In my current role I’m (un?)lucky enough to meet a number of people with a diagnosis of borderline personality disorder who are detained in private hospitals who wish to get out. I’m going to share some of the common features of these encounters and then explore some thoughts about the value and legality of compulsory treatment for this group of people.
While I don’t think very much of the science of borderline personality disorder, one of the values that the diagnosis brings is a set of diagnostic criteria and a wealth of evidence and theory about what it helpful and harmful. I know that even the people who are most critical of our diagnostic system pragmatically know the value of of writing a diagnosis in a benefits claim or housing application. This piece similarly makes use of what works rather than proposing a theory that might be more ethically sound.
The shared features of those I meet are:
They have a diagnosis of BPD/EUPD
They are at least 6 months into a placement to receive treatment for their ‘personality disorder’
Their self harm is more dangerous now than when they arrived
They have a history of traumatic events.
They are regularly restrained is response to incidents that would pass almost without notice in the community.
They were told this was a specialist unit with specialist staff.
The therapy on offer is different from what quality indicators would recommend.
The medication prescribed is different from what quality indicators would recommend.
Their ‘care’ deviates significantly from what is recommended.
Nowhere is it documented that people are aware of this deviation.
The clients themselves have no idea how far their ‘care’ has strayed from what is seen as quality provision.
Because the young women (and it is always young women) are not aware of how far their treatment has moved from what NICE would recommend, they often feel that it is futile to challenge their detention. They are told that their behaviour, which could easily be explained as an understandable reaction to being forcibly detained somewhere you don’t want to be, while sharing a living space with a bunch of erratic people you wouldn’t choose to live with - is a result of their disordered personalities. They are told they can leave the environment, which people unanimously agree is the trigger for the majority of their self harm, once they have stopped self harming.
One of the first questions a medic will be asked during a mental health tribunal is whether the ‘nature’ of the clients illness means that they are liable for detention under the mental health act. “If the Tribunal is not satisfied that a patient is, at the time of the Tribunal, suffering from “mental disorder of a nature or degree which warrants detention in hospital” for either assessment or treatment, then they have to discharge the patient” (Masked AMPH). This aspect of the tribunal is often fudged and I’ve heard some embarrassing tales of innate personality problems and intrinsic unreasonableness, but no-one articulates that every quality measure in the UK including NICE and The Confidential Enquiry into Suicide and Homicide for those with Mental Illness recommend that we avoid prolonged detention for those with this diagnosis. With those in mind, it’s possible to argue that the nature of what is described as borderline personality disorder is such that detention for prolonged treatment should be actively avoided.
Once the nature has been dealt with we can then talk about the degree of disorder. Because it’s common to see that risks have increased proportionately to the amount of restriction people experience, we can then argue that the degree is influenced by the detention, rather than the detention being required because of the degree.
Once this foundation has been laid, it becomes a relatively straightforward task to compare the care someone is receiving to what NICE recommend and question the value of detaining someone to receive treatment so at odds with what is seen as likely to be helpful. The consistent defence of the detaining hospital is often along the lines of “but they might hurt or kill themselves” as if the NICE guidelines were written for people for whom self harm and suicidality were not part of the diagnostic criteria. This “but what if?” reasoning can reflect reasonable cation, but I frequently hear it being used as a reason to continue detention when it could never have been used to instigate detention.
As of July 2020, every tribunal panel that I’ve made this argument to has discharged the client from their detention. These were not people who had been admitted for a brief crisis admission, they were all articulate young women who had been told that they had to receive therapy for a year or more and would be allowed to leave the hospital only after they they stopped doing the things they only did in hospital.
I’ve got a piece coming out in the Lancet in August arguing that one of the reasons we use long term private placements to treat this client group (with poor outcomes and huge cost) is so that risky people can be risky elsewhere. The placement acts as more of an insurance policy to the local area rather than something that is in the best interests of the client. My experience is that when presented with the evidence above tribunal panels can see the veracity of this. We need to stop compelling people to receive treatment that doesn’t bring a likelihood of recovery. Following the line of argument above can help.
I hope the above is useful if you’re challenging your detention or representing someone in such circumstances. If I can help get in touch,
Keir