July 4 juillet 10:15 – 12:15
Room NCDH–201
Chair: Trevor Hadley
, University of
Pennsylvania
In December 2000, the government published its white paper
on the reform of mental health law, heralding the most significant
reconsideration of mental health law in England and Wales in almost half a
century. The expert panel established to advise the government on these reforms
had based their approach on a variety of principles. Insofar as possible,
treatments for mental disorder were to be treated in the same way as physical
disorders (a principle of non-discrimination). Values such as autonomy figured
highly. Differential standards of intervention were proposed for those of
differing decision-making capacity, and due process safeguards were introduced. The government’s response takes a
markedly different tack. Non-discrimination, autonomy, and capacity have all
been abandoned as principles at the base of the legislation, and due process
safeguards have been considerably reduced. Instead, the government’s objective
would appear to be expanded enforcement of treatment regimes. In the words of
the Minister of Health, “Non compliance can no longer be an option when
appropriate care in appropriate settings is in place. I have made it clear to
the field that this is not negotiable.” The white paper adopts a variety of strategies to justify the
more restrictive approach. Chief among these is the appeal to
risk: wider powers are said to be necessary to prevent violence by people
with psychiatric problems. However, closer examination of this claim exposes it as problematic. Homicides by people
with mental disorders are lower than they have been for decades, and there is
little evidence to demonstrate that the increased powers proposed would reduce
these rates appreciably.
Further, the proposed amendments do not concern merely those at risk. The
proposed criteria for coercive orders may be justified not merely by risk to the individual or
to others, but alternatively on an ill-defined concept of ‘best interests’
of the individual concerned. The focus in the white paper on the prevention of
risk draws attention from this considerably broader function of the proposed
legislation.
The construction of ‘care’ in the professional and the
UK legislative and policy arenas has been the focus of much interest in recent
years. The introduction of the Carers Act and the strategy document ‘Caring
for carers’ highlight the importance government places on the ‘carer’
role. In mental health a ‘carer’ may also be a nearest relative as defined
by the Mental Health Act 1983 and have rights and powers under that Act. Growing
attention to the needs of ‘carers’ in their own right and a recognition of
the conflicting needs of ‘carers’ and users of services informs practice in
health and social care, whereas discourses of care focus on ‘care’ as duty,
burden and responsibility. The complexity of the roles and tasks that make up
the lived experience of someone who ‘cares’ for and about another is well
documented, especially in the areas of
older people, physical disability and learning disability. This paper
seeks to locate individual experiences of ‘care’ in mental health alongside
the construction of ‘care’ in policy and legislation within mental health in
the UK. It is argued that discourses of ‘care’ developed in relation to,
say, older people or people with learning disabilities do not fit easily in
mental health. Professional and legal expectations of the role of a ‘carer’
of people in a relationship where one or both partners have a diagnosis of manic
depression may not be shared by the people themselves. The paper draws on
preliminary research with partnerships and couples, and an analysis of the
development of ‘care’ in policy and law to suggest that, while practitioners
in health and social care recognise the needs of people who consider themselves
to be ‘carers’, not all people subscribe to the identity of ‘carer’ or
‘cared for’ in their relationship. Those involved in Mental Health Act
assessments and appeals against detention need to ground approaches in
people’s own experiences and meanings.
In
England, the government is currently undertaking root and branch reform of the
law relating to mental health. This paper will investigate the rights of the
mentally disordered in the context of this reform, critically examining the
extent to which the shift towards change has been caused by a crisis in mental
health law. It will suggest that the lack of faith in relation to the current
framework for the detention of the mentally disordered which has led to the call
for reform has been fuelled by the media, rather than by true failings in the
law. Of particular controversial significance is the government’s intention to
introduce a new indefinite (though reviewable) detention order for those with
severe personality
disorder
who are considered dangerous. The fact that such orders are intended to apply to
offenders and non-offenders alike has caused concern. Indeed, there is evidence
that the medical profession has been thrown into disarray, with a claim that the
new order may be boycotted (see BMJ, 7 April 2001 (Volume 322, Issue 7290)). It
appears that ‘treatment’, hitherto the key to the lawfulness of detention on
the basis of mental disorder, is rapidly being replaced by ‘management’. The
inevitable tension between the right of the mentally disordered person to
liberty and that of the general public to protection is becoming heightened;
indeed, the recent incorporation into English law of the European Convention on
Human Rights and Fundamental Freedoms by way of the Human Rights Act 1998 is
already having an impact on mental health law.
