The Wessely review of the Mental Health Act was conducted in the context of a gradual erosion of civil liberties over the last 35 years which contravenes international human rights legislation. The final report published at the end of last year (Wessely 2018) argues for additional safeguards for mental health patients and advocates a more patient-centred culture that respects the preferences of individual patients and family members. But it leaves in place an authoritarian structure which has resulted in widespread abuse within UK Mental Health Trusts and the system’s integrity would continue to depend on the benevolence and professionalism of psychiatrists. The Wessely review fails to address long-standing problems with under-funding, which have caused serious problems in the current system and is out of step with the reasonable expectations of service users.
Locking up a fellow human being should only ever be done for very good reason and after careful consideration of all possible alternatives. Forcing medical treatment on another person amounts to physical assault and should only ever be a last resort reserved for extreme circumstances. It is to the great shame of British society that detention and forced medical treatment have become normalised for one vulnerable minority whose basic human rights are being routinely abused within NHS mental health facilities. Last year’s review of the MHA therefore represented a once-in-a-generation opportunity to reform mental health legislation and to bring it in line with modern human rights law.
Historical development of UK mental health legislation since 1945
Lunatics, or people of ‘unsound mind’, started to be given special legal status several centuries ago in Acts of Parliament intended to legitimize the detention of people in mental asylums. Psychiatrists specializing in the treatment of the insane were given unique powers to detain these people and treat them, often against their will, in large institutional facilities called asylums.
After the second world war, many of the problems associated with long-term institutional care were recognized and this led to the first modern piece of legislation, the Mental Health Act of 1959, which removed the distinction between hospital and asylum (Turner at al., 2015). The legal concept of mental disorder was developed and greater emphasis was placed on voluntary treatment under less coercive conditions. The 1960s and early 1970s also saw the birth of charities such as MIND, the National Schizophrenia Fellowship (later renamed Rethink Mental Health) and the Manic Depression Fellowship (later renamed Bipolar UK) which campaigned for the rights of people with mental disorders.
In the late 1970s, there were moves for a major reform of the MHA. Unfortunately, the British media sensationally highlighted a number of incidents when bystanders were attacked and killed by patients released from asylums with a diagnosis of paranoid schizophrenia and the Thatcher government decided to selectively adopt the recommendations of an expert committee aligned with its authoritarian agenda, while rejecting key safeguards. The Mental Health Act of 1983 defined the circumstances in which a person could be detained and given forced treatment. An order to detain someone had to be signed off by a doctor, normally a psychiatrist, and a person detained under the Act had a right to have the detention reviewed by an independent tribunal at a later date.
In 1998, the UK enacted the 1998 European Human Rights Act and it became clear that the earlier MHA would need to be reformed in order to bring it in line with international law. An expert committee led by Prof Genevra Richardson was tasked with proposing changes. A discussion paper (Richardson, 1999) introduced many concepts that underline modern discussions of mental health practice. Since the 1960s, there had been a long-term aspiration in the UK to reduce the number of people treated in hospital for mental disorders by integrating them back into the community. The Mental Health Act Amendment of 2007 introduced Community Treatment Orders which allow people with mental disorders to be treated against their will in their own homes while being resettled in the community. It is clear from the green paper prepared by the Department of Health that the key priority of the Blair government was to keep the general population safe and that the rights of patients were of secondary importance (Milburn & Michael, 1999):
‘..too often, patients treated in hospital – both formally and informally – fail to follow their treatment plans on discharge and need to be re-admitted to hospital because their condition deteriorates following loss of contact with care services. It is totally unacceptable that a group of patients who are known to pose a risk either to themselves or to others when they fail to comply with treatment, should so easily drop out of care in this way – sometimes with tragic results’
Yet again, many recommendations and safeguards proposed by the expert committee were rejected by the Blair government. Yet again, reforms to mental health legislation were dictated by an authoritarian agenda based on exaggerated concerns about the risk posed by patients with little basis in fact.
