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TAG: The Mental Health Act

Podcast: Against Your Will – Compulsory Powers in the Mental Health System

John McGowan, Anne Cooke, Angela Gilchrist,  Rachel Terry and Emma Rye discuss involuntary treatment in mental health.

In this edition we discuss the compulsory powers available in the mental health system in the UK These include the Mental Capacity Act and the Mental Health Act (MHA). The regular panel is joined by Emma Rye, a Clinical Psychologist working in in the field of learning disabilities. Emma is currently in training to take up the role of a ‘Responsible Clinician’ under the MHA. We also have interviews with Dr Matthew Debenham, an NHS psychiatrist, and with service users Rai Waddingham and Raza Griffiths, both of whom discuss how compulsory powers were used in their own treatment.

As the Prime Minister has recently said she would like to ‘rip up’ the Mental Act (see below) our panel also offer Theresa May advice on what to replace it with.

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Links to things we talked about on this show:

A brief overview of the 2007 overhaul of the 1983 Mental Health Act. This 2007 update is still the dominant legislative framework today…
webarchive.nationalarchives.gov.uk/2013010…_078743

… and the Mental Health Act Code of Practice, intended to provide a guide for professionals, service users and carers on the operation of this legislation.
www.gov.uk/government/publicat…tal-health-act-1983

A useful summary of the principles of the Mental Capacity Act, which allows people to make ‘unwise’ decisions: provided they have the capacity to do so.
www.scie.org.uk/mca/introduction/…-2005-at-a-glance

Some information on Theresa May’s Mental Health Act announcement. A pledge to ‘rip it up’…
www.thetimes.co.uk/article/every-s…s-may-flm9tthf9
…and some suggestions for what might replace it.
www.theguardian.com/commentisfree/2…health-act-care

You can follow Rai Waddingham on Twitter @RaiWaddingham and find a range of resources on her website.
www.behindthelabel.co.uk/

A recent paper from the British Journal of Psychiatry suggesting that being admitted to a mental health ward may have negative consequences for suicidal risks.
bjpo.rcpsych.org/content/3/3/102

This Guardian article offers a personal account by a nurse involved in compulsory treatment.
www.theguardian.com/healthcare-netw…nts-what-choice

This short piece by legal commentator Joshua Rozenberg highlights some of the main issue in replacing European human rights legislation.
www.theguardian.com/commentisfree/2…stice-secretary

This small research study suggests quite mixed experience of involuntary detention and also addresses some of the issues in how to improve people’s experiences.
www.researchgate.net/publication/23…53059_Patients‘_perceptions_of_the_impact_of_involuntary_inpatient_care_on_self_relationships_and_recovery

Please note The views and opinions expressed in this discussion are those of the contributors and do not necessarily reflect the official policy or position of any of the contributors’ employing organisations.

We’d be interested in hearing about your experiences with these laws and with compulsory treatment. Comments below are gratefully received. 

Producer: John McGowan
Additional technical support: Saul McGowan
Music: www.bensound.com/

 

First, do no harm…

Following recent cases of euthanasia for mental health problems in Belgium and Holland, Clinical Psychologist Masuma Rahim discuses what we do when someone seems beyond help.

 

In my line of work – as a psychologist in a Community Mental Health Team – my colleagues and I spend more time talking about ‘risk’ than almost anything else. And when we say ‘risk’, we rarely mean ‘risk of harm to others’. We almost always mean ‘risk of suicide’. There’s an understanding that, when you work in mental health, a lot of your resources will be focused on trying, to the best of your ability, to prevent your patients harming themselves.

It was therefore with some surprise that I read about a 20 year-old woman in the Netherlands who had chosen to be euthanized. Having been sexually abused from the age of 5, she was considered to have an ‘untreatable’ Post Traumatic Stress Disorder, reportedly co-occurring with anorexia, depression and hallucinations. It has since emerged that, while only two mental health patients were euthanized in the Netherlands in 2010, this rose to 56 in 2015. A recent review showed that the overwhelming majority of those with mental health problems who chose to be euthanized were women with long-term conditions, often with some kind of trauma.

The right to end your life is a complex topic and perhaps one which it very difficult to have a settled opinion about. In health, the baseline often seems to be ‘preserving life above all else’. But whether you believe in the sanctity of life or not, it’s not quite that simple. When you work in mental health you work with people who are in emotional pain. Many will have been in that pain for years, and, as we know, the impact of mental health problems on people’s lives can be enormous. Academic and employment prospects, family relationships and physical health often deteriorate following the onset of psychological difficulties. Often, by the time people access specialist mental health services they are in need of more intensive support and though we try to give them whatever support they may need, we know that sometimes we, as professionals, fail to help them. We wrap this up as being ‘treatment-resistant’ or ‘failing to engage’ but what it means ultimately, is that ‘I, with my years of training and expertise, have not been able to heal you’.

