Here’s a controversial and provoking thought: the Mental Health Act is not, ultimately, about healthcare. It’s about security.
It’s not about individual autonomy and recovery, it’s about the politics of control. This is not my view: it is a position considered by many people who question the medical model of mental illness and its associated legal framework. It gets you directly into the debate about ‘revolving doors’ in mental health and/or criminal justice. Efficacy and recovery; recidivism and rehabilitation.
There is a presumption in UK law of capacity and individual autonomy. People are presumed able to take their own decisions, even where those decisions may be considered unwise. People who could be considered in need of healthcare often decline to receive it, including people who suffer with mental health problems. If you are reading this and have begun asking yourself if this is really true because, with mental health patients, we imagine that we reach an objective threshold after which we would employ the law to detain, assess and treat … think about the decades that have passed whereby patients with personality disorders who engage in seriously self-destructive behaviours were not detained until the criminal law detained them. Think about the inability of our system to divert such patients and the inability to access proper services in prisons. Look at the case of Garry David in Australia, to see a serious example.
It is a daily occurence for those of us working in the emergency services, to see a range of people declining care for injury or by leaving Accident and Emergency departments before being seen – this includes patients with mental health problems and those who under the influence of various substances. We often have to do a certain amount of running about in relation to it, just to be sure patients understood the implications of walking away from the NHS without treatment that had been deemed important.
Mental health care in most western countries, is available to those who both need and want it. It may not always be available in the timeframes that people would hope for or in the manner they would prefer to see it provided, but that can also be true of people who have physical healthcare needs or people who need policing services. But it is also made available through legal – and if need be, physical – coercion to those who may not want it:
The state takes a role in paternalistically determining that some people who do not want mental health care should receive it anyway and deploy the apparatus of the state, ultimately in the form of the police, to enforce the removal of certain people to psychiatric hospitals in a range of situations.
Over two years ago, I was delighted to be invited to the Essex Autonomy Project where I listened to various inspiring academics taking about autonomy. This including figures such as Professor Phil Fennell (Cardiff University Law School) and Professor Wayne Martin (Essex University School of Philosophy). The aim of the project was and still is, to bring together academic thinking across a range of disciplines and to target practitioners on the frontline to consider issues around autonomy and capacity. These seminars over two days – OK, it included a very nice dinner in a beautiful Essex village that shattered all of my northern preconceptions around Essex! – switched on the lights around a range of issues we call ‘autonomy’.
Those of you who have never heard of or read the United Nations Convention on the Rights of Persons with Disability should give it a bash. One thing that has always interested me in learning about mental health law is this issue of capacity. I’ve written before, right at the start of blogging, about how the word ‘capacity’ has been seized upon for various reasons, in differing contexts. The fact that the Mental Health Act can be used with regard to people who can take capacitious decisions, as well as those who cannot, is a peculiar feature for me. Once, when listening to an academic talking about the putative reasons behind pre-emptive detention under mental health law, he challenged us to explain why you would think it morally right. All of the answers focussed on risk and prevention of its realisation. None of it focussed upon healthcare.
Then he hit us with various predictive facts: at the population level, other things are predictive of far greater risk and yet we do nothing anywhere like as invasive. Young men drinking alcohol on weekend evenings: they pose far, far greater threats to our society than people who suffer from mental illness and it can easily be argued that cognitive functions are often at least as imparied when young people drink to excess as when they are mentally ill. It is equally true that young young men aged 18-25yrs driving cars will cause our society great harm in any given year. Yes, we regulate the purchase of alcohol and criminalise certain behaviours (like drunkenness, serving alcohol to intoxicated customers, etc, etc..) and our market economy disincentives young drivers to drive or incentives them to drive responsibly, depending on your view.
The politics of control
British academic Professor David Garland wrote in his pre-eminent book “The Culture of Control” about how the emerging policy around criminal justice, including where it overlaps with mental health care, is about proactive control, to reactive response. In a brilliant exposition of this – you must read his book – he detailed how successive governments across the world and of all political flavours, have gradually shifted criminal justice policy and social/welfare policy, to systems that attempt to control, because of the political fallout of failing to prevent certain high-profile events and other so-called welfare ills.
When I think about the role of the police in this shifting paradigm, one sees how police officers have been increasingly given powers to manage the fallout of deinstitutionalisation in mental health care. Not only in diversionary mechanisms like section 136 of the Mental Health Act, but also in the emergence of various orders like CTOs and ASBOs under mental health and criminal law, to name just two. We see a decrease in our society’s tolerance of certain risks. For me, one of the most interesting feature of those risks, is that they are capable of being the threats of “otherness”: we are not interested, generally speaking, of acknowledging the risks which pervade our society at a cost of lives and millions which are about us “all”.
And all of this takes me back to wanting to talk about stigma.
Courtesy of the Mental Health Cop