Community Treatment Orders and the Mental Health Act

In a report published yesterday the use of Community Treatment Orders (CTOs) was scrutinised for the first time by the Care Quality Commission (CQC), the regulatory body charged with (among other things) overseeing the implementation of the Mental Health Act. CTOs were introduced in November 2008 as a means of addressing the problem of so-called ‘revolving door’ patients: those who were detained for treatment for a mental disorder, then released back into the community, often with little support or after-care, and inevitably ended up back in the system. Such patients often refused to co-operate with community mental health teams and would not take their prescribed medication, which outside of hospital could not be enforced.

“Patients who are detained in hospital for treatment…can be discharged into the community if they still require treatment for mental disorder on the grounds of their own health or safety or for the protection of others, but it is agreed that such treatment can be given outside hospital” (CQC report p.96 available here)

The creation of CTOs was intended to ensure that these patients could be compulsorily treated (a phrase that for the most part means: being compelled to take their medication) in the community rather than having to be detained for a long time in hospital. This extension of compulsory powers beyond the confines of the hospital marked a significant shift in mental health policy and care. The government argued this was a sensible strategy not least because it would free up beds in acute psychiatric wards: patients could be quickly released under the terms of a CTO and only recalled if they did not comply with their treatment plan. This was branded as a way of empowering and freeing individuals who would otherwise be confined to a hospital. (A Foucauldian-minded commentator might consider that the introduction of CTOs hammered the final nail in the coffin of the asylum. However, I would argue that they merely shifted surveillance, monitoring and control to the community rather than the hospital. But that is perhaps another discussion).

CTOs were met with fierce resistance at the time the Mental Health Act (2007) was being debated, particularly by lobbying groups such as the Mental Health Alliance who were extremely concerned that the broad criteria for these exceptional powers would result in large numbers of mental health patients being subjected to excessive coercive controls. It was clear at the time that the government’s agenda was being driven by a concern about risk rather than the health and welfare of the individuals such powers would affect. Nonetheless, strong assurances were given that CTOs would be restricted in their use and applied only to ‘revolving door’ patients for whom no other treatment options seem viable.

It is therefore particularly damning that the CQCs report reveals that in implementing CTOs, their frequency of use far exceeds what was previously anticipated: “… given that CTOs are meant to help ‘revolving door’ patients who would otherwise disengage with services, 30% of the patients in our sample did not have a reported history of non-compliance or disengagement. This suggests that the high use of CTOs – much greater than government estimates at the time the law was passed – could be a result of the powers being applied preventatively beyond the group of patients for whom they were primarily designed.” (CQC report p.99)

I can understand why CTOs might be necessary for some patients who repeatedly relapse and continue to suffer, who would otherwise effectively be institutionalized for life. They might provide a safe halfway house enabling patients to reintegrate back into the wider world whilst maintaining strong links with their mental health team and access to support (I know I’m being idealistic here but it’s an argument ‘in principle’). However, it appears that CTOs are being used with alarming regularity for patients for whom there is no reason to impose any controls or constraints once they are discharged. Having not previously failed to “comply” (in scare quotes because it is an odious term) there is no justification for placing patients under such orders other than the perception that they pose a risk, either to themselves or others, and cannot be trusted to manage their own treatment without being monitored and controlled with the threat of detention. In what world does that enable people to attempt to take control of their own lives, to begin the delicate and tentative process of recovery, and to feel as though they have some say in what happens to them? If anything, this overuse of CTOs is disempowering and disenfranchising: hardly the best route to building much-needed trust between patients and mental health services and enabling people to manage their own lives.

Depression and sadness- media commentary

I was interested to read an article published today by a journalist called Mary Kenny on the BBC News website that refers to a longstanding argument about modern-day conceptualisations of sadness and depression. In it, she argues that as the stigma surrounding depression has decreased and it is more ‘acceptable’ as a condition than it was, say, 50 years ago, the idea that periods of sadness, bereavement and loss are part and parcel of normal fluctuations of human experience has been lost.

Increasing openness about personal distress and suffering marks a departure from a time when such things were kept behind closed doors, leaving the individual to suffer alone and in silence. The marked shift in attitudes towards mental health is no doubt a good thing (though there’s still a long way to go), but Kenny fears that the vocabulary now used to describe human experiences of loss and sadness is reductive and the use of medical terms implies that the experiences are indicative of disorder, of something having gone wrong, and therefore not a normal part of human life. She cites increasing use of the technical-sounding term ‘trauma’ in place of grief or mourning: when someone suffers a loss or experiences a particularly emotionally turbulent time they are described as going through a ‘traumatic experience’ for example. Yet bereavement, loss and mourning clearly are part of normal human experience, and thus her argument runs that we are losing touch with old rituals and rich, varied ways of describing such sadness as these experiences are increasingly brought out of the dark recesses of human nature and into the light.

