1. Dr Sarah Vicary @sao_sarah Dr Kevin Stone @kevinstoneuwe
Can the social approach survive mental health legislation (in review or in action?) BASW - Social Approaches in Mental Health Social Work Tuesday 9 October, 2018
Dr Sarah Vicary
@sao_sarah
Dr Kevin Stone
@kevinstoneuwe
Mental Health Social Work Special Interest Group

2. Presenters
Dr Sarah Vicary Dr Kevin Stone
@sao_sarah
@kevinstoneuwe

3. Introduction
Often conflated with the social perspective, or approach, least restriction has been embedded in mental health legislation in England and Wales since the late 1950s
But, what is least restriction and the social approach in reality and does it survive mental health legislation in review or in action?

4. What is least restriction?
The term was first coined in the United States and originally termed the least drastic alternative or the minimum dislocation from the normal environment
It arose following a legal judgement deeming a mental hospital as the most restrictive environment in which treatment could take place

5. What is the social approach?
The social approach is the idea that mental health should not just be considered in medical terms but be balanced by a consideration of an understanding of the social aspects of mental health and also use of social responses.

6. Least restriction and the social approach is a fundamental shift from hospital based services and one of the intentions of the Mental Health Act in England and Wales but what is the reality?
What effect does review of mental health legislation have and how does this translate in action?

11. Encompassing reduction in power of the state over the individual whilst seeking to replace medical models of mental health with ones that incorporate social and cultural factors, least restriction surfaced in the review of the Mental Health Act 1959 as a proposal that the applicant for compulsory detention should have the responsibility ‘to satisfy himself that the care and treatment offered is in the least restrictive conditions practicable in the circumstances’

12. The bedrock upon which this Act (1959) rested was the principle that people suffering from mental disorder should, as far as possible, be treated in the same way as those suffering from physical sickness. Certain inalienable policy implications followed from that principle:

13. first, that compulsion was to be used as little as possible
secondly, that care rightly became more important than custody; and,
thirdly, that treatment must not be confined to hospital—indeed, that the emphasis should be on community provision rather than institutional care.

14. David Ennals, Secretary of state for Social Services, Feb, 1979

15. But, what actually happened?

16. The 1981 White paper
“must satisfy himself that detention in hospital is the most appropriate means of ensuring that the patient receives the care and treatment he needs” (para 15)

17. 1983 Act, section 13 (2):
Must satisfy himself that detention in hospital is in all circumstances of the case the most appropriate way of providing the care and medical treatment of which he stands in need

19. The Richardson Committee
Wherever possible the principles governing mental health care should be the same as those which govern physical health
Included:
enhancing patient autonomy
least restriction
reciprocity i.e. duties to comply with care and treatment are balance by parallel duties on health band social care authorities to provide appropriate care and support

20. The long reform
Government response in effect was to reject much of the Richardson Committee report
Tension between individual right to liberty and state's duty to protect vulnerable people and the public from harm erupted into a struggle between the Government and its opponents which culminated in the Mental Health Act 2007 which amended the Mental Health Act 1983

21. Reform under New Labour
Homicides
Root and branch reform (Dobson, 1998)
2000 White paper
Dangerousness and public safety
Mental Health Alliance
2004 Draft Bill
Department of Health 2005 The Bill is not about service provision it is about bringing people under compulsion
Missed opportunity

22. Practice perspective …
Concept of least restrictive practice is challenging to implement.
Available resources
Timeliness of resources
Structural barriers to AMHP practice, 14 days, impact of rotas, non-social work AMHPs
Reliant on others’ risk assessments, and management – risk aversion
Professionals personal risk thresholds

23. What conclusions can we draw?

24. that the principle of least restriction did not fully translate from the United States to the United Kingdom:
in the former, the movement had been to develop non-institutional alternatives in the light of the prohibitive cost of treatment in hospital
in the latter the phrase least restrictive conditions practicable in the circumstances in effect meant no real economic push to develop mental health services and rather to expressly undermine their development by diluting the right to the least restriction of liberty

25. “That this was also the start of an imposition of duties on professional workers without the accompanying resources to carry them out”. “It and also excluded the idea that the applicant (or person) might legitimately question the care and treatment that was being offered which, according to the Royal College of Psychiatrists at the time, remained a medical matter”. Barnes et al., 1990 p. 25 Prior 1992

26. Barnes et al. 1990

27. decisions about appropriate care are those of the doctors.
In other words:
decisions about appropriate care are those of the doctors.
the person and applicant may have a legal say in the circumstances in which care and treatment is given but the precise contents of the medical programme are beyond question
Barnes et al. 1990

28. Did this cement the position of the medical professionals?
Dominance of the hospital as the primary treatment site.

29. Studies of mental health services in the United States suggest that a wide range of services can be used, are invariably as good and frequently better, generally slightly cheaper and sometimes substantially so.
They are remarkable not because they are innovative but because of their intensity, frequency and focus on the support network (Braun et al., 1981, Kiesler 1982)

30. Alternative care cannot be half-hearted or short-lived.
Provision needs to be collaborative: treatment being social support by
non-medical people and primary context the immediate social network, an integrated mental health service.

31. And what of the social approach?

32. Is this the social approach drawing for example on sociological understandings of support networks and a central characteristic of securing alternative care?

33. Report raises concerns over compulsory mental health admissions
Monday 12 Feb, 2001
shortages of professional staff, including ASWs, sharing similar racial and cultural backgrounds as patients
the over-representation of people from minority ethnic groups in mental health assessments
inappropriate hospital admission for black people, where alternatives could have been provided

34. Fast forward: current review
Announced by Government in 2017 and is due to report late 2018
Has a wide ranging remit:
To look at how the Act is used and to understand the reasons for:
• The rising rates in applications for detention
•The disproportionate numbers of people from black and minority groups detained under the Act
•Processes that are out of step with a modern mental health care system

35. Interim review
Published May 2018

38. The MHA cannot be viewed in isolation from the practical and legislative context in which it operates.
An aspiration of the review was and remains to reduce the number of individuals subject to compulsory detention.
In other words, the aspiration is to increase informal admissions and/or alternatives to admission, rather than compulsory admissions, in keeping with the original intentions of modern mental health legislation, first laid out in the 1959 MHA

40. Understanding mental capacity