MENTAL WELFARE
The Mental Treatment Bill By
R.
LANGDON-DOWN, M.A., M.B.
The Mental Treatment Bill was introduced into the House of Lords on 19th, 1929, and was read a third time in that House and the first time in the House of Commons before the Christmas holidays. The Government may be congratulated on the promptitude with which it has directed its attention to this matter and still more on the broadminded attitude which it has adopted in translating the ideals set forth in the Report of the Royal Commission on Lunacy and Mental Disorder into a Bill. In both these respects there can be little doubt that Lord Russell, who was a member of the Royal Commission, by his place in the Government was able to give valuable guidance and stimulus in framing the measure and later the expert knowledge necessary to pilot it successfully through the House of Lords. For the Bill, though not a long one, is remarkable for the courage with which it has followed the principles enunciated by the Royal Commission and in so broken with some doing longstanding formulas which have hitherto fettered Parliament in its dealings with the problem of Mental Disorder and its Treatment. Indeed in some respects it has gone even further than the Royal Commission itself ventured to recommend, having regard to the traditional attitude of the legislature. During its passage through the House of Lords certain amendments were made which were in the direction of improving the measure and these comments refer to the Bill in the form in which it emerged from the House of Lords and was read a first time in the House of Commons. The topics dealt with by the Bill are:
November
1.
An amendment and extension of the law of voluntary boarders.
2.
Provisions for the temporary treatment without certification of persons for the time being incapable of volition.
3.
Provisions
governing
the admission
4.
the powers, duties and expenses of Local Authorities. The reconstruction of the Board of Control, and
5-
Miscellaneous and
(a)
as to
general provisions, including:
modification of Section 330 of the principal Act designed to give greater protection to those who sign certificates or do other things in pursuance of the Acts in question, a
(b) provisions putting rate-aided on the same footing as other patients, enabling patients that are at present removed to a workhouse to
be removed to certain hospitals instead, and substituting the " " " for the terms and rate-aided mental hospital " " and asylum pauper." "
terms "
MENTAL WELFARE
16
With these later proposals there will be general agreement; as regards the protection offered to those who take part in the various procedures under the law the proposal in the Bill is identical in terms to that put forward by the Royal Commission. It has the effect of making it obligatory on the High Court should application be made to it to stay any proceedings that may be taken by an aggrieved person unless he can prove that there is substantial ground for alleging bad faith or lack of reasonable care. It is probable that this affords greater protection against the action going further than does Clause 330 of the present Act. There is little doubt of the anxiety of the Government and Parliament It is important for the to make the protection effective as far as possible. who take in the procedure prethose of these Acts that part proper working scribed therein, should have reasonable confidence not merely that an action in the Courts, taken as it usually is in these cases by a person of unbalanced judgment or even of disordered mind, should be stayed before being taken into Court, but that they shall be protected from the anxiety, loss of time and expense of having to apply to the Court to stay such vexatious actions. Every reasonable obstacle ought to be placed in the way of the initiation of such actions. It would appear from the debates in the House of Lords that the present proposal is not regarded even by those responsible for it as affording as full protection as might be desired and that any feasible amendment would receive favourable consideration. The sections of the Bill dealing with the constitution of the Board of Control and the powers and duties of Local Authorities cannot be dealt with in detail here. Suffice it to say that they are in accordance with the recommendations of the Royal Commission and provide for giving effect to other proposals in the Bill. There remain the important proposals in regard to Voluntary Boarders and Temporary Patients. It is in these parts of the measure that the new policy in regard to the method of bringing patients suffering from mental disorder under treatment is laid down. It must be admitted that this policy constitutes a noteworthy attempt to give effect to the principles held up for our guidance in the Report of the Royal Commission, viz: 1.
That the treatment of persons suffering from mental disorder should be brought into line with that of persons suffering from physical ailments as far as may be possible.
2.
