Joint Sub-Committee on Mental Health debate -
Tuesday, 8 Mar 2022

General Scheme of the Mental Health (Amendment) Bill 2021: Discussion (Resumed)

Chairman

Apologies have been received from Senator Aisling Dolan. I welcome our witnesses: Dr. Fiona Morrissey, disability law researcher, adjunct lecturer at the centre for disability law and policy in National University of Ireland, NUI, Galway, WHO quality rights trainer, mental health tribunal member and member of Disabled Artists and Disabled Academics; Ms Rosy Wilson, poet, retired adult education lecturer, mental health advocate and member of Recovery Experts by Experience; Dr. Liz Brosnan, academic, survivor researcher, mental health advocate and member of Recovery Experts by Experience; Dr. Charles O'Mahony, senior lecturer and former head of school in the school of law, NUI Galway; Ms Fiona Anderson, member of Recovery Experts by Experience; Ms Jennifer Hough, family member; Ms Deirdre Lillis, mental health advocate; and Dr. Harry Gibjels, retired lecturer, UCC, former mental health nurse and co-ordinator of the Critical Voices Network Ireland.

Before we hear the opening statements, I need to point out to our witnesses that there is uncertainty as to whether parliamentary privilege will apply to their evidence from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence on a particular matter, they must respect that direction.

I call on Dr. Fiona Morrissey to make her opening remarks. She is very welcome.

Dr. Fiona Morrissey

I thank the Chairman for inviting us to the committee and providing us with this unique opportunity to comment on the proposed amendments to the Mental Health Act 2001 in the Mental Health (Amendment) Bill, which will affect all of us in some way. It is important and pertinent that it is International Women's Day. I would particularly like to thank the people with lived experience for joining us here today to share their personal experiences, which can be difficult and traumatic.

I want to start with an opening statement. I want the committee members to imagine what it would be like to have their decisions taken away from them.

Imagine if someone else was making decisions for you. They could decide to take you away, lock you up, not listen to you, give you medication, block you from doing your work and living your life with your body and mind the way they are. Would you want this to happen to you? Wouldn't you have the feeling that you have lost your dignity and want it back?

That is a quotation from the drafting of the Convention on the Rights of Persons with Disabilities, CRPD, which was drafted in 2006. That is a common experience for many of the people here today. It helps us to reflect on the dehumanising impact of decisions being taken away from us or being forced upon us. The basic question we need to ask ourselves is: how would we like to be treated if we found ourselves in this position? Would we like to be listened to, supported and have our wishes and human rights respected, or would we want those wishes disrespected, taken away from us or forced upon us? This has been a reality for many thousands of people, including many of those here today, who have been admitted to the mental health system in Ireland under our mental health legislation or otherwise.

This can happen to any of us, at any stage in our lives, due to a myriad of life stressors. One in four Irish people will experience mental distress during their lifetime. We are all vulnerable to periods of mental distress. This legislation applies to all of us. It is not just about people who are detained under the legislation; we are all potential users of mental health services. We are all only one instance away from having these decision-making rights and human rights taken away from us.

Why is respecting human rights so important in the Bill? The basic right to make decisions and choices for oneself is called legal capacity and it is the right to be recognised as a person before the law. Once people lose that right, they are extremely vulnerable to having their other human rights and decision choices taken away from them and having their human rights violated. Under the Mental Health Act, many people have been deemed to lack capacity to make decisions for themselves and have been vulnerable to having their human rights violated. This causes additional trauma for the person from which they have to recover. In the Bill, we need to challenge the fundamental assumptions we have about people with mental health issues and their capacity to make decisions. We all make bad decisions but these decisions are never questioned unless we have a disability or a mental health diagnosis. The question we need to ask is why we preventively detain people and forcibly treat people experiencing mental distress under our mental health legislation. There is no evidence to suggest coercion works, so why are we still using it?

The UN Convention on the Rights of Persons with Disabilities requires us to fundamentally change our approach to mental health law towards a more human rights-based approach under the social and human rights model of disability.

Ireland ratified the CRPD in 2018, but has so far failed to implement many of its provisions or ratify the optional protocol. The CRPD requires us to move away from coercion in our legislation, which deprives people of their liberty and the right to make decisions for themselves. We are required under the legislation to support people to make their own decisions and to respect their wishes in the mental health system. It is critical that people are not treated differently under our new capacity legislation and mental health legislation and that we move towards a same human rights-based approach. The CRPD also requires us to move away from coercion towards a human rights-based approach.

