BRITISH JOURNAL OF PSYCHIATRY (2003), 183, 8^9 EDITORIAL

ThepoliticsofanewMentalHealthActThe politics of a new Mental Health Act concern with how to provide care towards a more exclusive focus on ‘treatment’. The Mental Health Bill reduces the JOANNA MONCRIEFF autonomy of psychiatrists in decisions about when to apply compulsion and what form treatment might take. It is not clear to what extent tribunals will engage in the details of treatment plans, but they will have the power to force doctors to ‘treat’ patients when the doctor feels that this is inappropriate. It seems therefore that the tribunal system has been designed to Recent proposals for reforming the Mental first time in the report (Joint increase the use of compulsory powers Health Act show that the Government Home Office & Department of Health rather than to act in patients’ interests. is keen to increase restrictions on current Working Group, 1999). The lack of an independent review body psychiatric patients and to extend the The subsequent White Paper was and the abolition of the Mental Health boundaries of psychiatric legislation. The clearly designed to incorporate both Act Commission further erode mechanisms proposals contained in the new Mental agendas. It also clearly stated the Govern- for protection of patients’ interests. Health Bill (Department of Health, 2002) ment’s objectives with the statement that seem destined to make it easier to be subject ‘concerns of risk will always take REACTIONS TOTHETO THE MENTAL to compulsory powers and more difficult to precedence’ (Department of Health/Home HEALTH BILL be rid of them. Office, 2000). These proposals seem to indicate that The Mental Health Bill has succeeded in the Government is motivated to increase uniting almost every pressure group, social control through the agency of psy- IMPLICATIONS OF THE charity and professional grouping against chiatry. I will argue that although the state MENTAL HEALTH BILL it (the only exception is the Zito trust, relinquished its historical role in which has supported it). The Royal College incarceration of the mad to the medical The Mental Health Bill published in July of Psychiatrists has described recent pro- profession in 1959, it is currently trying to 2002 outlines a detailed framework for posals as ‘unethical, unsafe and unwork- re-establish control over the process by new legislation. The Appendix lists some able’ (Shooter, 2001) and has joined enacting some of the most repressive of the main ways in which it differs from forces with other groups in the Mental psychiatric legislation of recent times. the Mental Health Act 1983. The general Health Alliance to oppose the Mental effect of the proposals is to increase the Health Bill. It is widely perceived that the circumstances in which someone might be Government has no interest in any genuine RECENT DEVELOPMENTS assessed and subjected to compulsory de- process of consultation and it has ignored tention or treatment and to reduce avenues some of the main proposals of the Richard- Informally, the impetus to reform dates for discharge. It will be particularly difficult son Committee, such as the introduction of back over a decade to increasing govern- to argue for discharge from a non-resident the concept of incapacity as a conceptual ment and media concern about the con- or community order. There has been some framework for legislation (Department of sequences of deinstitutionalisation. The debate about whether the new act will Health, 1999bb).). perception was that the closing of the old allow the preventive detention of people asylums meant that people with mental ill- considered to be dangerous. Some have ar- nesses were inadequately contained and gued that the treatability of all conditions HISTORY OF PSYCHIATRIC were putting the community at risk. The remains relevant because ‘appropriate LEGISLATION new Labour Government continued to medical treatment’ must be available express these concerns and instructed the (Sugarman, 2002). However, the existence Modern psychiatric legislation combines Richardson Committee, set up to make for- of a separate clause for people who pose a two distinct strands of law that emerged mal recommendations for new legislation, risk seems clearly to imply that there is no in the 18th century in England. The first to consider how the ‘scope of legislation requirement or expectation, in these cases, is the power of the state to incarcerate might be extended beyond the hospital to that ‘treatment’ will benefit the patient. the mad, which first appeared in the cover care and treatment provided in com- Extension of compulsory powers into 18th-18th-centurycentury Vagrancy Laws, which em- munity settings’ (Department of Health community settings inevitably means that powered local magistrates to confine those 19991999aa, p. 7).7).,p. use of the Mental Health Act will increase considered to be ‘furiously mad and Shortly after the Richardson Commit- above current levels. Community orders dangerous’. The second strand is the tee was set up the Home Office, in direct will entail that the act is applied to people concern of the state with protecting response to the case of Michael Stone, with lower levels of dysfunction than when patients’ interests. This was first manifested announced its concern to use psychiatric it was applied only to people who required in relation to the burgeoning 18th-century legislation to ensure the confinement of admission to hospital. The abolition of ‘trade in lunacy’, with the passing of the people with ‘dangerous severe personality guardianship is an indication of the Act for the Regulation of Private disorders’. This term was coined for the reorientation of legislation away from a Madhouses 1774 (Porter, 1990). This act

