Reducing coercion in hospital for people with learning disability and autism

My letter to Lancet Psychiatry in response to Hassiotis et al (2021) has been rejected as it is said not to add sufficient new information. I don’t agree and it concerns me that there does not seem to be sufficient discussion in the academic literature about the shortfalls in the government’s White Paper on reform of the Mental Health Act (MHA). As I have said before (eg. see previous post), the proposals should be supported but they do not go far enough in reducing coercion in mental health services, including learning disability services.

Not many people have argued as I have (see previous post) that new admissions under civil detention arrangements (Part II MHA) of people with autism or learning disability (and serious mental illness) should be prohibited to a secure hospital. I do not think the criteria for detention of people with learning disability, which already require associated abnormally aggressive or seriously irresponsible conduct, should be altered. The White paper proposes that autism and learning disability are no longer to be considered mental disorders warranting treatment under section 3. Such patients can be admitted under section 2 for assessment of factors driving any abnormally aggressive or seriously irresponsible conduct and section 3 continued if a mental health condition is the driver. My concern about this proposal is that it will result in too technical, not always very meaningful, arguments about whether there is a mental health condition in addition to learning disability. It is almost as though the White paper is encouraging the reintroduction of the term ‘psychopathic disorder’, which was abolished by the 2007 amendments, so that someone with a learning disability can then be detained if they have a psychopathic disorder as well as learning disability. I am not convinced this is the best way forward.

The White paper also talks about the warehousing of patients with learning disability and autism. Transfer to secure provision leads to unnecessarily long admissions. I’m not denying the need for more community rehabilitation, but the issues are not just about difficulty in placement and lack of appropriate community resources. It is also about developing the skills to manage learning disability patients with challenging behaviour in a more open way in Assessment and Treatment Units (ATUs). Prohibiting any further admissions of Part II patients to secure facilities by legislation will help to create the right environment for the treatment of such challenging behaviour.

Reversing re-institutionalisation

I’ve always tended to prefer the term de-hospitalisation to de-institutionalisation, because although the traditional asylums have closed, institutional practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since 1990 there has been a re-institutionalisation of mental health services, particularly with increasing numbers of secure psychiatric beds both in the NHS and private sector. For example, Rutherford & Duggan (2008) reported that the "forensic services population rose by 45% in the 10 years between 1996 and 2006". This resort to re-institutionalisation, as Turner (2004) said, partly “reflects a culture of risk management, [and] an overriding concern for public safety ... “ (see previous post). 

Despite the move to community care and the reduction in both mental illness and learning disability in-patient beds overall, the number of detentions under the Mental Health Act (MHA) 1983 continues to rise (Keown et al, 2018). This is one of the major reasons why the MHA is currently being reformed. Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases.

Of course, part of the motivation for the rundown of the traditional asylum was the institutionalisation of patients. The new MHA needs to bring a halt to their re-institutionalisation and do more to improve the process of de-institutionalisation started by the 1959 and 1983 Acts. The White paper has talked about the warehousing of patients, primarily for learning disability patients, although this also occurs for those with serious mental illness. To complete the quote from Turner (2004) above, the other reason for re-institutionalisation is “the burdens and pressures upon services trying to manage ‘revolving-door’ psychotic patients”. These patients are seen as difficult to manage and place and have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open door-environment. As I have said (eg. see previous post), civil detentions of people with learning disability and serious mental illness should be prohibited to secure provision. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. The 2007 amendments to the Act, which were motivated by an inappropriate over-concern with risk, need to be reversed by repealing community treatment orders (see another previous post).

Simplifying depression

Flow Neuroscience has “truly global ... ambitions” to “make depression treatment simple and accessible”. As an article in the Financial Times, which mentions this Swedish company, says, “Technology to treat the brain has come a long way from the hundreds of volts used in brute-force electric shock therapy in the psychiatric clinics of the 1930s”. Neurostimulation (see previous post) now includes transcranial magnetic stimulation (rTMS) (see previous post), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) (see previous post). Flow Neuroscience has introduced the first medically approved tDCS electricity-emitting headset for home use, which it says boosts an app-based behaviour therapy treatment programme. The blobs in their YouTube advertisment seem happier than the sad blob in the original Zoloft advertisement (see previous post).

