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.