In 2008, the world experienced a global financial crisis caused by lax regulation of financial services coupled with irresponsible lending by banks and other financial organisations. In the UK, the Cameron-Clegg Coalition government embarked on a decade of austerity and made substantial cuts to the health and social welfare budgets.
Actual risk posed by mental health patients
The current legislation regulating the use of detention and forced treatment on mental health patients is predicated on the assumption that a small minority of people with enduring mental health problems have violent tendencies and pose a serious risk to the safety of other ‘normal’ people.
While the general population guided by sensational journalism may think that people with enduring mental health problems pose a serious risk to others, most specialists who have researched the incidence of violence recognize that the absolute level of risk is very low – much lower than the risk attached to other common activities. In his report (Wessley 2018), Wessely misleadingly indicates that people with enduring mental health problems are slightly more likely to commit violent acts than people from the general population. In fact, the data show (Mental Health Foundation 2016) that those violent acts are much more likely to be committed by people with a history of substance mis-use or childhood abuse and the reason that people with mental health problems are (slightly) more likely to commit violence is that they are much more likely to have substance abuse problems or to have suffered childhood abuse.
What available data also show (Mental Health Foundation 2016, University of Manchester 2013, Van Dorn et al. 2012) is that people with severe mental health problems are much more likely to harm themselves than they are to harm others. In 2013, 1,876 suicides were recorded among mental health inpatients in the UK, compared to 51 homicides. The rate of violence over a four-year period among those with severe mental health problems was 2.88%, compared to 0.83% in the general population. Rather than mental illness causing violence, the two were found to be connected mainly through the accumulation of other risk factors, such as substance abuse and childhood abuse/neglect. Lumping all people with mental health problems into a single category and then searching for correlations with social problems leads to misleading generalizations and, as an epidemiologist, Wessely should know better than to perpetuate statistical data which are likely to mislead the casual reader.
Furthermore, people with mental health problems are more likely to be victims of violence than those without mental health problems. A 2013 British survey among persons with severe mental health problems found that (University of Manchester 2013):
– 45% had been victims of crime in the previous year
– One in five had experienced a violent assault
– People with mental health problems were five times more likely to be a victim of assault and any crime than those without
– Women with severe mental health problems were 10 times more likely to experience assault than those without
– People with mental health problems were more likely to report that the police had been unfair compared to the general population
The reality is that people with enduring mental health problems pose a minuscule risk to other people. There is no good reason to forcibly detain large numbers of mental health patients.
National statistics on compulsory detentions
The number of people forcibly detained under the provisions of the Mental Health Act has risen every year since the legislation was introduced. More than twice the number of people were detained in 2017 as were detained in 1990. During the same period, the UK population has only increased by about 20% and the incidence of serious mental disorders has been flat.
Since the enactment of the 1983 MHA, the number of consultant psychiatrists has risen threefold from 2116 in 1990 to 6365 in 2017. Even during the last decade of austerity, when the budget allocated to mental healthcare was reduced, the number of consultant psychiatrists employed by the NHS has increased.
|No consultant psychiatrists
|No mental health nurses
|No of compulsory detentions
Contesting the medical model of mental ill-health
The Wessely report (Wessely 2018) takes the medical model of mental illness for granted as if a consensus exists amongst professional and within wider society on the root causes of mental disorders and the best treatments. In fact, the medical understanding of mental ill-health is contested and other professions responsible for the clinical care of mentally ill patients propose alternative understandings of mental disorders. Some clinical psychologists (Johnstone et al. 2018) question whether mental disorders should be classified as medical illnesses at all and suggest that some syndromes such as borderline personality disorder should be thought of and treated as normal adaptations to trauma and childhood abuse.
