The audio for this podcast can be found here.
Hello, my name is John McGowan and welcome to Discussions in Tunbridge Wells, the podcast produced by the Salomons Centre for Applied Psychology in Kent. Today I am joined by our usual panel of Angela Gilchrist,
Angela: Hello John
John: We’re also joined by the recently named BPS British Psychological Practitioner of the Year no less, Anne Cooke
John: And finally, not boasting quite such an honorific but making up for it in searching intellectual rigour, Rachel Terry
John: We’re also very pleased to have a guest panellist today, our colleague Emma Rye who is a clinical psychologist working in learning disabilities in nearby Kent and Medway Trust, and we have a specific reason for asking you Emma which is that you’re currently training as something called a Responsible Clinician under the Mental Health Act. Now, we’ll say more about that in a little while but that’s a clue to what today’s podcast is about, is that correct, have I nailed that?
Emma: That’s correct, I am undergoing the training and have quite mixed feelings about it, I guess would be reasonable to say.
John: Well that sounds like you’re exactly the right person to have on because if there’s something that this raises it’s quite strongly conflicted feelings so our theme today is circumstances where people in the mental health system in particular are treated against their will or without their consent. I think we seem to be struggling to keep the Prime Minister out of our deliberations and she has very obligingly popped up mentioning the Mental Health Act in the last week, one of the very, very few things that she is mentioning specifically other than strength and stability, but she has said in an interview with the Sunday Times that she would, in quotes, ‘rip up’ the Mental Health Act, possibly literally, possibly on TV, as a show of strength, possibly not as a show of stability I’m not sure. But at this point I’m just going to ask you Rachel if you could initially just walk us through the territory of what the frameworks are, what we’re talking about, the legislative framework that we’re dealing with here.
Rachel: Okay, well there are two sort of main frameworks, firstly the Mental Capacity Act 2005 which is related to people that are deemed to be unable to make some or all decisions for themselves due to an impairment or disturbance of the functioning of their mind or brain, and in that instance it is meant to be taken on a decision by decision basis. If people are deemed not to have capacity then we would be making decisions based on what is deemed to be in their best interests. We also have the Mental Health Act 1983 which was updated in 2007 which is specifically related to mental disorder, is what it’s known as in the Act. That is a law which sets out when you can be admitted and detained and treated in hospital against your wishes and is often referred to as being sectioned.
John: You know, that’s the territory as I understand it but I wonder if we could first of all just turn to you Emma. You’re training under the Mental Health Act and this has been something that’s been available to psychologists, really, I think technically, since 2007 but not many psychologists have decided to train to take up those powers. Could you say a little bit more about your journey along to that point?
Emma: Yes, that’s right, that not very many people have taken up the opportunity, I think far fewer than was hoped for when the legislation or the amendments to the 1984 legislation was passed and I think that’s probably for the reasons I alluded to earlier, in terms of ambivalence, that not just psychologists but the other professions that potentially could take up this role, so nurses and occupational therapists, and probably the reason for that is ambivalence around power and what it might mean to have the power to detain somebody or keep somebody detained against their will.
John: I know that that’s been something where there’ve been quite strong feelings, I mean you were involved in a little bit of research a couple of years ago Anne weren’t you about psychologists’ feelings specifically about taking up those powers.
Anne: Yes we interviewed psychologists about their feelings about training as a responsible clinician, we were interested in the reasons that so few have trained, like you were saying. I was also part of a debate, the British Psychological Society debate, about the same thing a few years previously and it was really interesting what people said about their reasons for and against and one of the main reasons people gave for not wanting to train as a responsible clinician was the current system and, in particular, the assumptions that underlie the current system that there are things called mental illnesses that afflict people and that affect their ability to reason and make decisions and that one of the symptoms of mental illness is lack of insight and therefore people need to be treated, and by treatment we mean medication, psychiatric medication generally, and that that can be given to people against their will if necessary by forced injection, and that’s the kind of guiding idea or assumption behind the current system which was cited by many psychologists as one that they didn’t agree with and therefore they weren’t prepared to apply for particular powers within the current system.
John: I wonder, one of the things I did in preparation for this over the last few weeks is interview a number of people and one of the people I interviewed was a relatively local psychiatrist, Matthew Debenham, who I worked with many moons ago and found him actually to be somebody who used these powers very sparingly actually and was, in some ways I think, generally quite reluctant to use these powers but I talked to him a few weeks ago, he’s obviously a psychiatrist and these are the people who have been utilising the Mental Health Act particularly, the main people who operate that legislation, and I wonder if it would be worth just going to that interview now and we can discuss perhaps some of the things coming out of that when we’ve heard what he said about the process. It’s quite a long interview, about, oh in excess of 20 minutes, but I do think it’s quite interesting to really hear in detail how somebody operating that legislation may think about it and go about it.
John: Ok, I’m here with Dr Matthew Debenham, a psychiatrist, and it seemed like a very good starting point to talk about the whole notion of compulsory powers. Hello Matthew
John: Just to kick us off could you describe for us a bit, just your current role, just give us a little bit of context on your current role, I know you work in Kent but could you say a bit more beyond that.
Matthew: Yeah, I’m a consultant psychiatrist working in acute mental health services in Kent and I’m consultant for a ward at Priority House Hospital in Maidstone.
John: I worked with you a number of years ago and I had a background in working as a psychologist in wards and you were one of the consultants that I worked with and obviously something that arises in those contexts is the question of sometimes when people are either brought in to hospital or treated without their consent or against their will. Could you give us some kind of idea of the circumstances where a decision like that might be taken or where you might think about a decision like that?
Matthew: Often the decision to treat someone against their will is going to be based on risk so that what that means is the risk of not treating a person must be so great that the compulsory treatment in hospital is justified and that’s going to be justified in terms of risk to the person themselves and to other people.
John: What kind of legislation then is involved? I know there’s legal frameworks around capacity but also around mental health. Could you give us some idea of the main kind of differences between those frameworks?
Matthew: The Mental Health Act predates the Capacity Act and the Capacity Act puts into law practice that was already in place but structures it in a clearer legal framework. The Mental Health Act applies to the treatment of mental conditions and extends to the manifestations of that so that could include treatment for a physical condition as long as it is either a symptom or manifestation of mental illness but it is limited to the treatment of a mental condition. So the Mental Health Act is the legislation that’s more commonly applied to compulsory treatment in a psychiatric hospital but not exclusively. The Capacity Act includes the deprivation of liberty safeguards and also guidance around making best interest decisions. The Mental Health Act allows for treatment in hospital combined with a restriction in liberty which means that a person can be required to remain in hospital while they have that treatment and the time that they spend away from hospital is agreed and decided by the responsible clinician. Deprivation of liberty safeguards also allow a person who lacks capacity to make a decision about where they’re treated, to be held in hospital but it doesn’t allow for treatment so that if somebody lacks capacity to make those treatment choices and they are not falling under the Mental Health Act then a best interest decision would be made about treatment which is essentially where interested people, which includes professionals, families and carer, would make a decision about what that person would have decided had they had capacity and been able to make that decision for themselves. So I think that probably summarises it.
John: Well, that idea of incapacity, I certainly know that it occasionally came in in working where I worked with you, in the more adult focused services it sometimes came into play, and it was relatively clear to me the whole idea of, okay, somebody lacks the capacity to make a decision and things come into play in best interest. It did come up more for me in periods that I spent working in, for example, older people’s services, where you’re looking at a greater prevalence of organic problems, I guess, like dementia and some things like that but I’m wondering if we could just parse a little bit more the difference. I’m very clear on that but I wonder if people might not be quite as clear about the basis of a decision under the Mental Health Act where somebody, you know, may be broadly perceived to have capacity but there’s another legal framework that can come in ahead of that.
Matthew: Yeah, that is an important distinction and the Mental Health Act does allow for treatment against a person’s own decision making or against their will where the best interest decision is really trying to make a decision that is in line with the decision they would have wanted to make for themselves if they’d been able to and I think that’s a really important difference. There is clearly an overlap because there may be people who have a mental condition that has an impact on their ability to make decisions for themselves so they may lack capacity and also be mentally unwell at the time, and if either could apply then what we’d generally go for in a psychiatric hospital setting is the use of the Mental Health Act and what that does mean is that, even if a person is able to make a decision for themselves about treatment and is refusing that treatment, we still under the Mental Health Act, at least while they’re in hospital, have the power to enforce that treatment.
John: One of the things that often struck me having worked with you somewhat, I mean I should say that actually when I worked on a ward where you were a consultant I didn’t actually do all that much work with you, partly because I think your emphasis was on trying to move people through hospital in a relatively expedient and quick way, I think for very good reason, was always my feeling, that you didn’t particularly want people to linger in hospital unless it was absolutely merited and necessary but it did strike me that you were actually pretty thoughtful about the application of the Mental Health Act and what might be the more aversive consequences of doing that. Could you give me an idea, just in your decision making, of how you balance the needs versus the negative consequences as part of a decision?