That for those so suffering there should be ment and facility to receive appropriate possible stage of their illness.
provided
every encourageat the earliest
treatment
The scheme for Voluntary Boarders permits any person who is desirous of voluntarily submitting himself to treatment for mental disorder to be received in an institution within the meaning of this Act without a reception
MENTAL WELFARE
Order
in any hospital or Nursing Home approved for the purpose or, with of the Board of Control, into single care; and, with the appropriate safeguards a similar arrangement is possible for persons under 16. A voluntary boarder may cease to be so and leave the place of treatment on giving 72 hours notice of his intention to do so. All voluntary boarders have to be notified to the Board of Control and may be visited by a Commissioner. Any voluntary boarder who becomes and remains incapable of volition shall not be retained as a voluntary boarder for more than a month but must be discharged or dealt with under some other category according to the Acts.
the
or
consent
It will be seen that the implication from this is that in submitting himself for mental disorder the patient surrenders his liberty for the time being subject to the right to resume it on due notice given. This was so under the existing law; but the proposal under the Bill permits patients to be received as voluntary boarders not only in Registered Hospitals and Licensed Houses as at present but in other Institutions under the Act and in Homes and in single care subject to the approval of the Board. The notice required is increased from 24 to 72 hours so as to enable suitable steps to be taken to arrange for the care of the patient on leaving should that be necessary. The provision in the case of a voluntary patient becoming incapable of volition is new and is in with other sections of the Bill. harmony to treatment
This
provides
a
valuable and
salutary
extension of the
procedure
avail-
able for the purposes of obtaining treatment under the Acts. The extension to the other Institutions under the Acts has long been urged and the only possible
objection
to
this is that
improper advantage might possibly
be taken of it
to
obtain board and comfortable quarters at the public cost without justification, but no doubt this can be avoided with reasonable watchfulness, though it would
important to give the Medical Superintendent power to admit, admit or to discharge a boarder at any time. This provision is made in the interest of the public in the hope that patients will avail themselves of it in the very early stages of their malady; only experience can show how far they will be persuaded to take advantage of lt:A general use of it would undoubtedly tend in course of time to modify the general attitude of the public towards insanity and mental hospitals and be of to the latter. great advantage The application of the voluntary boarder principle to ordinary hospitals, nursing homes and single care is quite new and in many cases would be greatly preferable to the formal procedure of a judicial Order. In regard to this it will be noted that the Bill states that any person who is desirous of voluntarily mental disorder may be received as a volunsubmitting himself to treatment for tary boarder and in so far as this gives to the person in charge power to exercise control in the course of the treatment without formal certification it is entirely beneficial and desirable. The term mental disorder and the expression submitting himself to treatment," are new to the law and it is not clear how they will be interpreted but it is very important that benefit thus offered on the
refuse
seem
to
"
"
MENTAL WELFARE
i8
one hand should not be counterbalanced by benefits removed on the other. That is, it is most important that nothing in the Bill should interfere with the liberty that at present exists for patients suffering from mental ailments who neither require nor are in fact placed under control, being treated quite outside the provisions of the Lunacy Act or this Bill in ordinary nursing homes, " hospitals, etc. It would, therefore, be unfortunate if the new term mental disorder as used in this Clause were held to apply to any patient for whom detention was not necessary or in fact used. "
In its proposals for temporary treatment without certification the Bill enables a person who is suffering from mental disorder and is for the time being incapable of volition but who is likely to benefit by temporary treatment and on the written application of a relative or an officer of the Local Authority, supported by the recommendation of two medical practitioners one of whom shall be approved by the Board of Control for the purpose, to be received for treatment without a reception Order into any institution, hospital, nursing home or single care approved for the purpose by the Board. He shall be visited by the Official Visitors within a month of his reception. He may be detained as a temporary patient for six months unless he regains volition and retains it for 28 days. This treatment may be extended for further periods of three months or less but not exceeding six months in all. This provides a much needed relief from the necessity for the formality of a judicial Order in a great number and variety of cases where recoverv may well take place within the period named and thus save the unfortunate patient from the stigma which attaches to certification under the Lunacy Act. The recommendation contains no elaborate details but simply expresses the opinion of the Doctors that the patient is suffering from mental disorder, is for the time being incapable of volition and is likely to benefit by temporary treatment. The expression incapable of volition is a novel one in law and first cause some at difficulty but the spokesman of the Government assures may us that it is to be taken in a popular general sense and not in a strict technical "
"
interpretation.
