REDUCING COERCION ROUNDTABLE

REDUCING COERCION ROUNDTABLE

NAPIER UNIVERSITY CRIAGLOCKHART CAMPUS

7 MARCH 2023

INTRODUCTION.

GRAHAM MORGAN – MENTAL WELFARE COMMISSION

Hello everyone.

Despite the small number of us I am going to read this and give a twenty minute or so introduction to the chapter on reducing coercion from the Scott Review. Hopefully that will inspire discussion later. I work for the Mental Welfare Commission but for some years led the REDUCING COERCION workstream of the Scott Review.

First of all we offended many people with the very name of this workstream – coercive treatment. We spent many hours discussing this and cannot avoid the fact that treatment carried out against someone’s will, sometimes involving force, is by its nature coercive. This does not mean that the people doing this are carrying it out with malicious intent and with the wish to cause harm; in reality we believe that the intent behind most forms of coercive treatment are to avoid much greater harm and that this is usually what happens in practice.

However even though such actions are often carried out to save life I can still vividly remember running down corridors with nurses chasing me and alarms blaring and hate the memory of having a nurse follow me wherever I might go even when I went to the toilet or the shower. I know it was done to stop me harming myself but when I visit a hospital nowadays and hear the alarm go off or see people on constant obs it can bring me back to difficult times in the past. It is for these sorts of reasons that we agree with the Royal College of Psychiatrists that coercive treatment is often traumatic and people need help with this trauma.

I am not going to attempt to define coercion but you can find a table and a description in our report. Simon and I spent many hours working on this and felt we improved on Szmukler’s definition though that is maybe a bit arrogant! As an aside when looking at the harm caused by giving treatment against someone’s will we also thought another equally important element that needs looked at is the harm caused by failing or refusing to offer someone support or treatment especially when they are pleading for it, though I don’t think that appeared in the final report.

We agreed that forms of coercion will need to continue for the foreseeable future and that maybe it will never be possible to eliminate it. We based these opinions on the evidence provided by people with lived experience in Scotland and on international evidence that we obtained but in keeping with Goodings research we think we should work towards the eventual elimination of coercive treatment if at all possible.

Regarding reducing coercion I am going to fall into my idealistic ‘what if’ mode. I think mental illness however we define it and however we see trauma and the social environment as a part of it, is a horrific experience. I have a terrible feeling that some people think that if people were just nice to us and kind and addressed a few inequalities that face us everything would be ok, but we can enter realms where our reality is not amenable to reason and we can find we have emotions and behaviours that, far from being the grateful awkward response to the offer of support are raw wild expressions of grief and pain and anger. We do not always seek out help, sometimes all we feel is pain and pain is rarely something that we can easily deal with, it can be utterly disruptive and destructive even when we are begging and not begging for help at the same time.

This is I think, one of the key reasons why coercive treatment is needed and will continue to be but to contradict what I just said; I do believe that if we have a society and services where belonging and trust are taken for granted then kindness and that very love and compassion may prevent alienation and otherness. If we had a society and services where people were not looked on with suspicion and fear then maybe we would not look on society and services in turn with the same fear. Maybe distress would not get to the point that coercion is necessary or the preferred route.

If we had services we could turn to in the community, such as community and peer support as well as Wellbeing hubs and some alternatives to hospital when we are in crisis. If health Board Psychiatric emergency plans were living documents and the infrastructure of community services were truly in place. If hospital wards were designed so we want to be there and are made to feel safe rather than a clinical environment we feel alienated in and if in future, new buildings are informed by lived experience and look at reasonable adjustment and universal design we might end up with something we appreciate but which also serves its purpose well. If we had policies like ‘safewards’ adopted in hospital and if we can align between the human-rights based approach which we recommended, and the recovery approach: into an approach which would include mutual support, hope, appreciation, being valued, having people ‘on your side’ and having activity which we value and in addition if we had the beds we needed when we needed them and if our friends and relatives were listened to and supported. And If we anticipate crisis and relapse with genuinely participative joint crisis planning which comes into effect before we lose capacity then maybe we would cope better for longer, have better lives and when as will always happen, life falls apart, maybe we will have safe places and people to go to without coercion becoming necessary and if it does, maybe it will be less often and for less time. That is the hope.

