Wednesday, May 12, 2021

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.

Monday, May 10, 2021

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 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 pushed under a train 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.

Saturday, May 08, 2021

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 by the second opinion doctor 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.

Tuesday, May 04, 2021

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.

Monday, May 03, 2021

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.

Saturday, May 01, 2021

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.