I’ve been doing a lot of reading this week around the role of mental health law and psychiatry in society. This was initially sparked by my needing to find a strong argument against mental disorder as a positivist identity for another piece of work, which naturally led me to Szasz. I’ve previously described Szasz’s thoughts on the moral nature of mental illness in a previous post.
This week there has been a substantial discussion through the Critical Psychiatry Network on the role of Community Treatment Orders in mental health law. Community treatment orders (CTOs) were introduced in the UK partially in order to address the difficulty whereby individuals were repeatedly admitted and discharged from hospital under the mental health act – the charmingly named “revolving door patients”. CTOs allow the continuation of your detention under the mental health act in the community – such that conditions can be attached to your discharge from hospital; for example that you remain “compliant” (word used advisedly) with treatment and continue to engage with your treatment team. If these conditions are “breached” then the CTO activates in order to “recall” you back to hospital.
Officers of the state?
The existence of mental health law in many countries around the world places psychiatrists and other mental health professionals in an interesting, if morally difficult, situation. Szasz argues strongly that mental disorder does not exist and that the treatment of those with mental disorder as not fully morally autonomous is an abuse (Szasz, T. (2001). Mental Illness: Psychiatry’s Phlogiston. Journal of Medical Ethics, 27(5), 297–301). He continues this argument by suggesting that the subjective nature of mental disorder and the role of psychiatrists in diagnosis places psychiatrists in a morally dubious position. In fact, he suggests, that as psychiatrists are in effect enforcing the will of the state, through the use of the mental health act, this places them more on parallel with police officers and prison officers than medical professionals (Szasz, T. (1994). For Debate: Psychiatric Diagnosis, Psychiatric Power and Psychiatric Abuse. Journal of Medical Ethics, 20(3), 135–138). Szasz, as a good libertarian, does not like people exercising power through the state (Bracken, P., & Thomas, P. (2010). From Szasz to Foucault: On the role of critical psychiatry. Philosophy, Psychiatry, & Psychology, 17(3), 219–228).
I have some sympathy with Szasz’s position – I am certainly uncomfortable with the existence of mental health law as it distinguishes psychiatry from other professions. However – I can not accept Szasz’s denial of the existence of mental disorder and the impact it can have on an individual’s behaviour. I have very strong reservations about our current conceptualisation of mental disorder, but to deny its existence entirely is, for me, too strong an argument.
This places me in a difficult position. In most cases I would argue that if an individual is suffering from mental distress of sufficient degree that it interferes with their capacity to reason then we should be using Mental Capacity Law in the same way as other medical specialties. However there are, a very very small proportion of, people who whilst in crisis with evidence of mental distress act in a way that places themselves and others at risk. At present the Mental Capacity Act is not strong enough to allow for protection of these individuals. I feel that a big review of the current legislation is necessary.
Evidence based CTOs?
An explicit goal of CTOs was to reduce the rate of hospital readmissions through maintenance of the mental health act detention in the community. The ethical argument goes that if I maintain a loose control over your behaviour through the CTO I can reduce your risk of readmission to hospital, and therefore support you in the least restrictive way possible.
The uptake of CTOs following their introduction far exceeded governmental expectations and the rate of detention under CTO remains high – research was obviously necessary to assess the impact of this new legal intervention.
The application of randomised control trials to interventions such as CTOs is problematic and overly simplistic, however they are considered one of the highest forms of evidence in the evidence based practice system so that is what was arranged. The largest, and probably best, of these trials was the OCTET study. The study reported its findings in May this year and showed no reduction in readmission rates compared to use of extended hospital leave as would previously have been done prior to CTO introduction (Burns, T., Rugkåsa, J., Molodynski, A., Dawson, J., Yeeles, K., Vazquez-Montes, M., et al. (2013). Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet, 381(9878), 1627–1633. doi:10.1016/S0140-6736(13)60107-5).
The findings of the OCTET study were reiterated and reinforced this month by the publication of a review in the British Journal of Psychiatry (Rugkasa, J., & Dawson, J. (2013). Community treatment orders: current evidence and the implications. The British Journal of Psychiatry, 203(6), 406–408. doi:10.1192/bjp.bp.113.133900). This paper again reported no reduction in readmission rates and recommended a substantial review of the use of CTOs.
Coercion, psychiatric power and large elephants in rooms
Szasz was distressed by the amount of power invested by the state in practitioners of psychiatry. I share some of his concerns as I have said but can not follow him all the way to the conclusion of his argument.
I do have an ethical difficulty with the level of power that the Mental Health Act invests in clinicians however. If we devise a thought experiment where we are both discussing your difficulties and I, as a psychiatrist, recommend treatment with an antipsychotic drug. Do you refuse or accept? I am concerned that no matter how much eduction regarding the nature of the medication, its role and the additional support you receive that you can never fully avoid being coerced by the elephant in the room that is the Mental Health Act. Lets consider a situation where you may have been detained under the Mental Health Act for assessment (Section 2) and then treatment (Section 3). We begin to discuss planning for your discharge from hospital and I suggest that a CTO may be beneficial in ensuring that you remain concordant with your antipsychotic prescription, perhaps the use of a CTO might enable us to speed up your discharge planning? Again, in this situation I am not sure that it is possible for you to fully participate in the debate without being coerced by the existence of the Mental Health Act and the CTO in particular.
On-going role of CTOs?
I think that the findings and implications of these two reports are pretty conclusive. I can devise scenarios, affecting low numbers of individuals, where I could defend the use of CTOs, however ultimately CTOs were designed and introduced in order to reduce hospital readmission rates and they do not appear to do this.
I am uncomfortable with the use of the Mental Health Act in many situations. I have, unfortunately, seen many situations where I feel that it is being abused. In terms of CTOs I have always been uncomfortable with extension of the act beyond the role of hospital treatment in the short term for crisis intervention. The demonstration that they do not reduce readmission rates means to me that any possible extenuating circumstances become irrelevant, and that the extension of the act should be dropped.
As I said above I feel that the Mental Health Act is in need of revision. I can not see an alternative to its use at present in the case of a very small minority of individuals who pose a risk to themselves or others during time of crisis, but this use should be as brief as possible and lead to large degrees of support and protection of personal rights. The system at present is too open to abuse in my opinion, so on that I partially agree with Szasz – although I don’t think I would suit a police uniform.