St. Michael’s House, Dublin Mental Health Act, 2001: Implications for Mental Health Service Delivery Dr. Philip Dodd Dr. Janette Tyrrell, St. Michael’s House, Dublin October 2006.

Overview of Talk Mental Health Act, 2001:Provisions for I.D. Reference Guide/Case Law Clinical Presentations Required Service Responses Future

Before we start….. This Presentation should not be relied on as a legal interpretation of the Mental Health Act 2001. It is not intended to be a complete or authoritative statement of the law and is not intended as legal advice or advice of any type. It is a personal interpretation only and must be read in conjunction with the provisions of the Mental Health Act 2001, any regulations made thereunder and any other relevant legislation.

Mental Health Act 2001 Legally Binding Principles (S.4) Best interest of the person is the principal consideration in making a decision Due regard to be paid to the interests of others who may be at risk of serious harm Right to information and participation so far as is reasonably practicable Due regard, respect for dignity, bodily integrity, privacy and autonomy Rights are not diminished because of mental disorder Clinical judgement and professional discretion are key

Mental Disorder S3(1), (a) or (b) S3(1)(b) because of the severity of the illness, disability or dementia The judgement of the person is so impaired That failure to admit the person to an approved centre would (EITHER) Be likely to lead to a serious deterioration in their condition OR Would prevent the administration of appropriate treatment that can be given only by such admission AND (IN EITHER CASE) Their reception, detention and treatment in an approved centre would be likely to benefit or alleviate their condition to a material extent. S3(1)(a) because of the illness, disability or dementia There is a serious likelihood of the person Causing immediate and serious harm to himself or herself or to other persons

Mental Disorder Mental illness, severe dementia and significant intellectual disability are necessary but not sufficient. There must in addition be EITHER A serious likelihood of the person causing immediate and serious harm OR Failure to admit would lead to a serious deterioration OR prevent the administration of treatment that can be given only by admission AND admission would be likely to benefit or alleviate their condition to a material extent.

Definition of Significant Intellectual Disability “…a state of arrested or incomplete development of the mind of a person which includes significant impairment of intelligence and social functioning and abnormally aggressive or seriously irresponsible conduct on the part of the person.” (Section 3 (2))

Establishing a Mental Disorder through a finding of Significant Intellectual Disability A state of arrest or incomplete development of the mind includes: Significant impairment of intelligence AND Significant impairment of social functioning Abnormally aggressive or irresponsible conduct All of the above criteria must be established separately

Significant Impairment of Intelligence IQ<69 – indication of significant impairment of intelligence Psychometric assessment: standardised test reliable valid assessor competance appropriate for age, culture, language and social background Developmental and educational history important Measured within the last five years

Significant Impairment of Social Functioning Observed behaviour in coping on a day-to-day basis with the demands of his/her environment From occasional to pervasive, in areas such as self-care, communication, home living, self-direction, occupational, social and interpersonal skills Direct observation and interview with informant who knows the person well (parent, carer, friend) No one standardised assessment recommended (BPS, 2001) NW Belfast Health & Social Services Trust 28/5/03: Mental Health (NI) Order 1986

Abnormally Aggressive Conduct Criteria Must be associated with: ‘a state of arrested or incomplete development of the mind…. On Assessment: Based on observation of behaviours Judgement/Conclusions: Actions are outside the usual range of behaviours (Based on Unpredictability or Unreasonableness)

Seriously Irresponsible Conduct Lack of responsibility and/or Disregard for the consequences -whether capable of judging consequences or not -can include failure to act as evidence of irresponsibility

Assessment of Abnormally Aggressive or Seriously Irresponsible Conduct Observation (actual behaviour) Judgement (abnormality and/or seriousness) The conduct should result in actual damage and/or distress to self or others recently or persistently or excessive severity

Establishing a Mental Disorder through a finding of Significant Intellectual Disability A state of arrest or incomplete development of the mind includes: Significant impairment of intelligence AND Significant impairment of social functioning Abnormally aggressive or irresponsible conduct All of the above criteria must be established separately

Other Points…. Seclusion and Restraint (69 (1)) “ A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined….to be necessary” Restriction on Admission of patients (67 (1)) “a person suffering from a mental disorder shall not be detained in any place other than an approved centre” Inspector’s Report, 2005 “This Act will protect the rights of persons receiving care and will also protect those professionals providing care. It will ensure that standards of mental health care delivery, set by the Mental Health Commission, will apply equally to those with an intellectual disability and those without”. “Professionals working in the intellectual disability service must understand that persons who fulfil the criteria for having a mental disorder under the Act, and who are incapable of giving informed consent to treatment, must receive that treatment under the protection of the Mental Health Act 2001 and in a unit approved under that Act. To provide such treatment in the absence of informed consent, will be illegal.”

Vignette 1 22 year old woman, severe ID Long history of SIB Now Targeting staff – hair pulling and pinching & assault No formal psychiatric illness Problem behaviours (DC-LD) Not obviously autistic How do we manage/support this women? Where?

Service Response: R e s o u r c e De p e n d e n t Limited resources: Detention more likely Limited Guidance: Detention more likely ‘Expertise’ of Approved Centre M.H.I.D. Team (Vision for Change)

Vignette 2 67 year old man, moderate ID Chronic schizophrenia Acutely psychotic on withdrawal of Melleril (after 26 years) Lives with very elderly parents Refuses to leave family home (TV) No food x24hrs – drinking normally How do we manage/support this man? Where?

Service Response: R e s o u r c e De p e n d e n t No M.H.I.D. team: Detention likely “Expertise”of Approved Centre Home Care Option: Assertive Outreach Hassiotis, A. Advances in Psychiatric Treatment (2003) 9: 368-373

Vignette 3 24y.o. man, moderate, I.D., Down’s Syndrome Autistic Spectrum Disorder No previous history Parent deceased 3 weeks ago In respite Sporadic severe problem behaviours;depressed, withdrawn, sleep disturbed.

Service Response: R e s o u r c e De p e n d e n t Manage/Support in Respite House? With M.H.I.D.Team Welfare of the Individual: “Best interest of the person is the principal consideration in making a decision” (S.4 (1))

Implications for I.D. Services Positives Individual’s rights monitored External assessment of restrictive practices Policy and legislative framework for the development of services Improved access to mental health services and improved treatment It is the Law! Negatives Not Capacity Legislation ? Move away from social care to treatment model Little I.D. experience in Irish Mental Health Law Anxiety of interpretation!