Dear Nicky
Thanks again for the extension. Is there a mailing list I could join to know about these consultations in advance?
The first point I'd like to raise may not be in the consultation's remit but I feel needs to be said. There are themes like equality and reducing discrimination however these are not in sync with the fundamental proposition behind the medico-legal framework. I'll try to be brief.
What's wrong with forced treatment??
My own experiences of being a victim of coercive healthcare have been awful and harmful.
If the opinion of future generations judging on the immoral and unacceptable practices we consider acceptable today was something which mattered then the MHA 1983 would be repealed and the entire system of psychiatric coercion legislated for by the medico-legal framework would be abolished. It is an injustice.
This seemingly radical position is in tune with the vision of the Convention for the Rights of People with Disabilities (CRPD).This is the gold standard for disability equality and human rights. It denies the power of forced treatment and demands equality between disabled and able people. It is also in tune with the concerns of the UN Rapporteur on Torture who stated that forced treatment is form of torture and abuse.
The MHA 1983 is not in tune with modern psychiatric, disability and human rights concerns and the amendments in 2007 made this worse. It is a continuation of a historical injustice against the mentally ill caused by the specious application of the biomedical model. This model allows for coercive powers but the biopsychosocial model and the social model of disability do not guarantee these powers to mental health professionals.
The biomodel is also central to the medicalisation of mental health but generations of research and extensive funding have failed to find biomarkers which are useful in clinical practice as is common in physical healthcare. It has clearly not been scientifically proven, has been repeatedly debunked and isn't used in clinical practice where behavioural, emotional and cognitive symptoms are used to identify syndromes instead. The discovery of clinically-useful biomarkers has been the holy grail of research psychiatry and the absence of their use in the diagnostic arsenal used by clinicians is, I believe, a substantial indication of the fallacy of the biomedical of mental health so the use of coercion in mental health is wholly inappropriate.
It is also fundamentally discriminatory: the MHA treats the mentally ill differently from ordinary people. Again, this is the continuation of a historical problem that's tied into the inception of the asylum system which was based on the notion that the mad (and others) were subhuman. The laws which apply to humans apply less to the mentally ill especially with respect to liberty and free will. They need to be 'helped' by forced treatment whereas free citizens can't have healthcare forced upon them nor can their liberties be infringed as easily. Until recently the severely mentally ill couldn't run for parliament or be a director of a company. There's a different set of rules and this is what's discriminatory.
Psychiatric incarceration and other deprivations of liberty legislated for by the MHA fall outside the purview of the only other which inflicts incarceration: the criminal justice system. It requires a high standard of evidence to convict someone of a serious crime and there is a strong onus on protecting the innocent from being punished incorrectly. This is what's demanded by the rigorous judicial system but there is little of this rigour proffered for protecting the mentally ill from inappropriate incarceration. There is no demand for biomarkers and psychiatry is highly subjective. Again, there is a different set of rules, a lower quality one with none of the finesse of jurisprudence which protects ordinary citizens from the punishment of imprisonment, which is currently the worst punishment used for the worst crimes.
I'll leave this point here but to say that I'm trying to justify what a lot of victims of the MHA want: an end to forced treatment. Of all medical specialities it's only psychiatry which has a rights movement driven by survivors (of medical abuse). I am a survivor of psychiatric abuse which was and continues to be legalised by the MHA. As a group we do not want coercion of any kind. We want support and therapeutic experiences, not imprisonment or force of any kind. Just like any ordinary citizen. Forced treatment is abuse.
Suicidal patients
I expect a large portion of uses of the MHA would be on highly suicidal people. It is both bizarre to me as well as cruel and unusual harm to put suicidal people in a typical psychiatric ward and to use forced treatment. The current system is a disservice to the suicidal and does not promote recovery. It is inhumane to incarcerate suicidal people especially into a chaotic environment with lots of people in a variety of states of crisis.
Imagine failing a suicide attempt then being imprisoned in a ward where next to you a person is constantly screaming and wailing because of psychosis/post psychosis states. Something like this happened to me and it was not pleasant to say the least.