As I said hugely idealistic and quite rightly we had many replies to our consultation saying for these things to happen we need resources; that this is less a question of legislation and more about services. And yes it is. It is all about resources, as is developing community and trust and knowing we are a part of our communities. It is more than investing in mental health services; it is about investing in our society, investing and valuing staff and in the elements that mean that some of the most isolated people feel a part of and welcomed.

We found out many international approaches which have been shown to reduce coercion but rather than dictate what we want to happen years and years before anything is implemented we suggest that we have an improvement group with lived and carer experience central to it which looks at and makes recommendations, alongside government about some of the approaches that may ultimately lead to less coercion in the future but also in line with our economic social and cultural rights work stream help create a better quality of life for us. Alongside that we need to invest in research into these issues, especially coercion and to encourage high quality lived experience led research.

Now to slow down a little and to become a bit more focussed.

When we look at coercive treatment in more detail there is little judicial oversight of coercive practices at the time they happen, the levels of coercion and restraint and seclusion that currently exist may be higher than we imagine especially under adults with incapacity legislation and the sorts of coercive treatments that exist may not yet be fully acknowledged, there are of course the obvious in terms of physical restraint and seclusion but elements of peoples lives where they have possessions or food or clothes restricted, or where they have medication they are not aware that they are taking or are surveilled without their knowledge are all things we need to consider. We have a lot to learn from Seni’s law in England and the work that exists in the Netherlands. some of the concrete proposals we have made are to:

· Have increased scrutiny, monitoring and data about coercive interventions such as restraint and seclusion and covert medication which should lead to evidence ultimately about how to reduce it and for this to be led by the Mental Welfare Commission. At the same time those services that gather data about restraint will hopefully use this as a mechanism to examine their own practice and culture in that context.

· A change in the safeguards for coercive treatment, so some would have to be authorised by a tribunal or other body and our second opinion doctors (DMP’s) may need to authorise specific interventions and it may not just be doctors who do this (Maybe this is not just the province of medicine) also for there to be a right of appeal to these decisions.

· Maybe we should make sure we stop people being given treatment without consent if they have been detained but can make autonomous decisions about their treatment options

· Have a right to review of these forms of coercion and to establish a data base and register of restraint and seclusion.

· We think the Mental Welfare Commission should take a lead on analysing data and leading work to make the use of coercive treatment like this as ethical as possible with as little harm as possible, leading to changes in practice and reductions in the use of it.

Regarding detention, I mentioned trust and belonging at the beginning and also different communities of people. We think we should learn from research carried out by the Mental Welfare Commission and elsewhere to make sure that the treatment of people from diverse ethnic communities is such that all assessments have been made on the same basis as for all people, and without any assumptions which could be related to race or ethnicity. People should have been offered at least the same level of support for decision-making as for any other person. Their cultural, linguistic, religious or belief requirements should have been identified and professionals need to show how these needs will be met. If they or their supporters have said that racism or cultural insensitivity may be present we need to know these issues are being addressed. We also want to be sure there is culturally appropriate collective advocacy that the Government will resource and will also empower leaders of Scotland’s minoritised ethnic communities to lead on solutions which ensure access to mental disability services for their communities. It should also address racial discrimination though an approach which develops the Patient carer racial equality framework, with monitoring and enforcement by scrutiny bodies.

My personal opinion is that comparable actions should also happen with other marginalised communities who I imagine future research might also reveal comparable levels of discrimination in mental health services and coercive treatment.

Just to be a bit technical:

The criteria for coercive or involuntary treatment are

a person has a mental or intellectual disability or for the purposes of an AWI intervention is unable to communicate because of a physical disability, whether short or long term, and lacks capacity and in the case of the mental health act that there is treatment which would alleviate symptoms or prevent the disorder worsening and without such treatment there would be significant risk to the health, safety or welfare of the patient or to the safety of any other person, and the order is necessary. It may be that in the future we might need to redefine the criteria if legislation becomes fused or unfused.

you will be relieved that I am now nearing the final stretch of my talk and for this will concentrate on rates of detention, research and some practical changes we can make about detention orders and compulsory community treatment orders.

