More views of - or before - Cambridge Film Festival 2017 (19 to 26 October)
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15 February
A very strange choice of questions in the #MHAReview survey (and my attempts to answer them, without being sectioned) !
Q1. Based on your experience, do you agree or disagree that being sectioned has been the best approach for your mental health needs ? Please explain your answer.
1. Being 'sectioned' is, in itself, a piece of jargon that we do not need - it is worse than when the language was 'committed', or 'certified', and has no objective justification : unless Regulations determine whether, for example, the police can detain a person against his or her will, such a detention will be under some section of an Act of Parliament, but we don't call that 'being sectioned', but (usually) 'arrested'.
2. Detention against one's will is often not an approach for that person's 'mental health needs', but, usually, to keep someone in an environment that is neither usefully stimulating, nor therapeutic, for the benefit of and away from others (e.g. family or neighbours), until that person 'is better', so I cannot agree that 'sectioning' was for my needs, or implies any approach (good or bad) to them - the existence, nowadays, of crisis resolution and home treatment, which are approaches, and the paucity of places on wards, mean that I would not have been sectioned now.
3. It was a dehumanizing and degrading experience, and it licenses the use, on patients and regardless of whether they have capacity to consent, with powerful medications whose exact effect is guesswork to those who prescribe them, as is the incidence of very unpleasant side-effects (of which no warning was given) : they may quieten them, but so would psychological interaction, and without badly altering their brain chemistry. It is legalized experimentation with dangerous substances.
Q2. What could have happened differently that could have prevented you from being sectioned ?
1. As mentioned at Q1, the existence of crisis resolution and home treatment services, or the lack of ready availability of psychiatric places, which allowed people to be detained who could clamour for one now, and not be admitted.
2. Psychiatric services for those who really do need and want them have, unfortunately, been deprived of such funding that the only benefit is that people can no longer be put under detention for so little reason.
3. In my case, proper psychological engagement with me, as I was, rather than the police-led escalation of my mood, thoughts and fears, would have assisted.
Q3. How would you describe the care you received while sectioned ? This could be either in hospital or a Community Treatment Order.
1. I am not sure that it is correct that one is, as such, sectioned when on a CTO : certain sections and / or certain triggering events may cause a Responsible Clinician to put someone on a CTO, but my understanding is that one cannot say 'while sectioned' to mean on one.
2. The care was not 'care', but containment. In comparison with even some other wards on the same site, it had a reasonable programme of activities, such as a cooking group, or a so-called 'breaking-out group' (going into the city under escort of 2-3 nursing staff). Other activities were more patronizing, such as being given time to make a piece of art, but then have to have someone supposedly analyse it / one through it, or the community meeting (which I avoided, after being at it once). Asking for an hour's ground leave and walking around the grounds was best.
3. None of this was 'care'. One was indoctrinated with some medicalized account of one's self, and obliged to take medication (haloperidol) - this felt more like punishment for what one was not meant to think / have thought, with constipation, stiff and awkward arms and legs, painful neck-cramps. All depersonalizing, humiliating and taking away any status that one had in the name of psychiatry.
Q4. In your experience, what are the most important things that can help people stay well following discharge, and reduce the need to be sectioned again in future ?
1. The 'need to be sectioned' proved to be tied to finances - when funding for mental-health services became curtailed, it became less likely that anyone with my experiences (20+ yrs ago) would be sectioned.
2. Nonetheless, the important less that being 'sectioned' teaches a former detainee is to behave in such a way that psychiatrists lose interest and discharge him or her. Then, despite a mind that has almost certainly been damaged in the way that the nonsense about 'chemical imbalance' claimed justified one's detention, take sufficient medication to control behaviour that attracts others' attention.
3. For those who were desperate to be discharged (and did not just outright refuse to agree to the terms of Supervised Community Treatment, because then a so-called Community Treatment Order would be impossible to make), it will not be the CTO - no evidence of that whatever.
4. The 'need to be sectioned' - there is no such need, because it is driven by societal and family pressure, but only as long as there is money for it.
