I move: "That the Bill be now read a Second Time."
I want to make some relevant comments to illustrate why the Bill was necessary. Under existing law — the Mental Treatment Act, 1945, and amending Acts of 1958 and 1961 — around 3,000 people per annum are committed involuntarily to psychiatric institutions. These people are detained on the application of a relative and the certification of one or two doctors. They are detained under what are referred to as reception orders. These are not reception orders in the judicial sense but medical authorisations for the detention of persons. There are two types of order, a reception order and a temporary reception order, and two types of person to whom they apply, chargeable and private patients under the 1945 Act. Chargeable patients are those whose treatments are paid for out of public funds, while private patients pay for their own treatments. A temporary reception order lasts for up to six months and the reception order lasts for more than six months. The vast majority of people detained under these orders would be seriously ill, mentally disturbed and-or violent. I know many families dealing with such cases who suffer great stress and upset, often over a long period and in many instances with poor support or financial help. I acknowledge the difficulties suffered by these people and their families and I commend all those working in our psychiatric institutions who do so with great dedication and care.
The legislation which is under scrutiny relates to another group of people, those against whom detention orders are made but who are inappropriately held. In examining the 1945 Act, it is evident that its provisions have been abused by causing people to be committed who were not insane, violent or dangerous. The motivation of the relative who committed them was at last questionable. Many of these people are committed to resolve a domestic dispute. In the cases with which I have been involved the provisions of the Act were misguidedly used as a solution to marital breakdown problems.
Some people will recall the Adjournment Debate last June during which I highlighted the situation of a young mother from County Dublin who had been forcibly removed from her home on a summer afternoon and detained in St. Patrick's Hospital. A week previously she had obtained a protection order against her husband. Her marriage was most unstable and unhappy and she was under great stress. Her need was for a legal separation and the possibility of making a life separate from her husband. Her need was not for a detention order which removed her to a mental hospital.
My experience of such cases goes back well before June last year. In 1975 I was contacted by two women, one a mother of seven from Galway and the other a mother of 12 from Dublin, with whose cases I became very familiar. They were both in marriages which were violent and damaging but at that time there was no acceptance that a woman could leave, even in a very bad marriage situation. This was prior to the enactment of the family law Acts by the Coalition Government in the seventies. One possible relief for many women was when their husbands deserted to England. This was very common in the seventies and was called divorce Irish-style. The only other relief these women got was when their husbands died and they became widows. While unhappy marriages were not as uncommon as now — or at least we were not aware of them — the hardship for the wife and mother living in a dead marriage was considerable and unrelenting. In that context I was personally involved with a number of cases, but specifically with the two I have mentioned.
After a first committal by their husbands, the women endured what was in effect a revolving door syndrome, living in fear of being recommitted if they did not behave themselves. There were many in the seventies for whom the first battered wives home in Harcourt Street which opened in 1974 became a refuge from this type of home life and it represented their chance to make a new life with their children. The women I met through that refuge all recounted the same story. The signing doctors did not know them. They may have been neighbouring doctors and may have known the women vaguely but not as patients. They were very often the husband's GP. The doctors did not examine the women, most of whom had the awful experience of having the committal completed with the help of an ambulance and the Garda. Once inside the pshychiatric institution they were refused access to a telephone or permission to have visitors.
Many of those women afterwards lost custody of their children and they lived lives of isolation, feeling outcast because of their experience. When they tried to get an explanation from the hospital about their committal or to get copies of the documentation involved they came up against resilient opposition in every case. They were told they had no rights under the 1945 Act to such information.
Until the case of last June was brought to my attention it was my belief that amending legislation was in place which had introduced necessary safeguards against inappropriate or wrongful committal. I was most surprised to discover that this was not the case and that the 1945 Act, which had caused such difficulties to women in the seventies, was still the statute involved. I discovered that the 1981 Mental Services Act included the necessary reforms to prevent abuse but that it was never brought into force. The time for debate counted for nothing. I will return to that legislation later.
