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Mental health: the lowest standards for the weakest

Psychiatrists have broad powers to forcibly treat and incarcerate when a multi-disciplinary approach is neededDavid McCarthy 


Institutional abuse festered in the past as a result of poor and backward legislation and provision. If we indulge the lack of leadership and vision among today’s policy-makers about mental-health issues, we may be helping to write new tragedies for the future.

The proposed changes to the Mental Health Act 2001, the proposed ‘mental capacity’ legislation and the HSE Governance Bill 2012 have the potential to deliver far-reaching and innovative changes. The government can even boast a’ road-map’ – ‘A Vision for Change’, designed in 2006 to develop a ‘new way’ for mental-health provision.

One could be forgiven for thinking that Ireland was alive with revolutionary new thinking about provision of mental-health services.

Fear not: we still live with a legal system that in essence criminalises mental ill-health. The current Mental Health Act 2001 has enshrined within it broad powers for psychiatrists to forcibly treat and incarcerate citizens of this State. It appears that the review of this Act will not subvert the power of psychiatry and it is hard to see what, if any, changes will be made to the provision of ‘care’ in Irish psychiatry.

Minister for Justice Alan Shatter is preparing a Bill to introduce legislation on mental capacity. Currently in Ireland the only legislation in this field is outdated by over 140 years – the none-too-progressive Regulation of Lunacy Act 1871. New legislation must give legal recognition to the capacity for agency and choice of individuals. This capacity is not a quantity to be measured but a right that all human beings have, to be considered as the final arbiters in our own lives, and to be recognised as such by others. Ireland does not have legislation providing for this and so is in breach of the United Nations Convention on the Rights of People with Disabilities.

The UN Convention requires that “State Parties shall take appropriate measures to provide access by people with disabilities to the support they may require in exercising their legal capacity”. The new law must enshrine the authority of the individual in a mental health case to be the final arbiter in any and all decisions made on their case. Political debate already suggests that the view of the individual will only be taken into consideration, however, and there is a real danger that the psychiatrist’s view will nevertheless invariably prevail.

Health Minister, James Reilly, claims The Health Services Executive (Governance Bill) 2012 is the legislation that will reform the HSE and change the way healthcare is provided. The Minister says he will break up the current management structure, make efficiencies and change the way business is done. However, the leadership of the new ‘Directorates’ to be established can, under the legislation, only be held by existing HSE staff of a particular grade. The National Director for Finance or Internal Audit could be handed over the sensitive brief of mental health for example. If the Minister truly wanted to reform the health service he would open these exceptionally sensitive roles to outisde competition.

All these policy and legislative changes share a common thread: they undervalue the individual who is suffering. They are solutions that suit the state and its service-providers over the citizens of this so-called Republic. The situation is still worse when it comes to services. A big theme in the Mental Health Commission inspection report of October 2012 is the failure to sanction the promised multi-disciplinary teams that could provide a more holistic focus to mental health care than the current medical model. These teams were to be the gateway to community-based care that was to help break the system of institutionalisation which has so long fed stigma.

‘A Vision for Change’ has been sitting on the shelf for years. In September the €35 million we had been told was ‘ring-fenced’ for implementing the road-map was taken to cover the €130 million deficit in the HSE budget. What now becomes of Minister Kathleen Lynch’s promises?

Does this mean that the promised Directorate of Mental Health will not materialise? That community care is to be abandoned? That the multi-disciplinary teams are not to be established? That alternative therapies are not to be applied?  Does it mean   that human rights are to be left behind, all because a compliant patient is a manageable patient? We only can assume the absolute power of the psychiatrist will be retained.

There are close to 20,000 admissions to psychiatric hospitals and units each year, of which 90 per cent are recorded as voluntary. Many patients agree to be admitted as voluntary to avoid stigma. Others do so because the full implications of the decision are not explained fully. Many legislative protections in this state, however, only apply to those admitted as involuntary patients.

Voluntary patients remain in psychiatric units without the need or provision of an external review of their case. Some studies suggest that up to half of all voluntary patients are placed in lock-up wards or have their shoes removed, in an attempt to ‘manage’ their movements. The practice of voluntary patients having their treatment decided without external oversight is also likely to be continued.

In no other sphere of life would these sub-standards be tolerated. It is simply because – due to the legislative regime in this society – those with mental health issues are the weakest of the weak.


David McCarthy is CEO of Mad Pride Ireland