A Matter of Life and Death of the Bill

"The King's Speech I" by David Barrie is licensed under CC BY 2.0.

By Robert Lewis

“All that work, down the drain”

                                                          King George VI, “The King’s Speech” (2010)

At least one King could say it out loud, even if it was just that bloke who went for a swim in a pond with his shirt on.

The Bill is dead.

Huge numbers of experts by experience, professionals, voluntary sector contributors, civil servants and academics gave significant levels of their time and effort into the 2018’s Mental Health Act Review. Not just the Review, but also to the subsequent development of key reform concepts in the Bill, such as statutory care planning, introducing the nominated person, tighter criteria around CTOs, and other measures all aimed at reducing compulsion and promoting choice.

For many, the omission of the Bill from the King’s Speech leaves a trail of broken promises, of lost opportunities and betrayal. Most stark, of course, is the message that this betrayal sends to those racialised communities still disproportionately subjected to the controls of the Act. Also, to those people with a learning disability and/or autism, left pathologised and warehoused in hospitals in the absence of a suitable community resource. In fact, for all individuals seeking a greater say in their treatment and care and for those families and loved ones who could play a vital role in the individual’s recovery if only allowed to the table.   

So, what does this mean? And, does it actually matter?

Yes and no.

Yes, of course it matters. It is literally life and death for some. The psychiatric system can brutalise the black body and mind. It can brutalise the bodies and minds of many it comes into contact with. It breaks trust with people, it infantilises them, and it denies their autonomy and personhood. It can even sometimes, in spite of itself, actually help people - although rarely by design it seems, otherwise surely more would be defending its honour right now.

And, no, it doesn’t matter on some levels. For all of its promise, the Review and the Bill were significantly flawed. The Bill left untouched key assumptions. It left professional roles intact and comfortable with their well-established power. It left unchallenged the medical model and it kept multiple structural discriminations in place. It proved once again that the Mental Health Act has little to do with care and treatment. The Bill could not even bring itself to put principles and human rights at the front of the Act. However lauded, it would still have remained primarily a tool for compulsion and social risk management. As AMHPs, we would still have been the only actor with a clear responsibility to operate under the Act before the point of admission, while the resources we rely on had no such imperative, or ‘mirror duty’, placed upon them to attend to those who need them most at their time of greatest need.

Having been fortunate (although now it feels less so) to have been involved in various aspects of the Review and reform process since 2018, my increasing concern was that this Bill, and the amended Act that would have followed, was never truly going to achieve its aims. It whittled down and compromised the aims of the Review, marshalled by establishment-thinking that seemed unaware that it was maintaining and replicating existing power rather than leading us truly into a new era of practice. The positive messaging coming out of the Review could rarely be argued with, but evidence as to how the Bill would meet those core objectives was pretty scarce? To those of us who have gone through a number of amendments to this decades’ old legislation, including those introduced by the Mental Health Act, 2007, can we truly say that any of those revisions have really changed practice in the way hoped for? Appropriate treatment is available? Is it? Is it Really?

We clearly need wholesale cultural change in our systems. Legislation can help promote that change, if that legislation is structured correctly and aimed clearly at the promotion of human rights, social justice, supported decision-making, cultural competence and advocacy - before it even talks about locking you up. The Review and the pre-legislative scrutiny spoke to this to some extent, but the Bill was far too restricted to truly offer us the hope of real change. That moment has now passed, it seems.

Or has it?

Maybe we have just been too busy, too distracted, or too defeated to realise that little can be said to be lost when so little was offered in the first place.

The Bill is dead. Long live ……….. Approved Mental Health Professionals

In this space, there is no need to remind ourselves of what we do well and the positive impact we can have. AMHP practice is peer-led, so it is within our gift to effect the change we want to see. This isn’t about AMHP Leads or dedicated AMHP roles verses traditional AMHP roles. This is about recognising each other as leaders, supporting the talents we and our colleagues have, sharing our platforms, and communicating our ideas. Perhaps, rather than mourn what we never had by the Bill being shelved, we should take on the challenge to reduce compulsion and promote choice ourselves. Who better placed than us to help address racial disparity in the systems we work? After all, it is not that black males are eleven times more likely to be placed on a CTO. It is that AMHPs are eleven times more likely to agree to one if the patient is a black male.

We now have more tools, supports and guidance to lean on to help educate, cajole, and mobilise the systems we work in and with. We have a greater voice and representation into the spaces where it is needed. We have building communities of interest, discussion forums and, even, a Critical AMHP Blog. This is about promoting AMHP leadership in all its forms and, let us not forget, as AMHPs we also hold a huge amount of statutory power. So, let’s think about how we use that power too.

Others have talked here about the potential to reframe section 13. This is surely our greatest tool when it comes to affecting change - to do the job I believe many AMHPs set out to do when they undertook their training and invested their time and energy into the role. But do we really understand it? Understand just how far we can stretch and utilise section 13 consideration to get better outcomes for those referred to us? Are we operating in a mental health system that values our perspective? Or does it see us as supporting it rather than the individual?

So, ask yourself, who are you for. Reflect on that question a while. Ask it of other AMHP colleagues.

Answer that correctly and perhaps you are half way to finding a clearer path.

So, are you working in an AMHP service that values speed and “getting it done” over slowing it down and utilising your skills, knowledge and values? Does your service even understand that the “it” is your time, attention and consideration? That the “it” is compassion, the promotion of rights, the promotion of choice, and the challenging of discrimination. If it doesn’t, what are you doing to educate it?

Increasingly understood is the need to develop clearer models of anti-racist AMHP practice. This does not just mean seeking to understand better the lives and situations of people disproportionally subjected to our attention (although that is a good start). It means also opening up safe spaces for AMHP colleagues to talk about race, to develop a shared understanding of the impacts on us and others of race, of Empire, of whiteness, and of our own organisational structures. Unless our AMHP services are openly working towards being anti-racist, what conclusions could others draw about our silences?

The Review has at least given us the Patient and Carer Racial Equality Framework (PCREF – ‘anti-racist framework’). Are we elbowing our way into our Trusts to support this, to promote and engage with the approach? While not included in the development, local authorities and AMHP services have a clear responsibility to get involved now. Ask the question of your authority and Trust, what are you doing about PCREF and, ask of yourself, where is our AMHP voice in this?

And finally, we should also look routinely at how we engage individuals in more meaningful discussions and interviews, whether as part of an MHA assessment interview with doctors, or on our own. Do you really need to leave the room to have a ‘professional conversation’ about the person who is about to feel the weight of your decision? Adopt and develop approaches that emphasise partnership, listening and learning. It might be helpful to know if someone is not eating or sleeping or is troubled by things that others cannot perceive, but there are other just as important lines of enquiry when it comes to appreciating the risks that got us into the room in the first place. We can support individuals to develop an understanding of the choices they, and we, are faced within those critical moments, and not just to confront them with a list of their failings and inadequacies.

We do not need a Bill or Act to address racism in our practice, to reduce compulsion, and to promote and support choice. We do not need to get pulled along by systems who want us to “just get it done”. We can develop better models of AMHP practice, support each other to achieve these aims, and not have to wait for it to be legislated for.