Matthew: So, the question that I was thinking about in the previous answer was about what the powers are. There’s then a question that has to be asked, and in practice we all need to ask of ourselves, is whether a power that we can apply should be applied and that’s the balance between the benefit of treating somebody in hospital, because the Mental Health Act is largely about hospital treatment, against the disadvantages of treating somebody in hospital and it may be that there is risk associated with a person and the condition that they’re being treated for and that risk may remain whether or not they’re in hospital and whether or not they have treatment that’s available in hospital. So the way I would think about it is that, if they have a condition associated with risk and there is something we can do for them in hospital by treating them, that will mean that risk is reduced so that when they leave hospital there has been a benefit both in terms of their mental wellbeing and reduction in risk, then we should hold them in hospital and use the powers of the Mental Health Act but if, on the other hand, keeping a person in hospital either makes no difference or worse makes things more unsafe and contributes to their difficulty in managing life outside of hospital then, although the power to use the Mental Health Act may be there, it might not be the right thing to do.
John: And this I think is a very interesting point and one of the things I said to you before we started is this idea that sometimes when you hear people speak, especially if there’s been a serious incident or suicide or violent incident, that we sometimes hear people saying, oh well the problem is they didn’t get the treatment that they needed in hospital, but in some sense what you’re saying is that actually hospital may not always be, no matter how good we make it, may not always be as good as people would like or be able to help in the way that people might envisage. It may not always be helpful.
Matthew: Yeah, I think that’s right, there’s I think two misconceptions about hospital, the first is that it is always the safer place to be and the second is that because it’s a hospital there must be treatment available in hospital and that if there is treatment available in hospital that a person would leave hospital in a better state than they were when they came in. And sometimes that’s true but in cases where it’s not then that would be coming back to the occasions when it might not be the right thing to treat someone in hospital so as a kind of example of where that might be the case, well it’s really thinking about what kinds of treatment we do have in hospital. We’re quite good at using medication in hospital, and that’s important for conditions that respond well to treatment with medication and it may be that it’s worthwhile keeping someone in hospital for the time it takes for that medication to begin having an effect because then the expectation is that they will leave in a better state than they came in, but some conditions are not responsive to medication and often those are conditions where the best treatment is psychological treatments but those treatments first of all take time, secondly they really need to be done in a setting that is most conducive to benefitting from those treatments, and often an acute hospital where a period of treatment is often quite short and where those resources are not concentrated and where the environment is quite disturbed and where there’s a mixed population of patients and it’s very difficult to create an environment where they’re likely to respond well to that kind of treatment that being in an acute hospital at least may not be the right place for them so that is the lack of benefit a person is likely to derive from being in hospital. The second thing we then need to think about is what harm might the person come to while they’re in hospital waiting for a treatment that’s not available and for a lot of people they come into hospital because they are struggling with things that are going on in their life at the time and often those things are not to do with mental illness or mental disorder, they might be to do with relationship difficulties, housing difficulties, problems at work or a whole variety of personal problems that mean because a person cannot find a way to cope with those difficulties they come to mental health services in distress, they are sometimes brought into hospital, that gives them a temporary respite from what’s going on in their life although it’s still there in the background and unchanged by being in hospital and what can happen over time is that first of all being in that hospital environment where they have a temporary respite from the crisis that’s happening in their lives does give that temporary relief but at the same time they do have to leave because it’s not a permanent placement and when they leave they struggle with the fact that they’ve lost what felt like a protected environment and that, for a lot of people, means that they struggle even more than they had been before in coping with the things that have not changed while they were in hospital. And so, what people then find is an escalation in the distress as they leave, they feel the need to come back but the gateway to coming back can for a lot of people be raising the concern of professionals to a level that those professionals think they should come back in and what in reality that means for many people is doing things that place themselves at risk because that’s what professionals respond to, and I’m not thinking for most people that that’s a conscious and deliberate decision, but where there is that increase in distress because they are not coping and because they’ve had to leave hospital, that becomes the natural thing for them to do. So that by keeping them and actually deciding that they should come in in the first place, what we are really deciding at the same time is that we will create a difficult period for them at the point where they need to leave and that’s compounded by the fact that by having someone in hospital there’s an element of a nurturing environment which is then removed from them and that creates a sense of rejection and loss and so there then becomes a reaction to that as well. I think that if by keeping someone in a hospital setting we are offering something that helps them, those are all worrying aspects of things that can be coped with and offset the benefit of treatment they’re receiving. But if actually we’re not able to offer any treatment then it just becomes a negative experience.
John: And that’s very resonant actually what you’re saying, I mean sometimes people I guess feel safe in hospital and are attracted back there and one of my own experiences was that sometimes even when people in a conscious way found it quite aversive being there, that there may sometimes be a part of them that could come to depend upon it in a very unhelpful way or a way that did not help support their recovery really.
Matthew: Yeah, yeah.
John: A few more questions just before we finish from me and actually I asked a couple of my colleagues who present the podcast with me. One of them was, I suppose for me was, I worked in acute mental health wards for a number of years and I worked quite closely with a number of different consultant psychiatrists and they were all different, they were all absolutely different in the way that they related to and applied these kinds of legislative frameworks. Are there ways of trying to make that consistent, are there mechanisms within the system that try to improve the consistency of that? People have different considerations, different anxiety thresholds, different views and beliefs in the efficacy of hospital. How does that system become consistent or does it not?
Matthew: I don’t think it’s ever possible for it to be completely consistent because the practice of different individuals is going to be different and it also depends on how a team functions and how supportive a team is about making risk decisions and one of the things that I think is really important for any clinician making those, what can be quite difficult choices, is how well supported they feel by the team that’s around them and I think that what’s really very important in that is first of all having a consistent understanding about how different conditions, and it’s particularly around the management of personality disorders that some of these people struggle with making these kinds of decisions where consistency is most challenging. And there are things that we can do so as an example, one of the initiatives that we are starting in Kent is training to ward staff by the newly-appointed medical psychotherapist who is leading on personality disorders in the county and he will be going around to all of the wards and doing teaching sessions trying to generate a common understanding of how to manage that kind of risk. The other thing I think that’s important is the services that sit around the hospital wards. What I’ve seen is that one of the causes behind, or one of the underlying reasons behind inconsistency, is when people will make an assessment, have an understanding about what they think is probably the right thing to do but feel unable to act on that because they don’t have any alternative treatment so what I’m thinking about here is someone who might present in crisis, a decision might need to be made about whether they should come into hospital or not, often when they do come into hospital they will be detained under the Mental Health Act because they are saying that they don’t want to come into hospital and the clinicians involved in making those decisions don’t necessarily think that being in hospital is the right thing but because there aren’t any alternative treatment options for them to offer that person in the community they feel that they must bring them into hospital even though they know it’s probably not the most helpful thing to do.
John: That relates to a question from one of my colleagues about people sometimes staying on section, the colleague of mine who worked a lot in forensic services, people staying on section because they are deemed to continue to be at risk or there’s just not a suitable place to refer them in the community, I mean I guess that’s quite a tough dilemma. Does that happen, people staying detained under the Act, even when they’re not unwell enough technically, just because there’s nothing else?
Matthew: Yes, very much so, and I think it’s about an understanding of how to manage risk and where that risk comes from because for a lot of people the risk is intrinsic to them and the condition they have and it remains whether they are in hospital or not. For other people it’s very much a risk that is linked to a treatable condition and that’s really coming back to the answers right at the beginning of our conversation because, if by treating someone using a treatment that’s available to us in hospital we can change what’s going on for that person in a way that benefits them, then it’s a useful thing to hold them in hospital for the time it takes for that to happen. But if, regardless of what we do the risk is there and doesn’t change, then we have to be thinking about how we manage the treatment of that person knowing that that risk is there rather than what do we do while they’re in hospital to remove that risk because we already know that that’s not going to happen, and if the purpose behind holding a person is to keep them until the risk has changed but we know that risk will not change then we will never allow them to leave hospital. And what that means for someone is that if improvement in their condition and the way that they manage with the difficulties in their lives can only happen outside of hospital, for a lot of people that’s true because that’s where the difficulties lie and that’s where the change needs to happen, then by keeping them in hospital we are condemning them to never improving and never getting better but also because they cannot get better we cannot let them leave either so it’s a really nasty trap that we put ourselves into, where we’re focusing entirely on risk but not on what needs to happen for that person to improve.