The cases I have referred to and the numerous other cases about which I have been contacted by individuals, psychiatric workers and relatives, show an urgent need for reform. It is the function of law to provide clear guidance to those working in the psychiatric services and to provide firm safeguards against malpractice to users of the services. That is the purpose of this Bill. People with mental health problems are regrettably the poor relatives of the health services. Mental health has a low priority in terms of budgetary or monetary planning. There is a great need for broad-based reform which would concentrate on reducing overcrowding in our institutions, developing community facilities and changing the nature of our psychiatric institutions, many of which date back 200 years, from the isolationism of the past to greater integration for mentally ill people and their carers in the communities in which they live. I hope this debate focuses on those factors as well as on the provisions of the Bill. These guidelines are well documented in the 1984 Department of Health report, Planning For The Future.
I repeat that much too little has been done to implement the recommendations of the 1984 report, and successive Ministers for Health must stand indicted. I am concentrating here on an area which I feel is urgent and for which there is public concern. There has been unease over the years about abuse and the possibility of abuse in the 1945 Act. Incidents have been well documented in recent weeks by the media and by RTE. The need for urgent change has been identified. I appeal to all sides of the House to support my proposals and allow long overdue changes to be put in place.
The purpose of this Bill is to amend the Mental Treatment Acts, 1945 to 1961, where they deal with reception orders. In section 3 there is a misprint on line 14 in that the word "Part" should be substituted by "Sections" to read "Sections 14, 15 and 16 of the Principal Act". This section aims to end the practice in the 1945 Act under which chargeable or public patients are treated differently from private patients. There is no reason for safeguards to be different as between sectors. The fundamental freedom of the individual is in question in both instances and the basic principle demands equal and maximum safeguards for all, regardless of means.
Section 4 of the Bill provides for the establishment of mental health review boards, with one board in each health board area. These boards would consist of three persons, a barrister or solicitor, a medical practitioner and a lay person, all to be appointed by the Minister for Health. Section 5 deals with the work of the review board and how applications are made. Where an application for a review comes from a detainee, his or her parent, spouse or offspring or from the Minister for Health or the President of the High Court, the review cannot be refused under this section. However, it shall be at the discretion of the board to grant or refuse the review if made by some other person.
Section 6 deals with the outcome of the examination by the board and the decisions at which they may arrive. Section 7 involves a review of a person who has been conditionally discharged. Section 8 puts an onus on the board to seek a report from the medical officer in charge of each psychiatric centre for each person who has been in detention for a period of two years and make recommendations that he or she shall not be discharged or be discharged conditionally or transferred to care accommodation more suitable to his or her condition. Section 9 provides that the medical officer in charge of a psychiatric centre shall, in making the order, give that person a copy of the order and all documents relating to his or her detention. It also deals with providing documents on request after the person is discharged.
Section 10 repeals sections 259 and 260 of the Principal Act, 1945. Section 259 imposes a time bar on proceedings which may not be instituted after six months from the end of detention. This is quite an extraordinary limiting factor. It contrasts with normal periods of limitation for seeking civil actions, which for false imprisonment is six years and for actions for personal injuries, three years. Section 260 provides that civil proceedings cannot be taken under the 1945 Act except with leave of the High Court, and that leave shall not be granted unless the High Court is satisfied that there are substantial grounds for contending that the person against whom such proceedings are being brought acted in bad faith or without reasonable care.
As outlined, I am sure nobody could disagree with the thrust of this Bill or deny that it deals with basic safeguards and protection of civil liberty. I am dealing with the Minister for Health who is as informed and, I feel certain, as concerned about what is happening as I am. I confidently hope that this Bill will not suffer the same fate as the 1981 Act either by being rejected in total or being cast and left in deep freeze to await indefinitely the necessary ministerial directions to put it into force. I want this House to deal with the reality of our mental health problems, acknowledging that the people concerned are not able to articulate their needs in many cases and depend heavily on legislators to upgrade legislation, safeguard their rights and improve their conditions.
