Phil Barker, in his book Mental Health Ethics, writes that the world of psychiatry has helped propagate the idea that ‘choice’ is something that can be either given or facilitated by staff. He argues that choice is instead something that can only be taken away, or restricted. Indeed, this is particularly pertinent in cases of coercion, especially within the world of the Mental Health Act, and the subsequent detention of people in hospital because of the risk they pose to themselves or others as a result of their mental disorder.
Detention under the Act, and coercion in more general terms is a contentious issue within the field of mental healthcare, with many arguing that its foundations are diametrically opposed to Beauchamp & Childress’ principles of biomedical ethics – autonomy, non-maleficence, beneficence, and justice. Indeed, it could be said that the very act of coercion requires the professional or clinician undertaking the act to view the patient as ‘less than’ a person. If we deny an agent’s ability to act rationally (i.e., they are ‘mentally unwell’ and cannot make decisions for themselves), are we denying their personhood, and in turn, removing their ability to act autonomously? If we remove the possibility for someone to self-determine and to self-govern we are in effect denying their rights as a human being to autonomy and agency.
The concept of autonomy is in itself a contested one, and for the purposes of this I will be mainly drawing from feminist critiques. Much of the literature around autonomy fails to take into account the effect that oppressive socialisation and unequal societal structures have on those who are from minorities or those who are vulnerable, such as those with mental illness. Aristotle talked about ‘eudaimonia’ (or flourishing) as a notion of how a moral agent is able to achieve self-realisation. Is it fair to suggest that those suffering from mental illness are able to flourish and achieve self-realisation in a society in which they are repeatedly told that their inability to work is an innate failure of their human nature? Or that their reliance on benefits is not one of genuine need? Or that the only way that mental health services can work with them is by compelling them to by using legal framework? I don’t think it is.
I’d like to use an example to illustrate the above point. Jenny is 37. She has been using mental health services for 15 years, and has a diagnosis of schizophrenia. Jenny’s illness has meant that she has been unable to work for the last 10 years, and for much of that time has felt increasingly socially isolated – her community support group (of which she felt an enormous sense of belonging and purpose) disbanded five years ago due to health and social care budget cuts. Her physical health has been suffering because Jenny struggles to access her local GP services because she is paranoid about one of the other patients there. She is estranged from her family. She relies upon her Employment Support Allowance and Personal Independence Payment in order for her to pay her rent, bills, and food. Jenny receives a letter telling her that she is to be reassessed for her benefits. Jenny is unable to attend the appointment, as it is early in the morning and she finds it difficult to wake because of her anti-psychotic medication. She is informed that her ESA and PIP will be stopped, meaning that she is unable to pay her rent. Jenny’s mental health suffers as a result, and she experiences a relapse in her psychotic illness. She is assessed by an AMHP and two doctors, and is admitted under Section 3 of the Mental Health Act.
While the above is not a real case, it is highly likely that examples of this are happening up and down the United Kingdom. It is clear to see the inherent structural and societal disadvantages that Jenny has faced that have denied her right to self-actualise and to achieve autonomy. The ultimate result of this was Jenny’s detention under the MHA, a form of coercion that as previously alluded to, has enormous implications for one’s sense of self, agency, and personhood. It would be morally and ethically dubious to suggest that this was the best way to help Jenny.
There is another way that we can help Jenny: Diana Meyers, a philosopher of feminism, has developed the theory of autonomy competency, in which she takes a relational approach to autonomy. She suggests that autonomy competency (or, the ability to exercise autonomy) can only be developed in the context of social relationships, practices, and institutions. She highlights the importance of one’s social environment in helping develop skills of ‘self-discovery, self-direction, and self-definition’. By providing an environment in which Jenny is able to develop meaningful relationships, to promote aspects of herself that are important to her (i.e., talents, character traits, and interests), and a space in which she is able to interact and act with authenticity will ultimately lead to Jenny being able to operate in an autonomous way in a world that has been set up to oppress her.
As professionals, we have an obligation to help provide these opportunities for the people that we work with. As those of us who work in mental health services will know, the options available to us in the community are often poor at best or non-existent at worse and it doesn’t look to be getting any better. As such, we need to get better and more inventive with what we do have. In the Care Quality Commission’s Are We Listening? Report on Children and Young People’s Mental Health Services, a particular piece of local innovation stood out. It was discovered that a young person, who was struggling to engage in cognitive behavioural therapy, had a particular fondness of animals. The local team decided to offer the young person informal support sessions in an environment in which they could interact with animals and feel more comfortable. This flexible, personalised approach alongside evidence-based therapy ensured the young person’s ability to self-actualise, to achieve autonomy, and to flourish. While meaningful change on a societal level will require a much greater shift in government policy and public awareness, on a local level we need to do more like this to ensure that people like Jenny are flourishing too.
Polly Tickle is a Charge Nurse on an Adolescent Psychiatric Intensive Care Unit in London. He has a particular interest in Mental Health Ethics, and how philosophy interfaces with our day to day interactions and interventions with the people in our care. He is commencing an MSc in Mental Health, Ethics, and Law at the Institute of Psychiatry, Psychology, and Neuroscience in September 2018. He can be found at @pollytickled, tweeting indiscriminately.