'Empowerment' crucial to advances in mental health


OPINION:THE STEERING group on the review of the Mental Health Act 2001 has just published its interim report. This highlights the contradiction between the paternalistic ethic that informs the Act and the recovery approach advocated by A Vision for Change (the national mental health policy) and the Mental Health Commission.

A key element of the recovery approach is the promotion of patient “empowerment”, including the right to define the nature of one’s problems and to be centrally involved in decisions about treatment.

This approach involves questioning the sole authority of the medical perspective in mental health issues.

The report is to be welcomed. But to get beyond paternalism, we (patients, carers, psychiatrists and other professionals) will have to consider how to deal with risk situations without ceding decision-making power to a single professional group.

Consultant psychiatrists are given huge powers and responsibilities under the terms of the Mental Health Act. An application for involuntary detention may be made by a relative or other named individual and a GP is required to support this with a recommendation order.

However, once an individual is detained power resides with the consultant psychiatrist. And they are endowed with the authority to determine the nature of the problem, plus the vocabulary that will be used to describe it.

Moreover, the psychiatrist has the power to determine what treatment will be used, how it will be used and its duration. It is also within the psychiatrist’s power to decide what risks to the patient’s health will be tolerated.

They can order electroconvulsive therapy even if the patient, or their family, refuses it. Though the patient is seen for a second opinion shortly after admission, this is also carried out by a psychiatrist. The three-person tribunal team that reviews the admission order always includes a psychiatrist.

The powers invested in psychiatry are a legacy of the asylum era and can no longer be justified on scientific or moral grounds.

The 2001 Act not only predates A Vision for Change but also the massive cultural changes we have witnessed in recent years. Scandals involving politicians, banks, financiers and the Catholic Church have seriously undermined trust in our major institutions. Deference to authority figures is no longer the order of the day.

The medical profession has not been without its scandals either. There is evidence that a significant section of academic psychiatry, internationally, has been corrupted by its links with the pharmaceutical industry.

The development of second-generation antipsychotics, heralded as one of the great achievements of psychopharmacology, made huge profits for the companies producing them. Long after their introduction in the 1990s, patients and relatives were told about their safety and efficacy. There was talk about a “breakthrough” in treating schizophrenia.

We now know that these drugs are no less toxic than earlier ones and there is no evidence that they are more effective. In a recent editorial in the Lancet, two senior figures in British psychiatry wrote: “Second-generation drugs ... are no more efficacious, do not improve specific symptoms, have no clearly different side-effect profiles than the first-generation antipsychotics and are less cost-effective.

“The spurious invention of the atypicals can now be regarded as invention only ... But how is it that for nearly two decades we have, as some have put it, ‘been beguiled’ into thinking they were superior?”

Antipsychotics are probably the drugs most often administered to patients in dentention. But the science of these drugs is a mess and psychiatry stands accused of being “beguiled” into using and promoting them through its links with the pharmaceutical industry.

Even if the science of psychiatry was genuinely disinterested, and its veracity assured, privileging the voice of one profession in the world of mental health is problematic for other reasons.

In a recent qualitative study of the impact of coercive interventions, it was found that while some service users who received such interventions felt that involuntary treatment was sometimes needed, many felt their crises could have been managed differently. They said “ways that problems were formulated by mental health staff as psychiatric issues were sometimes contrary to the ways patients saw their problems and what was needed to solve them”. Participants in this study reported that the experience of involuntary treatment had left them with a “general distrust of others, particularly of medical professionals”.

They reported living their lives as if “on probation” in the aftermath.

This not only has implications for the personal relationships between psychiatrists and patients, but also for the profession and society it serves. As long as psychiatry is bestowed with powers to incarcerate and to treat on an involuntary basis, fear will persist.

The review of the Mental Health Act offers an opportunity to rethink the ways we deal with risk. Psychiatry should seek to minimise its role in the authorisation of force.

Such a move will require an understanding of the nature of expertise in mental health. But it could work to transform positively the relationship between psychiatry, its patients and the wider society.

Dr Pat Bracken is a consultant psychiatrist and clinical director of the west Cork Mental Health Service.

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