Modern psychiatric wards are light and airy
Monica is one of my blog readers. She often comments on posts. Her comments can be quite challenging. She has a very individual perspective, often making statements which force me to look more closely at my basic assumptions when it comes to mental disorder.
Monica’s most recent comments were in response to my last post, about Paul, a service user who killed himself while a hospital inpatient. Here, my implicit assumption was that it’s not a good idea to allow people to kill themselves if they suffer from a mental disorder and that as an AMHP I should make every effort to try to prevent suicide, including admitting people to psychiatric hospital, either informally or under the Mental Health Act.
As is often the case on my blog, Monica questioned this. She wrote:
“One good way to solve this problem would be to just not hospitalize patients for mental illness. If any deaths are due to conditions at the hospital, such as violence or accidents, they just won't happen if the patients are not in the hospital. Maybe suicides will still happen, in fact more of them since some hospitalized patients are there precisely because they are suicidal. So what? Some people would kill themselves, but suicide is the ultimate act of self-determination. If people are not smart enough to stay alive or have good reasons to prefer death, why should anybody prevent their suicide, and why should taxpayers pay for that?”
I could just dismiss this comment, but it does actually raise important issues – why do we try to prevent suicide? Are there times when mental health professionals, and indeed Society as a whole, should allow people to take their own lives? And what is the point in having psychiatric hospitals?
There is a very long standing and deep seated belief that suicide is a bad thing. Indeed, it was a criminal offence in the UK to commit, or attempt to commit suicide until as recently as 1961, when the Suicide Act was passed. The Christian Church regarded suicide as a sin, to the extent that people who committed suicide could not be buried in consecrated ground.
The Suicide Act, while decriminalising suicide, also created the offence of aiding, abetting, encouraging or procuring the suicide of another. Additionally, the Human Rights Act 1998 states “Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which the penalty is provided by law” (Article 2).
Taken together, these create a powerful imperative for a mental health professional, or indeed any individual, to actively work to prevent suicide, and negligence on the part of a mental health professional could lead to disciplinary action or even prosecution.
There are also National policies aimed at reducing the incidence of suicide. Saving Lives: Our Healthier Nation, published in 1999, aimed to reduce the death rate by suicide by 20% by 2010. A further document, National Suicide Prevention Strategy for England, published in 2002, made it clear that suicide was seen as a “major public health issue.” It stated: “Around 5000 people take their own lives in England every year. In the last 20 years or so, suicide rates have fallen in older men and women, but risen in young men.” It went on to say that in men under 35, suicide was the most common cause of death.
Monica talks about people who are “not smart enough to stay alive”. I’m not sure who she means here – is she talking about people with severe learning difficulties, who might endanger themselves by inadvertently running into traffic? Or perhaps young children, who don’t realise that fire can burn them? In either case, I would not want to live in a society that did not seek to protect such vulnerable people from the consequences of their actions.
Or perhaps she’s referring to adults of normal intelligence who act in ways that others might consider to be reckless or who take apparently needless risks, such as free diving, potholing, bungee jumping, or driving too fast.
The above examples all relate to mental capacity. If someone has the capacity to act in unwise ways, then of course they should be permitted to do so, as long as their actions do not adversely affect others. But if they lack capacity, such as through severe mental disorder, then I do believe, and the law supports this, that they should be protected and prevented from taking certain actions.
Monica is right to draw attention to the risks of being a hospital inpatient. Medical hospitals are often very dangerous places to be if you are ill – they can be repositories of nasty and potentially fatal diseases, and being in hospital can expose you to these if your immune system is compromised.
Similarly, Monica is right, in a way, to say that psychiatric wards can be dangerous places – there have certainly been a number of celebrated cases where restraint has led to the death of a patient, and there have also been instances where patients have been attacked and even killed by other inpatients.
So what would happen if there were no mental hospitals? Well, this has been tried. In 1978, in Italy, a law was passed that made actually made it illegal to admit people to mental hospitals. This experiment centred on Trieste. An interesting analysis of this can be found here.
Ultimately, what this meant was the closure of traditional style asylums and their replacement with community mental health teams. In practice, this did not actually mean that there were no inpatient beds, it simply meant that CMHT’s had small units with 6-12 beds attached to them which could be used for crisis intervention within the locality in which the patient lived. Their use of the powers of compulsory detention under their Mental Health legislation was very rarely used. I would have no problem were this model to be consistently adopted as a means of mental health provision in the UK.
Monica states that “suicide is the ultimate act of self-determination”. If I knew that I had a terminal illness, and the quality of my life became worthless as the result of this illness, then I would certainly want to be allowed to end my life without undue interference.
Many people feel the same; those that can afford to, go to Switzerland for an assisted suicide. Others have challenged the right in the Courts to end their lives and to have someone to assist them – so far, with little success. I don’t think such people should generally be considered to come within the remit of the Mental Health Act.
But there are many occasions when otherwise physically healthy people express the desire and intent to end their life as a direct consequence of mental illness or mental disorder. People with serious depression or psychosis may hear voices that tell them to kill themselves. They may develop the delusional conviction that their loved ones would be better off if they were dead.
The point is that when they are in that state, such people lack the capacity to make an informed decision. Suicide in these cases ceases to be an “act of self-determination”. I believe that it should then be the job of a humane society to protect them, and to try to bring them back to a state of mental wellness such that they no longer believe that they should be dead.
There are times when admission to hospital is the only means of ensuring people’s safety. Ignoring their need is not an option.