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.