"
Lord Russell said non-volitional means expressing no view one way or " It (the Clause) is not intended for the reception the other?indifference." of a patient who rightly or wrongly objects to treatment." If medical practitioners could be assured that that will be the interpretation placed upon the expression used in the Recommendation and that they will not be open later to attack on the ground that the power, for example, to make a voluntary movement was evidence of the existence of volition, there would be general approval for these clauses. It is hoped that some assurance may be given in the Act, otherwise in view of the risks to which doctors are exposed, there might be an unfortunate reluctance to take advantage of this "
provision.
"
There have of course been hostile critics of the proposal to omit the intervention of the judicial authority, but it may be said that it is this in the main
MENTAL WELFARE
19
that makes the Bill the valuable
measure it is. This adherence to outworn Lord Russell who in doing so received formalities was resisted legal by firmly the support of influential speakers in the House of Lords. Lord Russell's concluding words, which can be quoted with warm approval, were as follows :
It will enable the poorer classes to get at any rate some of the benefits which are now open to the more prosperous and happy classes. Further than that, it will do what the medical profession and those who have thought upon this matter desire: it will bring about the prevention of insanity. This Bill does not deal with insanity, and, therefore, we ask that it should be kept away from all mention of the machinery of insanity. Its whole object?and I am quite confident that it will be successful in this?is to take these people when they are suffering from mental illness in the same way as we take them when they are suffering from physical illness, and treat each according to his need, in the same way as in the case of physical illness. If that is carried out with any precautions that are suitable, provided they do not run counter to the feelings of the people whom we desire to help, I am confident this Bill will be of great good to the community."
The Mental Treatment Bill By
R.
LANGDON-DOWN, M.A., M.B.
The Mental Treatment Bill was introduced into the House of Lords on 19th, 1929, and was read a third time in that House and the first time in the House of Commons before the Christmas holidays. The Government may be congratulated on the promptitude with which it has directed its attention to this matter and still more on the broadminded attitude which it has adopted in translating the ideals set forth in the Report of the Royal Commission on Lunacy and Mental Disorder into a Bill. In both these respects there can be little doubt that Lord Russell, who was a member of the Royal Commission, by his place in the Government was able to give valuable guidance and stimulus in framing the measure and later the expert knowledge necessary to pilot it successfully through the House of Lords. For the Bill, though not a long one, is remarkable for the courage with which it has followed the principles enunciated by the Royal Commission and in so broken with some doing longstanding formulas which have hitherto fettered Parliament in its dealings with the problem of Mental Disorder and its Treatment. Indeed in some respects it has gone even further than the Royal Commission itself ventured to recommend, having regard to the traditional attitude of the legislature. During its passage through the House of Lords certain amendments were made which were in the direction of improving the measure and these comments refer to the Bill in the form in which it emerged from the House of Lords and was read a first time in the House of Commons. The topics dealt with by the Bill are:
November
1.
An amendment and extension of the law of voluntary boarders.
2.
Provisions for the temporary treatment without certification of persons for the time being incapable of volition.
3.
