- lack of confidentiality in services eg. on mental health helplines
- more information needed for patients eg. about psychiatric treatment
- differences between psychiatry and the rest of medicine should not be minimised
- patients' mental capacity, their will and preferences need to be taken more into account
- the dangerousness of people with mental health problems is exaggerated
Wednesday, May 12, 2021
Monday, May 10, 2021
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
Tuesday, May 04, 2021
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
Saturday, May 01, 2021
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.