I am a psychiatrist who started practice in this field as a trainee in 1972. I retired from clinical work in 2012 but continue with my academic interests. I am now Emeritus Professor of Psychiatry and Society at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London.
I was previously a consultant psychiatrist at the Maudsley Hospital (1993-2013), Medical Director of the Maudsley and Bethlem NHS Trust (1997-2001), and Dean of the Institute of Psychiatry, King’s College London (2001-2007).
I was also a visiting professor in the Department of Sociology (BIOS Centre) at the London School of Economics (2005-2014). From 2007-2015 I was an Associate Director of the NIHR Mental Health Research Network, with lead responsibility for Patient and Public Involvement (PPI). A major aim was to increase the involvement in mental health research of service users and carers as partners in the conduct of research, as well as to engage the interest and support of the general public.
My interest in compulsion and ‘coercion’ in mental healthcare
The use of compulsion has troubled me throughout my career, and indeed did so before I ever embarked on it. As a medical student, I found psychiatry easily the most interesting specialty. However, I was put off it by its relationship in some sense to ‘social control’. At the time I was reading Szasz, Laing and, especially, Foucault. The last’s ‘Madness and Civilization’ appeared in English in 1971. As a student I tried to work out some of the issues by writing a piece on the subject for the Melbourne University Magazine, with one of my tutors at that time, Sidney Bloch. Sid is very well known for his work on ethical issues in psychiatry and was instrumental in bringing to the attention of the western world the abuses of psychiatry in the Soviet Union. In the end, after a 6 month trial period as a Senior House Officer in psychiatry at Friern Hospital (known in the old days as ‘Colney Hatch’) I decided I would continue. I couldn’t imagine myself being satisfied with only, or predominantly, a focus on the physical. I was also exposed as a trainee to some inspiring teachers who worried as much as I did about psychiatry in relation to its social role, and who practised the discipline with great sensitivity to the ethical issues.
As a psychiatrist, I have always combined practice with research. My research has for a large part been dominated by a preoccupation with ‘coercion’. My doctoral dissertation was based on a study of compulsory admissions from the London Borough of Camden. For the past 20 years or so I have studied mental health law in relation to the use of coercive interventions, trends in the use of compulsion, the philosophy of ‘coercion’, the notion of decision-making capacity and the problems of ‘risk assessment’. An important area of my research has been the development and evaluation of methods for reducing recourse to coercive interventions in psychiatry, such as patients making ‘advance directives’ detailing their treatment preferences when well, anticipating a time in the future when they might become unwell and unable to express those preferences.
Instead of my interest waning as the years go by, it has grown. Indeed, given the growing use of compulsion and the damaging negative stereotypes of people with mental illness, I strongly believe that the issues now need even more attention and exploration – and that the general public should be engaged. The argument that there is an unfair discrimination against people with a mental disorder needs to be heard. The intimately related question of when it is justified to make treatment decisions in medicine in general for those whom it is assumed lack that capability is equally important. What constitutes that capability? How do we know it is impaired? How impaired does it need to be to warrant an interference in a person’s life?
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