Mental Health Act

Compulsory treatment essentially removes personal responsibility for self-management from the patient. Assumption of responsibility by the patient for their own recovery is a fundamental principle in the treatment of personality disorder. Therefore, for most people with personality disorder, detention to hospital represents management rather than treatment.

The five criteria for making the three forms of detention under the MH(S)A are similar:

Emergency Detention Certificate criteria state that the medical practitioner considers it likely that:

• the patient has a mental disorder;
• and because of that mental disorder, the patient’s decision-making ability with regard to treatment for that mental disorder is significantly impaired;
• the practitioner must also be satisfied that it is necessary as a matter of urgency to detain the patient in hospital in order to determine what medical treatment should be provided to the patient for the suspected mental disorder;
• there would be significant risk to the health safety or welfare of the patient or to the safety of another person if the patient was not detained in hospital;
• making arrangements with a view to granting a short-term detention certificate would involve undesirable delay.

Short-term Detention Certificate criteria state that the medical practitioner considers it likely that:

• the patient has a mental disorder;
• because of the mental disorder, the patient’s ability to make decisions about the provision of medical treatment is significantly impaired;
• it is necessary to detain the patient in hospital for the purpose of determining what medical treatment should be given to the patient or giving medical treatment to the patient;
• if the patient was not detained in hospital there would be significant risk to the health, safety or welfare of the patient or to the safety of another person;
• the granting of the short-term detention certificate is necessary.

Compulsory Treatment Order criteria which the tribunal must be satisfied are fulfilled: 

• that the patient has a mental disorder;
• that because of the mental disorder the patient’s ability to make decisions about the provision of medical treatment is significantly impaired;
• that medical treatment which would be likely to prevent the mental disorder worsening or alleviate any of the symptoms or effects of the disorder is available for the patient;
• that if the patient was not provided with such medical treatment there would be a significant risk to the health, safety or welfare of the patient or to the safety of another person;
• that the making of a Compulsory Treatment Order in respect of the patient is necessary.

Points to consider for each criterion include:

• EDC,STDC,CTO: The patient has a mental disorder.
• Personality disorder is one of the three broad categories of mental disorder in terms of the MH(S)A. The other 2 categories are mental illness and learning disability.
• EDC, STDC, CTO: Significantly impaired decision making ability(SIDMA):

• • Best available evidence indicates that hospital treatment is, on the whole, at best neutral and at worst harmful for people with personality disorder.
  • Therefore it may be difficult to argue that SIDMA is present on the basis of a patient refusing hospital treatment alone.
  • Best available evidence shows, on the whole, no significant benefit for drug treatment. Therefore it may be difficult to argue that SIDMA is present on the basis of a patient refusing drug treatment alone.
• EDC: It is necessary as a matter of urgency to detain the patient in hospital in order to determine what medical treatment should be provided to the patient for the suspected mental disorder:
• STDC: it is necessary to detain the patient in hospital for the purpose of determining
  what medical treatment should be given to the patient or giving medical treatment to the patient:
• CTO: that medical treatment which would be likely to prevent the mental disorder worsening or alleviate any of the symptoms or effects of the disorder is available for the patient:

The treatment provided for an individual should be phase-appropriate

Most patients who are considered for detention will need treatments aimed at promoting safety (Phase 1a), containment (Phase 1b) or self-regulation and control (Phase 1c). Hospital treatment may be useful in promoting safety and containment but is likely to have a neutral or negative effect on self-regulation and control. Therefore, although hospital treatment may alleviate isolated symptoms, for example high intensity nursing care may physically prevent suicidal behaviour, it is unlikely that hospital treatment will prevent the disorder itself from worsening, and may be likely to contribute to a global deterioration. Clinical experience suggests that these factors are even more relevant when patients are detained than during informal admissions.

Several different models of psychological therapy have been shown to be effective in the treatment of personality disorder.. All trials involved voluntary patients, and there is no evidence base for the treatment of involuntary patients. Furthermore, many of the treatment models expressly discourage use of compulsion for reasons of conflict with the general and specific factors and theoretical principles upon which the treatments are based.

• EDC, STDC, CTO: significant risk to the health, safety or welfare of the patient or to the safety of another person if not detained in hospital/ provided with medical treatment:
• As outlined above, while high intensity nursing care may promote safety by physically preventing suicidal behaviour and acutely lower the risk of suicide, hospitalisation and detention may actually increase chronic suicide risk and worsen prognosis.
• STDC, CTO: necessity: