I think it’s interesting to comprehend the Mental Health Act 1983 from the point of view of what it’s actually there to do. The short-title of the Act suggests that it is all about mental health and wellbeing. Of course, we know it’s not – the Mental Health Act is of no relevance whatsoever to anyone who is mentally well. From that point of view it should have been called the Mental Illness Act 1983. Perhaps it should have been the Mental Disorder Act 1983 – after all, in its own long title it is described as “An Act to consolidate the law relating to mentally disordered persons”, whatever they are. It brought together all nineteenth and early twentieth century law on lunacy and vagrancy, replacing that awful terminology with stuff that hasn’t survived contact with the real world either.
I wonder, however, whether it should have been called the Physical Security Act 1983 – after all, there is nothing in the Act itself that allows the state to intervene purely because someone has a mental disorder, however serious. Most police officers are familiar with situations in which they’ve used s136 of the Mental Health Act or arrested someone for an offence when it is ‘obvious’ that someone is very unwell, only to find that the assessing professionals do not or cannot apply the Act in those circumstances. It’s not mental illness that is the key factor: it’s the nature or degree of that distress which determines whether the law can be applied as llong as it is relevant to the health or safety of the individual person or the safety of others.
Nothing prevents people who are mentally unwell accessing various kinds of services if they want to and you can be as unwell as you want to be until you begin to represent a threat to your own or others physical wellbeing. Then – and only then, does the Act begin to have relevance. So it’s about physical security.
THE FAILURE OF COMMUNITY CARE
Many people have observed over the decades that community mental health care has failed, including Government ministers. My holiday reading this last half-term was the book Pure Madness by Jeremy LAURANCE in which he quotes psychiatrists who observed that a proper effort to deliver effective community care has never been fully tried. Not properly tested. If it has never been fully attempted, it cannot (yet) have failed because we don’t know what would happen if it were fully funded and properly driven. Many mental health professionals have remarked that patients often don’t need hospitalisation, it’s just that they do need that which is not available outside of hospital and this all then begins to focus keeping people out of hospital and mitigating the kinds of risks that lead to massive criticisms of mental health services – often measured in terms of suicides and homicides, or other untoward outcomes.
Long-term recovery rates are not, to my knowledge, measured in mental health services in the way they are in cancer or cardiovascular care. Other medical specialities take about things like 5yr survival rates (after a heart attack, for example) – what percetntage of those patients who have a heart attack are still alive 5yrs later? We know the number has been rissing steadily for decades as cardiac care improved. We know from various sources that actually, prognosis after a diagnosis of a mental illness is not progressing in the same way and nor is it measured as such. I don’t see how we can even raise such anomalies without reminding ourselves that so much else can matter in mental health: social circumstances, social care; community and family and of course, the decades long-funding disadvantage that mental health services have suffered. Last time I checked, the NHS was spending 13% of its budget on 23% of its ‘disease burden’ (health language). Remembering how complex the lives of some people can be when they are not in hospital and remembering that we’ve seen many areas lose their Assertive Outreach teams, it’s hardly surprising that the police are seeing ever more. In that respect, street triage is just a particular form of the Assertive Outreach concept: putting mental health professionals into positions where patients are found, rather than maintaining a position where patients are expected to engage on a service’s terms. Interesting that it’s happening at a point where Assertive Outreach teams are being cut in many areas.
Everything I’ve ever read about mental health care and treatment from the very many book volumes that all the various professionals I’ve come to know over the years have been kind enough to recommended to me, I’ve come away convinced that right across nursing and social work as well as psychiatry and psychology that the more we can reduce coercion and increase willing engagement with services who address power imbalances between patients and professionals the better it is to outcomes in mental health and wellbeing. Tell me if you think I’m wrong. You can’t help but draw the same conclusions from many of the interactions I’ve witnessed whilst policing – constant emphasis upon the least restrictive practices (as if, incidentally, the police were not governed by similar principles) that aim to promote cooperation without underlying threats of patients being sectioned or denied leave unless they comply with care regimes that may not suit them.
It is for this reason that I’ve often wondered whether a fluorescent, paramilitary looking police officer in black SAS-style fatigues with batons, cuffs and bright yellow stun guns helps to foster the kind of cultural environment that promotes engagement?! Is it not too easy to be see this as the wagging finger of the state hanging precariously over the professional-patient interaction saying, “Engage, OR ELSE!”? Accepting you might never achieve such goals and that some coercion and some policing may well be inevitable, should we not strive to create services in which policing plays no part at all, thereby ensuring its involvement is as limited as possible so as not to frustrate the achievement of what everyone seems to say they want?
Whilst most recently witnessing the work of street triage teams and in my own, wider professional experience, I’ve seen many people who appear unwell reject the implicit offer of health services for their distress. Only last night, I witnessed a mother in tears at her daughter’s predicament but the law was of no use in those particular cirumstances because she was not living her life in way that represented a risk to her own or anyone else’s safety. The ‘Physical Security Act 1983‘ did not apply to how unwell she seemed to be, even despite the mental health nurse having a view that services could help her with what he thought were moderate mental health problems. Like all other implicit offers of care from GPs or specialist services, no-one can make you engage with your doctor until certain thresholds were satisfied – and they weren’t. Writing this post reminds me that I haven’t (yet) engaged with my GP for the ‘over-40 bloke check’ that my GP surgery offers once men of my age have got beyond the agony of leaving their thirties. They haven’t chased me up about my obvious denial – I’m allowed to make my own decisions about my own health and health care however unwise others may think they are.
So I can’t help but wonder, as I get ever more involved in this stuff, about whether the things we most need to do – design services that really work for people on their own terms – are not obstructed by the things we’re busy doing instead, which increasingly focusses on threats, implied coercion and the ongoing criminalisation of mental distress?
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