This Bill cannot be answered with vague promises. I am not convinced that we need White or Green Papers in order to take the action that I have outlined as necessary. I would suggest to the Minister that the day is long gone when painting the railings of our psychiatric institutions can substitute for real fundamental changes in our services and in our law. I am particularly asking that the Minister, in his response, give an honest appraisal of the aborted 1981 Act in view of the fact that there is such a degree of public confusion and disbelief about that Act. There is no precedent for what happened with that legislation. What were the reasons it was never put into force? Are there sections that could be activated now through ministerial order? What was the outcome of the review of the legislation in the Department since 1981, as referred to in "Planning For The Future?"
I am aware that the medical profession opposed some of the provisions in that legislation. Doctors have told me that their fears and views have to be reasonably considered. One area of concern to them is the need for speedy action in times of crisis, when a mentally ill person is being disruptive and violent. They say it would be a very difficult procedure to demand in the legislation that two GPs sign the certification after examination. This would be particularly difficult in the case of a crisis at night, at weekends or, as was stressed in the original debate in the 1981 Act, in a rural area. I do not believe that these are insurmountable problems. I accept that there is a difficulty in this regard and I suggest that an amendment be introduced on Committee Stage along the lines proposed by the Irish Council for Civil Liberties in their report of the Mental Health Bill, 1981, which states:
The Bill should provide crises intervention facilities to be made available by each Health Board. These might take the form of a team on stand-by in cases of emergency and include at least a Doctor and a Nurse suitably qualified. In such circumstances, two accredited members of a crises intervention team should be empowered to sign a recommendation for a reception under Section 19 in lieu of two G.P.s provided they were satisfied that a crisis genuinely existed.
I believe that a satisfactory provision could be put in place recognising the reality of these cases which, as I said earlier, represent the majority of the numbers at present detained annually. I am aware that this problem was encountered in amending legislation in the UK and elsewhere. They have resolved the problem satisfactorily and perhaps we should look at that before putting legislation in place.
Let us look for a moment at the Health (Mental Services) Act, 1981. Many of the provisions of this amending legislation undoubtedly would have contributed to the rights of detained persons, most notably in requiring the written recommendation of two registered general practitioners for a reception order and dropping the distinction between public and private patients in this regard. Under the 1945 Act, which came into force in 1947, the procedure that applies to public patients is different from that applying to private patients. This is unacceptable to public opinion and it was recommended that it be dropped in the 1981 Act.
The 1981 Act also requires that a general practitioner who makes a recommendation is required to inform the person to whom it relates of his intention. The Act required the medical officer in charge of the psychiatric centre to give the person detained a copy of the reception order together with the recommendation for reception and a copy of any extension order. The Act also requires the medical officer to give the person a statement of his rights and entitlements under the Act. He is further obliged to provide persons detained with the necessary facilities for writing, delivering and posting letters. We would all agree I am sure, that these measures should be a fundamental right of any patient detained. The Act also proposed the abolition of the time limit on the institution of court proceedings, as I propose in my amending Private Members' Bill.
While the 1981 Act was an improved measure to protect essential civil liberties, it has to be acknowledged that it did not provide the complete answer for legislative reform, as one would have expected from the first major reforming legislation on mental health in 35 years. For instance, it failed to define mental disorder, it did not lay down the criteria for what should be considered an examination and alternatives to committal were not discussed.
In their comments and proposals on the Health Mental Services Bill, 1981, the Irish Council for Civil Liberties said in October 1980:
The Bill is a short document of some 20 pages, reflecting the narrowness of its scope, especially in comparison with the existing legislation which is a 130 page publication and which will be repealed by the Bill.
