"If seven maids with seven mops
Swept it for half a year.
Do you suppose," the Walrus said,
"That they could get it clear?"
It has taken more than seven years and many a bitter tear and tangled mop to force the Government to sweep away its much-heralded Mental Health Bill. Such was the climate of fear and suspicion created by its initial proposals that almost all those in the mental health field united in opposition, with the backing of The Independent on Sunday. The main concerns were that the so-called reforms were being driven by a Home Office agenda to allay public fears about the care in the community policy and not about improving the rights and safeguards of those in need of treatment. Coercion not compassion was seen to be the essence of the draft legislation.
Last week, in a surprise move, frustrated ministers from the Department of Health and the Home Office, together with the mental health tsar, Professor Louis Appleby, announced "a fresh approach to radically overhaul the law". This climbdown was greeted with relief by most in the mental health field, but it was also an expensive and missed opportunity to bring the 1983 Mental Health Act into the 21st century.
The Government has not given way totally to its critics. The simplified proposals include at least two of the most controversial measures: the introduction of supervision treatment orders, compelling people detained under the Mental Health Act to continue to take medication when discharged; and the removal of the treatability test, which currently results in some people deemed to have untreatable personality disorders being excluded from possible treatment. The limitation on the former has gone some way to acknowledge fears of people being forcibly given jabs across the kitchen table. Such orders would now only apply to a few patients who have been already detained in hospital (and may otherwise have to stay there). They will be welcomed by families who have long had to witness the deterioration of a loved person who stops taking medication, spirals into delusions and disappears into a Bermuda triangle of care, all too easily becoming lost between services.
Our belief is that given safeguards, such treatment orders could provide more incentive to community health teams to better monitor and protect both patients and families. Take the recent case of Ismail Dogan. If anyone in the mental health services had acted when it became apparent that he was missing outpatient appointments and not taking the medication that enabled him to lead a reasonable life in the community, then he might not have become so ill that "a bird in his ear" commanded him to go out and kill English people. No change in legislation would have forced the GP or crisis services to respond to a mother's plea for help. Nor do they go out to families in crisis if the patient - even temporarily - is not at home. This is the Catch 22.
The second of the retained proposals is to remove the "treatability test". At Sane we take the view that this may prevent some of those who fall between conflicting diagnoses from being left outside mental health services. We have come across too many people who are being refused the help they seek on the decision of one psychiatrist that is not always upheld by another. Daniel Gonzalez, months before his final breakdown, wrote to his doctor pleading to be given medical help. So did Michael Stone. But despite both having had at some time a diagnosis of schizophrenia, dispute as to whether they were "bad" not "mad" was the determining factor in their treatment, not the risk they posed to themselves or others.
No one is in favour of long-term preventive detention for a person who has not committed a crime and who is unable to benefit from current medical treatment. But as Professor Appleby has pointed out, some people with mental illness do not benefit from current medical treatment, yet are detained against their will. Nor have there yet been sufficient efforts to provide psychological therapies and, if all else fails, sanctuary. With safe use, these proposals could salvage lives that may otherwise be wrecked by exclusion and neglect.
The most disappointing omissions are the lack of improved rights for carers and access to advocacy for patients. Nor has any way yet been found to include positive rights to care and treatment. But our main concern remains that to match compassion with coercion will require not only huge increases in resources, but a culture change in the way mentally ill people are respected and the concerns of families taken seriously.
There is little point in detaining someone in overcrowded and squalid wards where staff morale is low and where so little is provided in the way of occupational and psychological therapy. There is equally little purpose in maintaining people in the community if life becomes so bleak that they are driven to suicide.
The new Bill should concentrate not only on the rare tragedies involving public safety, but on the many thousands who suffer quietly and desperately until they become so ill that they need protection for their health and safety - and those who care about them need a night's sleep.
Marjorie Wallace is chief executive of the mental health charity SaneReuse content