NAPIER UNIVERSITY
WEBINAR SCOTTISH MENTAL HEALTH LEGISLATION REVIEW
REDUCING COERCIVE TREATMENT.
Graham Morgan 23 March 2022
Hello everyone
My name is Graham Morgan, I am the chair of the involuntary treatment work stream at the Scott review and have had and continue to have experience of being treated against my will because of mental illness.
I am going to spend the next few minutes talking about what we think might lead to a reduction in coercive practices.
Coercion is a loaded word, especially to those working in the world of mental health trying to make a difference for people like me. Internationally, detention, treatment taken against our will, is seen as an act of coercion and by that we include the compulsory actions taken under the mental health act and the adults with incapacity act as well as restrictive practices such as restraint and seclusion and less obvious infringements of our liberties such as covert surveillance or medication or restricting who we may socialise with.
Whilst we know the majority of these restrictions are enacted with the intention of creating a better life for us and of enhancing our rights overall, we also know that they can and do cause harm.
A kind way of saying this might be that a surgeon has to cause harm in order to create health and maybe we sometimes need sectioned in order to be able to live.
We based our thoughts on the wealth of literature there is on coercion. This varies from the consultations involving hundreds of people with lived experience and their carers in Scotland, both before and during this review as well as through a search of the literature and evidence to date and numerous meetings with national and international experts during the review and the debates we held within our own compulsory treatment advisory group.
Perhaps most importantly we heard from people with lived experience that most of them think there are occasions when people need to intervene against our will. However despite saying this; these same people said that this does not always have to be necessary and that such interventions, despite their best intentions, are also almost always inherently harmful.
At the moment we think some coercive practices will need to happen for the foreseeable future but that these can be reduced and their necessity and harm diminished greatly.
I am going to spend the remainder of this talk saying how we think this could happen.
In our consultation we talk of the need to define coercion and make some suggestions for this. A definition is needed for a number of reasons, it can be used to help with the balancing of our rights and deciding on the need for interventions we may not want and it can also help when deciding whether and how particular levels of coercion should be authorised. Gathering of the data we need will also allow us to work out why it is exists in certain communities more than in others and from that work out how to reduce it.
We think we need laws that regulate coercive practices and that they can provide safeguards and support the wide range of rights we have. We also think that currently there may be some forms of coercive practice around such as restraint and seclusion where we are not yet sufficiently protected.
We also think that there are fundamental changes needed to how we approach our care and treatment that could lead to a reduction in coercive practice. We may not be able to eliminate coercion but hopefully we can start on that road.
Some of this may be stimulated if we learn from and implement approaches we already know are successful abroad, such as the Trieste model or the approach in Heidenheim or by using some of the open dialogue approaches from Finland.
Others may be seen at a societal level; too many of us feel alienated and marginalised by society and can as a result be suspicious of the mainstream and regarded as a threat by society. If we create a society that encourages a sense of belonging, connection and trust then we can reduce that tension and by doing so create services that are in tune with or developed by different communities; whether these be by diverse ethnic communities, the homeless community, deaf peoples communities or the wide range of other communities distinguished by the sense of difference that society bestows on them. Peer support and community mental health services that are genuinely based in the community and a network of wellbeing hubs may lead to a situation not only where our quality of life improves but also where less of us get into crisis and if we do, it is caught early.
Equally interventions such as early intervention in psychosis, intensive home treatment, crisis houses and services and other approaches may help with crisis and prevent our crises from getting to the point where coercive interventions become inevitable.
How these services develop we think will need to be decided on by all of us in the future, we need to use the evidence of what works for us and the research from practitioners and people with lived experience and their carers to create a society where we have some confidence that we can get the support we need to prevent, if at all possible, those terrible times when we end up in hospital against our will.
If we do end up in hospital we need to be sure that such places have been sufficiently invested in, that they are as pleasant as they can be and have been resourced enough so that approaches like ‘Safewards’ which have been shown to reduce coercion at a ward level can be successful.
Too many wards feel like toxic places where we are bored and uninvolved, where the environment is off putting and staff too busy to pay attention to us. If instead we could support each other, feel a degree of control, and a say in what happens to us have things to do and have attractive places to go to on and off the ward and if staff had enough time and enough investment in their own value and importance then maybe our stays would feel better.
At a very practical level there is the issue of safeguards for compulsory treatment: looking at what coercive practices are authorised and how they may be used. We want to look at short term detention certificates ; for instance research from the Mental Welfare Commission has shown that many short term detention certificates lapse rather than stopping due to an assessment of the need of them.
We are considering the level of restriction carried out in secure care and at the time limits on detentions well as the authorisation of specific forms of restraint.
We think we may need to look at the scrutiny powers of the Mental Welfare Commission when looking at the various forms of coercion that exist and that this needs to include addressing the systemic reasons for different forms and levels of coercive practice.
You have heard earlier about the range of supports we need – we are considering looking at the powers the mental health tribunal has and whether it should be able to require a range of supports to be made available in order to reduce the need for compulsion and to give us the best possible support if we are being treated against our will.
When looking at the definitions of coercion and its operation we think we should have regard to Seni’s law in England and the definitions they use there as well as definitions used in the Netherlands. Monitoring of coercion should not be just an academic exercise but should also include the need to reflect on and adjust practice in light of any events that have happened.
In parallel to this consultation we are also looking at the reasons for the rises in compulsory treatment that have undoubtably occurred over the last couple of decades. It may take much work beyond this review to clearly identify the reasons for these rises but hopefully a better understanding of this will lead to better approaches.
We are also asking the Mental Welfare Commission to look at the huge rise in Compulsory Treatment Orders that are carried out in the community. There is limited evidence on their worth or not. In Scotland there is some evidence that they reduce the time people spend in hospital but also evidence that they are racist in their implementation with black people being disproportionately treated under them.
There is also evidence that although the quality of people’s care may increase under them that people can feel unnecessarily stigmatised and controlled by them.
Again in line with our wider thinking we are considering the range of supports offered to people on these orders with the assumption that at present the focus is perhaps, too narrow.
That is me finished for the moment – I hope this gives a broad introduction to this area – we are very keen to know your comments and thoughts on it – do please ,despite its length, look at the section on this in our consultation document –our proposals are innovative so I think if you see this in writing it will make more sense.
Lastly, if I haven’t already said too much, it would be good to see a systematic improvement programme led by Scottish Government and involving services, people with lived experience and regulatory bodies, over several years, to reduce restrictive and coercive practice across the mental health system and also more Academic research on approaches to reducing coercion which is led by people with lived experience; I think this may give unique perspectives and lines of enquiry that we haven’t thought of before.
Thank you
(Photo, Navigation lights -Helensburgh Pier Feb 2022)
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