| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
We have to give society a powerful message, not that the Bill is about locking up people who may be seen to be deviant in any sense, but that it is a mental health Bill for people who have mental health issues. Social control is another parameter in society, but we should not use psychiatry as the lever for social control, particularly not when psychiatry is dramatically under-resourced. I am worried that if the message of the Bill is that if someone expresses any of those tendencies he is more likely than previously to be locked up, then those tendencies will not be expressed to a clinician or somebody who can help, they will be expressed by being acted out and somebody will be sexually harmed or killed.
8 pm
Baroness Royall of Blaisdon: I am grateful to noble Lords for tabling Amendments Nos. 4 and 5. My noble friend Lord Hunt mentioned earlier that, as a general rule, we have sought in the Bill to remove arbitrary obstacles to the use of compulsion where it is called for by the risk posed by a person’s mental disorder. The more we qualify and limit the definition of mental disorder, the greater the risk that some people will be excluded arbitrarily to their own disadvantage and potentially to the detriment of other people. It serves no one’s interests if decisions end up being taken on the basis of diagnostic or legal labels rather than the needs and circumstances of individuals.
We recognise that these are complex issues. We are not being simplistic, and I stress that we takes these issues very seriously. In relation to alcohol and drug dependence, I do not think there is any disagreement between us. Although it is clearly clinically regarded as a disorder or disability of the mind, it is excluded from the Act at present. The Bill keeps it that way, as we are persuaded that it is not appropriate to use the Act to force people to accept treatment for addiction where it is not linked with another mental disorder.
However, we do not agree that substance misuse in general should be excluded. The term “misuse” is used in a variety of ways. If all it means is the use of alcohol or of drugs that have the potential for harm or which are illicit, then the exclusion is unnecessary. Merely using alcohol or drugs is not regarded clinically as a mental disorder, and our understanding is that the same applies to an episode of misuse. However, if “misuse” is intended to mean the consequences of such behaviour, then we profoundly disagree with the suggestion that it be excluded. Many consequences of misuse, from acute intoxication to substance-induced psychosis and withdrawal states, are recognised mental disorders. Any of them, even intoxication in its most severe forms, might, in particular circumstances, warrant compulsory intervention under the Act. It would be wrong,
8 Jan 2007 : Column 84
The amendment next seeks to exclude sexual behaviour. If we are literally concerned with sexual behaviour, then we again believe the amendment is unnecessary. An episode of sexual behaviour, however unusual or, indeed, illegal, is not, of itself, diagnosable as a mental disorder, any more than setting fire to something constitutes pyromania. However, particular sexual behaviour may well be a sign of a mental disorder. Noble Lords have been careful to draft the exclusion in terms of no one being considered mentally disordered solely on the basis of sexual behaviour, but, even so, I worry what effect the exclusion might be interpreted to have, rightly or wrongly, in cases of people who, for example, have a personality disorder that manifests itself in their sexual behaviour.
The noble Earl and the noble Baroness, Lady Murphy, mentioned gender dysphoria and gender identity disorders. While we acknowledge that gender dysphoria is clinically recognised as a mental disorder, the allegation that people can now be detained because of it presupposes that it could be regarded as sexual deviance. We struggle to see who, let alone which healthcare professionals, would think of gender identity disorders in those terms. Similarly, we do not see how a new exclusion for sexual behaviour would change the position. If the exclusion is meant to protect lesbian and gay people, it is again unnecessary. It is now firmly accepted that homosexuality is no more a mental disorder than heterosexuality. We do not believe any doctor would attempt to detain a patient on the basis of sexual orientation, let alone that another doctor and an approved mental health professional would agree, and, if they did, we are confident that no court would uphold their decision.
If, however, the intention is to replicate the current exclusion for sexual deviance, we think it is wrong in principle. Although we have heard contradictory arguments, our understanding is that there are conditions that a lay person might regard as sexual deviance that are clinically recognised as disorders of the mind. They include paraphilias such as voyeurism, necrophilia and paedophilia, where they have a significant effect on the person’s functioning or pose a significant risk to others. We see no reason to distinguish those disorders from any other, and that view was shared by the Joint Committee that scrutinised the admittedly very different 2004 draft Bill.
8 Jan 2007 : Column 85
It is nothing new for dangerous paedophiles to be detained under the Act, as their behaviour is often linked to dissocial personality disorder, or, in the current ungainly terminology, psychopathic disorder.If such people can properly be detained under the Act, we see no reason why clinicians should be barred from using the Act to treat patients whose only clinically recognised disorder is one involving abnormal sexual desires or behaviours. If that is what the clinicians concerned believe is the right approach for the individual in question, then, provided all the relevant criteria are met, we believe the Act should allow it.
Lord Alderdice: Perhaps I may clarify what the Minister said, because I was really quite struck by it. It is not at all uncommon for people of any age or either gender to achieve sexual excitement and satisfaction through partial self-asphyxiation. It is not a one-off; it is regular behaviour. It is clearly a disturbance of sexual behaviour. Such people are a risk to themselves and, from what has just been said, I cannot see how they would not therefore be liable to be compulsorily detained. Will the Minister clarify whether I am correct in that or whether there is something that I am missing?
