Sir, – Dr Emma Farrell (Letters, March 21st) is disappointed by the College of Psychiatrists raising their concerns about the proposed revision of the Mental Health Act and calls it "an outdated mode of thinking that construes coercion with care".
In reality, the college has been compelled to act by a surge of concern among the ordinary frontline psychiatrists that make up its membership. While the “range of experts” who have been talking to the Oireachtas Subcommittee on Mental Health may feel the proposals are reasonable, the one group who have been conspicuous by their exclusion from much of the discussion has been the group with some of the most relevant expertise in the area, the consultant psychiatrists, medical specialists who actually have to work with this legislation on a daily basis. The college was only finally invited to appear before the Sub-Committee on March 22nd. While the college has outlined its reservations, I would reiterate that one of the greatest concerns is around raising the threshold for admission and treatment from the current grounds of a need for treatment to that of “immediate” risk. If you don’t pose a risk you won’t be able to access treatment.
Psychiatrists are deeply concerned that the revised act is based on a view of mental illness that is shallow and misguided, with ideas based more on One Flew Over the Cuckoo’s Nest than an understanding of modern psychiatric care. Mental ill-health is a wide spectrum ranging from transient low mood and anxiety that might be considered just a normal reaction to life’s stressors, all the way up to paranoid schizophrenia, where people are tortured by horrendous hallucinations and consumed by elaborate delusional beliefs.
Only a tiny proportion of people attending mental health services will be admitted to hospital and an even smaller proportion of them will need to be detained against their wishes under the Mental Health Act. For those people who are detained it is because they are suffering from a severe mental illness, most likely with psychosis, such as is seen in schizophrenia, and they are not merely “people in distress”.
One of the core features of psychosis is lack of insight; people’s experiences, their hallucinations and delusions, feel just as real to them as any other sensations or beliefs, so they are unable to see that they are ill. This is how psychosis and other severe mental disorders (such as dementia and eating disorders) can fundamentally differ from other forms of physical illness or disability, because the illness itself prevents people from making rational decisions about their care. Yet, with treatment, most of those who are treated under the Mental Health Act recover, and regain their capacity, and are able to make decisions again. They regain their autonomy and recover the life that they had before they became ill. The alternative for very many, probably the majority, is that otherwise they would not receive treatment, that they would deteriorate further in terms of symptoms, in terms of isolation and alienation, declining in self-care and functioning and moving to the margins of society. Eventually some of these people may qualify as posing an immediate risk and meet the threshold for admission under the revised act, but even those that did would be very quickly discharged from hospital again, still unwell, once that immediate risk had diminished. And we know that people will do worse under such a regime, because all the evidence points towards treating people early and consistently leads to the best outcomes, particularly with psychosis. With so many people mentally unwell, and lacking the capacity to engage in treatment, and mental health services powerless to help them, it is inevitable that we will see these same individuals drifting into extreme poverty, homelessness, and the criminal justice system. We only have to look to some parts of the US to get an insight into what this might look like.
If we wish to prevent the compulsory admission and treatment of people with severe mental illness, such as psychotic illness, then our legislators and we as a society need to make this decision with our eyes open and be fully aware of the consequences. It must not be sneaked through the back door with talk of autonomy and “human rights” without interrogating the inevitable result. It would be a real tragedy if the lesson we take from Ireland’s dark history of dealing with people with mental illness is to deny them access to the treatments they need to help them regain control of their own minds and their own lives. – Yours, etc,
Dr PAUL MATTHEWS,
Consultant General
Psychiatrist,
Kilcock,
Co Kildare.