Not sure how randomised controlled trials can be double-blind when comparing rTMS with sham treatment, as it causes a tingling sensation, which will break the blind. Also not sure how accessible the treatment will be (let alone value for money) as the headset costs £399 (although there’s also a renting option). Still the app is free to download. As I said previously (see post), I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than neurostimulation, which is really exploiting people.

(with thanks to Alex Macauley)

In favour of the person

I’ve mentioned before (eg. my article) that Martin Roth saw anti-psychiatry as “anti-medical, anti-therapeutic, anti-institutional and anti-scientific”. He made it sound very negative being against all those things. 

Actually, relational psychiatry is anti-positivist, anti-reductionist, anti-institutionalisation and anti-racist. It’s against all those things because the fundamental problem of psychiatry is the objectification of people.  It also recognises the limitations of treatment and that there are differences between psychiatry and the rest of medicine. 

So, what it’s positive about is people and their relations in social context. The extent to which psychiatry has a tendency to be positivist, reductionist, institutionalised and racist undermines its proper, personal task of supporting people with mental health problems.

Making mental health services more humane and efficient

An open letter to the media about mental health services is available to sign. It highlights the following:-

1. lack of confidentiality in services eg. on mental health helplines 
2. more information needed for patients eg. about psychiatric treatment 
3. differences between psychiatry and the rest of medicine should not be minimised 
4. patients' mental capacity, their will and preferences need to be taken more into account
5. the dangerousness of people with mental health problems is exaggerated

Psychiatric practice should no longer be based on the notion that primary mental illness will be found to have a physical cause, but move on to a more personal, relational practice.

Risk and blame in mental health services

I've mentioned before (see previous post) that the over-preoccupation with risk in mental health services in the last 20 years or so has been counterproductive. This is relevant to the current review of the Mental Health Act (MHA) (see another previous post). The new MHA needs to reduce coercion in mental health services and risk is not always best handled by increasing coercion.

As I wrote in my book chapter, one of the reasons for the rundown of the traditional asylum was the mistreatment of patients in a number of institutional scandals. These traditional services needed to be opened up and patients moved more to the community. I've argued that the recent scandals of Winterbourne View and Whorlton Hall should similarly lead to the prohibition of any further civil psychiatric detentions to secure facilities (see previous post), so that these people if they need inpatient treatment should be managed in open door wards. A secure environment is unsuitable for most people with learning disability or serious mental illness. The new Mental Health Act must deal with abuse and over-restrictive practices within services.

As I also wrote in my eletter, many psychiatrists were opposed to the rundown of the asylum and the development of community care because of their, at least perceived, loss of power in the traditional hospital. There is no longer an active debate about whether the asylums should have been closed, because the process has been completed. But at the time, because of the relatively high level of mental illness amongst the homeless population, it was argued that patients were being discharged irresponsibly from the traditional asylums ‘onto the street’. However, follow-up studies of discharged patients (such as TAPS eg. see my book review) showed that the rundown of the psychiatric hospital, at least in the UK, was not the main factor contributing to the numbers of homeless mentally ill. The tack of campaigning organisations, such as SANE, therefore, changed to blaming dehospitalisation for homicide by psychiatric patients, leading to a focus on public safety. High profile media cases, such as the death of Jonathan Zito, who was stabbed in a tube station by Christopher Clunis, led to the formation of the Zito Trust. The new Labour government concluded that community care had failed. Any homicide by a psychiatric patient had to be investigated, despite the fact that homicides by psychiatric patients had not in fact increased. There is no standardised approach to such inquiries, however, (see Ng et al, 2020) and many of them have been destructive (see my unpublished paper).

The current reform of the Mental Health Act has to be understood in the context of the last attempt to reform it, which led to the 2007 amendments. The introduction of community treatment orders (CTOs) then was hailed as saving lives, with fantasy estimates of how many suicides and homicides would be prevented. Of course there is no evidence that CTOs have reduced deaths (see eg. previous post) and they should be repealed (see another previous post).

