risk

Autonomy, Risk and the Politics of Control

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.

AUTONOMY

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.

The Mental Health Cop blog won the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”

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14 thoughts on “Autonomy, Risk and the Politics of Control”

  1. Psychiatric intervention as a means of institutional control, and the denials of autonomy it entails, was the major topic of Thomas Szasz for over 50 years of prolific writing. If you haven’t familiarized yourself with his ideas and arguments, I am confident you’ll find his work highly relevant to your interests. If you have studied Szasz, I’d be interested to hear what you have to say in response.

    1. Frankly, I haven’t read enough of his stuff … it would appear that his argument is not just one held by him then, but a range of academics and not just those writing on mental illness but all types of social control. I find this whole debate fascinating and regret the need to work for a living as I have a very large pile of books that need reading! :-)

      Thanks for the comment – always welcome.

    2. I have read Szasz’s ‘Myth of Mental Illness.’ I think mental illness is a fact and it is usually easy to discern. Mental disease is another matter, however. Schizophrenia, for instance, is listed in the International Classification of Diseases. The jury is still out, however, deliberating whether the schizophrenic brain is physically abnormal. Is there clear evidence of a lesion? What I’m sure about is that those diagnosed with schizophrenia have usually experienced at least one episode of being very unwell. Being unwell is, in other words, being ill – or having an illness which might well be called a ‘mental illness’. I don’t like the book’s title but otherwise I’m a great fan of Szasz’s work.

      1. http://m.schizophreniabulletin.oxfordjournals.org/content/early/2012/11/20/schbul.sbs135.full.pdf for a very recent academic article exposing the myth of schizophrenia as a deteriorating brain condition.

        As well as Szasz, RD Laing, Erving Goffman, Michel Foucault and Deleuze & Guattari are other academics who have addressed the issue of ‘mental illness’ as a form of social control – not to mention many texts of the controversial and somewhat cultlike but nonetheless immensely powerful religion Scientology.

        It’s worth remembering that when that Szasz book was published, homosexuality was listed as a mental disorder in DSM and homosexual men and women were frequently treated with aversion therapy and ECT in mental hospitals around the UK until 1973 when it was removed from DSM-II.

      2. Thanks for the link. I can tell you it is depressing to be told one has a progressively deteriorating brain as I was at age 25, but now many years later I surmise that that was mistaken.
        Recovery is much talked about by service users but I suspect professionals are still often sceptical. Indeed one consultant psychiatrist I met recently likened schizophrenia to alcoholism – ‘it can always recrudesce’.
        My main reaction to this paper, though, is that, encouraging though it be, it has too narrow a focus – it assumes schizophrenia is a disease tout court (while admittedly questioning a little the evidence for structural abnormalities).
        Mental illness, due to schizophrenia or whatever, is a big problem for society and, of course, for the police. It is a problem that is often merely contained. Rather than enabling patients to function better and become more self reliant, psychiatric care and the welfare system often conspire only to dis-empower those afflicted. Is this because despite an avowed belief in the medical model many clinicians actually take a moral view about mental illness?

      3. “I think mental illness is a fact and it is usually easy to discern.”

        I would question at least the second element of this comment. Is mental illness so easy to discern? Considering that the majority of mental health problems have at least some basis in adverse life experiences (I personally think all MH problems are a form of post-truamtic stress but even a more moderate stance must make a nod to this) then at what point does someone stop being “distressed” and become “traumatised” or “mentally ill”?