Such a sense of failure can strike at the very heart of your professional identity. Most people go into this work because, at some level, they want to help people in distress. Feeling impotent when you are unable to do so is never pleasant. But the reality is that some people have been so damaged by life that by the time we see them we cannot undo what’s happened – not to the extent we would like. Sometimes, when it seems all the options have been tried and found to be ineffective, it’s natural to feel at a loss and to wonder if there’s any way to help this person. And if that’s what professionals are thinking, why do we find it so difficult to accept that the person with the psychological difficulties might think it too? And the natural continuation of that is that, if the pain is too great to bear, and if there appears no way to reduce it, why shouldn’t we have a conversation about the point at which life stops being worth living?

In the UK, we have to abide by legislation related to mental capacity. Essentially, if you’re deemed unable to make decisions about issues such as your health or finances, other people – usually health and social care staff – can step in and make them ‘in your best interests’. Crucially, this legislation accepts that people who do have the capacity to make decisions about themselves have the right to make ‘unwise’ decisions. With Dignitas now a viable option for those with the financial means, we seem, as a society to slowly be coming to terms with the right people with severe physical health problems have to die. Despite that, the moment someone with mental health problems says they want to die, we spring into action to stop them doing so. For, although the Mental Capacity Act also applies to people with mental health problems, it is trumped in almost every circumstance by the Mental Health Act. What this means is that a person with mental health problems has fewer rights to make decisions about their care – and the value of their life – than someone who is not subject to the Act, even if they are deemed to have capacity. Yet again, the disparity between physical and mental health is clear.

Now I can’t say for sure, but I would imagine that a significant number of people who decide they no longer want to live do so being well aware of the consequences of their actions. The question for professionals is this: is it ethical for us to extend someone’s life (or at least prevent them from ending it) when a) they are saying that life is too painful for it to be endured any longer and b) they have the capacity to make decisions about themselves? Our job is to make people’s live better; not condemn them to years of suffering. Our legislation doesn’t allow these kinds of conversations to take place and it certainly doesn’t allow us to support anyone to make decisions to die. And even as I write, I worry that readers of this will assume I am pro-assisted dying and that I believe people in distress have the right to end their lives without the interference of professionals. I don’t believe that, but I would be at pains to describe exactly what I do feel. I know that the assumption that anyone who wants to kill themselves must lack capacity troubles me – particularly when people who are suicidal often end up in psychiatric wards which, with the best will in the world, are rarely the sanctuary they should be. I know that for some people life can be terrible, and I understand the desire to end the emotional pain. But I also know that I struggle with the idea that someone is ‘beyond help’; that, essentially, ‘recovery’ is not an option. Part of that may be what it says about my profession, and me – that sometimes we are impotent; that we have to watch you continue to suffer because we just don’t know what to do to help – but some of it comes from a feeling that the loss of life is a tragedy – a waste of talent and potential.

One reason I suspect it’s so incredibly hard to accept someone’s right to choose to die is that we’re not looking at it dispassionately; we’re not conducting a cost-benefit analysis. How can you look at dispassionately? Mine is not a profession of pure science; it is one in which our work is bound up with emotion and human connections and a desire to help, but also, if we’re honest, a need to feel able to help. A significant element of working in mental health is in helping people find reasons to go on; to find reasons to stay alive. But for some people, those reasons may not exist, and we have to find a better way to discuss these issues frankly, without moralising and judgement, but with a keen eye on the very complex ethical questions tied up with them. In physical health, palliative care pathways are well-established and the debate around assisted dying is ongoing – it’s time those of us in mental health started to have similar conversations.

With thanks to @maddoggie2 for her contribution.

Dr. Masuma Rahim is a Clinical Psychologist and writer. You can follow her on Twitter @MasumaRahim. She blogs at https://masumarahim.wordpress.com/ and regularly contributes to The Guardian.

Editor’s note: The issue of suicide (assisted or otherwise) is clearly one that many people have strong views about. Please let us know what you think below. Masuma has kindly agreed to contribute to the discussion.

Electroconvulsive Therapy: Whose decision is it?

Lisa is a 42 year-old woman. She has had a difficult life. She has experienced multiple traumas and has at times struggled with her emotions. Lisa has a few close family members and a small social circle, though she does at times feel a bit oppressed by them. In 2010 Lisa contracted HIV. She has been treated medically and was stable for some time, however in 2013 she started to deteriorate. She was seen by a psychologist as well as by medics. After a further twelve months she had had enough of interventions and decided she wanted to live the remainder of her life in her own way. Her family and friends objected as they could see she would rapidly deteriorate. However with support from professionals, Lisa utilised the Mental Capacity Act (MCA) to set some advanced directives. She was found to be capable of making these decisions under the MCA, and was legally allowed to refuse further intervention. Lisa did indeed deteriorate, and died a few months later in her own home with her family and friends around her.

