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Mental Health Bill [HL]

It is rather important to be clear about what we are discussing. We are speaking about legislation the purpose of which is to legally facilitate compulsion. When comparisons are loosely drawn with the question of physical treatments, one should ask oneself what precisely are the contexts in which patients are forced to accept physical treatments? When a patient has a brain tumour, the surgeon is required to receive the patient’s informed, written consent, for without it, it is a gross assault. Over the past few years, we have all been made very aware of the absolute requirement for full, informed, written consent. We are talking about legislation the whole purpose of which is to go in precisely the opposite direction and to ensure that, against the patient’s wishes, they are compelled to accept treatment. I feel, very much like my colleague the noble Baroness, that this clause is actually the key to it all. In many ways, it sets psychiatry right back 150 years. What do I mean by that? Some 150 or 200 years ago, people who were unacceptable because of their behaviour were locked up in jails or put into asylums of various kinds; and that was the progressive step. A few courageous doctors—and in many of these places there were not doctors at all—went out to work. They were called alienists because they were prepared to go out to places where there were no treatments of any kind. It was a question of containing a bunch of people who were very difficult to cope with and manage, who had a whole assortment of problems. What sort of problems were they? Some were organic problems; tertiary syphilis and other infections that left people in a physical and mental mess. Some were psychotic disorders, manic disorders, and a range of what we now know as schizophrenic disorders. Those diagnoses were not even available then. Why? Because it was all just a bunch of people who were disordered in their heads because of alcoholism, drug addiction—of a very different kind to that talked about now—and criminality. Then there were all the young women with moral imbecility: the ones who had had children out of wedlock. I well remember seeing an 85 year-old when I was a junior doctor who had been in a mental hospital since her early 20s because she had had a child out of wedlock. I was seeing her because she was demented, having been there all her life. Mental disorder, undifferentiated, meant that they were all put away when they were causing trouble. As time went on, some alienists began to try to differentiate. Were there any differences between all these people with mental disorder? It became clear that there were. Some had infections; some had psychotic disorders; some suffered from the effects of chemicals, including drugs, alcohol and so on. Some should not have been there at all. Some were petty criminals. Over many decades of careful and painstaking work, spending huge amounts of time with these people—often raising their families in the context of these mental hospitals as a way of spending enough time with these patients to find out what was going on—it gradually became apparent that they were dealing with whole different kinds of things, requiring different kinds of treatment. Why did the changes mentioned by the noble Lord, Lord Soley, happen in the late 1950s and early 1960s? They happened because of the discovery of such drugs as chlorpromazine and amitriptyline. The discovery of anti-depressants and mood-stabilising substances meant that people with bipolar disorders, as they came to be known, could get out. Patients with the range of schizophrenia and paranoid psychoses could have their symptoms dampened down. They were not cured, but their symptoms could be dampened down in order that they could be managed in the community. Most of them did not have personality disorders, in the terms that we are describing now, at all. Psychopaths ended up in prisons, in the Army and in various other places. They were not in hospitals. There were some alcoholics and people at the end of their tether from that point of view, and there was a lot of tertiary syphilis still around. The antibiotics, phenothiazines, anti-depressants and mood stabilisers enabled people to get out into the community. It was not that people with personality disorders were better. What are we doing in this Bill? We are going right back to lumping everybody together under mental disorder—except for alcohol and drug addiction, because even the Government know that if you put that lot in, the whole thing will collapse completely in practical terms. The rest are lumped together under mental disorder, as though it were all the same thing. When it comes to treating these people the first thing you do, as a responsible doctor, is to try to make an assessment to discover what you are dealing with. I am a psychotherapist by conviction and practice. If I am dealing with a psychotic disorder I will nearly always use some medication to try to help contain the disorder and protect the healthy part of the personality, in order that I can work with that. However, if I am dealing with somebody who has a personality disorder, I will almost never give them medication. It is rare to try to treat them in that way because it does not help and creates further difficulties down the line. That is different from how you would deal with a person suffering from alcoholism per se, as distinct from alcoholism in the context of a personality disorder. That, in its turn, is different from dealing with a neurotic disorder, an organic psychosis, or some other kind of deterioration. You try to see the differences in these things and treat them in different ways. I am very familiar with the kind of problem mentioned by the noble Lord, Lord Soley. East Belfast is not a notoriously peaceful part of the world where everybody gets along perfectly. I was a Belfast city councillor and an elected representative for the Assembly; I am more than aware of all the complaints about neighbours from hell and difficult people. I am also aware that sometimes wrong diagnoses are made; a personality disorder is described when it is not that at all, but a psychotic disorder that should be treated as such. However, bad psychiatry does not justify bad legislation. I find myself trying to deal with young people with alcohol and drug addiction problems. We are going to have to try to create a service that is not about medication, but quite the opposite. Let us try to establish degrees and other forms of training in psychotherapy, which did not exist in Northern Ireland. When you set these things up, can you get the resources to make them happen? No. My mailbox at the moment does not contain letters about the enormous growth of services for people with personality disorders. People write to me because the Henderson Hospital is being closed down, along with other facilities where people are being trained and have been working on these things for 30 or 40 years. They cannot get the resources to continue. When I look at my own facility on trying to admit somebody, what do I find? Is it possible to provide the appropriate treatment? Increasingly, mental hospitals provide only custodial care. You cannot even keep the trained staff that you have got, because they are falling ill, taking leave or taking early retirement. They are getting out, because they are dealing with only incredibly disturbed people of various kinds and cannot manage to keep their own heads together, never mind the heads of people like the young psychotic patient, who, from the one, sane bit of her head, said to me, ““Look doctor, please don’t have me go in—I know that I am really disturbed at the moment, but if I go in there, I am going to be worse””. I had to say to her, ““I know that you’re right””. It was actually true, and we tried to find another way of managing her. That is the reality of trying to work in such circumstances. I know that the kinds of problems that the noble Lord, Lord Soley, has described exist; but the question is: what are they about? Are they about individual mental illness? Most of the cases that he spoke of are not mental illness. Disturbances of personality will not be dealt with by the prescription of medication, for example. If you were going to provide some kind of approach that the noble Lord would understand, where would that come from? You could not simply say that it was all for psychiatrists to deal with. Psychiatrists are running away; they are avoiding these difficult people. Maybe part of the reason for that is because, when they have analysed the situation, they say, ““I know perfectly well that I can’t resolve this problem. Not because I don’t want to, or I am not interested, or I want a comfortable life””. This is not fundamentally that kind of problem. I have an interest in terrorism and in dealing with conflict. Lots of people say, ““These terrorists are mad, crazy and bad. They are psychologically distorted””. I have applied my energies to thinking about how psychology and social psychology apply to these people. It does, but not on an individual basis. What disturbs me about this whole approach is that the work of psychiatrists over decades, in trying to clarify the appropriate diagnosis—where does this come from, what is it about, what is the ideology, what is the prognosis of the disorder, what is the appropriate treatment, what is the package of treatment that we must give to this patient that is different from that for another patient?—is being destroyed by trying to deal with a social problem that is not necessarily susceptible to such an approach; it involves bunging them all back into a big bag that says, ““Keep them out of there because my House of Commons mailbag is too full of complaints””. That is understandable—it is a frustration and a real problem—but if we try to make psychiatry bear the burden of it, you will not solve it; you will wreck psychiatry and you will not do any justice to the benefit of healthcare. It is not a question of denying people services. These services do not exist in most cases. What you can do is to ensure that there is support for people in the health service who are already massively overburdened in providing the care that they already provide, and who find that they cannot continue to cope at all, rather than moving things forward to some kind of utopia that tries to deal with all of these problems.