The House of Lords may look like a bunch of old duffers, but they are currently doing a sterling job of preserving our civil liberties by forcing amendments to the government’s Mental Health Bill. There are two key proposals in the Mental Health Bill that we should be extremely concerned about: the removal of the ‘treatability’ clause and the extension of powers of compulsory treatment to those who live in the community.
The Mental Health Act is already quite a scary piece of legislation. It enables a doctor and a social worker to admit those with mental illness to hospital against their will, and a psychiatrist to extend that period of detention for an indefinite amount of time by applying different sections of the act. It is without doubt the most draconian piece of legislation on the statute book, in that it permits the state to lock up a person who has not committed any crime for an indefinite period. It could be the stuff of Kafka’s nightmares. Thank goodness, then, that enshrined within the act are the core principles of assessment and treatment which ensure that the sole purpose of the detention is to ensure asylum and treatment for the mentally ill person who poses a danger either to himself or others. It is this ‘treatability’ clause that the government wishes to remove.
The government has set its sights on removing the principle of treatment as it is this principle that makes it difficult to use the Mental Health Act to detain people with a Severe Personality Disorder. Psychiatry believes that such people cannot be successfully treated, and therefore fall outside of the compulsory powers of the Act (although the Act does specifically include people with Severe Personality Disorder in its criteria of mental illness.) Most people with a severe mental illness are treated with neuroleptic medication. This medication acts on dopamine receptors in the brain and is rather akin to using a sledgehammer to crack a nut. It does have the effect of minimising the auditory hallucinations that are characteristic of psychotic illness, however, and, however crude its workings, neuroleptic medication enables people with psychotic illness to function relatively normally with reduced symptoms. (There is a whole different post to be written on the use of neuroleptics which I shall, thankfully, save for another occasion.) This medication has no therapeutic effect for those with Severe Personality Disorders, as they do not experience the flight of ideas and auditory hallucinations characteristic of psychotic illnesses. Hence psychiatry’s argument that they do not respond to treatment and therefore cannot be compulsorily detained under the terms of the Mental Health Act for psychiatric treatment (although they can be detained for 28 days under a Section 2 for assessment.)
The government is extremely keen to encourage psychiatrists to detain people with Severe Personality Disorder, following the murder of Lin and Megan Russell in 1998 by Michael Stone, a man with a SPD who was known to psychiatric services. I am sure that the terrible circumstances of their murder affected us all at the time. But mental health campaigners, including prominent psychiatrists, believe that the danger posed by those with severe mental illness is greatly exaggerated by the media and that the government is currently using scare tactics to try to rally public support for its mental health bill. Tom Hamilton has already written an excellent post on the facts and figures of the ‘dangerous mad man at large’ scenario, so I won’t repeat the argument here. Suffice to say, most people in the field do not believe that the danger posed by a very small minority of people with Severe Personality Disorder in any way justifies the removal of the core principle of treatment.
This principle of treatment should be paramount in any law that permits the mentally ill to be held against their will. (Let’s be generous and overlook the fact that ‘treatment’ consists of little more than being held down by one nurse whilst another jabs a hypodermic needle in your buttock.) Because if the state assumes the right to detain people for 42 days without treatment, then psychiatric hospitals cease to become places of asylum and instead become prisons, with psychiatrists acting as unwilling jailers. So rather than remove the treatability clause, which is the only thing that affords the Mental Health Act its humanity, perhaps the psychiatric system could get just a bit more creative about what ‘treatment’ might actually mean for those with a Severe Personality Disorder? Most people with mental illness would welcome a more therapeutic approach to their disorder, and any steps in this field would render the removal of the treatability clause redundant.
The second issue at stake is that of Compulsory Treatment Orders in the community, which would enable community psychiatric services to compel those with mental illness to receive antipsychotic drugs, with the threat of a compulsory admission to hospital if they refuse. This seems to me to be an open and shut case of undermining our basic civil liberties. If I am diagnosed with a treatable cancer, which is likely to become terminal if I refuse treatment, it is still my inalienable right to refuse such treatment. Many people with mental illness believe that antipsychotic medication has a detrimental affect on their quality of life, and successfully manage their illness without resort to a drug regime. (And I haven’t even mentioned the terrible side effects such as tardive dyskinesia, ocular gyro crisis and the strange loping gait characteristic of long term neuroleptic use.) What people with severe mental illness really require in the community is more intensive support, regular monitoring and therapeutic intervention when symptoms become florid. This would necessitate an injection of cash to allow the community psychiatric services to provide the kind of therapeutic service they are both willing and able to provide. The current Act allows for compulsory intervention should individuals become a danger to themselves or others. I can't think of any clinical justification for favouring a weekly compulsory injection of a mind altering drug over a more therapeutic regime. Indeed, most clinicians - including psychiatrists - do not support the use of compulsory treatment orders.
The House of Lords is to debate the Mental Health Bill once more next week. Let’s hope they maintain their common sense.