John: I’ve got a couple of other quick questions which came from one of my colleagues. My colleague Anne wanted me to ask you, do you think we need the Mental Health Act as well as capacity based legislation, I mean personally I don’t think it’s going anywhere, but do you think we need it or could we just have capacity based legislation?
Matthew: We could, that’s an interesting question because I think that if we’d started with the Capacity Act we probably might not have needed the Mental Health Act but the history of the Mental Health Act goes back a long way to more than a hundred years back. I think the existence of the Mental Health Act does mean that we need to be quite careful in the application of the Capacity Act because potentially we could look at capacity in relation to mental disorders and say that either because of the distortion in the way that a person perceives their own illness that there is an impact on their ability to make informed decisions so that in a very broad sense anyone who is detained under the Mental Health Act could be understood to lack capacity and said that the deprivation of liberty could fall under the deprivation of liberty safeguards and the treatment could come under best interest. I think that one of the advantages of the Mental Health Act and why it’s important that we continue to keep it alive is that there is greater protection for the person receiving treatment that comes in the form of tribunals and hospital managers’ hearings and that allows a person to have legal representation to present their case to an independent panel who can discharge the section if they don’t think that the clinicians involved in treating are right in their view about detention, and one of the things that’s changed in recent years is that the burden of proof now lies with the treating body rather than the person themselves and what that means is that the evidence presented to that tribunal by the professionals has to be persuasive enough that they can demonstrate that detention under the Mental Health Act is absolutely necessary and those protections are not there in the Capacity Act.
John: The final question I had for you, and I think I probably know your answer to this given what you’ve already said, is do you think that somebody has the right to take their own life or should people when they’re suicidal always be detained under section if they refuse treatment?
Matthew: I think people do have the right to take their own lives, I think that’s something that creates a lot of anxiety for professionals because I think it creates a professional anxiety, the sort of sense that they may be held to blame as opposed to accountable which are different things, we are all accountable but that doesn’t necessarily mean to blame but also that people feel personally responsible for the people that they are looking after and nobody wants to see someone that they have a connection with and feel personally and professionally responsible for killing themselves and that always feels like a failure when that happens so I think there’s quite powerful reasons why people worry about the decision someone may make to take their own life. One of the things that we have to bear in mind is that a lot of people who do kill themselves have no mental disorder and no mental illness and it may be a very rational decision for somebody to make but where I think we have a very clear responsibility to prevent suicide is where that decision comes about as a result of their mental disorder and particularly where it‘s a mental disorder that we could, by treatment and intervention, change the way that they feel about their own lives and that’s why for example where someone might be very depressed, maybe thinking about suicide in the context of that depression but that’s a treatable disorder and that, if we hold them in hospital for long enough to treat the depression so that their mood improves, they no longer have those thoughts about suicide and that’s a very clear example of where detention under the Mental Health Act would be the right thing to do.
Anne: I thought it was really interesting the way that he made the distinction that I was just talking about between people, this is my interpretation of what he said anyway, he talked about people who had mental illnesses that we can treat in hospital and by which he generally I think meant we can medicate people and that for them hospital can be useful and therefore they should be sectioned, and then he was distinguishing that group from other people he said had social problems that shouldn’t be in hospital and at one point he referred to them as having personality disorders and he was saying, he seemed to be saying anyway, that those people should not be admitted to hospital and in fact, well he said that the problems that they needed to address were outside of hospital and seemed to imply possibly that mental health services didn’t really have much of a role in helping those people although I could have got that wrong.
John: I understood him to actually be saying that he felt that mental health services, although maybe this is coloured by my other knowledge of his working practices, that he found aspects of the mental health system to be actively unhelpful to those people. So what did the rest of you think?
Angela: I found it I suppose heartening that he was at least pointing to some of the dangers of keeping people in hospital unnecessarily and also the dangers of what can happen when people are hospitalised especially for protracted periods of time, that they actually lose their own powers as a consequence of doing that, however what was disappointing about it was that he doesn’t actually question the basis on which responsible clinicians can currently commit people to detention.
John: He was certainly coming to it from the perspective of illness based although I was quite interested in his remark that perhaps he felt, I mean this is maybe one from slightly later in the discussion, that we could think about it purely in terms of capacity but I’m just thinking while we’ve got Emma here just to get your reactions to that and also again just thinking about, you know, you’re somebody who, not unambivalently from the sounds of it, is thinking about picking up these kinds of powers, so what did you make of what he said and how does it relate to your own journey into this?
Emma: I mean, I thought what was really helpful was his talking about the difference between the short term risk and the medium to longer term risk, or that kind of came up in the conversation between the two of you, in terms of at the point of sectioning the focus is on the immediate risks to the person themselves and the people around them but at that time maybe that there also needs to be thought given to the longer term risks for that person’s mental health and ability to engage in mental health services that might be able to help them if they are compulsorily detained in that it might be such an aversive experience that it makes it much more difficult for that person to seek mental health services in a more helpful way in the future.
Anne: It tied in very much for me, I don’t know if you’ve had a chance to look at that recent article from the British Journal of Psychiatry that I sent around, I think via Twitter, that actually did some research trying to establish cause in terms of admission to mental health hospital and suicide because we know obviously that there is an association between suicide and being an in-patient in a psychiatric hospital, but obviously you can’t do an experiment, you can’t force some people and let some people kill themselves but they used an accepted method of determining cause for things where that’s not possible, for example it was used in determining the contribution of smoking to cancer and concluded that there is good evidence that psychiatric hospital admission contributes causally to suicide which, given that it’s our main answer to suicidality and a perceived risk of suicide, I thought was a staggering finding and this is only within the last couple of weeks.
John: In some ways that bears out what we were saying the last time we gathered for this discussion which was about the emphasis on just managing, you know, sitting on, squashing down, holding risk in the here and now and I think all of us were questioning the degree to which that was necessarily helpful to somebody in a bigger picture and we do have a couple of other interviews with service users who have been to different extents subject to compulsory powers, which we’ll go to a little bit later, that I do think also bear that out from a more subjective stance but that’s a system Emma that you’re getting involved in so what’s your motive for that?
Emma: I think one thing that it’s important to say is that at this stage it is not possible for non-medic responsible clinicians to actually do the initial sectioning so within the 2007 Amendment as it stands a responsible commissioner who is not a medic can only take that position from when the person has initially been sectioned, and that might seem like a fudging of that initial sectioning or the responsibility for that initial sectioning but that’s how the legal powers stand currently. Once somebody has been sectioned, I think, and bearing in mind I work with people with learning disabilities, that it’s incumbent on the system to really look at ensuring that person has the treatment and I mean that in the wider sense, not just medication or drugs but psychological treatment, and I think probably more importantly the whole nursing milieu on the ward which can actually be quite therapeutic for some of the people I work with who’ve had very traumatic backgrounds/childhoods of trauma and lack of nurturing, and whilst we may see a lot of acute wards as not feeling like therapeutic places at all, I think some wards that have been set up for people with learning disabilities when they have been set up well and are managed well, and we know there are lots of examples where that is not the case, then they can actually have a beneficial effect in helping somebody develop better attachments and think about how they might rebuild their lives in the community upon discharge. And so, as a responsible clinician, I would see the role of a non-medic to be really emphasizing the importance of those non-medical, non-medicine, non-drug treatments on the ward.
Anne: Can I ask you a question then, why are they called wards if they are not offering medical treatment? I‘m thinking for example of Peter Kinderman’s book where he suggested taking mental health care completely out of the health system, out of hospitals and having social care centres or crisis houses, I have written about crisis houses, why call them wards, why have a medical term at all?
Emma: I completely agree. I think there’s something about it being locked, I agree calling it a ward doesn’t feel helpful and making it look like a ward doesn’t feel helpful either so I would say that’s the unhelpful bit of the detention, to call it something else, but there’s something about it being locked that gives the literal containment for somebody who is very uncontained and who finds it very difficult to separate from that traumatic community from which they’ve come as in the family and local community that’s created the trauma, there’s something about the need to have that lock as a physical containment as well as the psychological containment but I absolutely agree about the use of the word ward and the lockable ward.
Rachel: But, and unfortunately I think it is the reality that sometimes some people probably do need some kind of support or treatment against their wishes so there is a need for some kind of legislation and protection. I mean understandably it’s extremely traumatic to have to go into hospital when you don’t want to, I think there are always going to be cases where that is needed and as I said earlier I personally think we are part of that, if we are working on in-patient wards which I have done we are part of the system whether we like it or not and we are seen as a member of the team that is keeping somebody in hospital. So therefore I think it is important that we put ourselves in positions to be making those decisions rather than just going along with them which I think is what we’re seen to be doing currently.
