There’s two things to get clear before I leap into this. The first is that while I’m not a fan of diagnosis I tend to work with people who use self harm as a way of coping, recurrently feel life is not worth living and who have had multiple experiences where people who are supposed to help have hurt them. Other people give them a diagnosis of BPD/EUPD but its not a way of understanding that I find useful.
Secondly….I had such high hopes for the changes to the mental health act. Why? Because in his review of the MHA, Sir Simon Wessely identified the fear that mental health staff experience and how that impacts on their use of restrictive practice. I wrote a paper with Rob Poole and Catherine Robinson a few years back talking about how putting people who self harmed and felt suicidal into private Out of Area units was a way of the NHS managing risk to itself. The risk would be outsourced to a private company and if anything happened to a patient then it was on someone else’s patch and the NHS remained blame free. You can read it here…
I want to expand it bit on what the review of the MHA identified. Under the title of Fear it states “Professionals are fearful that unless they adopt a cautious, risk averse approach to their patients, they will find themselves being publicly shamed for those occasions when those same people cause serious harm to themselves or others”
Under Risk aversion and its consequences we read:
“One of the things that I initially found baffling was how to explain the inexorable rise of detentions under the Mental Health Act, something that has been happening for many years…But there is another issue, difficult to pin down in statistics, but which has played a substantial role in this rise, and contributes to some of problems that we report in creating and sustaining a genuinely therapeutic atmosphere for those detained. It is the issue of risk and risk aversion”
With the he DSPD program “The initial optimism felt in some quarters has largely given way to disappointment as it became clear that most were just being detained for the protection of the public, and that better (and cheaper) alternatives were available. A similar but not identical argument is raised now, with justification, for the fact that some people with a learning disability, autism or schizophrenia are being “warehoused” as we now call it in locked rehab wards, or unsuitable long stay wards which exacerbate and not ease their problems”
We move on to the topic of Fear and risk aversion
“So whilst fear of the mentally ill has decreased in the public, parliament and media, a different kind of fear has increased - the fear of making a faulty risk assessment that influences many professionals.
“a pressure developed affecting all levels of staff, managerial through to clinical, to 'manage risk', which was the intended consequence of this shift in policy. But this soon slipped into 'managing risk to themselves'”. And Szmukler continues, this is understandable, since the consequences of a faulty risk assessment were and continue to be “quite horrendous... protracted investigations and scrutiny of the case, blame, negative publicity, formal inquiries, and scores of recommendations requiring implementation”
It is easy to see how this would have been reflected in a steadily rising number of detentions, as professionals of all kinds became increasingly risk averse, and more likely to make coercive interventions that at least in the short term were likely to reduce the risk of an early dreadful outcome – such as serious or fatal harm to a patient or a member of the public.
Some of the consequences are obvious – namely the rising rate of detentions. Others are not so obvious, but can be seen in the myriad reports we have from service users of unnecessary restrictions imposed upon them, usually justified in the name of safety. We are not talking about appropriately mandatory measures such as ensuring the absence of ligature points, but others that seem at best exaggerated or disproportionate and at worst petty, accompanied by statements such as “you never know what might happen” and “we just can’t take the risk”.
But we cannot act on our own. If we are seriously to tackle the problem of risk aversion action must proceed across the board – there is little point in professionals deciding to accept more risk if the courts, regulators, media and others do the opposite. Intellectually everyone accepts that there is no such thing as zero risk – even if you detained every person with any mental disorder for prolonged periods of time, an absurd proposition, you would still not eliminate it. Any probability judgement must be wrong sometimes, and that should not automatically mean that this is a fault, let alone negligence. But the dynamics of the risk society seem to be running in the opposite direction, accelerated by legal judgements such as the one handed down by the Supreme Court in the tragic case of Melanie Rabone8. As the President of the Supreme Court remarked recently, this judgement “where the hospital was held liable for the death of an informal patient who killed herself whilst on weekend leave of absence is bound to make practitioners less inclined to use informal care”. In other words to increase, not decrease, the usage of the MHA.”
So after reading Sir Simon Wessley’s recognition of the existence and impact of fear in our mental health services I was looking forward to seeing how this fear would be acknowledged and tackled going forward. How could we support clinicians to think compassionately rather than having to look over their shoulder? How could people do the right thing rather than be seen to do the right thing? How could we move away from the appalling situation where patients lose their liberty to assuage the anxieties of frightened clinicians and organisations?
