Similarly, yesterday was Schizophrenia Awareness Day (see Rethink webpage). In a tweet, I welcomed Rethink promoting those with lived experience of schizophrenia. But, there are many people diagnosed with schizophrenia who do not see themselves as ill and have no insight into their condition. They do not come forward to talk about their illness. A proper understanding of schizophrenia and dementia needs to fully represent those without mental capacity.
Although CPN has been going for over 20 years (see my article), I suppose it could be said that it has not always been very good at cultivating trainees over the years. Psychiatric training is a bit of an indoctrination (see previous post), so trainees do need support (see another previous post). Originally, CPN was formed in 1999 out of a Maudsley trainees’ critical psychiatry group (led by Joanna Moncrieff, the other CPN co-chair) coming together with others, like myself, who had been influenced by anti-psychiatry (see eg. previous post). It’ll be interesting to see how a younger group less directly influenced by anti-psychiatry can take critical/relational psychiatry forward.
As I’ve mentioned before (see previous post), Franco Basaglia in Italy was twice found not guilty of criminal liability following patient homicides. There has been considerable damage in this country caused by services being blamed for homicide by psychiatric patients (see eg. another previous post). The original motivation for such concern came from SANE, when its argument that asylums should not be closed because their rundown was causing homelessness amongst psychiatric patients was shown to be false. SANE, therefore, changed its tack to blaming rundown for psychiatric homicides even though these had not in fact increased. This campaign was reinforced by the Zito Trust, formed after Christopher Clunis unfortunately stabbed Jonathan Zito at Finsbury Park tube station. Homicide reports became mandatory even though they are often flawed, following the first by Blom-Cooper et al for Jason Mitchell (later accepted to be flawed by one of its co-authors, Adrian Grounds). Ray Goddard, the consultant for Jason Mitchell, had his picture put on the front page of the Sun (see previous post).I actually think the reform of the MHA in England and Wales needs to learn from the Italian experience of removing the ‘risk’ criterion from Mental Health law. The reason for involuntary treatment was no longer that the patient is dangerous but that they need help. The psychiatrist is, therefore, not obliged to repress and control social dangerousness. I also think that current reforms can learn from the ban introduced on admitting any further patients to the traditional asylums in Italy, which encouraged them being phased out. Too many people, including people with learning disability, seen as difficult to manage and place are currently ending up in inappropriate secure provision, often in the private sector. Any further such civil admissions should be prohibited to secure provision (see previous post), reserving secure psychiatric beds for people who need an alternative to prison. The government has said it wants to close such provision, at least for learning disability, following the Panorama exposure of abuse in Winterbourne View and Whorlton Hall, but has floundered in doing so, blaming lack of community resources, which of course is only part of the reason. Such civil detentions should be managed in more open environments, which if admission to secure beds was prohibited, would happen.
It might actually be worth reading what Italian law says (see english translation) It states very simple principles that involuntary health treatment must be implemented respecting people’s dignity and their civil and political rights. For some reason the government wants to change the current principles in the Code of Practice (maybe to make them simpler?). It wants to put new principles on the face of the Act, which in my view water down the current Code of Practice principles (see previous post). It would do far better to copy the simple statement from Italian law.
The direction of travel in the White paper has generally been supported. As I've been saying (eg. see previous post), I think the proposals do need to be taken further forward. I'm particularly pleased that advocacy services will be extended and their quality improved (see previous post) and that Mental Health Tribunal powers will be extended (see another previous post). Even though there was no consultation on reforms to Community Treatment Orders (CTOs), the government says it will work closely with stakeholders to make changes (see previous post). Where I think the government might be missing out is what to do about the abuse in secure learning disability services exposed by BBC’s Panorama programme (see previous post). It does intend to proceed with its proposal to improve the supply of community services for people with a learning disability and autistic people to reduce the number of people being admitted. However, it does not seem to take on board that most of these people do not need to be in secure facilities and that civil detentions should therefore be prohibited to secure facilities (see previous post). The same applies to those with serious mental illness who are difficult to manage or place, who do not need to be in secure facilities unless there is a court order imposed after a crime. Secure psychiatric facilities should primarily be seen as an alternative to prison.
Stakeholders do need to be involved in taking these reforms forward. As the government also says, legislative reform is only part of what’s needed to improve mental health services. They also need to be transformed by work undertaken by NHS England and NHS Improvement (NHSEI) (see previous post).
Criticism of the biomedical model of psychiatry that regards mental illness as brain disease has been labelled ‘anti-psychiatry’. Critical psychiatry arises out of so-called anti-psychiatry, but has additional roots in transcultural psychiatry, its alliance with psychiatric user/survivor groups, and the methodological critique of the neuroscientific basis of mental health problems and psychiatric treatment effectiveness. It is not opposed to psychiatry as such and argues for a person-centred shift for practice and research. This article discusses how a more truly biopsychosocial model, which critiques the biomedical model to produce a more relational practice, is needed not only for psychiatry but also for medicine in general.
Supportive relationships may be more important in treatment than any medication or psychological therapy. Therapeutic relationships need to be prioritised in services (Dale et al, 2020). Although some participants in the study had experiences of good practice, there were also experiences of severely stigmatising treatment, a lack of effective support and service fragmentation. Staff need to work holistically and collaboratively with service users. Inclusive, non-judgemental and non-discriminatory approaches should be adopted. Experiences of trauma and other difficulties need to be acknowledged. Patients need to be treated with respect and dignity.
Relational psychiatry promotes relational practice. Its theoretical basis about giving up trying to establish biological causes of mental illness provides a framework for person-centred care (see eg. previous post).