Angela: I think for me, while I can understand that there‘s an argument for being in rather than out, it’s not something that I would personally be willing to get involved with, insofar as I think that the whole basis of the legislation is faulty at this moment in time. I think it would be a major step forward if the Mental Health Act were one that was based on capacity rather than the kind of somewhat arbitrary judgements that it can be made upon at the moment. That would be a major step forward, it doesn’t mean that everything would be hunky dory, in fact it would be interesting to see whether detentions lowered in number as a consequence, they may not, but at least it would have a more just premise to it.
John: I wonder if that might be a very good moment to go to an interview that we did with Rai Waddingham who’s quite a well- known service user, activist, and really describes this notion of being detained in hospital against your decision, you know you have the capacity to make the decision but the system is going over, the system is over-riding your will. So let’s hear that, again there’s quite a lot in this interview but it’s an interesting story and thinking about it in contrast to what Matthew Debenham said, it’s a very timely reminder about some of the potentially very, or in line with what Matthew Debenham said actually, some of the potentially very negative consequences of having decisions over-ridden in quite that way and how potentially unhelpful that might be
John: Okay, I’m here with Rachel Waddingham, usually known as Rai Waddingham [pron Ray] and I was very interested to talk to Rai, or actually I think I will pass over to you to just set this up because I think you have some experiences which do seem very relevant to the point at hand. Could you tell us a little bit about yourself first of all?
Rai: Sure, so I struggled during my twenties a lot with experiences like hearing voices, having visions, unusual beliefs that led to me being hospitalised for quite a few years, under section at some points in that journey and since kind of finding a way through that with the Hearing Voices network I now work as a training consultant internationally, really trying to change the way that we see and respond to those kind of experiences. I also at the moment work in the NHS in Canterbury as part of the Open Dialogue service so it’s kind of interesting to go back into the system from a completely different angle.
John: And I think that, just mentioning the system, one of the reasons I was interested to talk to you, as well as having been interested in and an admirer of your work for some time, is that you have also had experiences of being detained in hospital under compulsory legal powers. Could you tell us a little bit more about that?
Rai: Sure, so when I first went into hospital, I think it was at the end of 1998 so it was a while ago now, I went in as a voluntary patient so I was admitted informally. It’s a kind of funny word, voluntary patient, because it’s not like I felt like I had a choice, it was more ‘come into hospital’ and you just don’t argue with doctors especially when you’re distressed and your family’s distressed but I was first sectioned I think when I decided I didn’t want to be in hospital any more and so I decided I wanted to leave and I didn’t know sectioning even existed, it was a bit of a shock to me for me to go, right I’m leaving, I need to get out of here now, this isn’t okay and then to have the nurses put me under a 5.2 or 5.4, whatever it’s called, an emergency hold, and then get doctors to come in and see me, it was really weird.
John: Just for people who aren’t familiar with those 5.2s and 5.4s, they are subsections of the Mental Health Act under which people are detained, yeah?
Rai: That’s it, so those kind of short term holds happened quite frequently in the years that I was in and out of hospital, it would usually be that I’d go in voluntarily and then freak out, either deciding I wanted to leave because I didn’t feel I was getting much help or I was struggling so much with the voices or so much with this fear that the alien that I thought was inside me was going to make me kill people that I just legged it from the hospital. I’d wait for a moment when no one was looking and I’d try to get out and start running and usually there’d be a nurse running after me and then they’d put me in one of these holds. So often it happened in a point of crisis and occasionally it happened when I said, you know what, I want to get out of here and those were the two kind of main ways of me getting sectioned.
John: And the whole experience, leaving aside for a moment the motives of keeping you in hospital against your expressed will, given the state that you were in, but even without that the whole experience sounds pretty terrifying really.
Rai: I think so, I mean the idea that someone can forcibly keep you somewhere you don’t want to be, whatever the reason, and that at that point when you’re given a little bit of paper, you’re under section, you have to get a form signed if you even want to go out for a walk on the grounds with your family, it just was, it was like going into another zone, I didn’t know it was legal to do that, it certainly wasn’t what I was expecting when I was first admitted and the more coercion that was used for me, I think the more I railed against it and became obsessed actually about getting out and spent more time trying to think about how to get out of hospital than work on the experiences that led me to be there in the first place.
John: So in one way it felt like a distraction from some of the treatment that you were having and a very dominating thought.
Rai: Yeah, I think so but also something about, despite those sections and hospital admissions and stuff like that, it felt like it only reached those crisis points where I tried to get out of hospital because the support I got when I was in hospital didn’t hold me, it wasn’t as therapeutic as I’d have liked. I felt very isolated with my voices and with my fears and so the kind of concerns and the worries and everything would build up to the point where I just needed to get out of there but then no one would listen to me and it would get worse and worse and then I’d run and then I got sectioned so it’s kind of like a knee jerk response to what’s seen as a very confused, distressed young woman, but they missed the run up to it.
John: It does sound as if one of the primary experiences you have taken away from that is that the response could have been, how can I put this, more creative to you in that setting.
Rai: I think so.
John: Rather than the feeling of jumping to holding you in when something had got very, very out of hand.
Rai: That’s it, because I can understand that while I’m legging it through the corridors the nurse that catches me has no other option but to place me under a section because you can’t stop someone from leaving the hospital legally without sectioning them but that it even got to that point is the worrying thing because there were so many other ways that could have gone. As I said, I came into hospital voluntarily and I think that even though I was very paranoid and very afraid of staff, if they’d have had some more time and resources to just sit with me and get to know me a bit better, then those kinds of situations wouldn’t have happened so often.
John: It’s something, just thinking about where the experience left you, where the experience ended up, I have spoken to a number of people all over the years but also particularly in the preparation of this particular podcast and they seemed to have landed in very different places with the experience of having been detained, some of them are really, really clear that it felt distressing and in retrospect you know, it really did them no good, quite the contrary. Some seemed to be in a position of saying that while it was clearly distressing and they were clearly in many ways an awful experience, they’ve kind of landed in a place where they see it as having been necessary and something that ultimately made a difference to them when they were not able to make particular decisions for themselves. Where have you ended up with it because it sounds like you do have a few years of perspective on it and clearly have thought about it a lot but where have you ended up with it in terms of how necessary or otherwise it may have been?
Rai: It’s a complicated one isn’t it, because it’s easy for me to sit here and go, it’s never necessary, compulsion, coercion we should just get rid of it in mental health services and I think 98% of me really believes that. I think having such levels of compulsion in a service that’s about health and wellbeing and helping people find their way through distress, it just doesn’t make sense because it sets up a situation where we spend more time running from services than actually engaging with it so I’m kind of coming out at a more anti-compulsion kind of stance but I also recognise that we are kind of trapped in this cycle because our services are so reactive and so under-forced and probably operating on a paradigm that portrays people like me as very unwell and having no insight into our own stuff and actually kind of perpetuates that by the way we are treated, that if you suddenly got rid of sectioning tomorrow and decided not to use it, people wouldn’t be safe because we’ve been in this stance for a long time so I feel like sectioning is like a systemic ill, it’s a systemic problem that the individual players, myself, the ward staff and everyone else, we don’t have much room for manoeuvre but because it exists it can almost stop us from looking at what the alternatives could be because I think it’s a failure when we section people because it means that somewhere along the line we’ve missed something, whether it’s when they were children, reaching out for help at school, did that get missed, whether it’s because people have experienced prejudice and discrimination, whether they’ve had negative sorts of interactions with services previously, whether they just don’t feel respected when they meet a practitioner, something has gone wonky there and we need to fix that in order to move away from sectioning.
John: I mean, in some sense, I think also what you’re saying is that the very availability of sectioning under the Mental Health Act, I’ll ask you about other legislation in a second, but under the Mental Health Act it kind of leads us down a path where we’re almost, well, what’s the old joke, you know, I wouldn’t start from here.
Rai: Mm, that’s it, I think it’s tricky because we are stuck in that so an example of that would be when I was on a Section 2, right at the end of the section the ward staff applied for a Section 3 for me and the social worker and the medical representative and all that really agreed that I needed to still be in hospital under a treatment section, it was a 6 month one, but my parents didn’t agree and they didn’t realise until then that they had rights as the nearest relative to oppose that section and luckily they got advice and did oppose it. They were under enormous pressure by the social worker to agree to the section, saying it was in my best interests, I would have more protection legally and all of that but my parents were like, well she’s complying with treatment, she’s being a good patient, she’s saying she will stay in hospital, why section her for another six months. And the answer was, it saves paperwork, and it’s less stress on her, you know, because if she runs off again we will have to go through this again and that’s why we’re doing it so it felt like a paper saving exercise, nothing about what was really in my best interests and I ended up being released probably a month later because I was doing a lot better so the fact that they almost kind of detained me just in case, it suggests that it’s almost a default if someone is still on the end of a Section 2 and still struggling, just move it up to the next one.