The proposed changes do not mention fear. This seems like a terrible missed opportunity. It might be politically unhealthy to challenge the stereotype of the caring and reflective mental health practitioner, but we don’t do anyone any favours when we ignore the huge numbers of unfilled posts, the increasing demands on services, rising incidences of self-harm and the human cost of seeing a number of fires burning and having to choose which fires to put out and which to leave.
With that rant over, lets have a look at some of the changes most relevant to those I work with and just as a reminder, they tend to be people who use self harm to cope, often feel suicidal and have understandable difficulties trusting others.
Grounds for detention
Here the old mantra of “risk of harm to self or others” moves to risk of “Serious harm”. Now there isn’t a definition of serious harm in the document but on another part of the government website it states:
“The risk of serious harm is the likelihood of a life-threatening and/or traumatic event. Recovery, whether physical or psychological, can be expected to be difficult or impossible.”
Now for those I work with, most of the ways that they use to cope would fall under that definition. This would mean that most of the people I’ve worked with in the community are liable for detention.
It adds something new to the thoughts about risk – “given the nature, degree and likelihood of the harm, and how soon it would occur, the patient ought to be so detained”
Here I find that when clinicians are frightened, they think “it’s happened once, it could happen again at any time”. I don’t see this as providing much protection for those I see detained.
For section 3 there are some extra bits
(b) serious harm may be caused to the health or safety of the patient or of another person unless the patient receives medical treatment,
(c) it is necessary, given the nature, degree and likelihood of the harm, and how soon it would occur, for the patient to receive medical treatment,
(d) the necessary treatment cannot be provided unless the patient is detained under this Act, and
(e) appropriate medical treatment is available for the patient.”
The difficulty here is that “medical treatment” is often a rather flowery euphemism for “stopping people hurting themselves”. It tends to involve people being watched, sedated and restrained. Where this brings about a period of respite and stability then we can all celebrate but too often I see it lead to a huge escalation in frequency and severity of risk. This new presentation in the face of restriction then becomes the justification for ongoing restriction. I don’t see these changes making a difference for the people I see stuck in “specialist” private units where a weekly DBT group run by an unqualified trainee is lauded as appropriate treatment
“Medical treatment” is something that
1. has a reasonable prospect of alleviating, or preventing the worsening of, the disorder or one or more of its symptoms or manifestations, and
(ii) is appropriate in the person’s case;
(b) references to medical treatment, in relation to mental disorder, are references to medical treatment the purpose of which is to alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations.”;
I still think that “we’re stopping them killing themselves” will justify all the above, regardless of how dangerous people are to themselves now compared to when they were admitted.
In summary, I don’t think these changes will benefit those I work with. There are some things I do like. People are to be consulted more and advance directives given more weight. I still think there’s ways around this but there’s more hoops to jump through to establish consent. I like that the Nearest Relative is replaced by a nominated person and that they can apply for people to be discharged more often. I don’t see what will stop a hospital getting fed up of them any more than the NR but at least there’s more choice.
The obvious change for the better is that people can apply for their release more often. While I think all the above does nothing to tackle the risk aversion, at least people get to roll the dice more regularly.
I’ve worked with people who sometimes did dangerous things in the community and frequently lethal things in hospital. On occasion I’ve been unable to convince others that hospital won’t keep people safe and learned of the patient dying in a restrictive setting. Other than the more frequent review from the tribunal, I don’t think the draft changes will help them. The implication of the review of the mental health act (which had “Reducing Compulsion” in it’s title) was that restriction was being used too often. The outcome of almost every serious incident review and coroners enquiry I’m aware of is that restriction isn’t used enough. There is a clash between the right to life and the right to freedom and we’ll never be able to manage this clash while pretending risk assessment is accurate and that zero suicide can be achieved. The best thing that staff can do to protect themselves is use high amounts of restriction and until we recognise this this, we can do nothing to address it.
The proposed mental health bill does nothing to address the levels of fear in clinicians that the review identified as contributing to increased restriction. Staff will remain afraid. Exporting patients to under regulated private units at around £300k a year will continue to be a way to manage individual and organisation anxiety. The cost to the patients themselves will be much higher.
Keir is the Clinical Lead of Beam Consultancy, offering therapy, training and consultation to help avoid prolonged hospitalisation of those who recurrently self harm and feel suicidal.
Many thanks to Tony @asifamhp for reading through a draft for me. :-)