Comparing mental health and mental capacity law data across borders: Challenges and opportunities

This chapter begins with the historical developments that put mental health and capacity law into context, then moves on to the relationship to other areas of law. It describes the principles, and the roles of professionals and relatives. It goes on to explain the procedures for using civil powers, and civil admission for treatment. Consent to treatment, leave from hospital, civil community treatment, and after-care. The chapter then details police powers under mental health law, court-ordered pre-sentence assessment and sentence of treatment, alongside other court orders. Transfer from prison to treatment is included, with restriction orders, then appeals against treatment and detention is outlined. The subsequent section outlines human rights law, the European Convention of Human Rights, misuse of mental health law, and finishes with mental capacity laws.

The increasingly complex interface between the Mental Health Act 1983 and the Mental Capacity Act 2005 has been discussed in this column over the last three months. The boundaries between the two statutes is becoming increasingly blurred with the Court of Protection, a specialist court that considers cases about people lacking decision-making capacity, commonly being asked to make decisions on mental health law as well. Northern Ireland is proposing to resolve the interface problem by repealing its mental health laws and replacing them with a single statutory framework for mental capacity law. If passed, it will give all adults with capacity the right to consent to or refuse any form of treatment. Physical and mental conditions will be on an equal footing and there would be no compulsory detention or treatment of adults with capacity. For those whose lack capacity, treatment will be available in their best interests with arrangements in place to authorise situations where the care arrangements amount to a deprivation of liberty. In this article Richard Griffith considers the new proposals for Northern Ireland and wonders where these proposals point the way for the other devolved nations to develop their mental health and mental capacity law for a 21st century Britain.

Unified mental health and capacity law: Creating parity and non-discrimination?

In Northern Ireland, the current main legal framework for compulsory intervention is the Mental Health (Northern Ireland) Order 1986. It is a traditional mental health law which enables detention in hospital if mental disorder and risk criteria are met. However, under Article 3(2), it states that people should not be detained "by reason only of personality disorder". There has been a process of law reform in Northern Ireland to create a non-discriminatory, comprehensive legal framework for all. This resulted in the Mental Capacity Act (Northern Ireland) 2016. The Act, when fully implemented, will replace the Order for everyone aged 16 and over, which is in contrast to most other countries where there are both mental health and mental capacity laws. Under the new Act there are no specific exclusions so, if a person is unable to make the relevant decision, including if the cause of impairment relates to issues associated with personality disorder, then compulsory intervention is allowed as long as the proposed intervention is in the person's 'best interests'. The Act was partially implemented in 2019 and currently is only used when the Order does not apply. This article explores: the development of this new legal framework; the implementation of the Act; and some of the ongoing debates, and practice complexities, related to services for people with a diagnosis of personality disorder.

In this article, I explore how the mental health and mental capacity laws in England and Wales can be used for suicide prevention. I criticise the use of compulsion for persons diagnosed with a mental disorder who nonetheless retain decision-making capacity and argue for a greater reliance upon capacity as a distinguisher between autonomous decision-making about the end of life and the risk to life posed by symptoms of mental illness. The label of 'suicide' is also criticised as an outdated legal notion carrying pejorative meaning. Although focused on the law in England and Wales, the arguments apply much more broadly to all jurisdictions seeking to reconcile the demands of respect for life and respect for autonomy.

Mental health and capacity law can often feel complex and bewildering. They are governed by a range of different legal frameworks, including (but not limited to) the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 (MCA), and the Human Rights Act 1998 (HRA). Each legal framework comes with its own unique set of legal principles and ideological baggage, and is also subject to the constant ebb and flow of case law. Last year alone saw major judgments handed down on, for example, the interface between the MHA and MCA,1 the zone of parental responsibility in relation to 16 and 17 year olds,2 and deprivation of liberty in intensive care settings.3 The legal frameworks are also subject to frequent legislative reform; most recently the Police and Crime Act 2017, which reformed police powers under sections 135 and 136 of the MHA and the duties of coroners to investigate the deaths of people who were subject to the Deprivation of Liberty Safeguards (DoLS). Even the judiciary and specialist legal practitioners struggle to keep abreast of the changes. However, mental health and mental capacity law is not ‘lawyers’ law’, in the sense that it is not primarily played out in the courtroom. It is written overwhelmingly for front-line health and social care professionals (and in the case of the MCA, family and other unpaid carers), most of whom will have had no formal legal training. The question, therefore arises, how can busy professionals become and remain fully conversant with these complex and fluctuating legal frameworks?

This article started with a question from one academic wearing an editor’s hat to another academic wearing an academic service user’s hat: conversing about a conference both had attended, the question asked was about the features that make conferences ‘good’ from a service user perspective. The question led to the comments that form Part II of this article. We then decided that we should combine resources and examine what the Convention on the Rights of Persons with Disabilities 2006 (CRPD) has to say about the matter, identifying the normative framework of rights in the context of academic conferences that belong to those who attend in the context of experiencing psychosocial/mental impairment which in interaction with attitudinal and environmental barriers cause them to experience disability; and the corresponding obligations on conference organisers and/or those who regulate the situation and so might be required to impose obligations on conference organisers. This material, in Part III, is followed by some final reflections and thoughts as to good practice.The context in which our arguments are framed is academic conferences on mental health and mental capacity law. Although our reference to ‘service user’ is therefore limited, some of our contentions can no doubt be applied to people experiencing other forms of disability and to conferences of a different type. These wider points are not a concentration in this article, but only because it was conceived and written with a more specific focus. Naturally, we are not suggesting that persons experiencing psychosocial or intellectual disabilities will only be interested in conferences on mental health and mental capacity matters, or that people experiencing other forms of disability will not have an interest in such conferences.