John: Well on that issue of how the legislation is used, I mean one of the things that’s arisen in the interviews I’ve done for this so far and I suspect also in the discussion that we have is that the underlying principle of the legislation and compulsory powers versus the way that they are employed in practice, and I have to say myself having worked with a number of consultants and in a number of wards over the years I have seen wildly varying practices in the degree to which these things are used, for want of a better word, well. The psychiatrist that I talked to for this podcast, he reckoned, this was only his perspective, that that kind of thing, you know checks and balances on decision making, he felt that that had improved over the years because, you know there is the principle of it but also there’s the way it’s employed and the way that it can be done which, as you say, it doesn’t sound like you had a very good experience of that either.
Rai: It’s hard to say whether it’s actually changed, I think it’s so different in different areas and in different teams and about the culture and how many serious incidents there’s been recently and all those things that mean I don’t think we can say it’s improved or got worse, it’s just fragmented. I certainly know of people that have been put on CTO’s, Community Treatment Orders, on release from hospital just in case they stop taking their medication when they’ve got no history of doing that and that’s a kind of more recent example of our overuse of the Community Treatment Orders that suggests that actually there is still something really problematic in the way this is being implemented, it’s certainly not the last ditch attempt and I think the idea of finding alternatives to sectioning is within the law but I rarely see workers really fighting to look for alternatives .
John: But one thing I wanted to ask you about I suppose before finishing is the broader principle, something that we’ve talked about quite a lot in our group in our team is the notion of the Mental Health Act which makes decisions around the basis of whether you’re of sound mind or not and trying to look at what people may rightly or wrongly perceive to be your best interests. It compared to something like the Mental Capacity Act where, you know, if you’ve got capacity you can kind of make the decisions that you like really and I just wonder if you felt that there would be any advantage or disadvantage to grounding, if we were to accept that the decision to treat people sometimes against their will, isn’t necessarily going anywhere. Do you think that might be improved or more humane if it was based on people’s capacity to make the decision rather than what other people thought was best for them?
Rai: It’s a tricky one, isn’t it, because I think that as long as we have legislation that allows us to give people, because if we say treatment, that suggests it’s a treatment for a particular illness or condition, but if we step back from that and go, actually what we’re doing is medicating people, that’s what we’re talking about, which is one particular way of working with distressing experiences but it’s only a small part, it’s rare that you’re sectioned into therapy or sectioned into a peer support group, not that you ever should be.
John: They have asked me to treat people under section before now and it’s always been quite weird.
Rai: Yeah, it kind of goes against the whole sort of principle of people actually opting into those kinds of relationships but primarily treatment is seen as a bi-medical/medication kind of thing so what we are talking about, should we take away people’s liberty and then should we forcibly medicate them are the two sort of big parts I guess of sectioning and compulsory treatment and even calling them treatments suggests that they’re indicated that that’s a good idea so I’d kind of like us to untangle a bit about what we mean by treatment and forced treatment and sectioning so that we separate the idea of actually taking someone to a place that we feel is safe because we’re worried about them harming themselves or hurting someone else, and taking away their human right to liberty which is a big thing to do, and then thinking about enforced treatment and actually injecting or putting chemicals into someone when they’ve said that they don’t want those chemicals which is a very abusive practice I feel. So untangling those two things would be really useful and then looking actually at what evidence do we have that the medication is useful and works? What about the harm caused by medication? We kind of need to look at all of those things before we say as a society we’re happy to keep on going with forced treatments and I’d say that the ills of forced treatments are kind of really huge so we need to minimise it as much as possible. I like the idea of thinking about capacity because that means you can make what are seen as unwise choices if you’re able to think through the consequences of your actions and communicate them with some support. I think one of the problems in the Mental Health Act is that if you have a ‘mental disorder’, in inverted commas, of a sufficient nature or degree so either past or present struggles with that your decision can be taken away and assumed that you’re not able to make that because your decision is seen as evidence of your illness or your lack of insight and that’s a horrible trap. I know when I came off medication I was threatened with sectioning and I was currently working in the mental health system, I was doing pretty well but I was really struggling because I was withdrawing from meds but the nature of my so-called illness was so severe and my history was so severe that they could have legally sectioned me because of that and not because I was a risk to myself, not because I was a risk to anyone else. So my decision to come off medication was seen as it didn’t matter what I decided because my views could be overridden because of the supposed illness that I apparently had and that’s worrying.
John: Mental health is one of the few areas where you don’t necessarily always have the freedom to make, for want of a better word, unwise choices, in other areas of health you can make the choices that you want, if you have cancer you can refuse treatment but mental health is exceptional in that regard.
Rai: And how great would it be if we could actually make advance statements that were respected in law so if I said in my advance statements that I never want to go on anti-psychotics and I never want ECT, the only thing I’ll accept is short-term benzos if I’m in a massive crisis, if that would actually be enshrined in law and respected, that would be amazing if I made that while I had capacity and then if for whatever reason I haven’t slept for a week and I get really confused and really overwhelmed and people are really worried about me they can take me into hospital if they think I’m going to jump off of something but they can’t give me anti-psychotics. I’d love that.
Anne: One of the things that she talked about, that she mentioned was how traumatic some people find it or a lot of people find it to experience medication by force which is often part of what happens when somebody is sectioned and I think that’s one thing that we could possibly separate out, it’s part of this kind of whole narrative that people are ill and need treatment that stops us I think asking questions that we could legitimately ask like, is there a place for detaining people without necessarily medicating them? That’s something I heard Peter Campbell, a very famous service user say years ago and it really struck me and I was amazed, I worked on inpatient wards myself at the time and I had never even thought about it and nor had most people I came across and I think probably still, very few people actually consider that because in our minds they’re all bound up with needing treatment and actually I agree with you Rachel there are times probably where people need to be kept safe because they’re in a state of mind for whatever reason that’s not their usual one and are a risk to themselves or maybe possibly even to others but I do think that’s a very different narrative from they are ill and need treatment and it has very different implications.
Emma: Absolutely, I think that’s very much following on from what I was saying earlier that treatment within the Mental Health Act is actually defined as not just medication, not just psychological treatment which I guess we can see as being an active thing that you’re doing with the person who’s detained but also the nursing milieu, so just the very fact of being there is part of the treatment, so it would actually be legal to detain somebody on no medication as I understand it with the nursing milieu as the treatment.
Anne: Yes, I think it possibly is legal but in the current culture it doesn’t happen and also the culture affects the nursing milieu as you call it in the sense that people see themselves as there to look after people with illnesses and often to insist that they take their medication, it doesn’t often happen that the treatment plan doesn’t include medication so you’ve got to take into account the context.
Rachel: The other perspective, having spoken at length to my psychiatric colleagues about this because I am very concerned about people being medicated against their will, the other side of it that they would say, which, you know, I have mixed views about, is for them it’s unethical to leave somebody very, very distressed when there is treatment that would help them and perhaps they’re not in the state of mind to make that decision so therefore for them they need to force medication to reduce that distress, I think that there’s a lot of downside to that and personally working in services I think a lot more could be done to take time to listen to people who are in hospital and hear their experiences, hear their worries, hear why they don’t want to take medication, and think about that, together, to get more shared understanding but I think that people that are enforcing medication aren’t doing it with bad intention.
Anne: No, I completely agree, they are doing it with the best intention, and actually I find that very scary that one of the things you linked to on the show notes John was a piece from The Guardian written by a nurse about why she calls her colleagues heroes for looking after ill people, and she talks about an episode where they forcibly medicated somebody and it really chilled me her kind of complete lack of questioning and her sureness that what they were doing was the right thing because of this idea that this person was ill and needed treatment like you said and she described the patient uttering what I think she called a primal scream of fear which made me shudder reading it, it’s horrible, and you know I’ve talked to somebody who described being force medicated and talks about it as like rape, brain rape and they said it’s worse than rape because with the chemical rape as he called it, the chemical goes into every cell in your body so it’s the kind of conversation we don’t have often as mental health workers and I think we need to listen.
John: Is there not bravery in that though, we all read that piece I think but it seemed to me that the person writing it who I think was anonymous, it was written anonymously I think, a nurse, is there not bravery in that, of saying that there is a really very nasty job to be done and somebody ultimately has to soak up those things for us as a society?
Angela: Not for me no, because I think you know, you’re perpetrating something that potentially is going to leave a very long shadow and that person is going to have difficulty trusting mental health professionals from then on and that’s going to have profound repercussions for their care from that moment on and I do agree with Rachel that there’s just not enough attention given to trying to engage people in other ways before medication is forced perhaps.
