I welcome time being taken to give proper consideration to the issues of MHA reform, as they do need to be got right and we need to learn from mistakes made following similar tragedies in the past. For example, a 2006 Observer article was written by the father of a man with a 17 year history of schizophrenia who, even though the father accepted that his son’s illness was difficult to treat, wanted to know why the mental health system, of which he was very critical, could not cope. The article appeared in the week following publication of a report into the care of John Barrett, who killed a stranger in Richmond Park, and which was said to reveal a litany of failures in his care. Homicide inquiries all tend to have the same findings that there is a need for improvement in risk assessment, communication, care planning and interagency working. These factors need to be improved in all mental health cases, not just those that lead to homicide. To focus on enforced treatment in the community (Community Treatment Orders (CTOs)) has been a distraction from the need to provide consistent, high quality community care by improving these aspects for all mental health care.
The more recent Guardian articles above show we are still facing similar problems in mental health services today to 2006 before CTOs were introduced. Part of the answer of the patient’s father then was that services were not sufficiently realistic about the lack of insight of people with schizophrenia and did not do enough to provide ongoing, consistent rehabilitative care, including accommodation for his son. Unfortunately services are still not always prioritising and providing high quality care for those with severe mental illness. This is where the focus for improvement should be.
The article was written before the last Labour government amended the MHA in 2007 to introduce community treatment orders (CTOs) amongst other changes. An Observer editorial accompanied this article and several letters were published in response. A Mental Health Bill, which led to the 2007 amendments to the Act, had already been introduced. Rosie Winterton, Minister of State for Mental Health at the time, in one of the published letters, argued that MHA reform was necessary to introduce CTOs to deal with the situation described by the father of the man diagnosed with schizophrenia. She seems to have seen CTOs as the answer to the then failing mental health system.
If services are still so dysfunctional and fragmented, why did CTOs not work? I posted then that CTOs “could well make the culture of mental health services worse by making them more custodial and less therapeutic”, suggesting that CTOs were “not the correct response to the bureaucratic, defensive failings of mental health services” described in the article. Mental health services need to be supported in providing high quality care, rather than being made fearful they will be attacked when something goes wrong. Mental health services have unfortunately become more fearful about what might go wrong in mental health services, rather than concentrating on the task of improving things for people with mental health problems.
The Critical Psychiatry Network (CPN), of which I am a founding member produced a position statement on CTOs in 2007. It argued that it was unethical to apply the MHA to force people to take treatment in the community when they are functioning well enough to be living in the community and have capacity to decide about their treatment. The use of force to remove someone from their home and take them to a "clinical setting" to force them to take medication cannot be justified and exacerbates stigma. CTOs can also frighten people away from psychiatric services, when these are just the people that need to be encouraged to keep in touch with services through informal assertive outreach. The temptation is just to continue CTOs once they are in place, because it is difficult to prove the negative that the person is well enough to be discharged once a decision has been made in the first place that they are justified. Having CTOs as an option, even expectation for some, means that the use of S17 leave and informal community care follow-up is not explored as much as it should be. These informal arrangements could lead to just as good, if not better outcomes (see eg. previous post). The number of people detained under CTOs has been far more than anticipated and they are discriminatory in their application (see eg. another previous post). The years since CTOs were implemented have just confirmed all the fears expressed in the 2007 CPN position statement.
This blog has consistently argued that psychiatry needs to move on from an outdated belief in mental illness as brain disease (see eg. previous post). Mental health practice does need to be rethought (see eg. another previous post). A new 10-year plan for mental health is required. This includes reform of the MHA following recommendations from the Parliamentary Scrutiny Commitee and WHO/OHCHR guidelines (see eg. yet another previous post).
I would go further than working towards abolishing CTOs for civil detentions (see eg. previous post). The Mental Health Tribunal needs to become the Mental Health Rights Tribunal with a single judge hearing appeals on both treatment and detention decisions (see eg. another previous post). Tribunals need to provide robust and objective accountability and effective protection for people with mental health problems. Medical evidence can come from the RC and an independent expert from a new integrated advocacy service of mental health lawyers, IMHAs and independent experts (see eg. yet another previous post). Advocacy services need to help detained patients exercise their rights by assisting patients to access legal advice and support at Tribunal hearings. Second Opinion Approved Doctors (SOADs) could then be abolished. If any hiatus in MHA reform leads to all these issues being taken forward, then all well and good from my point of view.
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