BEST INTERESTS OR LEGAL RECTITUDE?: Australian MHT

stakeholder and case-flow implications

TERRY CARNEY

University of Sydney

What is my argument?

Neither best interests (nor ‘TJ’) a sufficient, or sufficiently sound, basis for MHT practice; need nuanced re-balance of 3 domains: (i) law (fairness…)

(ii) medicine (optimal treatment) (iii) social (work, housing, ..

What is my structure today?

[A] INTRODUCTION– 1. Background; 2. Clinical or legal?; 3. Best interest or legal

rectitude? [B] TREATMENT AT HEART OF MHTs?

– 1. Treatment planning & Oz MHTs; Medication etc concerns; 3. What to do about it?

[C] LEGAL RECTITUDE HEARINGS OR ‘RELATIONAL SPACES’?

– 1. Consumer views; 2. Communication; 3. MHT ‘manner’; – 4. Good practice hearing tips.

[D] ADVOCACY ISSUES [E] CONCLUSION

[A] INTRODUCTION: What is my material?

Prior socio-legal studies (Peay, Perkins…) 4 yr Aust Research Council collaborative grant.

– 3 MHTs (Victoria, New South Wales and ACT) & NSW Law and Justice Foundation

Divergent State/territory law/practices– Vic: clinician-imposed; MHT review @ 8 wks; – NSW: MHT-imposed; review prompt– Differing levels of legal representation; virtual hearings…– Human Rights Charters in Vic and ACT only

What were our methods?

Qualitative and quantitative methods– Analysis of MHT records– Analysis of ≈300 files in each NSW & Vic– Hearing observations– Interviews with consumers– Focus groups

What has been found so far?

Fairness & TJ (Carney, Tait, Chappell and Beaupert, 2007);

Leveraging’ treatment (Beaupert, 2007; Carney, Tait and Beaupert, 2008);

Levels of representation (Carney, Beaupert, Perry and Tait, 2008; Beaupert, 2009);

Charters of rights, multi-member panels and ‘time/resourcing’ (Carney and Beaupert, 2008);

NSW MHT role in property management (Beaupert, Carney, Tait and Topp, 2008).

What is my mental health system?

Universal health care; limited mental health care In 2006–07 for population of 21.8 million,

– 209,000 mental health-related inpatient discharges, 75% from public acute hospitals

– 2,531 episodes of residential mental health care.– Main diagnoses schizophrenia (59%),

schizoaffective disorder (10%) & bipolar affective disorder (6%)

Service picture…

Beds are rationed: 2,211 in public psychiatric hospitals; 4,196 in acute care general hospitals; 2,165 in government and NGO residential mental health facilities

15 CTOs per 100,000 of population (cf 5 in Canada or 3 in the USA)

Australia is not Ireland?

Australia: MHTs alone, few $$, lawyers or clinical second opinions;

Ireland: MHTs (with 18 times the $$) + MH C’ssion + Office of Inspector, + universal legal representation + second opinions.

Best interests etc?

‘Best interests’ (Ireland?)– Empty/vacuous?– A ‘don’t argue’ conclusion, not reasoning…?

‘Legal rectitude’ (Australia)– Marginal/ignored (Peay etc); Travesty if abbreviated? – ‘Least restrictive…’ doesn’t really ‘translate’ for MH?

Supported decision making futures?– Art 12 Convention on Rights of Persons with Disabilities– Victorian MH Review Panel reform guide

Some hypotheses

Distress/powerlessness thesis– Acutely ill patients distressed?– Hearings rarely empower?

Legitimacy/impact dilemma– Need to maintain clinician confidence?– Unwilling/unable to engage ‘treatment’/social?

‘Charter-driven’ change?

[B] TREATMENT LIES AT HEART OF MHT REVIEWS?

Strongest message from consumers/carers Concerns include:

– Choice of treatment– Adverse side-effects of medication– Housing/cty support; discharge planning

Distressed that unable to raise concerns at MHTs… Compare overseas; eg Ireland

– Second opinion system– Office of Inspector of MH Services

Victorian Gardner Review shares concern?

For example #1

I told him: “Doctor please today is my day. For long time you treat me wrong way. You give me the wrong medication. I suffer so much but please today listen to me. I want to speak. You listen until I finish please.” He goes: “No, no, you don’t have the right to speak. You have a mental health problem” (NSW consumer, 2007)

For example #2

I just was so distressed because no-one was really listening to me, no-one was hearing what I was trying to say about my feelings, they might have been more interested in your actions, okay you take your medication, but they don’t know how it feels to have to suffer side effects. I was trying to explain that and I don’t think I felt really heard so I was bawling my eyes out, so was my mum and we just both had to leave the room you know (Victorian consumer, focus group, 2004)

So…Need from MHTs something more like?

