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Understanding Treatment without Consent: An Analysis of the Work of the Mental Health Commission
Ian Shaw, Hugh Middleton and Jeffrey Cohen (eds)
ISBN: 978-0-7546188-6-7 2007 138 pages Ashgate
Pauline Savy
School of Social Sciences, La Trobe University, Albury-Wodonga Campus, VIC
This book analyses treatment and consent issues specific to the role played by Britain's current Mental Health Act Commission (MHAC). It details the reform of the UK's Mental Health Act (1983), and ultimately considers the likely dismantling of the MHAC and dispersal of its powers to regulators within mainstream health services.
The authors set the current reform movement against changing definitions and treatment of mental illness, public concerns for safety, and increased legal emphasis on human rights. The current Mental Health Act 1983 is strongly rooted in the 1959 Act and so is more relevant to in-hospital treatment than community-based care. Since the advent of anti-psychotic drugs in the 1950s, mental illness has been regarded as more treatable outside asylums. Subsequently, the philosophy of community care for mentally ill individuals who pose a risk to themselves and others has become contentious. When incidents involving out-of-control individuals receive media publicity, public demand increases for protective measures; primarily the detention of likely perpetrators. Two homicides in the 1990s pressured the British Government to review its legislative means of defining and detaining dangerous individuals. At the same time, the incorporation of the European Convention of Human Rights into British law means that court outcomes must reflect this convention. Reform of the Mental Health Act 1983 and the MHAC has been a protracted and passionately debated process since 1993. The debates continue as a new Act heads towards passage this year.
The first four chapters trace the changing scope and powers of British mental health watchdog bodies. They provide an historical overview of the Acts and commissions established over the last two centuries to protect the public from ‘lunacy' and to guide and oversee the detention of mentally ill persons considered incompetent to consent to their treatment. Historical snippets of asylum life show inmates' rights overridden by overcrowding, poor hygiene, inadequate staffing and de-humanising, experimental treatments. This picture of the ‘encompassing tendencies' (Goffman 1961) of British asylums resonates with the rise and fall of the asylums in other parts of the Western world (see Australian publications such as Gardner 1977; Higgs 1931; Lewis 1988).
The next three chapters identify and flesh out the sticking points that have dogged reform of the 1983 Act. Here, the authors elaborate the tensions between interested parties and philosophies to reveal the especially thorny nature of simultaneously addressing public concerns and meeting human rights obligations. At the centre of the problem is the task of wording legislation to balance generality with specificity, and allowing for the necessary treatment of individuals whilst preventing their wrongful detention. On the one hand, definitions of mental illness, incapacity, risk and treatment must be broad enough to allow practitioners to make decisions about risky behaviours and symptoms. On the other hand, broad definitions may allow for nuisance to mean risk, for treatment to mean detention and for treatability to mean little more than detention and observation. Too broad a definition of mental illness means that drug users, ‘sexual deviants' and persons with a learning disability could be brought under the ambit of mental health legislation.
Treatability, or the pairing of detention with efficacious treatment, is a particularly contentious matter. Unless treatment can be shown to be therapeutic, detention appears to be a penal matter. One problem in specifying that detention must be paired with therapeutic treatment is that action may not be taken when individuals present with signs of dangerous behaviour; when a treatability test fails, individuals may be excluded from services and preventative action. Or, if detained and subjected to dubious treatments, they may be seen to have had their liberty removed for no therapeutic benefit. The requirement of treatability generates thorny questions for practitioners and their patients. What if the detained patient's disorder is dampened down by treatment but the risk remains? Is continued loss of liberty justified in the absence of florid disorder? Are individuals untreatable when they refuse to comply with treatment? Deciding whether or not to comply may hold ramifications for patients. Compliance may entail protracted treatment, monitoring and detention. Non-compliance may be regarded as a lack of insight and imply the need for compulsion and more treatment. Thus patients may be caught in a catch-22 situation.
As a sociologist and ex-psychiatric nurse, my interest surged at the elaboration of the nosologically vague nature of many mental disorders, the doubts around treatment of impulsive and potentially dangerous individuals, and the often thin distinction between punishment and treatment regimes. The tension between ‘knowing' that a person is in marked psycho-social trouble and the certain assignment of that ‘trouble' to a precise category is well known to psychiatric professionals who work holistically and to sociologists who work with concepts such as medicalisation and the discursive construction of reality. This discussion opens up the social determination of professional psychiatric decisions. That is, decisions that are not clearly underpinned by distinct illness categories and proven treatments are likely to reflect wider social biases. For example, ethnic minority groups such as Afro-Caribbean persons in the UK are over-represented in overall rates of detention and seclusion. Social biases may be at work in the form of cultural insensitivity in the assessment process and over-sensitivity to media-fuelled panic about young, black males. The diagnostic ambiguity surrounding personality disorders, notably psychopathic personality, is explored to show the weak correlation between impulsive, dangerous behaviour and mental disorder and mental incompetence. The authors emphasise the responsibility of psychiatry to tighten up doubtful categories of mental disorder, outcomes of treatment and measures of outcome. More scientifically-based evidence is required if future Mental Health Acts are to issue clear provisions and serve the interests of individual patients, practitioners and the public.
Don't be deterred by the book's focus on legislative change in the UK: it is far from a dry read. Its relevance to practice and the lived experience of mentally ill persons who cannot give lawful consent for treatment is robustly demonstrated in the way the authors present and flesh out all sides of the current debates. Given the scarcity of publications on mental health in Australia, and the issues ensuing from asylum closure and community-based care, the book should be of great interest to local psychiatric and legal practitioners, policy-makers and students of health sciences, social sciences and legal studies.
References
Gardner J (1977) Inside the Cuckoo's Nest: Madness in Australia, Planet Publishing: Fortitude Valley, Queensland.
Goffman E (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, Penguin: Harmondsworth.
Higgs W (1931) A Plea for Better Treatment of the Mentally Afflicted: What Can Happen to a Man 2nd edn, Kew, Victoria.
Lewis M (1988) Managing Madness: Psychiatry and Society in Australia 1788-1980, Australian Government Publishing Service: Canberra.
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