Is it time to call time on Community Treatment Orders?

Every so often I come across an article on Community Treatment Orders (CTOs). Usually the view expressed is critical and it always produces a stab of disquiet. More on the bad feelings in a second, but before that, it’s worth just establishing what we’re talking about. The norm that people with mental health problems can be given treatment against their will and detained in hospital is well established.  In the United Kingdom the Mental Health Act 2007 extended this principle by allowing people such compulsory treatment at home (i.e. without admission). The twinge of unease comes because I, in the face of a good deal of criticism from colleagues, thought this change was a good idea.

Let’s leave aside whether such compulsory powers are right or wrong. Feelings run high but there is no sense in which the abandonment of enforced treatment is on the table. Let’s also leave aside the idea of confining compulsory treatment to cases where people lack the capacity to consent. Unlike physical health (where any of us has a right to refuse treatment unless we lack capacity) the UK the Mental Health Act allows treatment on the basis of   mental illness While there are powerful arguments that this situation is unjust, these have struggled to gain traction.  Here I want to focus on the narrower question of whether, in a world were compulsion is established, CTOs have been helpful.

The rationale behind CTOs (introduced in 2008) was to facilitate compulsory treatment and to avoid the potentially distressing and dislocating effects of an admission to hospital.  At the time I was spending my working life in acute mental health wards and the downsides of being in hospital (forced or otherwise) were regularly right in front of me.  Because of this, the alternative of delivering treatment at home rather than in hospital struck me as, if not exactly good, then potentially better than the status quo. However, even after six years it’s clear that uncertainty persists as to whether CTOs are worth retaining.

Assessments of similar provisions across the world have been inconclusive. A range of methodologies have been employed and much of the work is either descriptive or involves comparing admissions before and after the introduction of CTOs. This was the kind of rationale used in a Guardian article arguing that an increase in compulsory admissions between 2008-09 and 2011-12 was proof enough of failure. It is of course, unclear just how many hospitalisations there would have been in 2011-12 without CTOs, so perhaps treating such figures as decisive is overdoing it. A third kind of evidence has been somewhat sparse: controlled trials. These are studies where people have been randomly allocated either to treatment involving CTOs or to treatment without them, At the time of the introduction of CTOs in the UK there were only two such studies (details here and here). Both of these suggested that allocation to CTO or non-CTO- based conditions had little observable effect on hospital admissions. The results were slightly ambiguous though as one of the studies did find that, for people subject to longer-term CTOs, there were fewer hospital admissions.

More recently, in this month’s Psychiatric Bulletin CTOs receive detailed consideration in five articles. This series of pieces features a contribution from researchers on The Oxford Community Treatment Order Trial (OCTET). This project is the largest controlled thus far involving 333 people. For detailed results see here and here. The short version of their findings is that the hope that I, and others, had of a reduction in hospital admissions with CTOs has not been borne out. Both admission rates and length of stay were essentially indistinguishable.

Is the case closed then? Well maybe not quite. In the face of the OCTET evidence, other contributors make three points. Firstly, it is argued that, while OCTET hasn’t shown a reduction in hospital admissions, there may be other indices by which CTOs might be considered helpful. Though you may hear the creak of moving goalposts, there is some merit in this. Readmissions may not necessarily be seen as a treatment failure, something I’ve argued myself in the past. There are cases where a move to hospital (say to try and forestall an intensifying crisis) might be helpful. Indices such as frequency of clinical contact and rates of preventable physical illness are areas where CTOs seem to produce positive effects. Secondly, one potential limitation of the OCTET trial, which lumps together a large and diverse group, is that it does not focus precisely enough on specific sub-groups who may benefit. For example those on CTOs for a protracted time period (as suggested in the study mentioned above). A third point (and one that is likely to raise hackles) is the proposal that the OCTET trial may partly be affected by the participation of clinicians who are lukewarm towards, or outright negative about CTOs. This may affect the appropriateness with which they have been used in the trial. In other words not a fair test. I suspect responses are on their way.

So where are we left? Critics say that OCTET and other controlled trials show that CTOs have failed to meet their intended purposes and should be given the boot. Those taking a more circumspect line argue that the very few controlled trials are insufficient to allow a final decision to be taken and that further work (and perhaps a wider range of outcome measures) is needed: especially to establish more precisely if particular groups benefit. One thing I’m struck by is that inconclusive evidence is seen as a reason to continue with CTOs rather than to abandon, or suspend, them. True, practice in healthcare ultimately must often make policy before the evidence is in. Otherwise innovations would never occur. Nonetheless, the evidence in favour of CTOs, though, has been far less convincing than I (and I suspect many others) expected.  Compulsory powers are not insignificant in their effect on people. Could it be time for a pause?