Beyond the encouraging rhetoric: what will this actually mean for people in practice?

I never met my grandfather. He died in 1954, long before I was born. I know that he was a police officer in London during the Second World War. I know that after the war he experienced post-traumatic stress. And when I was 17 I found out that he had died in the Three Counties Hospital whilst being given Electroconvulsive therapy (ECT). Six years of detentions and ‘treatment’ didn’t help him to recover. Instead, it had led to memory loss, outbreaks of violence, and ultimately his death. 

It became one of several Big Family Secrets. The stigma and shame of ‘the asylum’ led the family to live the lie that “he died of a heart attack when he was shaving”. In the words of Philip Larkin, “Man hands on misery to man / It deepens like a coastal shelf”. So it was with my dad – and so it is with me.

To some, this might sound like part of a subplot from Call the Midwife or an episode of Who Do You Think You Are? The (hopefully) well-intentioned, but barbaric practices of the past. Something that we can keep at a safe distance. Because things have changed since then, haven’t they…? live in a different age; an age where we are now moving steadily towards ‘empowerment’, ‘choice’, ‘autonomy’ and ‘therapeutic benefit’.  

Well, that’s what the recommendations in today’s report of the Mental Health Act would have you believe, anyway. The report recommends that four essential principles should be enshrined in legislation covering: choice and autonomy, least restriction, therapeutic benefit and the person as an individual.

Of course, these principles will indeed have greater weight if they become part of legislation. But beyond the encouraging rhetoric, what will this actually mean for people in practice? It isn’t enough to use language of ‘autonomy’ and ‘choice’ or claim that we are now moving towards ‘rights-based’ legislation when the stark reality is that it is still legally permissible to detain and treat people against their will.

Detention is a traumatising experience for many people and practices of coercion and restraint continue to remain a central aspect of many people’s mental healthcare. A small survey conducted by NSUN in 2016 asked people about their experiences of restraint. Respondents frequently cited the unnecessary use of physical force and the number of staff who were involved in each incident. There was also a clear link between instances of physical restraint and tranquillisation with retraumatisation: 

When I become agitated it is very obviously extreme fear and terror. On each occasion it is ALWAYS male staff pinning me down – always face down so [I] can’t breathe or move and who pull my underwear off/down to inject. They know the abuse history – it has been a police case. They never have talked to me afterwards. It is like being raped again.

The experiences described in the NSUN study are consistent with studies of women’s experiences of restraint representing events that re-enact experiences of trauma and sexual abuse (Gallop et al 1999). Today’s report also acknowledges that restraint:

“continues to be a routine occurrence on many wards, affecting disproportionately those from ethic minority populations, women and girls. Restraint, and particularly pain-based restraint and prone restraint, can be frightening and life threatening. Not surprisingly, sexual assaults and restraint can lead to lasting trauma for those affected”

That being the case, practices of restriction and coercion shouldn’t just be about what is ‘least restrictive’ as today’s report recommends. It needs to stop being legitimised in its entirety.

Survivors of the mental health system continue to share with each other their experiences of the many violent and abusive practices that continue to be perpetrated in the name of ‘care’, ‘treatment’ and ‘recovery’. In a recent article, Rachel Rowan Olive writes about The complaints I never made. She isn’t writing about the 1950s, she’s writing about her experiences over the last five years. The report itself states that only 30% of the respondents to their survey of service users and carers felt that they had been treated with dignity and respect.

We urgently need a Mental Health Act that is genuinely rights-based, draws on the collective knowledge and experiences of mental health service users and survivors and goes far beyond today’s recommendations for change. It is not enough to claim that in the future “even when deprived of their liberty, patients will have a greater say in decisions, including decisions about how they are treated” when the essential power dynamic remains the same.