So what you want to make sure that the patient’s complaint should be heard, looked into seriously and then see what could be done. Any alternative treatment can be tried or something can be given to counteract the side effects. So we have to make sure that the right things are done. So we listen to the patient’s complaints, their general complaints and we have to make sure that the clinicians also have listened and have done something (Victorian psychiatrist member, 2007)

[C] LEGAL RECTITUDE HEARINGS OR RELATIONAL SPACES?

Our consumers saw MHTs as like a ‘trial’ Anxious and fatalistic

– Distressed/powerless?

Contribution of physical ‘setting’ But also the ‘shape of power’

– Professional superiority/power

Example #1 Anxious/fatalistic

What were you expecting when you went in?

Not much really. I was just expecting them to try to, not belittle me, but make me feel a little uneasy. Said how all these things, about how they have all the notes about me and that and they expect me to behave a certain way, or something like that (NSW consumer, 2007)

Example #2 (Apprehensiveness)

I was a little apprehensive, I didn’t know what was going to be said or happen. I didn’t know what they would say to me and if I was to tell another person about that I would tell them that it’s not anything which they should worry about so that the next person who goes in there they should know it’s not something that will hurt you or get upset about or worry about (Victorian consumer, 2004)

Settings are part of the problem?

Can you describe the physical environment room or the hearing space?

Sure, big officious looking room. Huge meeting table in the middle, three chairs set up on the other side and my chair on the opposite side of the table. Very overpowering. …

How do you think it could be set up better, what would you suggest?

More of a round little table. Not a big board table like what I had, doctors do it all these days, they have people sitting on the corner not opposite, just the power thing (Victorian consumer, 2004)

Power/symbolism negative anyway?

So when you’re at the hearing so what do you think that hearing’s doing? The hearing is mainly to waste your time. They can because the doctor has the power of the government to keep you on CTO. Even the hearing is just the shape of power. Different sort of power (NSW consumer 2007)

Some people are very agitated before and they’ll do their bundle like you wouldn’t believe and then they’ll get in there and then, because of the pressure and the stress, they’ll swear at everybody and walk out. And you can see why it happens. One reason is the set up. Everything seems to be set up against the consumer, just in the order of the way the people speak. And they feel that they’re on trial and their whole life is on trial and every misdemeanour that they’ve ever done is going to be raised (NSW advocate 2007)

MHT introductions matter?

You bet they do! [T]hey started having discussions, you know addressing [the

advocate] and I said …”Listen do you mind if you at least give me your names?”, as they didn’t introduce themselves and they didn’t state their functions and [the advocate] picked up on that point as soon as I mentioned it to her. … And one of the members there took offence to that and said that she wasn’t going to tell me… that wasn’t necessary, yeah, … – it went on for about 5 or 6 minutes. And in the end they did introduce themselves and they did tell me what their functions were (Victorian consumer, 2004)

Endings too?

Do you think often that people just leave a hearing not knowing at all what happened though?

People can. If they go and they’re nervous and they don’t really know, first time in there. Legal process. Never been into any sort of legal process before. They would get some description of what’s going on but they don’t hear it. They’re too frightened. They do try and engage them though (ACT nurse, 2007)

So we need to learn to converse?

What I try to do is to get some sense of the person I’m talking to and how they would normally interact with other people and then work on those sorts of levels. We certainly are in an environment where there is lots of jargon around, so trying to de-jargonise, particularly medical matters, is really important. Making sure people really do understand as best they can what’s going on is important. And that varies enormously (Victorian member, 2004)

Adapt order/parties to taste?

I’ve got me wife sitting there that I’ve been with for 20 years, married with her for 20 years, I live with her and the judge’s made a decision without asking me wife, which is very wrong because I don’t live with the doctor, I live with me wife. So me wife’s got a better idea how I am and I find it that the judge [sic] should speak to me first then me wife to verify what I’m saying is right. And then ok listen to the doctor (NSW consumer, 2007)

Think about ritual/reception

The doctor doesn’t talk to the client, the doctor talks to the Board members. The lawyer talks to the Board members. The client talks to the Board members. So there’s no actual interaction between the doctor and the client. Or the lawyer and the client. And I think that makes a difference. … In terms of ritual, I think that thing about the psychiatrist member and community member also interacting with the client is quite important (Victorian advocate, 2007)

Consumers are people

Now that’s another thing, this is where they tended to ignore [the consumer]. It must have been awful for her. “All these people are talking about me and yet not acknowledging me. I could be like a leg on the chair.” That’s how she was treated. They talked about her (NSW carer, 2006)

It was just the way that he kept saying “yes, yes, yes, yes” to me. Sort of interrupting me when I was speaking. Yes we’ve heard that before from the person who advocated for me. Yet they asked me to speak (Victorian consumer, 2007)

An ideal MHT ‘hearing protocol’?