I see Kenny’s point and agree fully that the rich varieties and subtleties of human experience cannot and ought not to be reduced in the way she describes. But I feel that actually, her argument has nothing whatsoever to do with the stigma of depression and mental illness.

Firstly, she has identified the wrong target. Her suggestion is that reductions in stigma, accompanied by increasing frankness and openness about the prevalence and nature of depression have led to the loss of the “dark poetry of the human condition”. Yet I see no reason why in and of itself, wider knowledge of depressive mental illness should have this effect: if anything, it might enrich our understanding of such experiences.

The problem as I see it is that she is not actually talking about depression. Kenny appears to have conflated ordinary, normal kinds of experience such as bereavement, nostalgia and loss – which she views through a somewhat romantic lens – with the far more debilitating condition we have come to call ‘depression’. The very reason depression is considered an illness is that it marks a significant, distressing and impairing, departure from the vagaries of normal life (though the DSM-IV somewhat clumsily differentiates depression and bereavement through a seemingly arbitrary distinction regarding the duration of symptoms). It can disrupt or destroy a person’s life, relationships and ability to function in the world- it is not a nostalgic yearning for past loves, wistful sorrow or romantic melancholy as Kenny seems to think.

Here we come to the crux of the issue. Whilst it is still an open question as to quite how depression (as a mental illness) ought to be classified and diagnosed, it is certainly true that today certain kinds of normal human experience are overmedicalised and pathologised. Any period of sadness or social withdrawal may be instantly viewed through a medical lens, either by the person or by others around them. We are quick to judge that any deviation from our normal routines and moods is inherently pathological. Such feelings may of course signal the onset of something sinister but at the same time they may simply be, as Kenny is keen to emphasise, normal variations that we should accept as part of the human condition. It is the ‘illness’ label that is problematic here- the domain of ‘symptoms’ has perhaps spread too far and encroached on “normal” fluctuations in experience, but this is an issue to do with how we label and understand those troublesome and distressing periods of life that we all experience, not an issue about the stigma of what can be a devastating mental illness.

Conference Summary: Emotions and Feelings in Psychiatric Illness

Recently I attended a conference in Durham that was the culmination of a 3 year project funded by the AHRC entitled Emotions and Feelings in Psychiatric Illness. The 3 day event was a welcome opportunity for a diverse group of philosophers, psychologists and psychiatrists to engage in the kinds of conversations that enable one to grasp, if not necessarily buy into, widely differing perspectives and ideas about the nature of emotions and feelings in mental illness, and their function in classification and diagnosis. As one would expect from a conference explicitly focused on interdisciplinary engagement, the levels of explanation employed in different papers ranged widely, from the neurophysiological to the interpersonal, encompassing everything from neuroimaging studies to psychoanalytic theory.

A central theme of the conference was the role of phenomenology in the understanding, experience and classification of psychiatric illness: for many participants, paying attention to the emotionally-charged subjective experiences of psychopathology was central to their attempts to develop theories and explanations of psychiatric phenomena. What I found particularly gratifying about many of the papers presented was the fact that despite the inherent difficulties of traversing the sub-personal to the personal, the roles of emotions and emotional experiences were not being used as addenda to a scientific approach to understanding mental illness. Rather, they were integral to both the conceptual research and scientific studies being undertaken.

Phil Gerrans’ paper on studies of the experience of depression for evaluating models of emotional appraisal is a case in point. A more conceptually-based paper by Iain Law and Lisa Bortolotti questioned the rationale behind the classification of mood disorders by distinguishing between moods and emotions, and delved into Matthew Ratcliffe’s influential phenomenological account of mood as a pre-intentional necessary condition for experiencing emotions (and, more strongly, for possessing intentionality at all). There was also a strong emphasis on the use and analysis of first-person narrative in understanding psychopathology, with Shaun Gallagher making a strong case for the idea that the disruption or alteration of certain features of narrative structure might provide a kind of linguistic fingerprint of psychopathology, particularly with respect to dissociative disorders and schizophrenia. The enactive/embodied movement in philosophy of mind and psychology was well represented by Dan Hutto. He argued against critics for the primacy of affective cognition in radical enactivist views of our intrinsic world-relatedness and interactions, thus placing emotions centre stage rather than considering them secondary or additional to cognition and experience. Finally, Rachel Cooper struck a fine balancing note to proceedings at the end of the conference by questioning what role (if any) subjective experience ought to play in psychiatric classification.

In integrating phenomenology and subjective experience with a more traditional biomedical discourse, the conference represented a microcosm of the broader challenges faced across the Medical Humanities. It is often the case that reaching across disicplinary boundaries generates confusion and cross-talk, particularly where the predominant scientistic perspective is entrenched. However, the lively and rigorous discussions that ensued over the course of the three days gave grounds for confidence that such dialogue is not only possible but also, when framed well to capitalize on different disciplinary strengths, extremely fruitful and thought-provoking.