The Irish Council for Civil Liberties feel that major safeguards and protection need to be included in law and, therefore, subject to full open debate, rather than subject to ministerial regulations or local practice. They said:
Moreover law can do more than rationalise accepted practise, (sic) progressive legislation can act to stimulate progressive developments in the Mental Health Services.
I now wish to deal with two related areas. I am seriously concerned that no reports of the inspector of mental hospitals have been published since 1979. The Minister will be aware that we have debated this already in this House. I now see how this is related to the 1981 Act. Interestingly enough, that Act dropped the requirement in sections 247 and 248 of the 1945 Act that the Minister and the Oireachtas would receive an annual report on all mental institutions, including the Central Mental Hospital and private mental hospitals and on the care of patients in all those institutions. The anomaly we now have is that no reports have been issued by the inspector since 1982, which dealt with the years up to 1979. It seems that the inspector of mental hospitals is operating under the provisions of the 1981 Act, which did not come into force and is ignoring entirely his obligations under the 1945 Act where this is his statutory duty. This is an extraordinary situation and I am sure the Minister must agree that it must be resolved right away.
I question how mental health services can function properly without the statistics, the facts and figures, contained in these reports. Indeed, I read the last one published in 1982 and found it informative and reassuring. However, I would have to question what access people have to statistics if they cannot put their hands on an up-to-date report which one would expect in this important area.
The proposal in this Bill will give effect to Ireland's duties under the European Convention on Human Rights. Article 5 (1) of the convention provides that:
Everyone has the right to liberty and security of person. Nobody shall be deprived of his liberties save in the following cases and in accordance with procedures prescribed by law.
Article 5 (1) (e) states two broad conditions for depriving a person of liberty on mental health grounds and the detention must be in accordance with a procedure prescribed by law and must be a lawful detention of a person of unsound mind. The European Court of Human Rights held in the Wintwerp case, 1979, that any measure depriving a person of his liberty should issue and be executed by an appropriate authority and should not be arbitrary; paragraph 37 requires that the domestic law procedure be fair and proper and that it be complied with. We are not doing this under the 1945 Act and, therefore, we are in contravention of our obligations under the European Convention on Human Rights.
Article 5 (4) of the convention provides:
Everyone who is deprived of his liberty by a detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.
It, therefore, seems appropriate in the interest of carrying out our obligations under the European Convention on Human Rights that Irish legislators should entertain and enact the proposls to establish mental health review boards, as is proposed in my Bill.
The debate on this Private Members' Bill will be watched very carefully tonight, tomorrow night and next week by a number of groups and interested parties. Indeed, the Minister's response tonight is very much anticipated. We in Fine Gael are committed to this Bill and we sincerely hope it will be accepted and will be given effect in legislation, but there is broad consensus among those who are equally concerned. Among the groups who support the measures in the Bill is Women's Aid, which operate refuges in and outside Dublin. In an article in The Irish Times in June 1991 Ms. McDermott commented on the reality for some women who come to her refuge:
Ms. McDermott said that the use of threats of committal by husbands against their wives was a large problem so far as Women's Aid was concerned. The threat was usually coupled with a warning that if the women were committed, they would lose their children.
The use of the threat seemed to be more common among middle class than among working class people, she said.
The threat of committal was one of the ways in which some men kept control over their wives. "Fear is the greatest weapon of all." These wives often found themselves trapped, she said.
In some cases, the man would do things — like hiding the woman's shoes — to make her gradually doubt her own sanity. In other cases, years of stress, beatings and threats would lead the woman to seek medication and this in itself would become another piece of evidence that she was mentally ill.
Ms McDermott said she supported proposals for change. In a press release Ms. McDermott said Women's Aid is an organisation that provides support and accommodation for women who have been physically, mentally and sexually abused in their homes and they welcomed the Mental Treatment (Amendment) Bill 1992. The press release states:
Over the last 18 years we have dealt with a number of women who have suffered under the 1945 Mental Health Act. It is our experience that women who have sought barring orders against violent husbands have often found themselves committed to a psychiatric institution against their will.