John: Well perhaps this might be a good moment to hear from Raza Griffiths, actually who is a colleague of ours here, a great friend to the Salomons Centre and actually gets involved in all sorts of things and the interview we did with him is very much in that territory of the notion of having compulsion and certain things available to you cutting off your options. One of the other interesting features of Raza’s interview is that actually I hadn’t realised when I first approached him that he wasn’t describing the experience of being formally detained but he was describing an experience which I have also seen on a number of occasions over the years where, whether people mean it or not I’m not sure, but however it’s come about, the kind of threat of detention is floating around in the background and certainly listening to Raza speak, I almost think he probably would have been better off under the formal powers of the Mental Health Act because things would have been a lot clearer but let’s go to that now.
John: I’m here with Raza Griffiths. Raza is a writer and mental health activist and lecturer and among other things talks about personal experience. I should also add that he is currently in the process of writing or editing a black and ethnic minority manifesto for mental health.
Raza: Yes, writing it, yes.
John: Excellent. Raza, one of the reasons, we obviously talked about this a little bit before, but one of the reasons I was particularly keen to talk to you was that I read something you wrote about the experience of compulsory treatment. I was wondering if you could tell us a bit more about that.
Raza: The process of writing it or the actual experience?
John: Just the actual experience of the encounter with being treated in a way that you perhaps didn’t consent to or was imposed upon you for whatever reason.
Raza: Well there is a context to this which is that I was actually doing a PhD at the time and you know I was hearing voices, there were a lot of unresolved issues from, I think from my childhood and early adulthood which I’d never really faced and these were intruding into my life but I didn’t really want to be in that Mental Health Service user category, you know that mental category, because there was actually a media campaign going on at the time which was to stop the opening of a day centre for people with mental health issues in the community because it was being placed next to a school.
John: This was where you lived.
Raza: Yes, in South London, so there was a kind of reluctance on my part to kind of acknowledge that I was experiencing mental health issues which made it difficult for me to kind of access help so what happened basically was that it got to a real crisis stage and I rushed into my doctor’s surgery and I collapsed on the floor, I probably looked a bit like I was having an epileptic fit which was probably quite startling for my doctor and then I would stand up and be very lucid and say you know I‘m hearing voices and at the end of this my doctor said, look you really need to go to the hospital right now, so I was kind of rushed off to the hospital in a taxi and at that point someone appeared wearing a white lab coat who was the on duty psychiatrist I imagine, they asked me about what I was experiencing, I told them that, you know, I was hearing voices and I was doing things that probably were putting my life in danger actually so I definitely needed some kind of containment and support there but I felt very much as if there wasn’t really any interest shown in the context of my life, the social issues, nothing about my background, I was simply seen as a set of symptoms, behaving in a slightly odd way and this person in a white coat was going to use some kind of psychological instruments to measure my degree of weirdness as it were and I didn’t particularly feel that this person was very empathetic or understanding about me and I was measured and then according to the DSM I was given various kinds of labels, you know, which didn’t really mean anything to me, then I was put on this mental health inpatient ward and at some point I was medicated, I wasn’t really informed of my rights around medication, there was no real effort to educate me about potential side effects, no preparation, I was just medicated and obviously being in that situation it wasn’t really on the tip of my tongue to ask and say, well what are my rights and all of this, I just went along with it but as a result of that medication I had quite horrendous physical side effects and psychosomatic side effects, I felt as if I couldn’t breathe, I was hitting my bars, trying to put my head through the bars and breathe you know and in the process of doing that I basically sustained kind of bruising to my forehead, you know I was hitting my head really hard and as a result of that they then came and medicated me again with some injections in the middle of the night so the whole process, you know I was in such distress and I was met with a kind of physically violent response and I was met with very little attempt to understand, you know, why was I behaving like this, I wasn’t really treated like a human being, I was treated as a set of symptoms.
John: I mean, I’m wondering if that sense of kind of potentially being dehumanised in the mental health system is probably there more than many of us would perhaps care to admit, many of us who’ve worked in it, it can happen I guess for all sorts of reasons but as well as that there also sounds like there’s an experience in this that you weren’t exactly consenting to what was going on. Were you being treated under the Mental Health Act or the Mental Capacity Act at that point?
Raza: To this day I actually don’t know which is quite significant in itself and I think I would really have valued having some kind of advocate or social worker or someone just being there for me and just informing me of my rights, you know, and I’m not even quite sure when my family, the whole thing is a bit shrouded in fog to tell you the truth and I would imagine that there are quite a few people who, it’s not that they didn’t necessarily consent, although we know there are a lot of people who don’t consent and they’re still medicated, but some people just aren’t really aware of their rights.
John: I wonder if one of the issues that is perhaps going on here, I mean one of the things that was in my mind to ask you was the notion of were you able to make a decision or had you made a decision and the decision was overridden, and I think the Mental Health Act comes in to play when someone has perhaps made a decision but that decision is formally overridden in what’s perceived to be their best interests and that does then raise an array of potential legal protections that come into play at that point. In some sense what you’re describing is in some ways more distressing actually because it’s kind of so unclear.
Raza: There was no actual process that I was aware of that was followed through, it seemed quite arbitrary to me, yes.
John: In some sense, I mean you’ve talked about the fact that people really didn’t see you in the round at all at this point. Were they well intentioned in that treatment?
Raza: It’s hard for me to comment on the motivations of the people who were supposedly caring for me but I certainly think that more effort should have been made to try and understand my context and to win my trust and to have me more of, as far as possible, more of a consenting and active agent in my own treatment and absolutely no effort was made and I wasn’t even asked you know, what were you doing before you came here, there wasn’t really any attempt at all and I feel that I don’t want to be too ideological and say I’m totally against compulsory treatment but on the other hand I think that there are risks you know, we live in a very risk averse culture and obviously organisations they don’t want to be taking risks because it might blow up in their face but what they don’t factor in enough is the risk of actually subjecting someone to compulsory treatment. What are the long term risks, how might an experience of being compulsorily treated affect someone 5, 10, 15, 20 years later and I can relate something that really shows the power of the effect that that experience of being compulsorily treated had on me. So recently I basically read an extract from my diary in which I talk about that experience on the mental health inpatient ward, of being subjected to violence basically, and at first it felt like a very liberating and almost cathartic experience to talk about it because here I was Raza Griffiths, me, 21 years later talking about something which I felt deeply ashamed of and I was certainly very disempowered by this experience and here I was in front of an audience, you know, talking about it but what happened after I left that conference was that basically I just stopped breathing, I literally couldn’t breathe, I collapsed in the middle of a market in London, I had very intense severe chest pains, it almost felt a bit like a heart attack actually and I put that down to the fact that the episode I was talking about when I was medicated without my consent on a mental health ward relates to a time in my life when I couldn’t breathe and 21 years later literally just talking about it brought on that experience again, that is the power of the memory of those experiences, you know, and also that experience of being done unto rather than being brought alongside and, you know, me as an active agent in my own treatment, it really made me very reluctant to engage with any form of support for decades afterwards and I think that was not brought into the equation enough I don’t think.
John: I mean that’s so interesting what you say and certainly having worked on acute mental health wards for a number of years it’s incredibly resonant, the notion that people end up either formally or informally slightly geeing or pushing people into particular treatments because they’re afraid of the risks of not doing so but sometimes just not sufficiently balancing that against the potential other sets of risks and consequences for the person so their very focus can end up for reasons of anxiety or other, I’m not saying that they’re necessarily bad people, but can end up being very, very focused on the here and now and trying to avoid what they perceive to be quite an urgent risk but then to an extent not really fully considering the longer term, or even medium term actually, outcomes of doing that, as I say either formally or in your case, reading the account that you wrote, it felt actually that in some way you were being pushed or propelled towards the treatment without all of the protections of the wall. Actually you were kind of being shoved towards it as it was being offered to you as being in your best interests and there didn’t appear to be much of a feeling in you that you could say no. I mean, I wanted to bring together a couple of things that you said just to finish off which was you said that, first of all, that there probably might be some circumstances under which we perhaps as a society might need to sometimes treat people against their will but also you’ve been implying that a lot more can potentially be done. Could you say a bit more about that, if you really do need to treat somebody against their will why would you have to do it and what could we do to make that the least damaging experience?
Raza: Well, first of all, I actually find that maybe that’s the wrong focus, I mean, what I think we should be focusing on is rather than saying ‘well under no circumstances, no compulsory treatment’, you know, I think what we need to be focusing on is what are all the things that we can do to actually prevent it ever getting there and I mean there are actually mental health inpatient wards around the country where they’re experimenting with not using compulsory treatment, you know, and I think a lot of the things that professionals need to focus on are basically changing the professional culture and not having, because there’s a lot power invested in being able to compulsorily treat people, and I think in a way it may be quite difficult for professionals to kind of be, almost to give that up, you know, I think that’s a huge loss of power.