First of all despite the considerable amount of research that has been done into rising rates of detention here and elsewhere it is very hard to tell whether a rise or reduction in detention rates is desirable or not and why it has happened. It may be that a rise in detention reflects a rise in rates of mental illness and that with austerity and economic hardship crisis and distress increases. Detention in these circumstances may be a right and proper way to protect people from harm.

But perhaps a shortage of community services or perhaps a reflection that with staff shortages and pressure on beds and services a culture may develop where it is easier to detain than to give the sort of support people have a right to.

There is little clarity in this respect and maybe further research studies to see what actions we should take in light of their findings would help, the more data and evidence bodies like the Commission and others can obtain on this will serve to highlight these issues and areas of where change and knowledge may be possible but maybe of as much help, would be to reflect on the Human rights approach we took with the review – there is almost no research around coercive treatment that uses a human rights framework as the basis of the research – we would like to see future research designed that seeks to decide if a person’s human rights are enhanced by certain interventions or not; those balances between the right to life and health compared to rights to liberty and independent living and so on. After all we were tasked to look at our lives and the legislation in the context of human rights, it makes sense for some research in the future to be set up to measure against that framework.

Now onto detention and things like the time we are detained for.

We are aware from research by the Mental Welfare Commission that it is very common for sections to lapse when their time is completed and that this might be in contrast to them being revoked when they cease to be needed. We think there should maybe some pilot studies of different lengths of section to see if this would lead to their use when we are sure that they are needed rather than for them to be used when it seems it may be more convenient to do so.

Regarding Community based orders we are also aware that the evidence of their effectiveness is very weak, with contradictory findings from different studies. Some studies in Scotland show they provide protection for life and reduce days spent in hospital while others show no effect. We suggest that more research is carried out into them to help determine future policy, again looking at their value through a human rights lens, including our economic social and cultural rights but also trying to work out why they have been rising, how they can be best used and who they may or may not be effective with.

Because we cannot be sure either way as to whether they are effective and partly because they are currently not seen as a major issue in Scotland we think we should allow their continued use until we know whether they are of benefit or not. We also think we should make sure that CCTOs will ensure access to recovery-focussed, trauma-informed, community-based services and that from the beginning there are revocation strategies built in to ensure they are being used for the right reasons and to best effect.

I am going to finish with what may seem to be throw away comments but which are important to me and appear in this chapter.

The position of carers, it is often those we love most who are witness and deal with the worst of our distress and are most affected by it. I will never forget my brothers voice cracking with anger when I last talked of how I looked forward to stopping my medication and he said that each time that happened the whole family was on standby for the time I finally succeed in killing myself: those around us need listened to and respected and supported.

I constantly meet people who are told that have the capacity to decide whether to live or die when they are seeking help. It is utterly insulting and makes me think of the wider application of this sort of legislation. Someone I am close to seems to be at the end stages of addiction, going in and out of intensive care all the time, in what world does someone have capacity when they will do anything they can to stop being sober to the extent that they ruin their families life, their friends lives and also kill themselves? Somehow their judgement isn’t impaired? We can argue this with straight faces?

Sometimes I wonder at our definition of mental disability and feel for those who are dismissed as just being unhappy and told to take a walk or run a bath when they cannot imagine living another moment and sometimes I am aghast when people say they get better treatment from the police when they are in crisis than from the NHS. I am fed up with hearing stories about people told to go home at three in the morning with no money in their pockets, freezing temperatures and despair in their hearts – when they are returned to A&E by the police or ambulance a couple of hours later, we should hang our heads in shame.

We need our legislation to constantly have reality checks – a sort of what would you do in this situation ? Would you really? And you would accept the result without worry? A sort of do we have legislation that also allows and creates a common sense approach to the horror so many of us go through and for which we still have few solutions – let us at least empower those who care for us formally and who love us, to have the means to help us when the world is an impossible place.

(Photo's Moniack Mhor March 2023)