The Convention on the Rights of Persons with Disabilities (CRPD) requires a reconceptualised approach to rights enjoyment by persons with mental disabilities promoting equality through support, institutional and environmental adjustments, and envisaging ‘protection’ in terms of all rights enablement and not rights restriction. Mental health and capacity law has tended to focus exclusively on authorizing and regulating non-consensual interventions, contrary to the CRPD message. Scotland’s current mental health and capacity law is no different. The terms of reference of the 2019–22 independent review of this law included making recommendations on CRPD realization. The resultant recommendations sought to strengthen the voice of persons with mental disabilities, reduce psychiatric coercion, and secure the enjoyment of all rights whilst providing an aspirational but workable basis for achieving CRPD alignment. It proposed a new model for mental health and capacity law, centred on reconceptualising mental health and capacity law to take account of realization of all categories of human rights, equality in the enjoyment of such rights, and reduction of non-consensual measures. This article will consider the practical and conceptual CRPD implementation challenges faced by Scotland and other countries, and the Review’s recommendations, seeking to address them in their wider context.

Mental health and capacity laws in Northern Ireland and the COVID-19 pandemic: Examining powers, procedures and protections under emergency legislation

ABSTRACTAnxiety and insomnia are correlated in older adults and their caregivers, yet the moderating role of mental health literacy (MHL) is unclear. This study aimed to explore dyadic effects of anxiety on insomnia among Chinese chronically ill older adults and family caregivers across age groups and whether MHL moderates these effects. Data came from 1033 dyads of older adults and their family caregivers in China through the Guangdong Mental Health Survey. Anxiety was assessed with the Generalized Anxiety Disorder‐7, insomnia with the Insomnia Severity Index, and MHL with the Chinese National Mental Health Literacy Scale (consisting of mental health knowledge, attitudes, and capacity). The Actor‐Partner Interdependence Moderation Model was applied for analysis. Young caregivers' mental health attitudes, β = −0.558, p = 0.002, mitigated the effect of their anxiety on their insomnia, while older adults' mental health knowledge, β = 0.428, p = 0.019, enhanced this relationship. Older adults' mental health attitudes, β = −0.731, p = 0.004, reduced the impact of middle‐aged caregivers' anxiety on the latter's insomnia. Middle‐aged caregivers' mental health capacity, β = −0.367, p = 0.004, attenuated the effect of older adults' anxiety on caregivers' insomnia. No significant moderating effects were observed in the dyad group of older adults and older caregivers. Within caregiving dyads, enhancing MHL can potentially reduce the impact of anxiety on insomnia. Interventions aimed at improving the mental health attitudes of older adults and caregivers are more likely to alleviate anxiety and insomnia than mental health knowledge and capacity.

The duty to safeguard adults from abuse

The roots of mental incapacity and mental health legislation in England and Wales are deeply intertwined. Changes in healthcare policy, human rights principles, demographics and social attitudes have highlighted deficiencies in the law to protect the interests and rights of people considered to lack decision-making capacity. This led to calls for legal reform from social workers amongst other groups. The Mental Capacity Act 2005 took shape alongside the more controversial Mental Health Act 2007. Whilst mental capacity and mental health legislation are separate once again, both are concerned with the care and treatment of adults who are perceived as lacking capacity to make specific decisions. The Deprivation of Liberty Safeguards enacted as part of the Mental Health Act 2007 to amend the Mental Capacity Act 2005 will change practice for many social workers as they will give rise to new assessments and roles. Social workers will need to be aware of the potential interaction of the two Acts to ensure compliance with the laws and to promote positive practice. This article explores the interface between the Mental Capacity Act 2005 and Mental Health Act 2007 in England and Wales and examines and speculates on some of the possible implications for social work practitioners.

Toby has 26 years’ experience of working with people with severe mental health problems, and expertise in the fields of mental health in later life, dementia, and mental capacity, with an empha- sis on self-management, peer support, quality of life, rights, social inclusion and empowerment. Toby has written articles on values-based practice (VBP), co-authored a book on values-based prac- tice and mental health and mental capacity law for psychiatric nurses, produced VBP ‘key card’ information for the social care workforce throu- gh Skills for Care and is currently co-authoring a book on VBP and dementia. He is also a part time lecturer on a Masters course in dementia care at the University of West London (UWL). werment. Toby has written articles on values-based practice (VBP), co-authored a book on values-based prac- tice and mental health and mental capacity law for psychiatric nurses, produced VBP ‘key card’ information for the social care workforce throu- gh Skills for Care and is currently co-authoring a book on VBP and dementia. He is also a part time lecturer on a Masters course in dementia care at the University of West London (UWL).

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The United Nations Convention on the Rights of Persons with Disabilities (CRPD) took effect in 2008. This paper discusses a number of flashpoints where the CRPD will require real and significant reconsideration of English mental health and mental capacity law. The CRPD introduces a new paradigm into international disability law, relying on the social model of disability. While that is no doubt a good thing, there is as yet no clear sense as to how that is to be implemented. After providing an introduction to the Convention, the paper considers four specific areas: mental capacity law (focussing on the provisions of the Mental Capacity Act 2005), psychiatric treatment without consent, civil detention of people with mental disabilities, and mental disability in the criminal system (fitness to plead, insanity and diminished responsibility).