We believe the 1945 Act as it stands is open to abuse, particularly in relation to the most vulnerable people in our society.
Therefore we urge all political parties to support the Mental Treatment (Amendment) Bill, 1992, proposed by Fine Gael to ensure that proper legislation is enacted to amend the law which patently does not afford protection to this country's citizens. This Act must be amended to ensure that it cannot be used as a threat to women who attempt to protect themselves from violent husbands in the invoking of current legislation in the family law area.
It is interesting to note a common thread running through the reports of people who are the victims of that legislation. Other groups and people have supported it. In a "Today Tonight" programme, psychiatrist Professor Anthony Clare was in no doubt whatever about the need for reform of the 1945 Act. He talked about the need for transition from the custodial form of treatment which has been traditional in this country to the therapeutic which is now accepted in modern medicine to be the correct approach. He said his medical colleagues had no cause to fear change.
In a letter to The Irish Times on 25 January 1992 the administrator of the Schizophrenia Association of Ireland said:
Involuntary commital is traumatic for both the patient and family and unfortunately in some cases it is necessary. However, it need not be the only way. Ideally one should aim for voluntary admission as it is not hard to understand that treatment received voluntarily is much more likely to be effective. More attention might be paid to ways of exploring helpful routes to voluntary admission. For instance, our experience is that self help groups can help people to acknowledge the need for psychiatric care.
Following discharge the level of care available varies throughout the country. Today the family is usually the backbone of community care.
The administrator of the Schizophrenia Association of Ireland went on to give details of the support services they would like. Even though they are a group who would have first-hand experience of the need for crisis detention, they accept there is need for reform and that involuntary committal should not be the first line of action.
In the past year a separate organisation has been formed, called Wrongfully Institutionalised People, who are campaigning for change and support for this measure. They know they cannot do anything to redress the injustices that have been perpetrated against them over the years but they are determined that this practice ceases and that other people will not be victimised in the same way as they were. I would like to quote another psychiatrist, Dr. Michael Corry, who feels very strongly about this Act. In a letter in The Irish Times of 8 March 1990 he said:
Why doctors co-operate with this process is more than just a matter for their own conscience. It places them in an untenable position, as in essence, whether they like it or not, they fulfil a powerful political role in society which overrides their medical one. It raises three fundamental questions which cannot be fudged, namely: how is it possible to treat someone against their will? How can an atmosphere of trust develop between the doctor and his client when there is power on one side and fear on the other? How is it possible to expect human beings who are psychologically distressed to seek out help when they are afraid they might "get locked up"?
Forced confinement and forced administration of treatment, often hazardous and of dubious efficacy, gives psychiatry unbelievable powers that surely make it the most powerful body in the land. It is difficult to imagine that a professional body has such discretionary authority. Notwithstanding the fact that "judgements" are based on variable and subjective criteria.
He continues in that vein and has written to The Irish Times on other occasions.
I hope I have illustrated the case deserving of action. This legislation was not prepared in any cavalier way. This is an area in which I have a very strong and keen interest and I believe there is a definite need for this debate and for action. The issues we have to attempt to resolve are to bring equity and fairness into our application of this law, to bring in safeguards and to aim to prevent abuse. I accept that while aiming to prevent abuse, there will possibly be a margin in which there will be some abuse, but the least, we should have is proper accountabilty and proper redress for those who feel they have been wronged.
I am calling for a new emphasis on improvements in the psychiatric services and for an enlightened approach to the treatment of mentally ill people. Above all we need to debate this matter at every level, taking all interests into account. Finally, there is an overwhelming need for a single piece of mental health legislation and a comprehensive consumer-friendly, reader-friendly patients rights guide which should be readily available to all those involved, whether as providers or consumers, in the psychiatric service.