Q5. Do you feel you were treated with dignity and respect ?
As a person who was twice detained against his will ? Absolutely not !
Put on section 2 on c. 21 April 1996, the consultant did not even have the decency to tell me that she had taken me off the section - for years, until I saw my records, I thought that she had just let it expire.
Detention under section is one of the most humiliating and degrading experiences of my life - that is the true answer to Q5, that, apart from the GP's stupid 'experiment' of continuing me without medication after an abrupt week-long withdrawal (as I had no tablets, and he decided not to prescribe), which saw a re-admission in January 1997, I had no intention, after that, of going back to hospital again for more dehumanizing and status-less time there.
Q6. Where relevant, do you feel your carers (e.g. family or friends supporting you while you were sectioned) were treated with dignity and respect ?
More so than I was. I was only taken off haloperidol, during the first admission, when my somewhat hard-hearted wife, obsessed with how her life had changed, pleaded for me.
During the second admission (January 1997), she agreed to apply for me to be discharged from my section (section 3) - that, as I only established from the records, appeared to have been blocked within the period of 72h, but, again, there was zero transparency as to what had happened.
Besides, my wife was not a carer - she was a prime cause of the behaviour that was diagnosed as supposed mental illness.
Q7. What rights do you think a person sectioned under the Mental Health Act should have ?
1. They should have the rights that the Act already gives them - not available, in my experience.
2. A curiously open-ended question, but, certainly :
(a) the right to a full assessment of capacity to consent to treatment in compliance with the Mental Capacity Act ;
(b) based on being found to have capacity, the right to refuse treatment ;
(c) the right, again with capacity or based on a relevant advance directive, to refuse ECT, and not for there to be a deemed lack of capacity or an 'emergency' need for ECT ;
(d) not to be put on a CTO (and for all existing CTOs to be discharged), failing which explicit rights to an IHMA when a CTO falls to be considered and to be told of the right to refuse to agree the terms of a CTO and the consequences of so doing ;
(e) the right to much better than the tokenistic 'reading of rights' that patients are given, by staff who do not believe that someone detained against his or her will has any rights ;
(f) an easier way than displacing a nearest relative to have that a person of one's choice ;
(g) right to a second opinion ;
(h) better protection against ill-treatment than under s. 127 (has anyone ever been prosecuted successfully ?).
Q8. What rights do you think a carer (e.g. family and friend) sectioned under the Mental Health Act should have ?
They have too many rights as it is, e.g. to request a Mental Health Act assessment. Carers are often not the people whom those for whom they claim to care would choose, and the balance is too far in favour of abusers, who take away others' peace of mind, or even apparent sanity.
Q9. If you could change one aspect of the Mental Health Act, what would you change ?
It must be that, irrationally, it overrides people's capacity to refuse treatment (i.e. forced medication) for their alleged mental ill-health, but the very same people, with capacity to consent to treatment for a cancer or other such condition that will kill them (and a consultant in that field would be absolutely bound by their advance directive, if they lacked capacity, for such treatment, or to require them not to be resuscitated) - so much for parity of esteem !
(A close-run thing with the unnecessary involvement of the police, which makes people confuse their psychiatric detention with the criminal-justice system - e.g. returning 'absconding' patients, or under s. 136.)
Q10. Is there anything else you would like to tell us ?
The power of others to put people, either supposedly out of concern for them, or - as neighbours or as family members - by complaining about them or alleging being in fear of them, into a coercive environment that is unlikely to be therapeutic should be reduced / redressed in favour of those detained against their will.
How much has really been understood since, or changed because of, Placed Amongst Strangers [www.mentalhealthalliance.org.uk/pre2007/documents/placedamongststrangers.pdf] ?
[...]
Q16. Do you know which section(s) of the Mental Health Act you were sectioned under ?
Yes :
April 1996 - s. 2
January 1997 - initially informal, then a s. 4 holding power was used* when - peaceably - I decided that I wanted to go back to the ward where I had been admitted overnight, and six staff used face-down restraint on me, I was taken back in, sedated, and put onto s. 3
End-notes :
It looks as though that should have been s. 5, in fact :
Unless stated otherwise, all films reviewed were screened at Festival Central (Arts Picturehouse, Cambridge)
More views of - or before - Cambridge Film Festival 2012
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10 July
I worked as an advocate for eight years.
