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Something to think about

By Anon

I was very interested to attend this year’s Annual Meeting of the Royal College of Psychiatrists as a service user representative. I was joined by National Perception Forum’s Vice Chair, Keith Hall. The meeting took place over 4 days at the Imperial College in South Kensington, London.

A particularly stimulating session took place on the second day when there was an open debate on the motion that “This House believes that there is no place for a Mental Health Act in modern society”. Two psychiatrists presented their cases – one for and one against the motion - and then there was a general debate amongst delegates ending in a vote. The psychiatrist arguing for the motion said that 25 per cent of the world’ s countries manage without any sort of mental health legislation and that in England it is the way that people are labelled with a mental health problem rather than the symptoms they display that results in them being detained. It is not ethical to impose treatment on people who have mental capacity. Because of the mental health act 58 per cent of the general public see psychiatry and mental health treatment as coercive. They view psychiatrists as being on a power trip and abusing their power by detaining people in psychiatric hospitals. It is a false argument that the mental health act protects the public, especially as only 5 per cent of violent crimes are committed by the mentally ill. Some people enter psychiatric hospital on a voluntary basis but as soon as they discover what a disgusting and frightening place the psychiatric ward is they want to discharge themselves and leave as soon as possible. It is at that point that they face the nightmare ordeal of being detained under the mental health act so they are compelled to remain in hospital and lose their liberty. No wonder no one wants to enter hospital voluntarily. The hospitals are such terrible places that the majority of patients have to be forced to stay – surely instead of the mental health act it would be better to make hospitals places where people will feel happy to be treated in rather then compelled to remain.

The psychiatrist presenting the case for the mental health act said that the legislation was paternalistic and brought people back into good health. He talked of the role of the psychiatrist in relation to society at large. It is a humane legislation aimed at managing treatment and protecting society. The loss of liberty imposed by the mental health act was a short term loss for the long term gain of restored mental health. It compared to the loss of insight and mental capacity that mental illness brought.

Readers will not be surprised to learn that in the ensuing debate, psychiatrists supported the speaker arguing against the motion and that the motion was rejected by a large vote. I came away feeling that the argument was too black and white and an extreme of views – that is either a mental health act or no mental health act – I would have preferred an argument for some sort of middle ground.

On the final day of the annual meeting there was an interesting plenary debate on the motion: “Is it acceptable for people to be paid to adhere to medication?. The chair opened the debate by asking delegates to vote “yes”, “no” or “don’t know”. Interestingly the votes cast were: yes: 32 no: 74 don’t know: 13. I admit to readers that I was a “don’t know” vote.

As with the debate on the mental health act, the debate started with two psychiatrists arguing for and against the question. The psychiatrist arguing that it was acceptable to pay service users to adhere to medication pointed out that whilst some medical professionals felt that giving money offended virtue, giving money to shape social behaviour was in fact a corner stone of society. Paying service users to comply with their medication would incentivise staying well and keep people out of hospital – it was also empowering. Offering payment would help to get over the hurdle and ease difficulties that compliance with medication can cause. Offering payment could be seen as part of a general therapeutic approach to mental health care and would not disempower service users - it would be a better application of money than the cost of hospitalisation which results when patients lapse from the medication. Payment would assist people in keeping well and leading their own lives. Paying people to adhere to medication was an exciting new idea that was certainly worth trying to see whether it worked.

It was then the turn of the psychiatrist arguing against the proposition (incidentally she was a psychiatrist from Broadmoor Hospital). She opened by saying that interventions do not always have the intended effect. Paying service users could undermine the ethical relationship between patient and doctor. The doctor/patient relationship would become a matter of commerce and cease to be therapeutic. Making mental health a matter of commerce would undermine mental health services. People wanted therapy – not money. It was a delusion that payment would make people more compliant and reduce hospital admission. It was a dangerous argument as what would happen if people were offered more money not to take their medication and what would the effect be on the patient if their payment ceased because they had not complied with medication – it would be a form of punishment and not therapeutic. Patients could become dependent on the payments and lose autonomy – psychiatry would also cease to be seen as paternalistic. Paying is merely a superficial solution to difficult problems – it is a cheap easy way out as there should be other incentives to help people stay in good mental health.

This was followed by a lively debate from the floor and it seemed that the more forceful voices came from those who disagreed that people should be paid with only very few in favour of the idea. This was reflected in the closing vote: “yes”: 43 “no”: 72 “don’t know”: 5 – again I remained – and still remain - a “don’t know” on the issue, although I think it is an interesting idea worth exploring further – but obviously not by the Royal College of Psychiatrists whose view – after the debate – is firm on the matter.

I am very pleased that psychiatrists are debating such provocative and interesting ideas and it made for an interesting annual meeting. I came away thinking what a different world it would be if these two motions had suddenly found favour with the Royal College. Certainly if you readers have any views for or against these ideas it would be of great interest for Perceptions Magazine to receive them.