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About this book

This book explores how we can preserve the integrity of mental health provision in an age when community safety is dominant. Emphasising throughout the mentally disordered in the community, the book examines existing controls and services - compulsory detention, hospitals, supervised discharge, supervision registers, and so on - as well as new developments such as dual diagnosis and questions surrounding treatability.

Table of Contents

1. Introduction: Community Safety and Mental Disorder

Abstract
The question to be asked is this: how, in an age when community safety is dominant, can we retain the integrity of mental health? By integrity I mean how can we care for the mentally disordered when the tendency is to control, punish and regard them with increasing suspicion. The mentally disordered are a common sight in every large city. Some may be homeless, some may be substance abusers, and a small number may be violent, with an even smaller number involved in high-profile fatalities. Their high levels of visibility help to promote a sense of unease, assisted, of course, by the media and the shrill response of some pressure groups.
Philip Bean

2. Justification for Compulsory Detention

Abstract
Although most patients are dealt with informally, a small number are not. The current legislation is the 1983 Mental Health Act, where under Sections 2, 3 and 4 patients may be compulsorily admitted to a mental hospital. The Mental Health (Patients in the Community) Act 1995 (referred to hereafter as the 1995 Act) allows patients to be placed under supervision while in the community. Compulsory powers exist elsewhere, for example under the National Assistance Act 1948, where persons suffering from grave chronic disease, or being aged, or physically incapacitated and living in unsanitary conditions can be removed from home. It is to patients under the 1983 Act, however, that this chapter is dedicated.
Philip Bean

3. Doctors, Social Workers and Relatives

Abstract
Writing in 1980 about the way the 1959 Mental Health Act operated, I thought that the procedures for deciding and detaining a patient for compulsory admission had not worked well (Bean 1980). GPs and social workers rarely knew their duties, rarely knew the law and rarely offered much by way of assistance to the psychiatrists — frankly, the GPs did what they were told. When the social workers disagreed with the psychiatrists, they were invariably outmanoeuvred into having to accept the psychiatrist’s opinion (ibid. 1980). There have been changes since then; the 1959 Act has been replaced by the 1983 Act, social workers are now required to be Approved, that is, they have to complete a recognised training programme, and GPs are said to be rather better trained than hitherto in their knowledge of mental health legislation. But have these changes greatly affected things? Has the 1983 Act improved the social worker and GP input, and has the training improved procedures? The answer is, probably yes, at least in some respects, but we do not know for certain; unfortunately what has not changed has been the amount of research, which still remains unacceptably small.
Philip Bean

4. Control in the Community

Abstract
On 1 January 1994 Supervision Registers were introduced in Britain in accordance with Circular HSG(94)5 (Department of Health 1994). These were part of a so-called wider information system developed by health authority provider units to identify patients known to be at significant risk, or potentially at significant risk, of committing serious violence or suicide, or of serious neglect as a result of severe and enduring mental illness. A year later the Supervised Discharge Order was introduced under the Mental Health (Patients in the Community) Act 1995. Supervision was to be for a limited number of patients who, after being detained in hospital for treatment under the 1983 Act, needed formal supervision to ensure that they received suitable care.
Philip Bean

5. Policing the Mentally Disordered

Abstract
The civil commitment procedures under Sections 2, 3 and 4 of the 1983 Mental Health Act give powers for patients to be detained in hospitals when the patients are seen and examined in their own homes. Powers exist under Section 136 of the Act for patients in a public place, if they appear to be suffering from mental disorder, to be taken to a place of safety where they can be seen by a psychiatrist and an ASW in order that a decision can be made about treatment and care. Briefly, the legislation authorises a
police constable who finds a person who appears to be suffering from mental disorder in a place to which the public have access to remove that person to a place of safety. He may do so, if the person
(a)
Appears to be in immediate need of care and control
 
(b)
If the constable thinks it is necessary to do so in the interests of that person or for the protection of other persons.
 
A person so removed to a place of safety may be detained for a period not exceeding 72 hours.
Philip Bean

6. Appropriate Adults and Mentally Disordered Suspects in Police Stations

Abstract
This chapter is central to what I have called maintaining the integrity of mental health, and follows on from the second part of Chapter 5. It is about preserving, or rather sustaining and developing, the rights of mentally disordered suspects (or offenders, the terms have been used interchangeably) in police stations. In an age where community safety dominates, there is a tendency to trample over these rights of the unloved and the unlovely according to Herschel Prins, and to forget that their rights are worth preserving. In this chapter, an examination will be made of one way in which those rights are promoted, that is, through the so-called Appropriate Adult. The Appropriate Adult is there to protect the mentally disordered while being questioned by the police, and to help to prevent miscarriages of justice.
Philip Bean

7. Diversion: its Place in the Scheme of Things

Abstract
Diversion operates at the point where decisions can be made about whether a patient should or should not enter or remain in the criminal justice system. It does not fit easily into the current thrust towards community safety, for the aim is to treat rather than control or punish, and I say this without entering that debate about whether treatment is control or punishment. Perhaps the explanation lies in the differences between the various pressure groups; those wanting community safety are primarily concerned with controlling patients in the community, those for diversion are likely to be those supporting psychiatric values, and with a dislike of the criminal justice system. It is interesting that, over the years, supporters for diversion have had a considerable impact on policy, resulting in a government view that diversion should be pursued. As far as this book is concerned, and the central themes being followed therein, diversion needs to be examined sceptically to determine how, if at all, it helps to promote the integrity of mental health systems, and whether it fosters or frustrates community safety.
Philip Bean

8. Dual Diagnosis and Control

Abstract
In this chapter, the aim is to look ahead and highlight some of the likely areas of difficulty facing those services dealing with the mentally disordered offender. Already some of the warning signs have appeared, so that it is less about predicting what is going to arrive, and more about assessing what has arrived and determining what can be done about it. A recent arrival and one likely to cast a long shadow in the immediate future is dual diagnosis.
Philip Bean

9. Psychiatric Services and Treatability

Abstract
Whether a patient ends up in one control system or another is due often to contingencies. In effect, two control systems are in operation; a mental health system and a criminal justice system, one generally speaking taking non-offender patients, and the other taking offenders. I say generally speaking because things are rarely that straightforward. For example, the special hospitals take both types of patients, offenders and non-offenders alike, all detained in conditions of maximum security, and where non-offenders may remain detained longer. An offender may be charged with an offence and diverted out of the criminal justice system into the mental health system, the offence is then discounted, transforming the erstwhile offender into a civil patient. This is the so-called parallel system, where sometimes the systems work in harmony, sometimes not, and sometimes without an apparent regard for any other.
Philip Bean
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