Choice and control – or co-ercion?
Community Treatment Orders or Compulsory Detentions under Mental Health Act
Radar, 5 July 2011
The conventional wisdom is that we are gradually moving towards a world where as disabled people we have more choice and control and are less likely to be forcibly put in institutions. But is it true?
When Steven Neary went into a care home for respite for a few days – Steven has autism and a learning disability and lives with his father – he was kept in for a whole year. The case went to the Court of Protection which found that the London Borough of Hillingdon had breached Steven's human rights; as the EHRC put it ‘Steven, like everyone else, has a right to personal freedom and a family life and the state should not take away this without good reason'. Quite.
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Steven and his family may have won that battle (congratulations) – but there are so many people who are living in institutions or facing compulsion outside them: we need to win a wider war.
Take Community Treatment Orders (CTOs). They allow people with mental health problems who are still thought to need treatment (on the grounds of their own health and safety or for the protection of others) to stay out of hospital – but only as long as they comply with treatment. If they don't, they can be recalled. In 2008, when CTOs were introduced, all the talk was of reducing the numbers compulsorily detained in hospital – people would be able to leave hospital just as long as they carried on taking the meds and would be freer, so the theory went. Government thought about 400-600 people would be subject to CTOs each year. The reality has been very different. CTOs are running at over 4,000 a year (10 times the level predicted) and compulsory detentions in hospital have gone up as well. So whereas in 2006-7 42,855 people were subject to compulsion, by 2009-10 there were almost 50,000 – more people detained in hospital plus new people having compulsorytreatment in the community[1].
The light blue figure of 4,017 represents CTOs in 2009-10.
Is this a symptom of cautious practice, a way of managing the anxieties of professionals? Whatever the cause, this jeopardises human rights and risks entrenching inequalities. 18% of people receiving CTOs so far have been black/black British. And of course it is not just people who lack mental capacity who are treated without their consent – many do have capacity. This is not a great chapter in the move to progressive mental health policy and practice.
There are also institutions that people seem to enter quite voluntarily but where real choice is in doubt: catering for people with a range of experiences of disability – older people with physical impairments or dementia, younger people with learning disabilities or complex impairments. Where they are really chosen – for instance, for company by an older person who otherwise would live alone – all to the good. But where they are used only because of economies of scale, where the alternative is just 15 minutes a day of home based care, where dying at home is not made possible – then we need to challenge the fact that so many people are channelled towards institutions. A choice is not a choice if there is no range of viable options. I've seen at firsthand how the bias towards care homes can operate – and how strong you have to be to negotiate for high quality home based support.
So let's pause before we agree that choice and control are growing, that we are freeing ourselves from institutions. For many disabled people that is true – and it is liberating. But for too many others the opposite is the case: coercion and institutionalisation prevail. And the problem is growing. The Joint Committee on Human Rights in Parliament, and the Equality and Human Rights Commission, and the UK Government as it implements the UN Convention on the Rights of Persons with Disabilities, need to think hard about co-ercion and implement change. Otherwise we will carry on with warm words on choice and control, whilst for some citizens – especially black disabled citizens, especially people living in poverty – the experience is very different.
We know a lot about models of support that work – through peer support, choice and control. We need to campaign to make them more widely and fairly available. And we need assessment and planning devised jointly, in co-production, with advocacy and individualised support – so disabled people can realise potential, and be supported to be drivers of their own lives.
Liz Sayce – Radar Chief Executive
[1] In 2006-7 there were 42,855 compulsory detentions. By 2009-10 compulsory detentions had gone up by almost 3,000 to 45,755 AND there were 4,107 CTOs. So for the first time almost 50,000 people were subject to compulsion either in hospital or outside (49,862 to be precise).
[1] In 2006-7 there were 42,855 compulsory detentions. By 2009-10 compulsory detentions had gone up by almost 3,000 to 45,755 AND there were 4,107 CTOs. So for the first time almost 50,000 people were subject to compulsion either in hospital or outside (49,862 to be precise).