The forensic theory of risk comes from Mary Douglas (1992). Talk about risk is a political process. Debate about accountability is a contest to muster support for one action rather than another. People pressurise each other in society and a conformity is created. The charge of causing risk is a stick to beat opponents. Ulrich Beck (1992) advocated in his book Risk Society that science needs to stop pretending it is neutral. It needs to become more conscious of its political nature. As I said in my talk:-

There is a debate about the balance between risk taking and risk aversion. If anything, what the Risk Society seems to mean is a shift towards the risk aversion end of this relationship. The word risk has been pre-empted to mean bad risks. The promise of a good political outcome is couched in other terms. Yet any society which did not take risks would not be making the most of its opportunities for growth. Over-cautious risk-averse behaviour can be crippling.

The new Mental Health Act again needs to open up debate about the balance between risk taking and risk avoidance. The 2007 amendments were an aberation in progress towards freeing up mental health services started by the 1959 and 1983 Acts. Risk aversion is leading to too many people being detained for too long and inappropriately and forced to have treatment when it is not benefitting them. This situation needs to change and the White paper does not go far enough to correct it.

Second opinion for enforced psychiatric treatment

I've mentioned before (see eg. previous post) that patients detained under the Mental Health Act (MHA) should have a right to a second opinion of their choice for medical, nursing and social matters. Currently, detained patients who are not consenting to medication must have their treatment certified after three months by a Second Opinion Approved Doctor (SOAD) from the Care Quality Commission (CQC). The government's White paper to reform the MHA (see another previous post) proposes that patients refusing medication treatment must have it certified by the SOAD at day 14, and by 2 months if they do not have relevant capacity, rather than 3 months. I don't think it's fair that patients with capacity should have stronger protection in this respect merely because they have capacity. Protection should be the same for detained patients with and without capacity, although at least civil detention should actually be difficult to justify for people with mental capacity.

As I've also mentioned (see previous post), SOADs, certainly these days, merely tend to 'rubber-stamp' Responsible Clinicans’ (RCs') treatment plans. For example, I think it's reasonable for a SOAD to consult the nearest relative about the treatment of an incapacitous patient, but I don't think I've ever seen it happen. SOADs need to take account of the will and preferences of the patient (see another previous post), including any advanced statement or Advanced Choice Document but I'm not convinced they do.

As I've again also mentioned before (see eg. previous post), I think a better safeguard would be to abolish SOADs and have their function taken over by the Mental Health Tribunal (MHT). The MHT should be able to require the RC to reconsider a specific treatment decision in a Tribunal hearing, if necessary, as proposed by the White paper, following a preliminary ‘permission to appeal’ stage. Personally I've no objection to this decision being made by a single judge sitting alone, particularly if it makes the Tribunal more responsive in these circumstances, as it's simpler to organise a single rather than three person panel. If necessary, the judge should be able to seek advice from a panel of medical members. The judge will be able to consider and make a judgement about any conflict between the RC and second opinion doctor of the patient's choice and made in their best interests.

Finally, in my previous post, I've talked about independent clinical opinions being available routinely for patients and nearest relatives as part of an improved advocacy service. As I keep saying, the White paper proposals do not go far enough. They need to be put under proper scrutiny on the basis of these alternative proposals that I am making.

Principles of the Mental Health Act

I've indicated before (see previous post) that I think the White paper on reform of the Mental Health Act (MHA) actually dilutes the principles in the current Code of Practice. I'm not exactly sure where the four principles come from that were produced by the Wessely review and went into the White paper: choice and autonomy; least restriction; therapeutic benefit; and the person as an individual.

The current Code of Practice in chapter 1 has five overarching principles: least restrictive option and maximising independence; empowerment and involvement; respect and dignity; purpose and effectiveness; and efficiency and equity. I do not think these principles should be replaced without clear reason, which the White paper does not seem to provide. These principles were strengthened when the Code of Practice was revised in 2015 from the Code first published in 2008. Certainly they seem stronger and more comprehensive than the White paper principles.

For example, having maximising independence as part of least restriction seems more positive. Similarly, empowerment and involvement as a principle seems better than mere choice and autonomy. The continual complaint of patients found by the independent review was the lack of respect and dignity they experienced in treatment, so it is helpful surely to have these as principles, whereas they are not included in the White paper. Adding person-centred care as a principle, which is presumably what the review meant by person as an individual, is helpful, as people should not be treated as objects. I think this was meant to be covered by purpose in the current Code of Practice. Effectiveness is not the same as efficiency and this distinction may be lost in the more generic term of therapeutic benefit. And anyway, isn’t the whole point of the Act for treatment (and assessment)?, so I’m not sure what’s added by including therapeutic benefit as a principle.

