Jeremy Dixon

Mentally disordered offenders' views of ‘their’ risk assessment and management plans: Perceptions of health risks

In Britain, there has been an increased emphasis on the use of risk assessments in mental health services over the past 20 years. Mentally disordered offenders subject to Section 41 of the Mental Health Act 1983 (England and Wales) are defined as posing a serious risk of harm to others. They are thus dealt with by forensic mental health services, which are often seen as specialists in risk assessments. This paper is based on original research in three mental health trusts in the South of England which was carried out between March 2009 and September 2011. The paper examines mentally disordered offenders’ awareness and attitude to formal risk assessments in relation to theories of governmentality. Service users subject to Section 41 of the Mental Health Act 1983 were aware that their level of risk was being assessed by professionals caring for them but were commonly unaware of the content of these assessments. These risk assessments were viewed by participants as a means through which professionals measured and monitored behaviour. Although participants often referred to levels of risk, they did not view risk screening schedules as objective, but rather emphasised the need to persuade staff that their risk had reduced. Despite showing a limited awareness of the content of these risk assessments, participants generally identified more risks, in relation to their vulnerability, than did the professional assessments. However, participants generally identified fewer risks in relation to the dangers they posed to others than did professional staff.

End of life care: A scoping review of experiences of Advance Care Planning for people with dementia:

Despite increasing attention given to dementia by international governments and policy makers, the focus of end of life care has been on the dying trajectory of malignant disease. People with severe dementia have complex physical and psychological needs, yet the disease is not always recognised as terminal. Advance Care Planning involving people with dementia and their families can provide opportunities to discuss and later, initiate timely palliative care. We conducted a scoping review of studies exploring decisions associated with the EoLC of people with dementia. Eligible studies had to report on decision making at the end of life and by whom (the dying person, clinician/health professional or relative/family member). Twenty-five eligible studies reported on Advance Care Planning and end of life care decisions for individuals with dementia. The papers highlight several challenges that need to be addressed in order to provide adequate and effective care for people with dementia as they near the end of their life.

Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty

BackgroundIn most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis.MethodsTo capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature.ResultsInitial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies.ConclusionsTogether these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury.

Balancing risk and recovery in mental health: an analysis of the way in which policy objectives around risk and recovery affect professional practice in England

This chapter explores two dominant themes within mental health care today - risk and recovery. Drawing on governmentality theory, the chapter focusses on professional practice in England where there has been an increase in law and policy focussed on risk management since the 1990s. It is argued that public concerns about the perceived risk that people with mental health problems are seen to pose to others has led to a range of ‘safety first’ policies. These policies have promoted the use of standardised risk tools and coercive treatments in the community. However, a focus on risk only tells half the story as the Government has also introduced policy objectives promoting notions of recovery. Whilst the concept of recovery is contested most definitions focus on the subjective experience of service users arguing that they should be able to define what recovery means to them. This poses an implicit challenge to mental health professionals seeking to frame and manage risk. The chapter charts the tensions between these two sets of policy objectives. It is argued that service users are only enabled to define their own recovery in cases where professionals do not view their choices as ‘risky’. The chapter concludes by examining the way in which mental health professionals currently assess and manage risk. The chapter demonstrates that professionals have resisted the use of standardised risk tools. However, policy directives instructing professionals to minimise risk continue to frame professional practice. Consequently, professionals are only able to facilitate service users’ recovery goals in limited circumstances.

Treatment, deterrence or labelling:mentally disordered offenders' perspectives on social control

Mentally disordered offenders are a group of service users who experience substantial amounts of control and supervision. This article uses theories of social control to analyse the way in which mechanisms of control are understood by this group. Semi-structured interviews with mentally disordered offenders in England who were subject to a restriction order under the Mental Health Act 1983 (as amended by the Mental Health Act 2007) provided the empirical basis for this study. The offenders had a number of perspectives on the restriction order. Firstly, it was seen as a mechanism for identifying those suffering from a mental disorder and for providing appropriate treatment. Secondly, the restriction order was viewed as a form of disciplinary control through which societal norms might be internalised. Thirdly, it was seen as labelling offenders in a manner that was experienced as limiting and oppressive. A number of research participants were aware that the order acted to limit staff actions. These participants saw the order as a means by which they might shape the support that they received in order to further their own aims.A video abstract of this article can be found at: https://www.youtube.com/watch?v=qwIwDI2sOTY&feature=youtu.be.