Provisions
governing
the admission
4.
the powers, duties and expenses of Local Authorities. The reconstruction of the Board of Control, and
5-
Miscellaneous and
(a)
as to
general provisions, including:
modification of Section 330 of the principal Act designed to give greater protection to those who sign certificates or do other things in pursuance of the Acts in question, a
(b) provisions putting rate-aided on the same footing as other patients, enabling patients that are at present removed to a workhouse to
be removed to certain hospitals instead, and substituting the " " " for the terms and rate-aided mental hospital " " and asylum pauper." "
terms "
MENTAL WELFARE
16
With these later proposals there will be general agreement; as regards the protection offered to those who take part in the various procedures under the law the proposal in the Bill is identical in terms to that put forward by the Royal Commission. It has the effect of making it obligatory on the High Court should application be made to it to stay any proceedings that may be taken by an aggrieved person unless he can prove that there is substantial ground for alleging bad faith or lack of reasonable care. It is probable that this affords greater protection against the action going further than does Clause 330 of the present Act. There is little doubt of the anxiety of the Government and Parliament It is important for the to make the protection effective as far as possible. who take in the procedure prethose of these Acts that part proper working scribed therein, should have reasonable confidence not merely that an action in the Courts, taken as it usually is in these cases by a person of unbalanced judgment or even of disordered mind, should be stayed before being taken into Court, but that they shall be protected from the anxiety, loss of time and expense of having to apply to the Court to stay such vexatious actions. Every reasonable obstacle ought to be placed in the way of the initiation of such actions. It would appear from the debates in the House of Lords that the present proposal is not regarded even by those responsible for it as affording as full protection as might be desired and that any feasible amendment would receive favourable consideration. The sections of the Bill dealing with the constitution of the Board of Control and the powers and duties of Local Authorities cannot be dealt with in detail here. Suffice it to say that they are in accordance with the recommendations of the Royal Commission and provide for giving effect to other proposals in the Bill. There remain the important proposals in regard to Voluntary Boarders and Temporary Patients. It is in these parts of the measure that the new policy in regard to the method of bringing patients suffering from mental disorder under treatment is laid down. It must be admitted that this policy constitutes a noteworthy attempt to give effect to the principles held up for our guidance in the Report of the Royal Commission, viz: 1.
That the treatment of persons suffering from mental disorder should be brought into line with that of persons suffering from physical ailments as far as may be possible.
2.
That for those so suffering there should be ment and facility to receive appropriate possible stage of their illness.
provided
every encourageat the earliest
treatment
The scheme for Voluntary Boarders permits any person who is desirous of voluntarily submitting himself to treatment for mental disorder to be received in an institution within the meaning of this Act without a reception
MENTAL WELFARE
Order
in any hospital or Nursing Home approved for the purpose or, with of the Board of Control, into single care; and, with the appropriate safeguards a similar arrangement is possible for persons under 16. A voluntary boarder may cease to be so and leave the place of treatment on giving 72 hours notice of his intention to do so. All voluntary boarders have to be notified to the Board of Control and may be visited by a Commissioner. Any voluntary boarder who becomes and remains incapable of volition shall not be retained as a voluntary boarder for more than a month but must be discharged or dealt with under some other category according to the Acts.
the
or
consent
It will be seen that the implication from this is that in submitting himself for mental disorder the patient surrenders his liberty for the time being subject to the right to resume it on due notice given. This was so under the existing law; but the proposal under the Bill permits patients to be received as voluntary boarders not only in Registered Hospitals and Licensed Houses as at present but in other Institutions under the Act and in Homes and in single care subject to the approval of the Board. The notice required is increased from 24 to 72 hours so as to enable suitable steps to be taken to arrange for the care of the patient on leaving should that be necessary. The provision in the case of a voluntary patient becoming incapable of volition is new and is in with other sections of the Bill. harmony to treatment
This
provides
a
valuable and
salutary
extension of the
procedure
avail-
able for the purposes of obtaining treatment under the Acts. The extension to the other Institutions under the Acts has long been urged and the only possible
objection
to
this is that
improper advantage might possibly
be taken of it
to
obtain board and comfortable quarters at the public cost without justification, but no doubt this can be avoided with reasonable watchfulness, though it would
