or a particular kind of difference in terms of psychology or psychiatry. It is quite clear that dependence on alcohol and drugs involves a disorder of the mind. There is no doubt about that. There is not much doubt either that it is also similar to lots of other kinds of addictive behaviour. When treating one of these folk, often you get rid of the alcohol problem and they turn to drugs; then you get rid of the drug problem and they turn to gambling, an eating disorder or whatever.
It is not an issue of principle, and the Government know perfectly well that if they were to include all those people as likely to be detained, the services would collapse completely because of the enormous number of people involved. It is not to do with there not being a possibility of violence; in fact, there is a much greater likelihood of violence from this group of people than from people suffering with schizophrenia. However, the Government recognise that they cannot cope. The truth is that they cannot cope with lots of the other folk they are going to bring in anyway. It is hard enough to find a bed for a psychotic young suicidal patient at the moment, and it will be even worse with a lot of these other things.
Let us take the reason for some of the exclusions being set down here. Some are about real difficulty of diagnosis. If, for example, someone comes along and speaks about being low-spirited—they are not sleeping at night, they have lost interest in a lot of their affairs and are not behaving in their usual way—they might well have a depressive disorder but, of course, if their wife died three weeks ago, it would be a perfectly normal reaction to one of the vagaries of life. As my professional colleague the noble Baroness, Lady Murphy, pointed out, the difficulty is that if you do not look for all of the things that are around, the diagnosis can be faulty.
Taking personality disorder as an example, there is often a circular argument: this person is breaking the law; they do it repeatedly and do not stop; there must be something very disturbed about somebody who behaves in that way; therefore, they have a personality disorder and need to be treated. More insidiously, if the psychiatrist does not have much understanding of or sympathy for the cultural or religious background of the person involved, there is another kind of circular argument: this person has some very strange ideas; they might be religious ideas. I come from a part of the world where a lot of the religious ideas that are very current among people would be regarded as quite mad on this side of the water. I refer not just to religious ideas. One colleague came across to work in Northern Ireland, and after interviewing
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I guarantee that the reason for the undoubted fact that many more people from Afro-Caribbean backgrounds find themselves in a mental hospital is that there is less understanding of the cultural and religious beliefs and actions of many of those people by my colleagues in psychiatry. You find a difficulty in coping with and managing someone who has a very different set of understandings of what life is about. You think, “It’s a bit strange. How am I going to deal with it?” At present, the fastest growing special interest group in the Royal College of Psychiatrists is the spirituality group. It is not so long since there was no such group. Why? Because 10 or 15 years ago, it would not have been politically correct to regard spirituality as a proper professional interest within psychiatry. Now, people have begun to change their view of it.
This amendment tries to point out that, without a serious look at understanding issues such as culture, politics, religion, breaking the law, sexual behaviour and so on, we could end up dragging into the net all sorts of people who are not suffering from mental illness in a proper sense and it becomes a question of how we deal with people who are difficult, different or deviant in our society. That is a real problem for colleagues in psychiatry, not least because of a move to diagnosis on the basis of people’s behaviour and a set of symptoms, rather then necessarily understanding something more about the depth of the disorder and its likely prognosis.
Unfortunately, over the past few years I have heard from Ministers a set of views that suggests that there is a simplicity about all of this—that it is very easy to be clear about certain matters; that clearly psychiatrists are not taking their responsibilities seriously and are avoiding all sorts of issues because they are distasteful or difficult. The reality is that these are difficult questions, not susceptible to clean bits of legislation. Psychiatrists sometimes have real difficulty assessing these things, and find themselves lapsing back into making mistakes because of their own cultural, religious, or political views.
I ask that we take these things seriously, not because Amendment No. 4 necessarily solves all the problems, but it points up some of them, and I hope that Her Majesty’s Government take that problem very seriously.
Baroness Finlay of Llandaff: The background to these amendments has already been stated, but I briefly want to look at their importance from the other end of the telescope. It takes me back to the days when I was a GP. I am remembering two patients; one came in and told me that he wanted to kill somebody now, and that he had a knife in his pocket and an axe in his bag. With persuasion, he handed me the knife to lock up and then agreed to go and see a friend of mine, who was a psychiatrist. The
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