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first enshrined the role of a doctor in ‘certi- JOANNA MONCRIEFF,MBBS, MSc, Department of Psychiatry and Behavioural Sciences,University College fying’ madness. ,Wolfson Building, 48 Riding House Street, London W1N 8AA,UK. E-mail: j.moncrieff@@ucl.ac.uk These two concerns persisted through- out the 19th century. The involvement of (First received 3 January 2003, accepted 9 April 2003) a magistrate remained and was extended to private asylums in the 1890, as a further means of regulating this sector.sector. DISCUSSION (b)Non-resident orders for compulsory assessment and treatment in the community. From the first decades of the 20th century the Government’s agenda changed This historical summary demonstrates that (c)Tribunals will make decisions about compulsory radically. This took place in a political successive governments and government- assessment and treatment in all cases lasting longer than 1 month.Tribunalmonth. Tribunal will approve a care context in which state intervention and appointed bodies have taken the lead in promoting medical notions of mental dis- plan presented by the‘clinical supervisor’and will social welfare were becoming increasingly be able to retain the right to discharge a patient order. These justified expanding possibili- accepted and health policy was dominated to itself. Tribunal may apply a treatment order by enthusiasm for prevention and early ties for psychiatric treatment and freeing when the clinical supervisor wants to continue treatment. The Macmillan Commission, up the process of assessment.assessment. from legal and therefore political scrutiny. which established the framework for the (d)Tribunals will only review cases on the basis of Mental Treatment Act 1930, was decisive The medical and psychiatric profession points of law. were more ambivalent about the appropri- in its endorsement of the medical model (e)Anyone can request a Mental Health Act assess- of : ‘There is no clear line ateness of the wholesale medicalisation of mentmentandtrustshaveadutytorespondtoall and trusts have a duty to respond to all of demarcation between mental and physi- this process. ‘reasonable requests’. Recent reforms are justified on the basis cal illness’ it declared (Royal Commission, (f )The Mental Health Act Commission is abolished. 1926). There was enthusiasm for abolishing of facilitating psychiatric treatment, but at (g)(g)Guardianship is abolished. the role of the magistrate in commitment the same time psychiatrists are rendered proceedings despite the fact that the Royal less autonomous. Having professionalised (h)(h)The right to prevent admission and request discharge oftheof the nearest relative is abolished. Medico-Psychological Association did not the process of dealing with the mad in recommend this. 1959, the Government now appears to be However, it was not until the Mental clawing back power to itself, in the belief REFERENCES Health Act 1959 that the principles out- that psychiatrists are not locking enough people up (TodayToday Programme, 1998). In Department of Health (1999aa)) Reform of the Mental lined by the Macmillan Commission were Health Act 1983. Proposals for Consultation (Cm 4480).4480).(Cm fully realised. By abolishing the involve- contrast to other initiatives to increase the London: Stationery Office. input of health service users, the reforms ment of a magistrate and the legal proceed- __ (1999(19 9 9bb)) Report of the Expert Committee: Review of ings that accompanied such a procedure, suggest a diminished concern with protect- the Mental Health Act 1983. London: Stationery Office. ing patients’ interests. It may be that the the act handed the responsibility for detain- __ (2002)(2002) Draft Mental Health Bill. London: Stationery ing the mad entirely over to professionals. medicalisation of the process of psychiatric Office.Office. detention and care has allowed the state to Again,Again,itit is interesting that the Royal Department of Health/Home Office (2000)(2000) Medico-Medico-PsychologicalPsychological Association and the devise more repressive measures than Reforming the Mental Health Act.The New Legal British Medical Association had not recom- would have been tolerated in a system that FrameworkFramework. London: Stationery Office. mended this in all situations (Unsworth, was more overtly political. Joint Home Office & Department of Health 1987). The state also reduced its role of reg- Working Group (1999)(1999) Managing Dangerous People with . London: Stationery Office. ulating psychiatric activities by abolishing DECLARATIONOF INTEREST the inspection system that had been operat- Porter, R.R.Porter, (19 (1990) 9 0) Mind Forg’d Manacles: A History of Madness in England from the Restoration to the Regency. ing since the 19th century. However, the None.None. London: Penguin Books. act did set up a tribunal system in recogni- Royal Commission(192 (1926) 6) Report of the Royal tion that some mechanism for the protec- APPENDIX Commission on Lunacy and Mental Disorders (Cmd.(Cmd. tion of patients’ interests was necessary. 2700). London: Stationery Office. The Mental Health Act 1983 reflected a Features of the Mental Health Bill, Shooter, M. (2002)(2002) White Paper on the Reform of the renewed concern with protecting patients’ 2002 Mental Health Act 1983. Letter from the Chair of the College’s Public Policy Committee. London: Royal College interests, reflecting the influence of the civil of Psychiatrists. http://www.rcpsych.ac.uk/college/ rights movements on the 1960s and 1970s. (a)Broad criteria for compulsory powers include the parliament/responses/mhbReg.htm It narrowed the definitions of certain cate- presence of any mental disorder (no exclusions), Sugarman, P. (2002) Detaining dangerous people with and compulsion is necessary for ‘health, safety or gories of mental disorder and placed restric- mental disorders. BMJBMJ,, 325325,,659. 659. protection of others’ or if there is thought to be tions on the administration of psychiatric ‘substantialrisk’and‘itis necessary thattreatment ToToday d a y Programme, Radio 4 (1998) See psychiatrists treatments in the absence of consent. It also be provided’ (Department of Health, 2002, hit back at the . BMJBMJ,, 317,1270. reintroduced an inspectorate, the Mental p. 4). Medical treatment must be available in all Unsworth, C.(19 (1987) 87) The Politics of Mental Health Health Act Commission. cases, butthis includes‘care’. Legislation. Oxford: Clarendon Press.

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