The medical concept of a ‘mental disorder’ is problematic and permeated with social and cultural constructs. Psychiatric diagnoses have been evolving over time since the publication of the first Diagnostic & Statistical Manual in 1952 and some categories of mental illness fall in and out of fashion according to the cultural prejudices of the time. Many of the criteria used to assess mental disorders reflect prevailing attitudes. The assessment of whether an idea or behaviour is ‘normal’ or ‘healthy’ or ‘insightful’ depends on the prejudices of the dominant culture. It is hardly surprising that people from other cultures and traditions are over-represented in mental health wards as they are more likely to hold beliefs considered ‘unusual’ by a white psychiatrist brought up within the Christian tradition.
Many patients and survivors highlight serious conceptual problems with the medical model of mental disorder. Psychiatrists are supposed to assess the level of ‘insight’ but this is a highly subjective process which puts the patient at a disadvantage. Often, the medical concept of ‘insight’ as assessed in a psychiatric interview is treated as equivalent to the legal concept of ‘mental capacity’ used to decide the patient’s decision-making capacity. Such medical practices place psychiatrists in positions of power over the patients in their care. They also have the effect of undermining and devaluing patient perspectives.
Composition of the Wessely Committee
The Wessely Committee does not properly represent all professions responsible for mental healthcare in the UK, neither does it represent patients or service users most affected by its proposals. As someone who has been affected by the MHA, I do not feel represented by the people who took part in the exercise and I refute claims that service users have been adequately represented.
The Chair of the Committee is held by Wessely a psychiatrist and past President of the Royal College of Psychiatrists. The three other chair people are Baroness Neuberger, a rabbi with strong establishment connections, Sir Mark Hedley, a retired high court judge also with impeccable establishment credentials, and Steve Gilbert, a service user who has made a career out of advising local authorities on mental health policies. This is the sort of establishment committee which tells its political masters what they want to hear.
Other committee members include three psychiatrists from academic backgrounds and the usual collection of senior executives from charitable organisations working in the mental health field. There is not a single clinical psychologist or practising social worker on the committee. Not a single practising mental health nurse. Not even a psychiatrist with a strong background in clinical work who would have practical experience of applying mental health legislation. Wessely has a background treating soldiers with traumatic conditions such as Gulf war syndrome in the authoritarian culture of the Army where people on active service have lesser rights than in mainstream society.
The claim has been made that service users have been fully integrated into the work of the committee. Gilbert assembled a sub-committee made up of service users and then organised a series of workshops around the country to which service users were invited to attend. I considered attending one of these workshops, but for me this would have meant travelling to London and staying overnight in order to make the early morning start. It also meant giving up a day’s work at a time when I was struggling financially. Others have pointed out how the early morning start would have effectively excluded a large number of service users who are not well enough to travel across London during the early morning rush hour. The National Service User Network which represents a large number of service users from across the country was excluded from the review.
Although charitable organisations like MIND and Rethink Mental Health do a lot of good work, I do not consider that they represent service users. The senior executives of these charities are generally not service users and their experience of mental ill-health is most often second hand. During the last few decades, these national organisations have become more professional in the way that they are organised and managed and nowadays they are led by executives who have made a career in the charitable sector. More recently, some of these organisations have started to bid for government contracts to provide care services and they are no longer independent of government influences.
For too long, so-called service users have been expected to passively accept treatment in a paternalistic culture of doctors and benevolent charity workers. However well meaning Wessely and his colleagues may be, it is wrong to sideline service users. It is time that our voice was listened to with greater respect.
Wessely assessment of the status quo
In a refreshing change from past pronouncements by the psychiatric establishment, Wessely acknowledges some of the serious problems that are endemic in the British mental health system (Wessely 2018). He accepts that many patients experience a level and quality of care that are unacceptable. He realizes that the quality of care as perceived by patients is significantly worse than perceived by professionals. For the first time to my knowledge, a senior psychiatrist has acknowledged the serious abuse suffered by some patients in British mental health facilities.