John: And a lot of fear in not recoursing to those powers actually.
Raza: Yeah, but I think a lot of it is to do with relating to human beings and treating people as human beings basically, you know within a mental health inpatient ward it’s just not really geared up in that way and I think there needs to be a fundamental change in professional cultures so that we make mental health inpatient wards, when people are at their most vulnerable, do every possible thing you can to not subject them to violence and a potential re-traumatisation.
John: That was Raza Griffiths, just talking about the experience of being detained but not formally, the threat of detention in the background……
Emma: Well actually, he said that he wasn’t sure if he’d been detained or not?
John: Well there was the uncertainty and I have certainly seen that in many people.
Angela: I found it heart breaking quite honestly and what really stood out for me was that nobody took an interest in him as a person and he was not informed of his rights even and that flags up a huge amount about mental health advocacy and what’s happening there. Everybody’s entitled to a mental health advocate but clearly few people are getting them.
Rachel: If they’re detained under the Mental Health Act, they are.
Angela: Ok, but few people are getting them even in that context I think, that’s really something that we need to call attention to.
John: That’s what I meant about Raza’s interview in the sense that the experience sounded so traumatising and awful that it felt like there would have been a lot more clarity in it had actually the formal powers been in place and the safeguards, because you know the Mental Health Act does come with safeguards built into it, in term of reviews and tribunals and advocacy and advice and he had none of that.
Emma: Although as I understood it he was talking about an admission 20 years ago so before the 2007 amendment.
John: 2007 amendment and also updated codes of practice which come along every so often with the Mental Health Act I think, we can link to all of this stuff on our website but the most recent one was in 2015 I think and these things are again putting in more safeguards.
Angela: Well, and listening to Rai’s interview I was utterly shocked that somebody could be banged up for another 6 months essentially because somebody didn’t feel like doing the paperwork that might be necessary to letting her go out for a while. Now I just don’t think that’s acceptable and I don’t think it’s something that we should be colluding with at all.
Emma: I didn’t think it was the paperwork about letting her go, it was the paperwork around the 5.2 or the 5.4 that was what they were concerned about.
Anne: But she was saying in effect that she could have challenged that and if somebody had been prepared to do the paperwork, then as I understood it she might not have been locked up for another 6 months.
Emma: Well it was her parents being informed about the rights of the nearest relative that enabled that.
Anne: Well again, it’s an advocacy problem and I just don’t think this stuff is acceptable
Emma: I guess funding has come into my mind because I think that there are some excellent advocates but the resources for them to be available to all patients, legally they are available to all patients, but there is almost certainly a resource issue there.
Anne: That’s something we haven’t talked about much, is the ethics of this and I was involved in some of the discussions around that led to the amendments to the Mental Health Act and one of the things that we put forward that wasn’t really taken into account, I don’t think, was the need for the principle of reciprocity, in other words if we’re going to take people’s rights away we need to provide them with something in return, something good and adequate and I think in the current system we’re not doing that, you know, you can argue that we really, really aren’t giving people something back in return for taking away their rights.
John: Well I mean in some ways Matthew Debenham’s interview actually was a response to a question I think I put to him from you Rachel, about the notion that you know, I mean there are several issues here aren’t there, one is the way that the Mental Health Act itself is constituted and some of the provision, I mean one can question the underlying basis, there are safeguards and provisions within it as well, that may be different from the way that it’s necessarily employed in all circumstances and I think the question you asked Rachel was about the degree to which people stick around on the Act because there simply aren’t resources outside.
Rachel: So, you know, to go from 24 hour care, if you want to call it that, to nothing is usually deemed to be too big a step so often people might, if they’ve been hospitalised for a long time, move to a kind of hostel or supported accommodation and often there aren’t places available in there so people might be staying in hospital much longer than they need to be, detained under the Mental Health Act when actually they shouldn’t be because there’s no support for them in the community or not enough support which is really shocking I think.
John: I suppose the other issue that’s floating around in this discussion is the degree to which, and this is one of the reasons for having this discussion in the first place, is that I know that we all sit in slightly different places about the degree to which we would get involved or not in the use of these powers and actually I’m still not totally clear actually Emma from your other answer just what getting involved in taking up these powers actually adds to what you can do, because you talked a lot about the importance of a therapeutic milieu and things, I’m still feeling a little bit uncertain as to what being able to have the responsible clinician status and some access to these powers adds in to that for you.
Emma: I think it’s something around therapeutic risk taking which you know many of our psychiatrist colleagues are able and willing to do, but bringing a psychological perspective on that in terms of attachment, formulation and issues around power and control for the client group that I work with.
John: What, so people might be less controlled, are you saying, are you trying to downgrade the amount of control that the system exerts over them?
Emma: Exactly, at the same time as thinking about how the control or safeguards that are put in place acknowledge the psychological needs of the person.
Rachel: In terms of thinking about treatment recommendations, also you know at the moment treatment does tend to mean medication in hospital but I think as a psychologist we’d be trying to think a lot more about the whole person and what has led them to feel very unsafe and in need of extra care and support and which kind of psychological treatments potentially or social interventions might be needed rather than perhaps enforcing medication.
Emma: I might have to say, in the inpatient Learning Disabilities services that I’ve been working in that I’ve seen excellent practice.
John: I have got to say, I wonder if I would necessarily claim that for psychology particularly because I found the interview with the psychiatrist very resonant actually, I mean, I will stick my hand up and say, and I worked in acute inpatient mental health wards for 7 years and if I’d stayed around doing that job I almost certainly would have trained in the same way that you’re doing Emma and a lot of it was about this issue of actually trying to keep people’s admissions shorter or really feeling that I, not necessarily because I was a psychologist, but I felt that I would have something to offer to make the system as it existed work.
Angela: Well I think it’s important that psychiatrists aren’t sort of split off here and made to be the bad guys in the system. I would be anxious that we are all working together and pitching towards something new and something different for all of us. I don’t really think it’s acceptable at the moment that they’re, you know, the sort of bogeyman in the equation.
Anne: Absolutely, we’re all subject to the same external contexts which at the moment, you know, with the cuts to services there are so few beds that often people are sectioned just because it’s the only way they can get access to a bed and that’s really sad.
John: Not only to get access to a bed but within that context of those cuts, I mean I have very strong feelings about the funding of mental health services that is not enough, but after all those years on wards I do have, you know, really very ambivalent feelings about the notion of the cuts on wards themselves partly because I’m with him in that interview which is that so many of the admissions that I saw would have been better served somewhere else, people were there because of risk and not only was there this issue of being you know really quite traumatised as Raza and Rai spoke about, also what Matthew Debenham spoke about, was just this issue of people actually, even though in any conscious way they may have really disliked being in hospital at the very minimum, but also it being something that they ultimately became quite dependent on and we as a system are really eroding those skills for them, skills to hold themselves, and I wanted to think about getting involved in that and those powers because I felt that I could perhaps help some of those people, in those positions particularly I think.
Angela: It is inevitable when people are in hospital for a long time that they’re going to lose their ordinary powers, when they’re subjected to a routine day in day out when they have no autonomy you actually have no option but to become dependent, that’s the only way you can survive in that system.
Emma: Actually, when you say those skills I guess some of the people I’ve seen who are inpatients never had those skills in the first place, they didn’t have the opportunities to develop those skills so actually they are developing those skills as in patients.
Anne: Yeah, I guess the population I have always worked with is adult mental health which is a different ball game but yeah.
John: There are different considerations I think, one thing it puts me in mind of, a couple of other things before we finish that have kind of been touched on and would be really interesting to expand on, one is this difference between the Mental Health Act and the Mental Capacity Act, the Mental Capacity Act being about, you know, if you have the capacity to make a decision that that decision will be honoured if you have capacity even if people hate it, even if it’s perceived to be unwise, but that not applying under the Mental Health Act which is grounded in this idea of soundness of mind, you know, mental health, mental illness so you can clearly have the capacity to refuse treatment or refuse hospitalisation or whatever it may be but that ultimately can be overridden in what may be perceived to be the interests of treating you. Now, Anne you came in with some very reluctant views on that and Angela you were suggesting what we would be able to bear as a society, not having the Mental Health Act but actually only doing it on capacity, how would we feel about that if we just let people make decisions in all circumstances even if we hated those decisions?
Anne: I think there’s no argument for a mental health act, personally I would just have a capacity act.
Angela: I think it would be better, yes, but I would have to say I still think it would be very difficult, I’ve sat with professionals in meetings talking about capacity and as soon as there’s any doubt about somebody’s capacity people tend to err on the side of caution which is obvious I guess but people can have very different opinions as to whether somebody has capacity or not so I still don’t think, you know, everything would be perfect, but it’s a much better premise for beginning.