        I know someone who illustartes this point perfectly. They went through a very difficult time as a child, and since suffered depression symptoms (self-reported), whilst appearing fairly ‘normal’ to the outside world. As a child and teen they used daydreams to escape their distressing reality. Now as a young adult when the problems have begun to show and MH treatment has been sought, they suffer with hallucinations/breaks from reality and hear voices, on top of severe depressive symptoms. At what point did they become “mentally ill”? You certainly wouldn’t have spotted it until recently, unless in an in-depth psychiatric assessment.
        And what about all those who are turned away from receiving help – previously the standard procedure for some – yet are a huge risk to themselves in terms of suicide or self-harm? Are they mentally ill? Are they just very distressed? What about when they reach the pitch of dissociating from reality and hearing voices themselves?
        Mad, Bad, Sad – and all the shades of grey inbetween…

  2. Szasz argues that with the status quo (and he was first writing this many years ago since when all to little has changed) those who should be inculpated are exculpated, and those who should be exculpated are inculpated. That is to say, in true topsy-turvey fashion, we not only detain persons who have not been found guilty of a crime (under the MHA) but we also allow the plea of insanity to mitigate the punishment of those who have been found guilty of a crime (under the criminal justice system).
    You bravely suggest, MentalHealthCop,that the MHA is not about healthcare but about security. I would go further and say psychiatrists are more like probation officers than doctors. One would expect a doctor to have his patient’s interest uppermost but psychiatry as practised in the NHS is, as you say of the MHA, ‘not about healthcare but about security.’ It would probably be better if psychiatrists discarded one or other of their hats and were open and honest about whether they were primarily concerned about the well-being of their patients or the security of their community.
    There is still that mad versus bad question which has to be answered. There is a philosophy special interest group in the RCP, members of which examine the concepts underpinning psychiatry and the diagnosis of mental disorders and consider whether they are scientific or value-based. I recommend the work of Bill Fulford, including his seminal ‘Medical Practice and Moral Theory.’
    The scope of any discourse about mental illness goes beyond scientific language, but to those in fear of even greater stigma being attached to the ‘victims’ of psychiatric treatment let’s always remember that many are ‘more sinned against than sinning’.

  3. I think ‘security’ and detaining seriously ill people before they commit some terrible act to either themselves or others is actually a pretty good idea.

    I’d recommend Tony Maden’s ‘Treating Violence’ (Oxford 2007) for a thoughtful and practical analysis of the problem rather than questionable Tomasz Szsaz and RD Laing.

    1. I’m making no judgement about whether it’s a good thing or not, given my own profession. All I will say, is that it’s at odds with other risk management strategies we have for other predictable events.

      I’ve read Maden and the others and feel it has much more credibility than the others. An excellent book which I just re-found as I started to pack up my house ready to move!

    2. Its just vanity and hubris to pretend to be able to predict who will commit some terrible act and who wont. Psychiatrists are not issued with crystal balls upon graduation you know. Society just likes to think they can. Most are not vain and hubristic imso it’s just the position they are in.

    3. “I think ‘security’ and detaining seriously ill people before they commit some terrible act to either themselves or others is actually a pretty good idea.”

      It is interesting to note that metal health patients who are deemed “at risk to others” (usually with a schizophrenia or other psychotic label attached) are detained far more readily than those deemed “a risk to themselves”. Suicide attempts, self-harm etc can be brushed aside by MH professionals who refuse to help and/or hospitalise the person, whereas the moment someone may be deemed a risk to the “general public” (even though they are more likely to be victims that perpetrators) they is a call to whisk them away out of sight. As MentalHealthCop says: “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”.” Emotional distress leading to mental illness is the point at which the “general public” realise mental illness isn’t so “other” after all and seek to shunt the person away in fear, whereas MH services see the person as more “capable” and “healthy” and not sufficiently mentally ill to intervene in an emergency.

      1. We aren’t really suggesting that being detained is the only yardstick of an appropriate effective and compassionate response are we? Yes, there is an excessive reaction to ” risk to others” but we don’t want to increase our rates of detention of those who self harm

  4. “I’m making no judgement about whether it’s a good thing or not, given my own profession. All I will say, is that it’s at odds with other risk management strategies we have for other predictable events.”

    People with mental illness labels suffer the indignity of being subject to many double standards. That is why their is a service user movement. In the UK the mentally “ill” are in the same place homosexuals were in the 1960’s.

    MH services often don’t manage risk, they attempt foolishly to eliminate it. The results are brutal for the people the systems supposedly “helps”.

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