However, while it is refreshing to see a senior psychiatrist publicly acknowledge serious failings in the system, it is difficult to know what to make of the bewildered tone with which these acknowledgements are made. Wessely was the President of the Royal College of Psychiatrists when many of these abuses were being committed or tolerated by his fellow professionals. The Royal College of Psychiatrists is supposed to uphold professional standards within mental health facilities. Psychiatrists are not only doctors practising medicine, they are leaders of multi-disciplinary teams and are responsible for what goes on within those facilities. They are responsible not only for their own actions and shortcomings but also the actions of all team members. Wessely cannot possibly claim ignorance of the abuses committed within NHS mental health facilities as these have been well documented for many decades.
When Sir Wessely adopts a bewildered tone acknowledging the institutional abuse and low quality of clinical care suffered by patients treated in NHS mental health facilities, my reaction is:
Where the fuck were you during this time, simple Simon?
Changes to MHA proposed by Wessely Committee
Wessely makes a number of recommendations designed to provide stronger safeguards. Although these are long overdue, they are no less welcome. He suggests that a new Mental Health Act is drafted with an emphasis on four core principles. In fact, this follows closely the recommendations of the Richardson report and one wonders how many abuses could have been avoided if only those recommendations had been followed during the drafting of the 1983 MHA. In addition, Wessely proposes a number of additional safeguards designed to enhance the rights of people being detained under the Act. Advance directives are to be given extra legal weight although, regrettably, it would continue to be possible for an advanced directive to be ignored under certain circumstances, at the discretion of a psychiatrist. Finally, Wessely proposes that treatment plans should be discussed explicitly with patients and should take into account the wishes expressed by patients and their family or trusted advocates.
Although many of the recommendations are welcome and attempt to make best practice more widespread, nevertheless they fall short of the expectations of many patients and survivors of the British mental healthcare system. The Wessely report also ignores a major controversy which questions the validity of the medical model of mental healthcare provision. Two chair members of the English Hearing Voices Network Akiko Hart and Rai Waddingham have co-written an Alternative Review of the Mental Health Act (Hart & Waddingham 2018, Hart 2018). The race equality campaigner Suman Fernando has dismissed Wessely’s review as a ‘psychiatrist’s report’ (Fernando 2018).
Detention, coercion, loss of autonomy
To someone newly diagnosed with a serious mental disorder, the NHS presents a hostile environment where high quality healthcare is unlikely to be provided and where the risk of detention is real. The system of care has been designed with an emphasis on staff safety often at the expense of patient care. Patient preferences are often not taken into account and there is an over reliance on pharmaceutical treatments resulting in sub-optimal outcomes.
Over the last 35 years under the 1983 Mental Health Act, the number of forced detentions has risen dramatically while it is generally recognized that the prevalence of serious mental disorders has remained flat. This suggests that people with mild forms of mental disorder who do not present any risk are being detained in record numbers without having committed any crimes. The majority of these patients present no risk of violence either to themselves or to others.
There is a very general principle in law which is the principle of proportionality. Any sanction or punishment should be in proportion to the harm or damage caused. It is quite clear that any law that allows the forced detention of innocent people who present negligible risk to themselves or others fails the principle of proportionality. According to most legal norms, the way that the MHA is being used to detain large numbers of innocent people is unlawful because the sanction is grossly disproportionate relative to the alleged risk.
Many patients detained in mental health facilities are treated with various forms of physical treatment with or without their consent. In some cases, there is little evidence that the treatment will benefit the patient. Even when there is evidence that the treatment could be beneficial if given at therapeutic doses, powerful pharmaceutical treatments are routinely given to patients at such high doses that any therapeutic benefit is likely to be minimal. The widely discredited practice of poly-pharmacy, in which a cocktail of powerful drugs is administered because the psychiatrist has been unable or unwilling to identify the correct drug based on an accurate diagnosis, is too common. Many survivors believe that the primary purpose of using powerful antipsychotic medication at high doses is to make patients compliant and easier to manage. Most patients are not given the opportunity of a second opinion, despite this being official NHS policy, and remain trapped in a system of health care which is not tailored to their needs and is of limited therapeutic value. Many patients leave mental health units with traumatic complications that are more enduring than the mental conditions they were experiencing before admission.
