So, you want to write about mental health.
By checking out the previous series of Freudian Script, which concentrated on specific conditions – like depression, psychopathy and autistic spectrum disorders – the writer can get to grips with a sensitive and accurate portrayal of a mental health problem.
But what about the experience of living with a mental health problem in the UK? How do mental health services function? What happens when you have an urgent problem one morning? How about at midnight? What goes on inside a mental health hospital? Who comes to see you if you can’t leave the house?
And what about the professionals who work in mental health? Who are they and what do they do? How do they interact with other areas of medicine, social workers, and emergency services?
The next series of Freudian Script concentrates on these aspects of mental health. Because I live and work in the UK, this will focus on the British experience of mental health but I would love to hear from people in other countries and gain additional perspectives.
To kick off, we will be looking at the the main law relating to mental health in the UK – The Mental Health Act.
DISCLAIMER: This blog post is designed for writers of fiction. If you need advice relating to mental health law, please seek out a lawyer or mental health advocate
What is the Mental Health Act?
Born in 1983 and revised in 2007, The Mental Health Act is the principle piece of legislation governing mental health problems in the United Kingdom. It specifically deals with what happens when a person who has, or is suspected to have, a mental health problem requires treatment but refuses it.
History of the Mental Health Act
The first piece of mental health law in the UK was the Madhouses Act 1774. This gave licensing powers to the Royal College of Physicians to license madhouses, which could detain “lunatics” under the authority of a doctor. There were several versions of the Madhouses Act, before it was replaced by the Lunacy Act 1845 and County Asylums Act 1845. These laws dealt with the detention of “lunatics, idiots and persons of unsound mind” and set up local Lunatic Commissions to monitor them.
A note on language: The terms “lunatic” and “idiot” are now derogatory insults, but they were the medical language of the time for mental health problems. The problem was that they were used as insults and so health professionals changed them. You can see this process continuing with “retard”, “mental” and even “special”.
Then came the Lunacy Act 1890, which involved a Justice of the Peace in detaining people. This was replaced by the first Mental Health Act (1959). It encouraged the treatment of people with mental health problems without detention but provided for it if necessary.
However, this was still inadequate, as it was unclear whether treatment could also be enforced. This question was finally answered by The Mental Health Act 1983, and further refined in the 2007 amendment.
Sections and “sectioning”
A section is a legal term referring to part of a law. All laws have them. However, in mental health, the phrases “I’ve been sectioned” and “he’s been put on a section” are common ways to refer to being detained under a Section of the Mental Health Act. The numbers refer to the part of the law that’s being used.
To detain someone under a section, there are two requirements: that the person has a “disorder of mind” – not necessarily a diagnosed mental illness – and they are a risk to themselves and/or others.
I’m not going to go through the whole law, but I’m going to touch on the most commonly used Sections and how they work.
Section 2 is for assessment and lasts up to 28 days. While the purpose of Section 2 is assessment, patients can also be treated on it. To place someone on Section 2, you need two doctors and an Approved Mental Health Practitioner, or AMHP (rhymes with lamp) – usually a social worker. One doctor is a Section 12-approved doctor (i.e. a doctor who meets the requirements laid out in Section 12 of the Mental Health Act), and the other can also be a Section 12 doctor or a doctor who knows the patient well (e.g. GP). The AMHP represents the views of the family, which harks back to the days where your family could place you in an asylum – and get you out.
Section 3 is for treatment and lasts up to six months. The assessment also requires two doctors and an AMHP. People can go on a Section 3 after a Section 2 if their treatment needs to continue or people can go straight on a Section 3 if they have a diagnosed mental health problem and are presenting with one of their typical relapses.
If patients come into hospital voluntarily (known as “informal” status) but deteriorate and want to leave, they can be assessed by the Duty Doctor or their consultant psychiatrist and detained for 72 hours. This is to allow a full assessment to take place. Nurses have a similar holding power under Section 5(4), but this only lasts for four hours – until a doctor can use Section 5(2).
This is a police power. They can take the person to a “place of safety” – usually an A&E department, police cells or a specially-designed suite at a mental health hospital. From there, they can have an assessment to see whether they need to be placed on another section, admitted informally or go home with support. Sometimes, people are placed on Section 136 while intoxicated (because being high can look a lot like mental illness), and when they sober up, there’s no need for further mental health intervention.
Appeals and Nearest Relative
Anyone on Section 2 or 3 can appeal against it. A mental health lawyer is provided free of charge and a tribunal is conducted. This involves independent judges – usually doctors and lawyers – considering evidence provided by the treating team and the patient. They can order the immediate discharge of the section or ask for certain conditions to be met.
The patient’s nearest relative can apply for the person’s discharge from the section. This again harks back to original asylum law. The nearest relative is usually spouse, oldest parent or oldest child. The treating psychiatrist (also called the Responsible Clinician) can bar the discharge if there is immediate danger – often hard to prove. If the nearest relative blocks a section during the assessment stage and the treating team thinks they don’t have the patient’s best interests in mind (because of financial gain, abusive situations, etc.), they can be displaced. But that can be a difficult legal process.
If a person doesn’t have a nearest relative or an unsuitable one, they have access to an Independent Mental Health Advocate (IMHA). That person supports them on issues such as mental health law and their rights as a detained patient.
Leave and discharge
Just because someone is on a section doesn’t mean they have to stay in the building. The Responsible Clinician can use Section 17 leave (i.e. leave as described in Section 17 of the Mental Health Act) for people to leave to ward under certain conditions – usually for certain periods of time, within certain hours and possible escorted by staff or family. If people refuse to come back or run off, the police can return them to the ward.
When the person has recovered enough to go home or chooses to remain informally, the Responsible Clinician alone can discharge them from the section. It’s considered very bad practice for a section to lapse without a follow-up assessment.
Community Treatment Order
This was one of the new measures put in place by the 2007 amendment. It provides for the group of patients who never recover insight into their illness and need monitoring and medication to prevent dangerous relapses. These people are placed on a Community Treatment Order (CTO) from a Section 3 by two doctors and a social worker. It basically requires them to meet certain conditions – usually taking medication and keeping appointments. If they fail to do so, they can be recalled to hospital without a further assessment. Once in hospital, the Responsible Clinician decides whether to change it back to a Section 3. Sometimes, they just have their medication in hospital and leave again. There is also an appeals process attached to CTOs.
The Mental Health Act is a frightening and confusing beast. Add this to the fact that the person is usually suffering from a severe mental health problem and it can be absolutely terrifying.
The most common fears I hear expressed are that they’ve been arrested and imprisoned – especially if police are involved – or that the hospital has no right to hold them. All patients are given their rights, but it’s difficult to take in any information while distressed.
As a writer, The Mental Health Act can be dry and convoluted and your audience is likely to have limited knowledge of it. Give them a way in through the person experiencing this traumatic experience – and it is traumatic.
In the Mind series “Your Voices”, one woman talks about her experience of psychosis and being sectioned:
While everyone was celebrating the Olympics I was sectioned and spent a week in hospital. I had started to hear voices and was living in a very strange world. Being in hospital was a terrifying experience and I couldn’t understand why I was there or what had happened to me. I thought the nurses were trying to kill me and I refused medication. Eventually I accepted the drugs and I did recover. I was released after a week and received treatment in the community.
If you have any questions about the Mental Health Act or other parts of the UK mental health experience, please feel free to contact me in the comments or via email.
If you have personal experience of the mental health system, please get in touch. Your stories help a new generation of writers portray mental health problems with less stigma and more truth.