important to give the Medical Superintendent power to admit, admit or to discharge a boarder at any time. This provision is made in the interest of the public in the hope that patients will avail themselves of it in the very early stages of their malady; only experience can show how far they will be persuaded to take advantage of lt:A general use of it would undoubtedly tend in course of time to modify the general attitude of the public towards insanity and mental hospitals and be of to the latter. great advantage The application of the voluntary boarder principle to ordinary hospitals, nursing homes and single care is quite new and in many cases would be greatly preferable to the formal procedure of a judicial Order. In regard to this it will be noted that the Bill states that any person who is desirous of voluntarily mental disorder may be received as a volunsubmitting himself to treatment for tary boarder and in so far as this gives to the person in charge power to exercise control in the course of the treatment without formal certification it is entirely beneficial and desirable. The term mental disorder and the expression submitting himself to treatment," are new to the law and it is not clear how they will be interpreted but it is very important that benefit thus offered on the
refuse
seem
to
"
"
MENTAL WELFARE
i8
one hand should not be counterbalanced by benefits removed on the other. That is, it is most important that nothing in the Bill should interfere with the liberty that at present exists for patients suffering from mental ailments who neither require nor are in fact placed under control, being treated quite outside the provisions of the Lunacy Act or this Bill in ordinary nursing homes, " hospitals, etc. It would, therefore, be unfortunate if the new term mental disorder as used in this Clause were held to apply to any patient for whom detention was not necessary or in fact used. "
In its proposals for temporary treatment without certification the Bill enables a person who is suffering from mental disorder and is for the time being incapable of volition but who is likely to benefit by temporary treatment and on the written application of a relative or an officer of the Local Authority, supported by the recommendation of two medical practitioners one of whom shall be approved by the Board of Control for the purpose, to be received for treatment without a reception Order into any institution, hospital, nursing home or single care approved for the purpose by the Board. He shall be visited by the Official Visitors within a month of his reception. He may be detained as a temporary patient for six months unless he regains volition and retains it for 28 days. This treatment may be extended for further periods of three months or less but not exceeding six months in all. This provides a much needed relief from the necessity for the formality of a judicial Order in a great number and variety of cases where recoverv may well take place within the period named and thus save the unfortunate patient from the stigma which attaches to certification under the Lunacy Act. The recommendation contains no elaborate details but simply expresses the opinion of the Doctors that the patient is suffering from mental disorder, is for the time being incapable of volition and is likely to benefit by temporary treatment. The expression incapable of volition is a novel one in law and first cause some at difficulty but the spokesman of the Government assures may us that it is to be taken in a popular general sense and not in a strict technical "
"
interpretation.
"
Lord Russell said non-volitional means expressing no view one way or " It (the Clause) is not intended for the reception the other?indifference." of a patient who rightly or wrongly objects to treatment." If medical practitioners could be assured that that will be the interpretation placed upon the expression used in the Recommendation and that they will not be open later to attack on the ground that the power, for example, to make a voluntary movement was evidence of the existence of volition, there would be general approval for these clauses. It is hoped that some assurance may be given in the Act, otherwise in view of the risks to which doctors are exposed, there might be an unfortunate reluctance to take advantage of this "
provision.
"
There have of course been hostile critics of the proposal to omit the intervention of the judicial authority, but it may be said that it is this in the main
MENTAL WELFARE
19
that makes the Bill the valuable
measure it is. This adherence to outworn Lord Russell who in doing so received formalities was resisted legal by firmly the support of influential speakers in the House of Lords. Lord Russell's concluding words, which can be quoted with warm approval, were as follows :
It will enable the poorer classes to get at any rate some of the benefits which are now open to the more prosperous and happy classes. Further than that, it will do what the medical profession and those who have thought upon this matter desire: it will bring about the prevention of insanity. This Bill does not deal with insanity, and, therefore, we ask that it should be kept away from all mention of the machinery of insanity. Its whole object?and I am quite confident that it will be successful in this?is to take these people when they are suffering from mental illness in the same way as we take them when they are suffering from physical illness, and treat each according to his need, in the same way as in the case of physical illness. If that is carried out with any precautions that are suitable, provided they do not run counter to the feelings of the people whom we desire to help, I am confident this Bill will be of great good to the community."