Asking for service user involvement and consultation is important - vital in fact - to creating better services but there's basic common sense which everyone shares which isn't being applied especially with respect to crisis care for suicidal people. You, the reader, could think of better solutions if you asked yourself what you would want if you ever found yourself in that profoundly awful state.
In my opinion the revolution in crisis care comes from common sense. Psychiatric hospitals need to strive to be highly therapeutic environments if they're to be suitable for the suicidal. There needs to be high levels of support available. Facilities for the crisis care of the suicidal need to be more specialised and appropriate. They also need to move far away from the current model towards much smaller wards.
There are examples of pioneering work in this area. Though it has now closed Kaya House in Barnet was a significant innovation. It was a small house in the suburbs which was repurposed for crisis care.. Staff had lived experience and were able to offer much higher levels of support because of a superior staff to patient ratio. Patients generally thought the experience was good and at a much higher level than for a typical psychiatric ward.
I believe the Maytree is a similar example of a leap forward to better crisis care based upon basic common sense as well as service user contributions. These examples are sadly few and far between. The dearth needs to be addressed as a priority because the current system is making things worse for suicidal people. If promoting recovery is a priority there needs to be much better handling of the suicidal based on being humane to people who are suffering. The typical one-size-fits-all approach to crisis care severely underserves the suicidal and many other human crisis experiences.
Measurement: getting it right
CQC inspections are simply not enough. There needs to be a robust performance management framework which seeks to identify good performance as well as bad performance but poor performance more because it's usually the precursor to catastrophic performance. This needs to be done by the governemnt so they'll have the power of performance management data at their finger tips. Performance management using the balanced scorecard approach is a mature system in children's social care. While not perfect it has still protected the safety and outcomes of children in need and children looked after however adult social and crisis care lags behind.
It is difficult of course especially given how little is currently measured. One thing I believe needs to be collected and assessed is the reason for the use of coercive powers, ie what is the exact nature and degree seen by mental health and other professionals who use the MHA powers.
As I've descried earlier, coercion in healthcare is a travesty and is harmful. It is highly subjective and open to abuse. It lacks standardisation even though a second MHP is sometimes consulted. Given the variance of the use of the act it's obvious that there would be variation in the justifications used to forcibly treat with some good practice and bad practice. This could be captured as part of a statutory return concurrent with whatever other monitoring data is collected. The data needs to be inspected carefully first to identify trends of poor performance in the use of coercive powers (eg certain wards may overuse coercion on BMEs) then to identify which circumstances are incorrectly used to justify forced treatment. This way is better than the appeals system because it seeks to prevent inappropriate detention from ever happening rather than correcting it once it has happnened through the appeals process.
Also, there's a specfic way of thinking about data which needs to be applied but is often found absent: capture and better the experiences of the worst off. Much of measuring stuff in organisations has come over from profit making business practices where the average alone is suitable. In health and social care there's another important type of measure: the minimum or worst off. It is important to improve as shown by raising the average but it is also vital to raise the bottom 5%. Measures can be easily designed to report this quantity also.
It is also important to follow up on people who've been detained. They'll have the worst outcomes of all people with mental health problems I expect. Aftercare is essential to helping these improve but there's a postcode lottery. Also, a lot of people who've been victims of the MHA disengage from all healthcare or just conact with psychiatric services as a direct and understandable reponse to forced treatment. They will have even worse outcomes because disengagement cuts them off from support. Investigting and understanding this group and what sort of services they'd want is an important area to look into to reduce the bad impact on recovery which forced treatment has.
The least restrictive principle
I believe this could be a significant step forward if it is considered a priority for practice. Given that restriction of movement is used as punishment for crimes its use in mental health should be as minimally restrictive as possible. It is vital they are afforded as many liberties as possible because they are not to be punished like the incarceration of criminals aims to do.
For example, there should be regular shopping runs by staff for sectioned patients. They should still be free to consume even if their movement is restricted.
They should be free to smoke whenever they want and if this means they smoke in their rooms then they should be allowed because if they were free they could. I think I speak for all psychiatric smokers when I say fuck the law which makes it illegal. It discriminates against psychiatric patients and treats their liberties as lower than a citizen OR A PRISONER. Problems with restrictions on smoking are a common source of strife which shouldn't exist if we were treated equally.