Baroness Royall of Blaisdon: The key question is whether the person has a mental disorder and how the criteria for that mental disorder are defined. The fact that that person has what we would regard as a sexual deviancy does not mean that they have a mental disorder. It is important to remember that the criteria for detention include whether it would be appropriate for them to be treated in hospital. A clinician would decide that. If that person should be treated in hospital, clearly the clinician believes that that person has a mental disorder. If they do not believe that that is the case, they will not ask for him or her to be treated in hospital. If the noble Lord would like me to clarify those points in writing, I shall certainly do so and place a copy in the Library.
Lord Alderdice: That would be extremely helpful, because it seems to me that the Minister’s answer does not clarify things. If some further thought were given to it, perhaps the inconsistencies might become even more apparent.
Baroness Royall of Blaisdon: I shall certainly write to the noble Lord.
I am not aware that it is suggested that the commission, or likely commission, of illegal or disorderly acts is, by itself, a clinically recognised mental disorder. Hence, the proposed exclusion is again unnecessary. It has been suggested by noble Lords, and in the evidence cited by the noble Baroness, Lady Barker, that the purpose of the amendment is to prevent the Act being used for social control. If that is the case, we are fully supportive of the objective. However, the Act already achieves this objective. This is a mental health Bill; it is not about social control. We are all aware of what happened in Russia, and noble Lords have quite rightly brought
8 Jan 2007 : Column 86
Redundant material should not be included in Acts both as a matter of good drafting practice and for fear that an unintended meaning will be read into any such words. The courts will assume that Parliament would not have put material in the Act if it were unnecessary. However carefully drafted is an exclusion—I know that noble Lords have been most careful in their drafting—there is always the risk of it being interpreted in an unexpected way or being misunderstood and misapplied in practice. If, as in this case, an exclusion is unnecessary to start with, we think it better not to take that risk, remembering that what is at risk is whether people get the treatment they need to relieve their own suffering and, where relevant, protecting other people from harm.
Many noble Lords understandably raised the issue of people from black and ethnic minorities being disproportionately affected by the Act. We fully acknowledge that rates of admission and detention are significantly higher for some BME groups and that they are more likely to arrive in care through the criminal justice system. Once in hospital, some groups of BME patients are more likely than white British people to be subject to measures such as seclusion or restraint. This fuels a circle of fear which deters many BME patients from seeking early treatment for their illness. We have heard many examples of that cited today. The reasons for this are complicated and still not fully understood, but the problem has effectively been left unchallenged by government for decades. Last year, we published a comprehensive, five-year action plan for delivering race equality in access to services, experience of services and outcomes from services. A high level of resources has been committed to the plan and it has made a sound start. Bridging the system of equalities once and for all might not be easy, but we cannot be satisfied with anything less.
However, excluding cultural and religious beliefs from the definition of mental disorder is unlikely to help. It is possible of course to have disordered cultural and religious beliefs in any culture or religion, and indeed in any person, regardless of whether they see themselves as belonging to a particular culture or religion. Such beliefs may well be symptoms of clinically recognised mental disorders, but in the absence of such a disorder, political or cultural beliefs, values or opinions are simply not mental disorders. It is therefore unnecessary and potentially a source of uncertainty and misunderstanding to exclude them from the definition.
Disordered thinking and beliefs are central elements of many mental disorders. That these are expressed in cultural, political or religious terms makes them no less disordered than if they were
8 Jan 2007 : Column 87
The noble Baroness, Lady Murphy, asked why the Government said that cultural beliefs could be signs of mental disorders. This is not what we said and indeed it would have been extraordinary had we done so. What we meant was that sometimes disordered thinking expresses itself in religious, political or cultural terms.
8.15 pm
In summary, Amendment No. 4 seeks to exclude various behaviours and beliefs from the definition of mental disorder. On substance misuse and sexual behaviour we disagree about the objective if those terms are meant to cover the consequences of misuse and what is currently termed “sexual deviance”. On the rest, we differ only as to means, not ends. Noble Lords say that it should be explicit in the Bill that it cannot be used for what some have described as social control. We say that there is simply nothing in the Bill which would allow it to be used that way. Adding unnecessary words does nothing to alter that but does increase the potential for confusion and misunderstanding in practice and the risk of an unintended meaning being read into the words by the courts.
It is for the same reason that, while agreeing entirely with what he seeks to achieve, I cannot support the amendment of the noble Lord, Lord Adebowale, to make explicit that dependence on alcohol and drugs does not preclude a person from treatment under the Bill if they also suffer from another mental disorder. I understand that this group of people is getting bigger.
For the reasons the noble Lord has eloquently and colourfully explained, I agree that it is essential that people using the Act in practice are clear about what the exclusion for dependence means, and perhaps more importantly what it does not mean. We have tried to spell this out in the draft code of practice for England that we have issued alongside the Bill. But if the noble Lord does not think the current draft of the code is sufficiently clear, then of course we would welcome his suggestions for improving it.