Narratives of Illness and Offending: Mentally Disordered Offenders’ Views on Their Offending

Narratives have been used in both the sociology of health and illness and in criminology to examine how groups of people present themselves in moral terms. This article focuses on the narratives of offenders with mental health problems in England subject to section 37/41 of the Mental Health Act 1983 to examine how they justified offending prior to admission. Participants presented illness in a variety of different ways indicating a range of moral positions towards offending. In line with previous research a first group used mental illness to excuse offending and saw themselves as achieving moral reform through treatment. A second group also used illness to excuse offending, but did so inconsistently, seeking to mitigate responsibility whilst distancing themselves from treatment obligations. A third group portrayed themselves as dishonourable both due to their category of offence and the type of illness experienced. A final group rejected both labels of illness and offending, seeking to portray themselves as consistently moral.

The nearest relative in the Mental Health Act 2007: still an illusionary and inconsistent safeguard?

Abstract The role of nearest relative (NR) is intended as a safeguard in the Mental Health Act 1983 (as amended in 2007) to curb the excesses of professional discretion and protect patients from unwarranted compulsory hospitalisation. It is unique to the mental health compulsory detention process in England and Wales. There are, however, evident tensions in the role and a lack of clarity surrounding the precise functions of the NR. There is also some uncertainty and confusion among practitioners about the scope of the NR involvement, and government plans announced recently to review mental health legislation will include a focus on the role of family and carers in the care of detained patients. Despite long-standing concerns about the role, there is remarkably little published research available to date on its use and effectiveness, in so far as evaluating the extent to which it provides an adequate safeguard for patients, as intended by the legislation. This article will briefly explore the background to the role, highlight some of the difficulties and tensions within it and conclude with some observations about where further research and reform may be needed to provide greater protection and clarity for patients, relatives and health and social care practitioners.

A human rights approach to advocacy for people with dementia: A review of current provision in England and Wales:

In this article, we review current advocacy services for people with dementia in England and Wales (provided, respectively, under the Mental Capacity Act 2005, the Mental Health Act 1983/2007 and the Care Act 2014) through the lens of the United Nations Convention on the Rights of Persons with Disabilities (CRPD). We examine what a human rights’ approach to advocacy support would entail, and whether current frameworks in England and Wales are adequate for this approach and provide a sufficient safeguard. First, we consider how the human rights of persons with dementia have become increasingly important and the extent to which the CRPD provides an opportunity to bolster safeguards and protection. Second, we discuss cause and case advocacy, and how these advocacy models could be shaped by the CRPD to promote the rights of persons with dementia at each stage of the disease. Third, we highlight current dilemmas and challenges in the provision of advocacy support in England and Wales by focusing on case law, commissioning of services and current practice. In particular, we analyse how the different legislative schemes have given rise to some confusion about the various advocacy provisions, as well as potential for overlap and discrepancies between different regimes. We also highlight the need for further research to address important gaps in knowledge, including the scale of need, patterns of referral and attitudes to advocacy services. The article concludes by highlighting how advocacy support could be recalibrated as a universal right to promote the aims and aspirations of the CRPD, and how education is needed to address the stigma of dementia and promote the benefits of advocacy in protecting the rights of those with dementia.

The Views of Mental Health Manager towards the Use of a Family Work Model for Psychosis in Guangzhou, China

Family Interventions in Psychosis (FIP) have been promoted internationally but have been criticised for being based on western cultural models. This paper reports on a focus group study with 10 Integrated Mental Health Service Managers in Guangzhou, China using thematic analysis. Managers believed FIP might benefit families but identified potential difficulties due to (a) families avoiding services due to the ‘shame’ of mental illness (b) unrealistic expectations of services amongst families (c) deferral to ‘key decision-makers’ within families when discussing family issues with workers. The findings indicate that FIP work should focus on interaction between carers in the first instance with service users being introduced into sessions at a later date and that more attention needs to be given by the research community to how FIP may be adapted to cultural norms within China.

Addressing Decision Making on End of Life Care for People with Dementia

Dementia affects approximately 36 million people worldwide and the number living with dementia is expected to increase to 66 million by 2030 [1]. Dementia is recognised as a public health priority which urgently needs attention by the World Health Organisation [2]. Despite recent national and international policy initiatives, people with dementia continue to receive invasive treatment such as artificial nutrition and hydration and inadequate care towards the end of their lives [3]. In our scoping review of decision making and advanced care planning for people with dementia, we outline some of the challenges of decision making that people with people with dementia, their families and health professionals face in talking about a complex and sensitive issue.