When I started, there was no such thing in name as IMHA (Independent Mental Health Advocacy) for people detained under the Mental Health Act 2003 as it then stood (commonly known, for no good reason, as ‘being sectioned’), but our contract, and our arrangement with the mental-health trust, meant that we went onto the wards and could give people just the same help with the Act, but without the powers given to IMHAs, for example, to look at hospital records (I never needed to).
IMHA is a very specific thing. The training to become one, I have to say, is rubbish and factually incorrect or misleading in several places, when, that is, it is not box-ticking and jumping through hoops. That apart, one could and should be very competent in being able to explain a person’s rights to him and her.
Yet that is not because of the training, but because of the limited compass of what one typically needs to know from day to day, whereas the vast numbers who are on supervised community treatment (usually thought of as a Community Treatment Order, or CTO, though it is not an Order as such) indicate either that few people take the chance to have their rights explained, or that (which has to be laid at the IMHA’s door) they do not understand their rights.
Considering supervised community treatment is a triggering event for a person to be advised of his or her rights to see an IMHA, so I should be interested to see figures for how many exercise it. Just a guess, but I imagine few, because it is typically hard, as a patient, to believe that there is a just and fair system and that one has any right that is not compromised.
After all, the person may already have poured his or her heart out to an advocate that he or she should not have been detained under (the civil sections of) the Act, and have been told that, all impressions and intents to the contrary, the psychiatric unit is not a prison or part of the criminal-justice system. Under IMHA, one would be able to know more about the detention, and, safeguarding not telling the person something that would injure his or her health, to pass that reason on.
So that is IMHA, and the typical scope of enquiries that one might have under the Act. Contrast that with, say, a matter of contract or of family law for the same person, whether or not still in hospital. For good or ill, advocates largely ignore the question of capacity, and so will support clients (including seeking to find them, without charge, increasingly unavailable legal representation) to do what they seek. This never happened to me, but he or she may want to give up a tenancy, and, if he or she refuses to have advice on doing so, may be guided through an irreversible process that will later be regretted.
That is one point where I say that advocacy is not better than nothing : with nothing, the person might not get there on his or her own, whereas what, of lasting good, has been achieved in the name of empowering the client ? I had colleagues who had had to help with such folly in the name of empowerment, and who gained some reassurance, by relying on the generalized and self-perpetuating ‘advocacy principles’, that they had, by doing their job, done the right thing. I cannot say or think so – that is the mindset of advocacy, but it is wrong.
Advocacy puffs itself up with the notion that it is a profession. It even uses terms from ‘taking instructions’ to ‘attendance notes’ that are (did one’s colleagues but know it) properly those of solicitors, but with this important difference : The Law Society will not allow a solicitor to proceed, without some independent verification of capacity, if her or she doubts that the client lacks it (in relation to the legal task in hand and the decisions that have, or may have, to be taken). There is no equivalent of The Law Society for so-called generic advocates, but just guidance from bodies such as Action for Advocacy.
Advocacy is not a real profession, although caught by the requirement to provide a service with reasonable care and skill (but advocacy services have scant notion of liability, risk and the scope of a duty of care), and it will sidestep the protection that, as just seen, a solicitor will have to employ to achieve outcomes that can be as damaging, if not more so.
Damaging, if not pointless, for my manager once required me to fly in the face of a direction from a judge in the belief that going to a full hearing would give the client closure* (I had no such belief, and it did not, because he wanted to appeal, and then, when told that he had no grounds for an appeal, wanted a second opinion) : to my mind, if a judge, prior to trial, expresses the view that, without x, a case cannot succeed, one either gets x, or tells the client that one cannot support him to go to trial unless he agrees to get it.