According to the 1998 European Human Rights Act, it is illegal to force treatment on a patient that is of no therapeutic benefit. Forced treatment is only allowed if it will benefit the patient and forced treatment whose only purpose is to control the patient is unlawful. Under human rights law, there is also a clear obligation on doctors to provide effective treatment where this is available and it is clear from many accounts of survivors who have been denied appropriate treatment that many psychiatrists have been failing in this legal obligation. Because of these many systemic failures, any new system should not rely on the benevolence of psychiatrists as experience shows that this cannot be assumed.
Forced treatment in the community
Although some of the original intentions behind the introduction of Community Treatment Orders were humane, the reality has been very different under a regime of austerity which has resulted in mental healthcare being grotesquely under-funded. I think most ordinary people would be uncomfortable with the idea of forcing people to take powerful medication in their own homes. This represents an unprecedented escalation in the powers of the state and a serious infringement of civil liberties. There is no other example of a similar infringement of civil liberties. People with mental health problems based in the UK effectively live in a medico-police state in which their freedoms are significantly curtailed.
Institutional abuse and neglect
Once someone has been detained inside a British mental health unit, they face an environment which is often unsafe and where they are at risk of physical and sexual abuse. While prison authorities have a duty of care over their prisoners and deaths are investigated, the NHS does not properly assume responsibility for the safety of patients detained in mental health facilities. There are regular reports of physical and sexual assault in mental health facilities. In some locations, dangerous face-down restraint is routinely used to restrain and humiliate patients. Complaints about physical and sexual abuse are routinely ignored. Some independent professionals talk about a system of ‘institutional abuse’.
Many patients and survivors describe a toxic culture within NHS mental health units. One weekend last year, an offensive message was posted on Twitter which had been placed on the Mental Health Nursing Group Facebook page by a mental health nurse. The Facebook post showed photographs of haloperidol vials arranged as decorations on a Christmas tree and made disparaging remarks about patients. The post had been ‘liked’ by a large number of members of the Mental Health Nursing Facebook Group. The reaction on Twitter was polarised between patients with experience of NHS mental healthcare and nurses and doctors who are part of the system. Very few medical professionals were prepared to publicly condemn the post, with some explaining the behaviour in terms of black humour. Some of us also contacted the Royal College of Nursing and other professional bodies but none of these were interested in taking this further. When the nurse who posted the original material became aware of the furore on Twitter, she would not give an apology for the offense cause. While the founder and administrator of the Mental Health Nursing Facebook Group page publicly condemned the post, in secret he threatened to ban any members of the Facebook group who made any other material public.
The reaction from survivors of the NHS mental health system was strong and unanimous. Many gave testimony that the message posted on Facebook reflected accurately the culture that they had experienced themselves in NHS mental health units.
Apart from a toxic culture, the way that whistleblowers are treated and scapegoated by the NHS is another indication of a deficit of integrity at the top of the medical profession. Time and again, the General Medical Council has shown that they consider the reputation of the profession to be more important than the safety of patients. Valid complaints are rarely handled without bias. Recently, Dr Clare Gerada, past President of the Royal College of General Practitioners aggressively raised concerns that complaints from patients were causing doctors to commit suicide. Such views should have no place in a patient-centred service.
Much could be said about the institutional racism found in the NHS. As this is an issue receiving much coverage elsewhere and as this problem has been acknowledged by the Wessely committee, no more will be said here.
Mental healthcare in austerity Britain
After highlighting the dramatic rise in the number of forced detentions under the MHA, particularly in the last decade, the Wessely committee attempts to identify the root causes (Wessely 2018). Some of the possible causes suggested are societal causes, legal changes which mean that someone who is not objecting to detention but lacks the capacity to give consent must be treated as if they did not give consent and a more risk-averse culture. But Wessely ignores the elephant in the room which is the effect of austerity during the last decade. Following the 2008 financial crisis, the Cameron-Clegg coalition government chose to embark on a programme of austerity which has decimated mental healthcare services. At the same time, the welfare system has been reformed with the introduction of Universal Credits, causing great harm and hardship to many vulnerable people.
