I used to visit a patient every month to give his depot. He lived with his family who had immigrated, bought a house and because of the astronomical price of houses in the area, had to let out the most desirable part of the house in order to afford the mortgage. They were friendly people and had been making slow but forward progress, financially speaking until the husband became ill. Let’s call it paranoid schizophrenia for simplicity.
His English was slightly better than his insight which was completely absent. That meant that even if he’d had the vocabulary to talk to me about his illness, symptoms, medication and so on, he wouldn’t have. He wanted to come off his depot and in his limited reasoning, being honest about symptoms, unless they are fully controlled, wasn’t going to achieve that. Telling the nurse everything’s ok, might just achieve it.
Paranoia and suspicion militate against levelling with professionals, you see. So he soft soaped me every month that things were going swimmingly and surely that meant the doctor would take him off his depot. That state of insightlessness is not uncommon unfortunately. Fortunately, we front line clinicians know who these patients are. And even more fortunately for Zing, we’ll call him, his wife was switched on. She knew he wasn’t back to how he’d been before and after such a length of time, might never get there. She had Zing and a baby to look after. Family were in a country a long way away and flights were expensive.
You see, when psychotic, Zing had slashed his own throat and made a spectacularly good job of it. Having come to a country with a first world medical system probably saved his life. So he had two protections against relapsing and having a second try; his wife’s vigilance – and probably love, but they weren’t a demonstrative couple so I couldn’t be sure – and a CTO that enabled me to legally enforce his depot.
A CTO (Community Treatment Order) is a community section. Here’s a definition. ‘CTOs require patients to accept clinical monitoring and allow rapid recall for assessment but do not authorise forcible treatment outside hospital.’
You’ll immediately see it doesn’t give us much power at all. More on that another day.
I just want to say a little about our courageous government’s (the dancing queen this time) and their pet academics’ attitude to this legislation. I mean the CTO that meant I could give this life saving monthly depot even though the patient would have refused it if he could. Maybe I’m being overly dramatic and it didn’t actually save his life. Perhaps all it did was merely prevent a second blue-lit ride to A+E and a second disfiguring scar on his neck, not to mention preventing PTSD for his poor wife and family too far away to help.
Anyway, the attack on CTOs was victorious in 2018 when the new MHA was published.
Before that, the report of the investigation into its reform was published. It’s called Modernising the Mental Health Act: Increasing choice, reducing compulsion, or the Wessely report. You’ll see how it crows about its aims. ‘Increasing choice, reducing compulsion.’
The report made over 150 recommendations to the UK government on reforming mental health law. None make you and your loved ones safer. Whoops, in the spirit of honesty there’s just this one.
42. Detention criteria concerning treatment and risk should be strengthened to require that:
a. treatment is available which would benefit the patient, and not just serve public protection, which cannot be delivered without detention; and
b. there is a substantial likelihood of significant harm to the health, safety or welfare of the person, or the safety of any other person without treatment.
Don’t get your hopes up, parents. B is just there for smoke and mirrors. A explains what the true priority is, trivialising public protection.
I’ll just clip three that have special reference to Zing, his wife and child.
5. It should be harder for treatment refusals to be overridden, and any overrides should be recorded, justified and subject to scrutiny (see Annex on Treatment Choices).
Harder. I’ve explained in other posts how hard it is already. Read the Nottingham Inquiry testimonies for collateral.
More and more paperwork. Who on earth has time to fill in even more blasted forms. Surely I’ve convinced you by now that managers cascade every last drop of work they are allergic to downhill. I bet you can’t guess what ‘subject to scrutiny’ means in real life and which politician-adjacent profession will be paid handsomely to do the scrutinising.
7. Decisions about medication should, wherever possible, be in line with the patient’s choice and patients should have a right to challenge treatments that do not reflect that choice.
‘I don’t like needles.’
13. Patients should be able to choose a new Nominated Person (NP) to replace the current Nearest Relative (NR) role under section 26 of the MHA.
This one needs explaining. NR used to be called next-of-kin. The NR, which the patient cannot choose, has legal rights and powers. On the one hand, they can request an AMHP to assess their relative for detention under the MHA (i.e. the first step to getting their relative sectioned). On the other hand, they can apply in writing for their relative’s section to be taken off, can formally object to an admission and can apply for a tribunal on the patient’s behalf. Back on the first hand, they can refuse to do all that, e.g. when the NR can see their relative needs admission and treatment.
I remember patients wanting to sack their next-of-kin because they agreed with the admission and wouldn’t oppose it. It was practically impossible to achieve this though, certainly within the time frames of sections. No worries, Recommendation 13 will now make it easier for patients. Fortunately, at least for now, Recc 13 doesn’t appear to have been accepted.
You’ll see that none of the necessary balancing has been done, of one person’s rights against another’s, of community protection (*) versus one individual’s preference, the need to treat a mad patient even when they don’t want it. No, the investigation was told what to deliver – more rights exclusively for patients and less for everyone else – and they courageously delivered it.
*) you know, those inconvenient people who work, pay tax ++, obey the laws, don’t take drugs and so on.
Ok, I’m finishing this post cos I’m making myself sick. But I’ll return to the Wessely report and the reformed MHA one day.
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