What we did was to go to trial without x, and it was a futile exercise, built on unrealistic ideas that the client would see that the process had been gone through and exhausted, in giving the client the right to ignore a very big judicial piece of advice for no very good reason. Did the client have capacity in relation to these matters ? I rather doubt so, and his ‘instructions’ were of a repetitive, yet not always consistent, kind that was unlikely to find judicial favour in any case. I say all this as a former solicitor (though none of my colleagues had any legal training whatever.)
So on lack of proper safeguards for imprudent decision-making there are concerns, but advocacy is also founded on the shaky basis, touched upon already without calling it such, of giving the person the right to have his or her say. If it’s having a say that rights were infringed, and that hospital staff should not have done what they did, how crushing is it to put all that into a complaint, and then have back from the complaints department that there is ‘no evidence’ that what the client claims happened.
Does one, in hindsight, guard the client’s expectations of the process so that he or she will not be crushed by the outcome, or has the client made his or her own bed ? To make the complaint with the client, it was necessary to come alongside and to empathize with what he or she said, and one is forbidden (despite being permitted to say what is likely to happen from past experience) to express one’s own opinion, because that is a big advocacy no-no except by taking the client, with his or her consent, to someone else such as a solicitor who can express one, and give advice.
If, faced with a client who is upset by what happened and wants to make a complaint, one cannot really say that most complaints procedures are a whitewash and that the client will just be upset more, because that would stray from what is likely to seeking to persuade or advise : the client alone must decide, and one has no opinion to express.
The blind leading the blind ? Sadly, yes, I think so, however well-meaningly grounded in peer support, and little better than kindly do-gooders, unanswerable to anyone much when it all comes unstuck. Add to that people who know things that they do not, such as how one cannot (one cannot ?) be dismissed for being off sick or that, even if the time-limit for bringing an employment claim may turn to be passed, one can simply argue that one could not bring a claim before (and so simply), and the cacophony becomes unbearable.
Either non-IMHA advocates such know more, and be qualified as legal executives, or they should do less. They are not professionals in any meaningful sense, and they should not be allowed to help people without capacity to do objectively undesirable things on some woolly basis of empowering them.
As to IMHA, I reserve judgement, but a five-day training on the Act before IMHA came in was a much better grounding in how it works than the dedicated IMHA module. The advocacy world went soft when the statutory training was announced : there should have been exemptions for existing advocates, more intensive training for new advocates, and none of this vague competency-based accreditation, which does not substitute for solidly understanding the Act and how it applies to different situations.
As if this were not enough, you can now read The Ten Glib Compromises of Advocacy (in retort to The Advocacy Charter)...
End-notes
* It may be explicit enough in what I wrote last night, but I still remember so much of the blinkered vision of advocacy's so-called principles that I was accustomed not to portray that as appalling cynicism - support the client to go to trial, not because we believe that he now, with the stance that he has taken, stands any chance, but just so that we have reason to shut him up !
In the same way, one insulated oneself, in the way that I mentioned earlier on, from questioning whether the principles that had one facilitate someone doing / not doing something just because, at that moment, he or she felt like doing / not doing it were sound or right.
More views of - or before - Cambridge Film Festival 2012
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15 May
I added this comment the other day to this, a report on the @Mental_Elf web-site (by Kathryn Walsh) called Community treatment orders fail to reduce psychiatric readmissions for people with psychosis :
One of the criteria for the trial is said to be ‘capacity to give consent’.
I wonder whether this is ‘a red herring’, if the seeming legal niceties of ‘putting someone’ (as it is often put) on a Community Treatment Order (CTO) are not actually observed.
From professional experience*, I believe that the legal opinion has been expressed that it is possible under Mental Health Act 1983 (as amended), and without a patient ‘applying for’ it, for him or her to be given section 17 leave to, say, a care home or a non-NHS specialist unit. (I am thinking of someone on s. 3.)
In theory, if hospital authorities needed to, ‘reasonable force’ could be used to oblige him or her to go. Forget how ‘untherapeutic’ that is, because the general regime of psychiatric units (e.g. locked wards, compulsion as to ‘treatment’ under the Act – usually an injection, and the dehumanizing environment and attitudes) can hardly be conceived of as therapeutic – or, when it is not that, it is cajoling, coercing, wheedling and blackmailing to seek (a form of) compliance.
