Sir, – Recent proposed revisions to the Mental Health Act are troubling, particularly the plan to raise the threshold for psychiatric admission and treatment.
Only a tiny proportion of people attending mental health services will be admitted to hospital, and even fewer are detained under the Mental Health Act.
For those few who are detained, it is because they are suffering from a severe mental illness, most likely with psychosis, where a core feature is not realising that you need treatment.
Autonomy is a noble goal, but usually a temporary loss of autonomy to enable treatment leads to greater autonomy and quality of life in the longer-term for people with severe mental illness.
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The proposed legislation has many failings, but the most serious is the proposal to raise the threshold for detention to an immediate risk.
If you don’t pose an immediate risk you cannot access treatment.
If this were to be accepted in the false dichotomy that physical illness is different to mental illness, we would not admit people to medical and surgical wards unless they were on the verge of dying.
We already have many people with serious mental illness in extreme poverty, sleeping rough, or incarcerated, and these proposals will lead to even more people caught up in homelessness and the criminal justice system, not receiving the treatment that they need and experiencing poor quality of life and premature death.
We do not have to look far to see the consequences of this revolving door approach in other countries, such as parts of the US, and those of us who have experience of working in such systems are alarmed that we are moving in that direction in Ireland.
Irish society has prided itself on caring for and protecting the weak and the vulnerable, but we are at risk of denying the vulnerable the human right of timely healthcare and treatment.
The need for evidence-based mental health legislation is dire to avert the likely outcomes of more homelessness and misery that are definitely on the horizon. Action is needed now.
If psychiatrists do not stand up for the severely mentally ill who will? We, in a similar way to our patients, have often been silenced in the face of misconceptions and stereotypes of what is mental illness and what is modern evidence-based psychiatric treatment.
Our most vulnerable patients are sometimes unable to recognise that they are ill and will benefit from treatment.
We as their doctors require society to support us with a humane legislation that enshrines their access to treatment. – Yours, etc,
Dr EUGENE BREEN,
Dr CHARLES BYRNE,
Dr AOIFE HUNT,
Dr RICHELLE KIRRANE,
Dr PAUL MATTHEWS,
Dr AIDEEN MORAN,
Dr MAEVE MORAN,
Consultant Psychiatrists
and Members of the
Faculty of Adult Psychiatry,
College of Psychiatrists
of Ireland,
Dublin 2.
Sir, – We are writing in response to a letter by Dr Paul Matthews (April 3rd). While the Irish College of Psychiatry has been compelled to act by a surge of concern among frontline psychiatrists, our group, some of whom have "frontline" expertise of being detained and treated under mental health legislation, also feel compelled to act out of concern for human rights violations. Under current Irish mental health legislation, people experiencing severe mental distress are at high risk of being denied the right to make decisions about their treatment, deprived of their liberty and having their human rights violated.
Surely, the people with lived experience of being treated under this legislation are the most important “experts” on this?
This is not based on a “shallow” and “misguided” view of mental “distress” based on One Flew Over the Cuckoo’s Nest, this is based on recent “lived experience” of being detained and treated under our mental health legislation by a sizeable number of people in Ireland.
We need to challenge the assumptions we have about people who experience severe mental distress and how they are supported.
Mental health is the only area of healthcare where people can still be treated without their consent, even though research shows no greater risk than the general population. “Lack of insight” is often used as a justification for this, but research shows people in mental health settings have similar levels of decision-making capacity to those in general healthcare settings. The threat of coercion permeates the whole system and affects everyone admitted on a voluntary or involuntary basis due to regrading powers in the legislation.
It is misleading to state that people won’t be able to access treatment unless they pose an immediate risk. People can access treatment and care they wish to receive without the need for coercion if appropriate supports are provided. We are confusing coercion with access to treatment and care, but what form of treatment and care are we offering? Last year, the WHO released a report that signalled the failure of biomedical mental health systems and stated that a fundamental shift within the mental health field is required.
There is no evidence that coercion works. It has a profound impact on the person and should not be viewed as necessary to treat people. Research suggests that it can lead to more trauma from which the person has to recover from, lead to a loss of control and deter people from seeking help when they need it.
Coercion is extremely stigmatising for the person and can lead to a breakdown of trust in therapeutic and family relationships, leading to further isolation and alienation.
We don’t have to look to the US to see what can happen when people are not given appropriate supports and are deterred from seeking help when they need it.
Statistics show there is already a high level of mental health issues among people in our criminal justice system and on our streets.
Our new Assisted Decision-Making (Capacity) Act provides a system of supports to enable people with capacity issues to access treatment and care without the need for coercion. Our new mental health policy, A Shared Vision, also states that coercion should only be used in emergency circumstances. Why is our mental health legislation not moving in the same direction? Ireland is obliged to move away from coercion to a human rights-based approach to comply with the UN Convention on the Rights of Persons with Disabilities. This is not “sneaking it in through the back door with talk of autonomy and human rights”. Dr Dainius Puras, a psychiatrist, and former UN special rapporteur on the right to physical and mental health, along with other psychiatrists, has called on states to move away from these practices. The real tragedy is that people are still being treated under coercion and having their human rights violated in Ireland in 2022. This is at odds with WHO guidance, the UN and international best practice in mental health.
Respecting human rights leads to better outcomes for everyone, people using mental health services, frontline staff working in services, families, and society.
It enhances recovery, helps eliminate stigma and discrimination, and promotes a sense of trust and respect. People with lived experience are best placed to judge this legislation based on the care they received under it.
We need to consider how the legislation puts us all at risk of human rights violations and work together to achieve better outcomes.
A strong ethos of respect for human rights in our mental health legislation is surely better for everyone! – Yours, etc,
Dr FIONA MORRISSEY,
Disability Law Researcher,
Lecturer, ATU,
Adjunct Lecturer,
NUI Galway;
JENNIFER HOUGH,
Family Member;
Dr CHARLES O’MAHONY,
School of Law,
NUI Galway;
FIONA ANDERSON,
Recovery Expert
by Experience;
Dr LIZ BROSNAN,
Academic, Survivor
Researcher,
Recovery Expert
by Experience;
ROSY WILSON,
Recovery Expert
by Experience;
Dr HARRY GIJBELS,
Retired Lecturer, UCC,
Former Mental
Health Nurse;
DEIRDRE LILLIS,
Advocate,
Social and Health
Education Project,
Galway.