To the noble Baroness, Lady Masham, I must stress that the Bill does not exclude people who are dependent on alcohol or drugs from the Act entirely. If such a person has another mental disorder, then of course the Act applies in the normal way. That is true even if the other mental disorder is a result of the dependence or reinforces it, or if the dependence exacerbates the other disorder or makes it harder to treat. The amendment would put into words only what is anyway the case because of the absence of
8 Jan 2007 : Column 88
I noted the fine words of the noble Earl, who urged me not to reject the amendment out of hand but to listen carefully to the debate which has ensued as these are extremely important issues. I regret, however, that I am going to have to ask the noble Earl to withdraw Amendment No. 4 at this juncture and I hope that I have reassured the noble Lord, Lord Adebowale, that he may safely not move Amendment No. 5.
Baroness Carnegy of Lour: The noble Baroness, Lady Murphy, in one of her fascinating contributions—she opens a world to me of which I know nothing—reminded us of how psychiatry was used in Russia, Germany and so on in comparatively recent history and she added that this was done in many cases with the best will in the world of the psychiatrists who thought they were doing the right thing.
When the Government think about this—if they do, and I hope they will, or if they do not, we will make them think about it—will they consider what would happen if a group of recently arrived immigrants was sitting in the Gallery, immigrants from central Europe, from Russia, from Germany, and they heard the Minister say there was no need to put in a Bill like this the fact that you could not be shut up as a case of mental illness because of your cultural, religious or political views? Those people, I believe, would be astonished. They are citizens of this country. It is going to apply to them. Surely the Government have got to think of their point of view. Will the Minister remember that?
Baroness Royall of Blaisdon: Of course we will consider the point of view that might be expressed by that group of people. But we have to distinguish between the democratic system in which we live and the system that existed previously in the Soviet Union, East Germany and other countries under the Soviet flag. The situation in this country is very different: we have safeguards, such as the courts and the law. We are confident that the safeguards we already have and those we are putting in place are adequate to ensure that this legislation will not be used for social control. This is a Mental Health Bill—it has nothing to do with social control.
Lord Soley: I understand the root of the concern, but let us touch briefly on the Soviet Union point. When those people were locked up in mental institutions—Solzhenitsyn was perhaps the classic example—most of the doctors knew that what was being done was wrong. The problem for them in most cases, as it was for the directors of the institutions concerned, is that irrespective of whether they agreed or not, if they did not do it they lost their job at best and ended up as an in-patient at worst.
What stops this happening, as my noble friend just indicated, is not the definition in the Bill but two things—the rule of law, which did not exist in the
8 Jan 2007 : Column 89
What was missing then—never mind the Soviet Union—was the application of mental health tribunals which allow people to challenge the system. The issue is not really whether such a thing could happen, because any authoritarian Government could just lock people up if they chose to do so. However, the checks in place in a western democratic society that has the rule of law are the law itself and the pretty sophisticated mental health review tribunal approach which we have developed in recent years and which I welcome greatly. That is what prevents the system returning to what it was in the Soviet Union as well as to what was considered fairly normal here in the 1950s and earlier.
Earl Howe: We have seriously overrun our time, and I am sure that noble Lords will thank me for being brief. The Minister’s reply was not unexpected but it was disappointing. I was disappointed that none of what was said so powerfully by the noble Baroness, Lady Murphy, or the noble Lord, Lord Alderdice, made any impact.
The Minister took a very purist line. What we have heard in evidence from the real world, described by the noble Baroness and the noble Lord, was, I hoped, enough to stall her in her tracks, but that proved to be a fond hope. What she said did not appear to me to be based on the real world; indeed, her reply to the noble Lord, Lord Alderdice, seemed largely circular. She talked about not excluding people who drink habitually and have withdrawal symptoms. That is exactly the group that the Government are excluding from the Bill—that is what alcohol-dependence means. The Government’s position on this issue is extremely confused.
The key question is whether the Bill should be used for moral control of, for example, drunkenness, fetishism, and so on, or for the treatment of people who are ill. The Bill should be used to treat people who are ill. I was very struck by the story told by the noble Baroness, Lady Murphy. Twenty years ago a psychiatrist of my acquaintance asked a Russian psychiatrist whether people who tried to escape were detained in Soviet mental hospitals. The psychiatrist said yes, but only if the person was mentally ill—but only a mentally ill person would try to leave the Soviet Union. That was the kind of distortion of professional ethics to be found there.
The noble Lord, Lord Soley, spoke extremely powerfully, but I return to my earlier point about perception and trust. If you have people in the black
8 Jan 2007 : Column 90
The noble Baroness, Lady Murphy, said that this amendment was about stopping detention creep. That is a very good way of putting it; its aim is to prevent inappropriate detention. As the noble Lord, Lord Alderdice, put it, we are in danger of driving into the net a large number of people who should not be there. This is a set of issues to which I am sure we will have to return. In the mean time, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Lord Hunt of Kings Heath: I think this is an appropriate moment to break. I suggest that Committee stage does not begin again before 9.27 pm. I therefore beg to move that the House do now resume.
Moved accordingly, and, on Question, Motion agreed to.
| Next Section | Back to Table of Contents | Lords Hansard Home Page |