Thanks for attending/participating; Introductions all round; Conversational, not ‘formal’ tone of voice/manner;

chit-chat; Address the range of issues, not just focus on the

‘legal answer;’ Ask consumers what ‘they’ think; & acknowledge

what is said (even if different); Acknowledge the emotional side and provide

empathy/support;

Protocol (continued)

Ask how consumers feel; their views on side-effects; alternatives; non-medical issues;

Ensure everyone has a say; Use non-technical language; Provide summaries along the way; Identify other outstanding issues & explore; Be encouraging, empathetic and respectful.

[D] Advocates or support?

A good question given equivocation about lawyers role/cost?

Legal advocacy a basic right irrespective? Lay/community advocacy as = priority?

– OPA submission to and endorsement from Gardner review?

– Victorian government position?

[E] Conclusion; where to now?

The health context is dominant. Little time is available in which to check the legal fidelity of the admission, or the clinical evidence on which it is founded; information about the social or family context is rare, and few clients are legally represented or informally assisted by the presence of family or friends. The bulk of the clientele are seriously ill, and are ‘repeat’ players (with chronic, relapsing conditions).

Flexible engagement of legal, medical and social domains

Potential for flexible MHT procedures, combining liberty-protecting and the ‘allocative’ roles via best elements of ‘case conference’ models (cf Wood, 1998)

Consider not only legal criteria but also issues in medical and social domains

– Eg concerns about misdiagnosis, adequacy of treatment (including access to psycho-social support), choice (and side-effects) of medication,

– discharge planning, community services, employment, housing and involvement of friends and family.

Wood revisited

As Em. Professor John Wood recognised:

It is important to look at the structure and availability of tribunals with [wider] factors in mind, rather than merely the very narrow formal conception of the tribunal as concerned almost wholly with the need for a statutory order. It follows that the functions of the tribunal are likely to be understood as a general review and not merely a forensic contest as to the justification of the Order (Wood, 1999: 134).

References

Beaupert, F. (2007). 'Mental Health Tribunals: From crisis to quality care?' Alternative Law Journal, 32(4): 219-223, 232.

Beaupert, F. (2009). 'Mental Health Tribunal Processes and Advocacy Arrangements: "Little wins" are No Small Feat '. Psychiatry, Psychology and Law, 15(2): 90-107.

Beaupert, F., T. Carney, D. Tait and V. Topp (2008). 'Property Management Orders in the Mental Health Context: Protection or Empowerment?' New South Wales Law Journal, 31(3): 795-824.

Carney, T. and F. Beaupert (2008). 'Mental Health Tribunals: Rights drowning in un-“chartered” health waters?' Australian Journal of Human Rights, 13(2): 181-208.

Carney, T., F. Beaupert, J. Perry and D. Tait (2008). 'Advocacy and Participation in Mental Health Cases: Realisable rights or pipe dream?' Law in Context, 26(2): 125-147.

References (continued)

Carney, T., D. Tait and F. Beaupert (2008). 'Pushing the Boundaries: Realising rights through mental health tribunal processes?' Sydney Law Review, 30(2): 329-356.

Carney, T., D. Tait, D. Chappell and F. Beaupert (2007). 'Mental Health Tribunals: "TJ" implications of weighing fairness, freedom, protection and treatment'. Journal of Judicial Administration, 17(1): 46-59.

Peay, J. (1989). Tribunals on Trial: A Study of Decision-making Under the Mental Health Act 1983. Oxford: Clarendon Press.

Perkins, E. (2003a). Decision-Making in Mental Health Review Tribunals. London: Policy Studies Institute.

Wood, J. (1998). 'What I Expect of My Psychiatrist: The mental health review tribunal'. Advances in Psychiatric Treatment (1998), vol. 4, pp. 197-201, 4: 197-201.

Wood, J. (1999). 'Control and Compassion: The uncertain role of Mental Health Review Tribunals in the management of the mentally ill'. In: D. Webb and R. Harris (ed) Mentally Disordered Offenders: Managing people nobody owns. New York: Routledge: 127-140