Considering the mistreatment of patients uncovered by the investigations into Winterbourne View and Whorlton Hall (see last post), I think there needs to be explicit reference to the principle of avoiding  inhuman and degrading treatment. Part of the motivation for the Wessely review was because of racial disparities in the application of the Act (see eg. previous post), so I think anti-discrimination, including anti-racism, should also be included as a principle.

It is surprising to me that so many people seem prepared to accept that any change in the MHA is better than none, when there is good evidence that the principles proposed in the White paper are insufficient. There needs to be proper scrutiny of the White paper proposals.

Civil psychiatric detentions should be prohibited to secure facilities

I've mentioned before the scandals of Winterbourne View (see BBC report) and Whorlton Hall (see BBC report) exposed by Panorama (see previous post). The White paper on reform of the Mental Health Act (MHA) talks about needing to prevent the warehousing of patients in psychiatric hospitals. As I've said before (eg. see previous post), the White paper does not go far enough in its reforms. Specifically in this regard, it does not go far enough in preventing further mistreatment of detained patients as happened at Winterbourne View and Whorlton Hall.

The mistreatment is not just of people with learning disability and autism, but also serious mental illness. What happened with the rundown of the traditional asylums, including those for learning disability (mental handicap as it was then called), is that difficult to manage or place patients have been shunted to secure provision, often out of the NHS in private facilities. I called this situation a scandal in 2007 (see my eletter). It has continued and needs to stop. What I'm suggesting is that any new admissions of civil detentions (part II of the MHA) should be prohibited to secure facilities.

It's as though psychiatry has forgotten its history of opening the doors of the asylum (see my 2015 talk on making the mental hospital therapeutic). By 1963, 80% of English psychiatric patients were in open wards. The advantages were said to be striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. When I first started in psychiatry, we used to pride ourselves that acute wards were open. These days most of them are locked, if only behind key fobs, which patients and families do not have. This level of security may continue for those that may be difficult to manage because of their level of disturbance or aggression, as they may be moved to low, even occasionally medium, security, really designed more for forensic (Part III) patients who have committed a crime. This transfer to secure provision may follow unnecessarily long admissions to psychiatric intensive care units (PICUs), which were originally designed merely for very short-term treatment. And people can continue to spend unnecessarily long in secure facilities, rather than their disturbance being managed properly in a more open way. 

Part of the problem, as the White paper recognises, is about patients who are difficult to place. There is a need for more community rehabilitation, which the White paper recommends for learning disability. It should also have recommended it for serious mental illness. But the issues are not just about difficulty in placement and lack of appropriate community resources. It is also about developing the skills to manage people with disturbed mental states and challenging behaviour in a more open way in acute treatment to prevent further aggression and disturbance. I worried about the development of PICUs when this first happened because I thought it would mean, and I think has happened, that acute wards would lose the skills to manage disturbance and aggression. 

The White paper misses this point about Winterbourne View and Whorlton Hall. It makes a distinction between the criteria used for detention under Part II and III. But the criteria for these admissions should remain the same, except that, as now, Part III cases may have a restriction order, as the real issue is about the environment in which Part II admissions take place. Any further admissions under Part II should be prohibited to secure facilities.

The future of psychiatry

I recently came across an obituary for Lyn Pilowski (who I have mentioned in parenthesis in a previous post). Unfortunately she died aged 46 in 2007 of a brain tumour.

What interested me is that Anthony Clare (who I have also mentioned before eg. see previous post) thought she "embodied the future of psychiatry in the years to come". I think this just shows that Clare, despite his emphasis on an eclectic approach to psychiatry, really was a biomedical psychiatrist (see previous post), even if at the softer end of that spectrum. 

The hope of brain scanning for elucidating the biological basis of schizophrenia, which Pilowsky could be said to have embodied, has failed (see eg. another previous post). Psychiatry needs to be helped to become more relational in its practice.