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The elephant on the table
Article Type: Editorial From: Mental Health and Social Inclusion, Volume 18, Issue 4.
Over the years, many innovative programmes have been described in the pages of Mental Health and Social Inclusion. Invariably these are services designed to foster self-determination and recovery. Services designed to help people get back in the driving seat of their lives: take back control over their lives, their problems and the help they receive. Services designed to enable people to explore their possibilities and pursue their ambitions. Services that recognise that people are the experts in their own lives. These ambitions are reflected in the objectives of the Mental Health Strategy No Health Without Mental Health (HM Government, 2011) which aspires to decrease the discrimination that erodes opportunity and promote recovery and inclusion. They are also integral to the development of Personal Health Budgets for people facing mental health challenges:
Personal health budgets are closely aligned to one of the central strands of service transformation in mental health: recovery. Adopting a recovery focused approach to mental health services means moving beyond symptom and risk management to support people to re-establish a meaningful life for themselves with their mental health condition. Recovery requires services to look beyond treatment to consider wider issues such as housing, employment and family relationships. As a highly personal journey, recovery depends on services being able to develop individually tailored approaches. Personal health budgets are a tool to support more recovery focused services by allowing individuals to define their own outcomes and design their own packages of care and support (NHS England, 2014, p. 1).
The ideas about recovery and self-directed support embodied in the development of Personal Health Budgets challenge traditional assumptions. Typically, the presumption is that there are one set of experts within mental health services: mental health professionals. It is assumed that, because of their specialist knowledge, these experts must decide what is wrong with people, prescribe what should be done to put it right, and get people to comply with/adhere to these prescriptions. In recovery-focused services there are two sets of experts: experts by profession, qualification and education, and experts by lived experience. The goal of these services is to recognise and build on the expertise of lived experience, enabling people to define their own outcomes and design their own packages of care and support. Professionals need to move from being "on top" to being "on tap": making their expertise available to inform the decisions of people facing mental health challenges rather than prescribing what is good for them.
But there is an elephant on the table: the Mental Health Act.
At the same time as ideas about recovery, self-determination and self-directed support have come to the fore the assumption that professional "experts" know best remains widespread (among both people using services and those providing them). The reality is that professionals continue to determine whether people need help ("gate-keeping" in services), what sort of help and support they require, and ensure their compliance with these prescriptions using the force of verbal persuasion and the force of law if this fails.
As a result, on the one hand, many people with mental health problems and their relatives/friends continue to report having difficulty getting help when they need it – "It feels like I literally have to have one foot off the bridge before I can access services" (Mind, 2011, p. 18). On the other hand use of ultimate power, in the form of detention and compulsion via use of the 1983 Mental Health Act, has increased alarmingly and extended beyond the boundaries of the hospital (see Figure 1). It was argued that the introduction of "Community Treatment Orders" (CTOs) in 2008 (allowing people to be compelled to receive treatment in the community and recalled to hospital if they refused) would decrease the number of people detained in hospital. It was estimated that only a small number of people – maybe 400-600 – would be subject to CTOs. The reality has proved very different. Between 2007 and 2013, the number of people compulsorily detained in hospital rose from 44,093 to an all-time high of 50,408. At the same time the number of people subject to CTOs has increased steadily to 4,647.
Despite their widespread usage, evidence for the effectiveness of CTOs is notable by its absence. On the basis of a randomized-controlled trial in England, Burns et al. (2013) concluded that there is "no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty" (Burns et al., 2013, p. 1627). They found that:
Despite a more than three-fold increase in time under initial supervised community care, the rate of readmission to hospital was not decreased by CTOs. Neither was the time to readmission decreased nor was there any significant difference in the number or duration of hospital admissions. We also recorded no differences in clinical or social outcomes (Burns et al., 2013, p. 1632).
Although only a small proportion of people facing mental health challenges are compulsorily detained and treated, the fact that this is possible impacts on all facets of mental health care: "Most clients never face commitment but they know the power is there" (Chamberlin, 1977, p. xiv).
The 1983 Mental Health Act is intrinsically discriminatory.
First, it denies people considered to have "mental disorders" the right to be "innocent until proved guilty" that other citizens enjoy under the law. With the possible exception of people considered to be terrorists, UK law does not allow most people to be detained because they might commit an offence. Someone who, for example, drinks, has a short temper and a history of getting into fights cannot be detained because they might commit an offence. However, if someone is diagnosed with a mental disorder, they can be compulsorily detained if it is considered they might be a risk to others, even though violence is no more predictable in those with a mental disorder and those without (see Szmukler, 2010; Fazel and Grann, 2006; Fazel et al., 2009).
Second, it allows those diagnosed with a "mental disorder" to be compulsorily treated in a way that would be inconceivable in relation to a physical disorder (see, e.g. Szmukler, 2010; Perkins, 2012). If you have, say, cancer then you have every right to refuse treatment offered, even if that treatment may save your life. The only exception to this is if, in the terms of the 2005 Mental Capacity Act, you are not able to understand the nature of the treatment, why it is proposed, and the consequences of accepting or refusing it. However, even if you fully understand all of these things, if you are diagnosed with a "mental disorder" then you can be forcibly treated if professional experts think that the nature and degree of your disorder makes treatment "appropriate" or "necessary" for your own health and safety or the protection of others.
The frontispiece of the English Mental Health Strategy says that:
This strategy sets out our ambition to mainstream mental health, and establish parity of esteem between services for people with mental and physical health problems (HM Government, 2011, p. i).
This desire for parity of esteem is further articulated in the Royal College of Psychiatrists (2013) publication Whole-Person Care: From Rhetoric to Reality. Achieving Parity Between Mental and Physical Health. Surely, such "parity of esteem" must include parity of esteem for the judgements made by people with capacity whether or not they have a mental disorder?
The UK has ratified the United Nations (2006) Convention on the Rights of Persons with Disabilities which explicitly includes people with mental health problems. The Annual Report of the High Commissioner for Human Rights (2009) indicates that the 1983 Mental Health Act does not comply with Articles 3, 12 and 14 of this convention:
"respect for inherent human dignity and individual autonomy including the freedom to make one's own choices" (Article 3).
people must "enjoy legal capacity on an equal basis with others in all aspects of life" (Article 12).
"the existence of disability shall in no case justify a deprivation of liberty" (Article 14).
Compulsory detention and treatment deny people their rights, "work against the recovery goal of reclaiming a meaningful life – a process that is based on self determination and respect for the individual as a citizen of society" (Slade et al., 2014) and there is little evidence of their effectiveness in terms of health service usage, social functioning and quality of life (Kisely et al., 2011). Furthermore:
Mental health legislation also actively reinforces the destructive myths that result in discrimination and exclusion: that people with mental health conditions have lost the ability to 'act rationally' (and so are unpredictable and dangerous and must be detained for the good of others) and/or have lost the ability of 'sound reasoning' (and therefore their expressed views, wishes and preferences can be disregarded – for their own good, of course) (Perkins, 2012, p. 20).
If we are serious about promoting self-determination, recovery and inclusion, surely the time has come to create real parity between physical and mental health (see, e.g. Disability Rights Commission, 2003; Dawson and Szmukler, 2006; Szmukler et al., 2010; O'Hagan, 2014): a Single Mental Capacity Act covering both mental and physical health conditions? At the very least, should we not, like Norway (Helsedirektoratet, 2006) have a national plan to reverse the trend of every increasing compulsory detention and treatment in mental health?
Rachel Perkins and Julie Repper
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