I was delighted to speak with Dr Pat Bracken and Dr Charles O’Mahony on the Irish Centre for Human Rights podcast. We covered a lot of ground, speaking about the current reform of the Mental Health Act in Ireland and also more broadly about the power imbalance in mental health services, which remains grounded in law and in one profession, and is an incredibly potent tool that permeates right down through services to maintain the status quo.
Full podcast available here and where ever you get them:
Here is an overview of what we spoke about:
We all accepted that we weren’t going to do it 100%.We weren’t going to get there in this particular rewrite of the Act, but we thought that we could get it some way towards it. My own particular disappointment, and it stems from my own views... are that I see the main problem as the power that is vested in one profession in one voice, when in fact mental health is a messy territory.
There are contradictions. There are different voices. I’m not arguing for a free for all, but I’m arguing that to do justice to the people that we are talking about, that is, people who are struggling with mental health issues, to do real justice to them, we need to acknowledge that different voices have a legitimacy.”
Dr Bracken added:
“There are different ways of understanding mental health problems. Different solutions are out there, and just to give one professional voice all of the power to determine what happens, that’s where I see the main problem as it stands at the moment with the current Act. And indeed the rewriting of the Act won’t change this… nothing in the current proposal is going to change.”
Dr O’Mahony continued:
“One of the real difficulties of mental health law is that, you know, from its inception in the 1800s, there has been a reliance on risk and dangerousness as the primary rationales for treating people with mental health problems differently to other people in the health system. So it’s quite extraordinary when you look at the powers under mental health legislation that somebody can be involuntarily detained and forcibly treated even when they have capacity to object and to refuse their consent. So, you know, there’s very difficult questions here.
“Very often there’s a conflation of having a mental health problem with being a danger where a lot of the research shows that if you’re a person mental health problem, you’re more likely to be the victim of violence than a perpetrator. ”
“Part of the conversation then has to be about moving beyond our traditional approaches in law and within our medical system and looking at what the UN Disability Convention requires, which is supported decision making, crisis intervention, non coercive community based supports and alternative ways of responding and supporting people who are in distress rather than the default responding.”
Dr Bracken spoke about being involved with the World Health Organisation Guidance on community mental health services. It provides a detailed description of person-centred and human rights-based approaches in mental health, and summary examples of good practice services around the world.
“Unless we embrace the idea that we can move towards non coercive practices…and move towards really respecting and listening to the voice of the service user, unless we embrace that as our goals, we’re not going to make it. That’s what we were looking for (in the WHO report) – services had set that as their goals. And lo and behold, around the world there are services that work safely and positively in this direction.
And there are some brilliant examples that we put forward.You know, obviously the the one that that everybody thinks of is the service in Trieste in Northeast Italy, which for 50 years has been working with the philosophy of non coercion, of holistic care of community based services.
“A lot of psychiatrists are very resistant even to the work of the World Health Organization and they see it as anti-psychiatry. They see it as eroding their autonomy and it’s couched as putting people at risk and undermining their rights.”
Dr Bracken added: “I define myself as a critical psychiatrist. I’ve come to the conclusion that, critical thinking is not a negative thing. It’s not about knocking ideas or, or rubbishing a profession or whatever.
But I do feel that when it comes to mental health work, we need to start creating practitioners who are able to reflect critically on their own professional, professional assumptions, practices and histories, the history of where their professions come from and, and, and, and the, the practices that have historically come down.”
“Psychiatry was born in the asylums of the 19th century, You know, whether we like it or not, our profession, that’s where the profession came from. And I think we still have a very institutional kind of legacy that is in our heads.
I’m very impressed by the Open Dialogue approach which developed in Finland. Which specifically trains the professionals to hold back on their professional knowledge, to allow a space where a family or a group of people around the person who’s in crisis can use their own words and their own reflections to come up with a way of talking about the problem and then coming to solutions. I think that way of working is something a lot of psychiatrists are interested in that there’s a big, big projects going on now in, in different parts of the world, you know, with this kind of open way of engaging with people.”Sometimes, Dr Bracken added, for professionals, it’s about realising that you don’t have “all the answers and all the knowledge… being able to put your knowledge aside sometimes, being able to reflect critically on that knowledge, where it came from.”