Detention & mental capacity
When detained compulsorily under the Act, basic personal liberties are removed, and it can invoke enormous emotional strain on patients and their families. Between 2019-2020, there were 50,893 detentions recorded. The number is likely to be higher than this as not all detentions are documented. During this same period, Black people were more than four times as likely as White people to be detained.
To better understand the experiences of those detained, King’s researchers carried out detailed assessments of mental capacity and clinical characteristics in patients in 250 consecutive admissions to psychiatric hospital under the MHA. The research found that 86% of those formally detained for compulsory treatment were not able to make and communicate decisions about treatment i.e they lacked mental capacity.
60% of those patients who chose to be admitted voluntarily lacked the proper capacity to make decisions about their treatment and care. For voluntary patients, those who lacked the capacity to make these decisions were more likely to experience feelings of having been coerced and to refuse treatment.
These findings highlighted the clear failure of the MHA to give people a say in what happens to them during detention and the negative impacts this has for the person and the effectiveness of treatment.
Advance Care Planning
An Advance Decision is a statement of instructions about what medical and healthcare treatment you want to refuse in the future, in case you lose the capacity to make these decisions. These are sometimes known as “advance directives” and they enable people to make these decisions during times when they feel better able to plan for their care. However, even when patients have outlined advance directives about their care in the event of detention, the MHA did not require that these to be acted upon. This essentially bypasses the one route to which patients may be more empowered in the decisions about their treatment.
A major challenge in the development of effective models of advance decision-making is for those patients who have fluctuating mental capacity, such as in bipolar disorder. In collaboration with the charity Bipolar UK, King’s researchers surveyed service users on their own experiences and perceptions of ADM to gain insight into how to develop better models of ADM . 88% of those surveyed expressed a desire to be involved in the planning of their treatment in the event that they lose the capacity to make decisions, but only 36% had done so.
In 2017 King’s adopted a collaborative approach with service users, clinicians, policy makers and third sector organisations to form its Mental Health and Justice (MHJ) research project, recognising the importance of including all voices. The MHJ project was awarded £2.5 million by the Wellcome Trust. Building on King’s research from the early 2000s, the MHJ project developed a new model of ADM grounded in the lived experience of fluctuating mental capacity as well as in psychiatry, ethics and law.
In collaboration with service users, friends and family of service users, legal experts, and clinicians, the model was then developed into the Preferences and Advance decisions for Crisis and Treatment (PACT) document and guidance materials fit for implementation studies in clinical services.