Critical debate 9.4

Possible answer to:

• When we detain people in hospital, and we justify this on the basis that they are a danger to themselves and others, in what ways can such coercion and paternalism be commensurate with an espoused ethos of recovery?
• What might the impact of detention be for service users and the mental health workforce?
• Who, indeed, are the ‘users’ of services in such a context: the primary patients or the public at large?
• Is it possible to conceive of forms of mental health legislation that do not justify compulsion and coercion? 

Possibilities

You may consider that coercion and paternalism are completely incompatible with notions of recovery. Or you may feel that skilled nurses can endeavour to maintain caring therapeutic alliances and trust however restrictive the system. The reality may indeed lie somewhere between these poles, and good nurses can play a substantial role in softening the experiences of a coercive mental health system. For example, even forensic mental health services and high security hospitals have begun to develop a recovery ethos, and patients who have benefited certainly buy into a notion of recovery. Some patients who are highly critical of the coercive nature of modern mental health services have reported occasions when they felt, with hindsight, the exercise of restrictions was justified – for example, being prevented to abscond when in a vulnerable state.

That said, we should not underestimate the negative impact of detentions. This can be very alienating for patients and hugely breach the potential for trusting relationships with staff. The conflict this can potentate can also be alienating for staff. Already traumatised individuals can be readily retraumatised. The precipitation or exacerbation of violence can lead to both patients and staff being hurt. Most psychotherapies require consensual and cooperative relations, and these are at the very least disrupted by coercive practices.

Rogers and Pilgrim in their Sociology of Mental Health and Illness book argue that the actual service users of a coercive system that serves social governance and control functions are the state and the public. That is, the service exists to manage and control social deviance (madness and disruptive behaviour) and the point is to contain such people and behaviour to protect the wider public. Other radical theories suggest that the mentally ill are a useful ‘other’ to denigrate and demonise, justifying their segregation and detention, enabled by mental health law. From this perspective, the government have a useful ‘bogeyman’ and can make political capital out of claiming to protect the public from such dangerousness. Commentators like the journalist Adam Curtis go further to argue that western governments get away with having to develop manifestos for a better society because they can fall back on the appeal to protect from danger, for example the danger of international terrorism.  

As for alternative legislative systems that are not all about compulsion and coercion, we can only imagine. The Mental Health Alliance did concern itself with such discussions in the period leading up to the reform of the Mental Health Act 1983. This was about making the case for a rights based approach, including having the right to a range of different forms of  treatment and support. Such a legal instrument might actually lead to more pluralistic service provision, especially if individuals had a legal right of redress if provision was lacking in range or quality. Treating dangerousness independently of mental disorder has some appeal, as outlined in the chapter. But this may result merely in shifting the large numbers of people detained in mental hospital wards into prisons, which may be a pyrrhic victory for campaigners. Arguably, any change in the law would have to more closely attend to the limits of compulsion and coercion, but if we wish to prevent the serious harms of suicide, for instance, some restrictive powers would have to remain. Mental health law is clearly not distinct from the wider political economy, and we can only imagine what a service might look like predicated on less coercion and adequately resourced.