Rachel: I think there is a big role here for more thinking about advanced directives which I think might be something that Rai touched on in her interview, so giving people a chance to talk about the kind of treatment they would like if they did have to go into hospital, um, I think that we should be doing that a lot more and giving a lot of weight to those kinds of documents which we’re not doing currently which would help.
John: Yeah we can help in the current context of while we have a Mental Health Act that overrides capacity we would have other elements that we could bring into that. I mean personally I don’t. What do you think Emma, would you go with, I’m guessing you probably have more experience of the Mental Capacity Act than the rest of us, you also possibly Angela because you worked in older people’s services which due to the prevalence of dementia and organic problems the Capacity Act can come in more frequently.
Anne: I actually think things are clearer where things have an organic cause, I think when we’re talking about mental health conditions and they have a variable, shifting cause, establishing capacity is a much more difficult issue.
Rachel: The Mental Capacity Act currently doesn’t have the safeguards that the Mental Health Act does in terms of advocacy and tribunals.
Anne: But it does have deprivation of liberty safeguards.
Emma: Yeah but interestingly in Matthew’s interview he seemed to be saying that he thought that we could work within the Mental Capacity Act without the Mental Health Act apart from the issue about safeguards but there’s no reason why those safeguards couldn’t be put in for the Mental Capacity Act in a similar way in terms of tribunals and…..
John: You’d certainly have to beef it up, but he’s certainly not the only psychiatrist and I don’t know if this is necessarily common but a psychiatrist colleague who I think has been willing to think about that, I mean I have to say I think while I find the idea appealing, I think we might struggle as a society with allowing people the liberty to make decisions that we really find hard to tolerate, and of course part of the history of mental health legislation is a kind of swinging pendulum between personal rights and a wider group to exercise control, I personally think we might struggle with it, I wonder if it would be more realistic to think about some of those other, giving more weight in the interim to some of those other counterweights as Rachel says but also one of the other things that we have only touched on absolutely fleetingly, I’m thinking of you particularly here Rachel, you worked for a number of years in secure services and that’s also somewhere where the Mental Health Act operates in the sense that rather than just simply being sent to prison you can be detained under a section of the Mental Health Act and you know held in a different way. Is that a good way, is that a better way than prison or are there better ways again in the sense of public safety?
Rachel: I think it’s a messy issue because for some of the people I worked with, many of them, their offending behaviour was very clearly linked to what you might call mental distress/mental illness but for others it was a lot more messy picture, I don’t think there’s this mad/bad sort of discrepancy and it’s very, very messy and often people end up being in hospital for long periods when actually they perhaps weren’t unwell, if you want to use that term, but they were perhaps risky in terms of if they were to be released from hospital they might be violent or whatever but that wasn’t in relation to their mental health as such but because they had had a mental illness at some point and they had gone down the hospital route, they were kind of being kept in hospital for a long time which was not ideal for anybody really.
John: What do other people think, I’m aware that the discussion up to this point has sort of been guided a wee bit by risk to self, you know we’ve been talking about things like suicide, but what about where the risk is to the wider social group?
Anne: I think that there’s an idea generally that being sent to hospital is the soft option whereas actually I think it can often be a lot worse than when people are in hospital, for example, you don’t know when you’re going to get out…
John: You mean worse than being in prison.
Anne: Yes sorry, interesting Freudian slip there, you don’t know when you’re going to get out, you’re often required or even forced to take medication so I think it’s far from being the easy option often.
Rachel: Another thing that we haven’t really talked about which is quite controversial, I would say, which came in with the 2007 amendment is the introduction of Community Treatment Orders so now as well as sort of being forced to have treatment in hospital I think the idea was that it would reduce people’s lengths of admission which is a positive thing but the idea is now that you can be forced to have treatment when you’ve left hospital and that if you don’t take your medication or if you don’t attend certain appointments, etc, then you will be recalled to hospital.
Anne: Something we haven’t mentioned at all as well is the Human Rights Act and how that impinges on all of this and as I understand it the Human Rights Act in a sense trumps all the other acts we’ve spoken about and when we Brexit Theresa May has made it clear she wants to tear up the Human Rights Act and that potentially causes a lot of problems because we don’t yet know what will replace it, you know there is some talk of a British bill of rights but until such time as we know what might be in that we are in very murky waters with all of this.
John: I suppose a couple of things about that, I gather there has been a lot of passion expended on the Human Rights Act and certainly when Michael Gove was Justice Secretary it was on the docket at that point. From what I have read there are some concerns with the way European human rights legislation was incorporated into British law and it is apparently worth a rethink, or it seems to have got furled up in all the discourse around Brexit and foreigners and their laws and things, but I gather there are appropriate ways of going about this and improving the legal position as it stands, I can chuck in a piece by Joshua Rosenberg from the BBC, the legal guy at The Guardian, which sort of walks through some of the issues about this with perhaps less heat than we’ve had but it is a really important point as to how the basis on which we may deprive people of liberty can stack up in relation to other laws and, again, I think it’s something about this tension between social control and where we value liberty. I mentioned the Prime Minister, I think we’re going to have to end in a minute but one of the things I wanted to try and end on with you today was, okay Theresa May said that she would tear up the Mental Health Act, it’s one of the very few things that she will talk about specifically at all during the Election campaign so I think it probably behoves us to pay attention. Now one of the pieces that we linked to is a piece by Mark Brown in The Guardian where the specifics are light but he says, well this is what Theresa May should replace it with, but each of you, now prime ministers are busy people, but if Theresa May is elected, IF Theresa May is elected, and is still Prime Minister on June 9th, and you each had 30 seconds to make your pitch to her, what would you say? Rachel?
Rachel: I don’t really have a strong opinion on the Mental Health Act, I think maybe we should keep it but I think that we need to make inpatient environments much more therapeutic, we need to have much more space for talking to people, hearing about their perspectives, we need to have advanced directives and we need to have much more investment in community mental health services, for example, open dialogue, would be my argument.
John: Okay, Angela?
Angela: I would say please tear it up by all means, it is clearly not fit for purpose, I’d like to see it replaced with something based on capacity but I also want attention paying to the Human Rights Act which is currently enshrined in European law. If that gets translated into a British bill of rights I hope it is something equally as rigorous and protective.
John: Right, well, I’m guessing that she might be able to listen to that having been Home Secretary for all those years, you’re talking the language of human rights and law and justice. Anne?
Anne: Mrs May claims to be very keen on evidence, I would go with the evidence that inpatient wards as currently constituted are often unhelpful and we badly need alternatives, we need a non-medical crisis house in every town so that when people are compelled to be held against their will it can be somewhere that’s helpful. Also, have legislation based on capacity rather than a notion of mental illness and, thirdly, have legally enforceable advance decisions as we have in physical health.
John: Okay, Emma?
Emma: Mrs May, it is extremely important that you understand that when someone has a mental health issue this is not an illness in isolation from their socio-economic environment. The more your government makes cuts to Social Services, Education and other services which protect the most vulnerable in our society, the more we will see people develop significant mental health problems. When the Mental Health Act is used to detain someone it is because services were not able to offer the right help in the right way. The cuts in front line services must be reversed if the need for admissions is to be reduced.
John: Okay, right.
Anne: And what about you John?
John: What about me? I think I would be a little bit more prosaic, I think it’s kind of easy to ask for more money to be spent, I think it’s easy to ask for therapeutic environments to be better, I think that the big underlying tension here is this thing I’ve said about social control versus liberty and I would like to see somebody who really cares about liberty put into the Department of Health as a kind of counterweight to the other pressures which are not just about the Tories but were there with Labour, they’re there through society so I would have David Davis, the Brexit Minister, transferred to Health. Pull him out of Brexit, somebody else can do that. I disagree with him in many things but he really does I think genuinely care about civil liberties to the point where a number of years ago he even resigned his seat over the issue, so bring in ‘Monsieur Non’ into the Department of Health, that’s what I would do.
John: Okay, I think we’re going to have to stop there so thank you everyone. The best way to follow the podcast is to subscribe, you can do that on itunes by searching for Discussions in Tunbridge Wells. You can also find links to some of the things we’ve talked about on our blog, Discursive of Tunbridge Wells. As well as that you can follow us on Twitter @CCCUAppPsy and on Facebook if you look for Canterbury Christ Church University Applied Psychology. I’ll also post links to the Twitter feeds and other resources of our speakers and interviewees insofar as I have them on that, so all that really remains for me to do is to say thanks to all our contributors, I know that this is a really very difficult and emotional topic for many people and I’m particularly grateful to Rai and Raza.