Mental healthcare has long been under-funded in the UK. The mental healthcare service is often described as a Cinderella service. Since the creation of the NHS in the early 1950s, the leaders of NHS Trusts around the country have chosen to systematically under-fund mental healthcare. For any other patient group, this would be called discrimination.
Second class citizens
During the last 50 years, successive reforms of mental health legislation were intended to modernize mental healthcare and to safeguard the rights of people with mental health conditions. In reality, these reforms have created a hostile environment in which people with mental health conditions are treated like second class citizens with diminished human rights. Anyone with a mental health condition can expect to face severe stigma in wider society. But in the UK, such stigma finds its clearest expression in a legal and medical system which attaches more importance to minimizing phantom risks of violence than to the human rights of vulnerable people.
As someone with a mental ‘disorder’, I am wary of entering any hospital operated by the NHS. As I enter a hospital, I am very conscious of the fact that I could have my liberty taken away from me at any time. Any junior member of staff could object to my ‘attitude’, blame this on my mental state and assault me. I also know from experience that any complaint I lodge will be ignored and no action will be taken to address my complaint.
A someone with a mental ‘disorder’, I am not regarded as a full member of Homo Sapiens. Instead, I am relegated to being Homo Sapiens Discordia, intermediate between a full human being and a mountain gorilla. I am granted some human rights but only as determined by Homo Sapiens Normalis. If my behaviour is determined to be abnormal or objectionable or disturbing, then I can be locked away, physically abused and assaulted.
Some proposals of my own
It is clear that many of the failures and shortcomings described in this report are consequences of systemic problems that exist in the NHS and the medical profession. In order to improve the quality of healthcare, these systemic shortcomings need to be addressed. However, it is our contention that the legal framework of the Mental Health Act facilitates these shortcomings while failing to provide sufficient safeguards.
Here are some proposal for reforming the Mental Health Act and the practise of medicine in the UK:
- Review of Mental Health Act chaired by a leader from the SU movement to propose a radical reform of mental healthcare provision in UK in order to place the interests of patients at the centre of the system
- Royal Commission to review current status of psychiatric medicine in the UK with a view to reforming the profession. Clear demarcation between the medical and legal enforcement roles of psychiatrists. A psychiatrist treating a patient should have the same doctor-patient role as any other doctor with sole priority to provide the best treatment to the patient. MHA to be enforced separately by forensic psychiatrists with no involvement in the future treatment of patients.
- Compulsory detentions to be notifiable events that trigger enquiries designed to correct poor practice
- To counter the upward trend in the number of sections, set targets for reducing the number of compulsory detentions to pre-1983 levels
- Additional legal safeguards for mental health patients and dedicated fund of legal aid money to support legal prosecutions by patients against NHS mental health trusts. NHS to be legally obliged to release all information to patients seeking to mount a prosecution.
- 20% increase per year to mental healthcare budget every year in the next 10 years; if the money cannot be found from outside the overall health care budget, then the budget allocated to physical healthcare should be reduced in proportion – this would only require a 2% reduction in the budget spent on physical healthcare
Note about the author
I am a Physicist and Chartered Engineer working on the development of medical imaging and clinical diagnostic technologies. I am the father of two children of university age. I have also been in contact on and off with mental healthcare providers for 40 years, since first being referred to an NHS adolescent psychiatric unit at age 13. I have been sectioned once when I was given treatment against my expressed wishes. On another occasion, I was admitted as a voluntary patient after being threatened with a section by the crisis team (‘either you come in voluntarily or we will section you and you will come in involuntarily’). For the last 20 years, I have been in the care of a private psychiatrist, having decided that the ‘care’ available within the NHS would not allow me to work as an engineer, be a Dad or retain my dignity.
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