In Alberta, forensic services have been recently integrated
as part of a provincial forensic psychiatry program. The Provincial Forensic
Psychiatry Program focuses on integrating services with the community and
facilities across the province. The Provincial Forensic Psychiatry Program of
Alberta has to provide expert and specialized inpatient and community
assessment, treatment, rehabilitation, follow-up, consultation and
education-research services for, or related to, adults and adolescents with
mental health problems who are in conflict with the law. The target population
includes adults and adolescents who are 12 years of age or older, in conflict
with the law or thought to have mental health problems, legally mandated for
assessment and treatment services and require assessment and treatment for
mental health or behavior problems. Priority is given to individuals who are on
probation, those with court-ordered treatment conditions, sexual and violent
offenders and individuals with severe or persistent mental illness. Community
Forensic Psychiatry Services are to be developed in partnership with the
Government Ministries inclusive of Justice, Regional Health Authorities, Alberta
Mental Heath Board, Community Mental Health clinics and provincial programs.
Interdisciplinary team members of the community geographic teams will be part
of, and coordinated through, one of the clinical core centers of the Provincial
Forensic Psychiatry Program. Mental health treatment services are to be provided
in the community whenever possible for forensic psychiatry clients. These
services would include individual, family and group therapies for violent,
sexual, mentally ill, not criminally responsible, and other adult and young
offenders, and psychiatric clinics in correctional facilities and group homes.
Community geographic teams will be developed to work in
conjunction with core forensic psychiatry services situated in Edmonton
and Calgary. Community geographic teams are defined as dedicated resources that
will be developed in partnership with Regional Health Authorities, existing
Community Mental Health clinics and other provincial programs. These resources
will include direct and indirect services in other regional centers and rural
areas for those individuals who have difficulty with assessment and treatment
due to distance, transportation, lack of forensic psychiatry expertise in more
remote areas. Consultation-liaison services would be available for clients who
access the general mental health crisis services that are available in all
regions, thereby diverting clients who would have previously been directed to
the forensic system. Other specialized services which would be offered would
consist of provincial family violence treatment programs and diversion
strategies which would, again, divert mentally ill individuals from the justice
system to the general mental health system.
In recognition of the shared responsibility between ministries and the community, with respect to mental health and justice related issues, Alberta has adopted a unique approach. A Partnering Deputies Committee for Mental Health and Justice has been created to support the delivery of services at a provincial level. Working in partnereship as government ministries (Alberta Health and Wellness, Children’s Services, Justice, Community Development, Human Resources and Employment) with non-government board organizations; namely the Alberta Mental Health Board and AADAC, there is a commitment to collaboratively plan, develop and implement an integrated approach to improving service delivery/support to Albertans with mental illness and involved, or with the potential to involved, with the justice system. The purpose of the Partnering Deputies Committee is to provide mental health and justice initiaves with an authoritative and decision-making body to ensure successful implementation, consistent with strategic direction and policy framework.
The authors will describe the process used to develop an
integrated service delivery model, and teh Terms of Reference of the Partnering
Deputies Committee, Mental Health and Justice. Examples of four provincial
initiatives that have been developed from this approach will also be presented
inclusive of a Provincial Family Violence Frameweork, Provincial Diversion
Strategies Framework, Young Offender Services and a provincially focused
Forensic Psychiatry Program.
The Australian state of New South Wales has a population of
7.5 million, the capital, Sydney, a population of 4.5 million. Central Local
(Magistrates’) Court is the court of summary jurisdiction for the inner city area covering the major hotel, business
and tourist district, a number of residential areas, and a deprived inner city area with a
number of hostels
for the homeless and a significant population of itinerant street
dwellers. The court processed more than 4000 cases in 1998, the most
recent year for which statistics are
available. In February 2000, a new psychiatric assessment service was
established in the
Central Local Court covering the inner city region of Sydney. Central
Local Court Psychiatric Service is manned by a full-time psychiatric
clinical nurse consultant, a part-time consultant forensic psychiatrist and
a roster of on-call trainee forensic psychiatry registrars. In its first
year of operation, the Central Local Court Psychiatric Service received more than 200 referrals. This paper will present an
analysis of the
first year of operation of the service, look at some of the issues
raised in the process and the implications for the future of this and similar services.
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