Support or Coercion for the Mentally Ill?

by Andy Porter

Squall 9, Jan/Feb 1995, pg. 29.

At the same time as introducing the Criminal Justice Act, the Government is planning legislation on mental health, similarly restricting individual rights and targeting a group already disadvantaged and discriminated against.

The long-term policy of closing old mental hospitals and enabling people to live in the community is now well advanced. Many young people, even those with severe problems, have never had more than short spells in hospital and are consequently less institutionalised and more independent than they would have been in the past. The policy has its problems but overall it represents an increase in freedom and opportunity for those regarded as mentally ill.

As always, the support services for people living in the community are inadequate and under-resourced, many people are suffering as a result. This has led to a reaction, particularly from the Tory right, attacking the whole idea of care in the community with some going as far as to call for a return to the old hospital-based regimes.

At the same time a small number of highly publicised violent incidents have been used to create an atmosphere of panic in the press and in government. We are told that community care is leaving dangerous and disordered people on the loose; unsupported and unsupervised.

The overall effect is to drive a greater wedge between “them”; the mentally ill, and “us”; the law-abiding fearful public. The old hospital system reinforced the idea that mental illness was an irreversible condition and that the best thing to do with lunatics was to separate them from decent people and control them by force. The same attitude has been adopted with regard to squatters, travellers and ravers; isolate them, force them to conform or lock them up.

Fortunately the Tories don’t have the option of returning to the old hospital system; the changes are too far advanced for that and many old hospitals are already closed and sold off. Nor are they prepared to significantly increase the funding for community care, which is an obvious answer to the problem, simply giving people the support that they need.

Instead the Government are pandering to prejudice by introducing a new policy of supervision in the community.

The first stage of this is Supervision Registers. Already in place in most areas, the register is a list, maintained by the local health authority or health trust, of those users of mental health services judged most likely to harm themselves or others. The registers have been hurriedly introduced by the Government without any legislation to back them up - although this is on its way. At present local health authorities could decide not to implement the policy but only a handful have done so.

The Register has been opposed by User groups and by mental health campaigns such as MIND. The new policy is at fault in a number of fundamental ways:

• the criteria for inclusion are vague and will be open to wide interpretation from one region to another.
• the decision to register is the responsibility of a consultant psychiatrist alone.
• there is no right of appeal to an independent body.
• it is unclear how widely information on the Register will be circulated.
• there are no additional resources available for operating the registers and there is no guarantee that people who are registered will get the services they need.

Even the Royal College of Psychiatrists have criticised the new registers, largely on the grounds that they will be completely ineffective. In some areas the Register exists but psychiatrists are not putting any names on it. Users of services are anxious that the registers will increase prejudice and stigma and create a small group targeted as the really mad and dangerous ones. Registration will be solely on the basis of a psychiatrist’s judgement, no actual crime or act of violence needs to have been committed. How long before employers, insurance companies and other agencies start asking applicants: “Are you, or have you ever been, on a supervision register?” A new and permanent form of social control will have been introduced.

Inclusion on the Register is already seen by users of mental health services as a coercive and negative step based on an arbitrary decision which they have no real opportunity to challenge. There is a real fear that people will stop using services simply to avoid the risk of registration.

Worse still is a piece of legislation announced in the Queen’s speech: Supervised Discharge Orders. Under this legislation some people will only be discharged from hospital if they agree to certain conditions; primarily continuing with medication.

At present, under the 1983 Mental Health Act, people can only have compulsory treatment if they are inpatients detained involuntarily under one of the Mental Health Acts on grounds of mental illness and significant risk to self or others,

The new legislation extends the state’s control to people who are no longer subject to the terms of the Mental Health Act (that is as the Act currently stands. The legislation may take the form of an amendment to the Act). This is a profound and significant erosion of human rights. People who are well enough to be discharged from hospital will now have their right of choice concerning treatment denied.

In practice the legislation will be mostly applied to people diagnosed as schizophrenic or manic depressive and who are being prescribed major tranquillisers - for example chlorpromazine (also known as largactyl) and depixol. These are strong tranquillising drugs which suppress psychotic symptoms (delusions etc.) but also have proven short and long-term side effects which are damaging to health. These include parkinsonism and tardiv dyskinesia, a condition involving serious problems with muscular control leading to muscle spasms, shaking and other movement problems. The condition can be irreversible particularly if the drugs are taken long-term.

People with a history of psychotic experiences, like schizophrenia, at present have to make a difficult decision whether or not, and for how long, they take the medication, but at least it is their own decision. Only if they are acutely ill is the decision taken for them. It is a very different matter to impose this potentially harmful medication on people who are well enough to make a rational decision not to take it.

We all expect the right to choose whether or not to have medical treatment. This right is going to be denied to a small section of the population that already suffer from discrimination and prejudice. It is a cheap alternative to providing people with the care and support that they actually need.

Supervision registers and supervised discharge orders should be seen as another attack on our rights and opposed by us all.

Andy Porter is the Director of MIND in Brighton and Hove and is also an active campaigner against the Criminal Justice Act.