Almost certainly, someone whose consideration for a CTO is ‘triggered’ by the Act (e.g. by application or referral to a First-Tier Tribunal, or at the time of contemplating s. 17 leave) will have been plenty depersonalized and demoralized by all of this already, before one even gets in sniffing distance of a formal meeting ‘to consider’ the Order.
Where the Principle of Least Restraint then (not least if no one cannot work out whether it is the CTO regime or that of s. 17, including the example that I gave above, that amounts to least restraint) ?
Patients who have already been brutalized by a place such as I describe (and will typically lack self-confidence and self-esteem), even if formally given the choice to consent to an Order [I understand that they aren't actually 'Orders', and the question of consent is more honoured 'in the breach', I gather], have no obvious reason to say No, when it means that they can go home.
(I believe that anyone would snatch at going home, whatever they are asked to agree to, because he or she (wrongly, I think, because not informed) assumes that it is that, or staying put.)
No reason obvious to the patients, then. If they were properly and independently advised as to (a) being able to say No, and (b) What, if they did say No, would be the Responsible Clinician’s (RC’s) options then, the position might be different :
If the RC cannot secure agreement from the patient to meet the conditions that are sought and / or the Approved Mental Health Professional (AMHP) won’t countermand the Order, there is still a position to fall back onto, i.e. s. 17 leave, or even discharge (since there no longer is supervised discharge).
But how many patients oppose a CTO ? How many think – more relevantly, are told – what happens, if they state openly that they will not comply with the conditions, rendering the notion of putting them on an Order ‘dead in the water’ ?
The RC has beds ‘to unblock’, considering a CTO is forced by certain events, but, if the patient is patently saying No, what will the RC do ?
So an Order is effectively dangled, and capacity to consent is really falsified : the patient is not allowed to weigh up whether to agree to the conditions for a CTO in compliance with the test under the Mental Capacity Act 2005 (as amended) simply because he or she is almost certainly not given the full information, which, if he or she had, could be understood and applied.
In truth, I think that the real scenario of a CTO coming about is having huge debts, but being marched down to a bank and told that you need a personal loan from that specific bank.
So not told any safeguards, e.g. that :
(a) the bank can advise only on its own products, and there may be other products
(b) even if the borrower won the Lotto that night and could pay back the loan, interest is charged up front;
(c) there are arrangement fees;
(d) the Bank of Mum and Dad is only too willing to help out, etc., etc.
Such a transaction, if challenged, wouldn’t stand up to the Financial Services Authority (FSA). For me, the way that CTOs are ‘secured’ is no better, but there is no adequate FSA, and patients affected are unlikely to have recourse to one, because they just ‘wanted to go home’.
End-notes
* There is a little more about that experience here in relation to mental health advocacy.
More views of - or before - Cambridge Film Festival 2012
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1 March (updated with Tweets, 2017)
Well, no...
Despite the mental-health charities waving flags, I do not think that it has changed very much - or in the right way - for most people, and this is why :
1. How many people will ever be a company director, and is just removing bars relating to mental health, without regard to safeguarding shareholders and those with whom the company may do business or interact, the right approach ? Limitations on being fit to act as a director that do not stereotype mental ill-health, but reflect the fact that it and many other criteria might make staying a director inappropriate, should have been considered.
2. Some can now serve on a jury, itself not an everyday calling (many enough are never asked), but - across the board - not someone on a Community Treatment Order. That is still wildly discriminatory.
3. Of the groundbreaking areas, being an MP is the thing anyone is least likely to do. Rather than just doing away with the previous law, the law should have been revised, so that an MP is as capable of carrying out parliamentary and constituency duties over time as a company director.
Three roles that affect almost no one in ordinary life, and this is a triumph ? No, it is just repealing legislation, rather than considering what should have been passed in its place ! It paves the way for no new and better legislation to deal with the real issue of discrimination in mental health in the slightest.