Also, there should be minimum standards for communiction and entertainment - again, preserving liberties available to ordinary citizens. Phone, internet and TV should be minimum standards as should single rooms with locks on the door (staff can have a master key).
These suggestions are about making the crisis care experience minimally restrictive and unfair. They also help make the environment less stressful and more therapeutic. Hopefully uses of coercion can also be reduced using the least restrictive principle.
Crisis care shouldn't feel like punishment and it should be therapeutic. Equal rights with free citizens should be guaranteed and enshrined. Any rights based approach is denied by the biomedical which ultimately dubs the mentally ill as subhuman. Freedom is better for well being and recovery, and equality of liberty under the law is the better future. At least that's what I think future generations will understand as acceptable human and disability rights.
Phew...I could write more but I know some poor soul will be reading all the consultation responses. I would like to write about the experiences and treatment of people who self-medicate are also important. All prescribers of psychotrophics would advise slowly coming off them rather than going cold turkey however this opportunity is not available to people who self-medicate - you'd call us alcoholics and other addicts or perjoratise us as junkies or understand that people can find their own psychotropic addictions which work for them rather than get prescribed them. The humanising personal empowerment perspective (self-medication is understandable and okay) isn't venerated by psychiatrists but what they get wrong could fill a couple of university libraries. Irrespective of this, the emotional suffering-based point I will quickly make is forcing self-medicators to go cold turkey when sectioned causes real psychological harm. Avoidance of forced treatment should be considered because this is real distress and torturing. Even 'recovered' addicts would agree that instantly stopping their drug is something some people find extremely distressing while slowly tapering off is much kinder even if the free personal choice of medication is disregarded. I'm a suicidal junkie and illegal drugs can create better than life experiences and help me escape a life I don't want to experience. It's awful being sectioned and it's made more so by the distress of enforced sobriety. They bring a simulacrum of happiness where the real thing doesn't exist.
Many thanks for reading my thoughts. I'm confident they'll be listened to and like any plea to stop or reduce forced treatment it will be ignored.
Kind regards
Arj Subanandan
- sent from a tablet
Thank you.
- sent from a tablet
On 10 Sep 2014 14:32, "mentalhealthcode" <Mentalhealthcode@dh.gsi.gov.uk> wrote:Dear Arj
Many thanks for your email and yes we are happy to receive comments next Monday.
Many thanks
Nicky
Dr Nicky Guy
Mental Health Act Code of Practice Review
Rm 313, Department of Health, 79 Whitehall, SW1A 2NS
E: nicola.guy@dh.gsi.gov.uk T: 020 7210 5350 M: 07810 831 130
Follow me on Twitter @NickyatDH or the Code Review @MHCodeDH
Please note that I work from home on Fridays
From: Arj Subanandan [mailto:arj.name@googlemail.com]
Sent: 10 September 2014 13:57
To: consultation.co-ordinator@dh.gsi.gov.uk; mentalhealthcode
Subject: Extension
Hello
I've just been made aware of this consultation. I'd like to respond but the deadline is too soon. Is there any chance I could submit something on Monday? I would appreciate the extra time the weekend offers and it shouldn't make a significant impact to your work to allow a slightly late contribution.
Regards
Arj Subanandan
- sent from a tablet
---------- Forwarded message ----------
From: "Cheryl Prax" <praxuk@btinternet.com>
Date: 9 Sep 2014 21:27
Subject: FW: MH code
To: "SOAP GOOGLE" <speakoutagainstpsychiatry@googlegroups.com>, "edwardr. driscoll" <edwardr.driscoll@hotmail.co.uk>, "Sharon Racklyeft" <racklyeft1@hotmail.co.uk>
Cc:
Last chance to comment on the Code of Practice. Email your comments by Thursday this week.
https://www.gov.uk/government/consultations/changes-to-mental-health-act-1983-code-of-practice
We need to tell them all our complaints about how professionals don't follow the Code now and are unlikely to follow it in the future etc. Any personal experiences will bring it home. Don't let the psychiatrists be the only ones to put their point of view forward.
Regards
Cheryl Prax
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