The right to treatment, social care, and liberty

The Mental Health Commission annual report 2020 provides important detail on recent trends in involuntary admission.

Involuntary admission to psychiatric inpatient care is governed by the Mental Health Act, 2001, which was introduced incrementally between 2001 and 2006. At the time, there was broad acceptance of the need to update existing legislation in order to better protect patients’ rights and increase adherence to the United Nations’ Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991).
There were, however, clear gaps in the new legislation, which did not address in detail the process of voluntary
admission; did not establish a minimum standard of care to which patients were entitled; and did not allow for shorter periods of detention explicitly for assessment purposes. These deficits remain today. In fact, the 2001 Act was quite crisply focussed on two key issues: Revised procedures for involuntary admission, and strengthened governance mechanisms, especially mental health tribunals and changes to inspection processes. Its overarching aim was to enhance protections of the human rights of the mentally ill, especially those who receive involuntary care.

Fifteen years after full implementation of the legislation, much has changed in mental health services, with additional changes over the past year owing to Covid-19. Against this background, the Mental Health Commission
(MHC) recently provided an update on mental health services in Ireland during the first year of the pandemic in its
2020 annual report. The Commission’s Chief Executive, Mr John Farrelly, notes that, “in the peak months of April and May, services came under severe and relentless pressure. The collaborative, flexible and committed effort of all involved contributed significantly to protecting the life, health, and welfare of patients and residents.” As usual, the Commission’s report provides a wealth of useful information about mental health services over the course of 2020, a year in which some 1,946 mental health tribunal hearings took place.

Mr Farrelly draws particular attention to the increased involvement of gardaí in involuntary admissions: “It is even more concerning that this occurred during Covid-19 when persons requiring treatment might have been even more vulnerable and intervention by the gardaí could have caused more distress.” Mr Farrelly’s concerns are well-founded. Garda involvement should be a last resort and, in my experience, usually occurs only when there is no other alternative admission pathway. That said, it is worth noting that Ireland’s rate of involuntary psychiatric admission (“sectioning”) is low by international standards, at approximately half the rate in England. Rates vary considerably across countries, but Ireland’s rate is notably low at present.

This was not always the case. In 1838, the ‘Dangerous Lunatic Act’ permitted the transfer of an individual to an “asylum” if they were considered dangerous and either mentally ill or intellectually disabled. This soon became the admission pathway of choice, partly because it gave the police full responsibility for transporting the individual.
The “dangerous lunacy” procedure was widely used, and Irish “mental hospitals” soon housed more people per capita
than any other country in the world, before or since. Services have changed considerably since then, but continuous monitoring is needed in order to ensure that involuntary admission is as infrequent and patient-focussed as possible.
Despite the best efforts of many excellent gardaí today, their involvement in what is already a difficult process can
increase stigma. Alternative approaches, involving “authorised officers” of the health service, are available. Upcoming
legislative changes will likely prioritise these pathways more.

Mental health law is, however, complex to draft and challenging to implement. In addition to the concerns outlined
above, some of the issues that patients raise in relation to the Mental Health Act, 2001 include difficulty understanding how the involuntary admission system works, problems knowing precisely what to expect from mental health tribunals and a feeling that the appeals process in the courts is unlikely to produce the result they seek. Ultimately, reducing rates of involuntary admission requires not only legislative reform, but also more extensive community mental health services, enhanced social supports, and political determination to protect the rights of people with mental illness and their families – the right to treatment and social care, as well as the right to liberty.

Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of The Science of Happiness: The Six
Principles of a Happy Life and the Seven Strategies For Achieving It (Gill Books, 2021)