In its current format, the proposed Bill would still deprive people of their capacity to make decisions for themselves. We need to remove stigmatising language from it in order that people are respected as human beings in society and under the legislation. The ethos of human rights must permeate the general principles and the entire legislation to comply with our obligations under the CRPD. We also need to effect cultural change in practice and how we view people with mental health issues and disabilities. This is a unique opportunity for Ireland to have human rights-based legislation and provide a better future for all of us. Let us remember that this proposed legislation could apply to any of us at any time. In that context, we have an opportunity to provide better outcomes for everyone, namely, people using mental health services, staff working in services, families and society in general. This helps enhance recovery, eliminate stigma and discrimination and promote a sense of trust and respect for people experiencing mental distress. Reform of our legislation provides Ireland with a unique opportunity to be a world leader in implementing CRPD human rights in mental health and capacity legislation providing a better future for all of us.

I will leave the committee with some quotes from people with experience of being treated and detained under existing legislation, the first of which is: "it is an awful feeling to know your liberty and rights can be taken away from you at any time and that you have no say whatsoever in your treatment." After successfully filing a legal challenge for differential treatment under the Americans with Disabilities Act in 2003, Nancy Hargrave, who was detained under US mental health legislation, said: "It seems fundamentally unfair that I choose or refuse chemotherapy which is saving my life, but I don't have the same right to choose or refuse psychiatric medication."

A former UN rapporteur on the right to physical and mental health has urged countries to move away from coercion towards a more human-rights based approach where people are supported to make their own decisions and decision-making capacity is not taken away from them. We all have the right to make decisions and choices for ourselves. According to Mr. Dainius Pras, UN rapporteur on the right to physical and mental health, we need little short of a revolution in mental health care to end decades of neglect, abuse and violence, the status quo is simply unacceptable and we need to provide a better future for all of us. Anyone of us could be detained or treated under this legislation.

Chairman

I invite Dr. Brosnan to make her opening statement.

Dr. Liz Brosnan

I thank the committee for the invitation to address it. I represent Recovery Experts by Experience, a group of people with lived experience that has made two submissions to the UN on mental health legislation and the need for reform in Ireland. My experience encompasses over 20 years of activism and user-led and survivor-led research. This is research that comes from the perspective of people who have used services.

My personal experience and research with people around the world lets me speak with some authority to the fact that mental health legislation is not fit for purpose in our experience. We have been arguing for a long time that the medical model is completely inadequate. It is informed by a biomedical brain chemistry perspective that does not take people’s lived experience or the situation in which they are living into account. From our perspective, I would make the point that psychiatry is not a neutral standpoint. The perspective of psychiatry is very influenced by the physical approach those in the profession take to the brain. As a profession, psychiatrists are very much bound up with and are, we would argue, under undue influence from big pharma such that medication becomes the sole treatment that is available to us and we really feel that denies people's human rights.

I would like the committee to consider one point, which Dr. Morrissey mentioned, namely, the idea of coercive control. Once somebody goes into an acute unit, that person is automatically and inevitably under the power of the treating teams and is not able to control his or her destiny within the services. That person must comply. Most recently, I was working with the HSE as an area lead for mental health engagement. I would have heard feedback from people who came to local forums to try to influence positive change and make things better from the perspective of lived experience. Those people told me instances of their experiences on acute units where they had to conform to be compliant. They had to work to become good patients so they could fit in. That meant taking their medication or doing what they were told to do by the nurse. This is a situation that is rife for abuses of power because people need to do what they are told. For instance, one person told me he had been approached by a nurse who seemed to be in bad form and that nurse towered over him, told him to go back into his room, and if he did not do so, he would be thrown into seclusion.

The Mental Health Act and the Mental Health Commission have devised regulations but in many instances they are red tape. I know from working with colleagues in mental health services that they are very bound up with responding to the Mental Health Commission’s visits. Enormous amounts of energy and resources that could be spent working with and listening to people and giving them person-centred care is bound up in preparation for inspections by the Mental Health Commission. I was a layperson on tribunals but I do not have time to speak to that. Dr. O'Mahony will speak to that and mental health review boards.

There is much that is good in what we have seen so far, but one point I would leave with the committee is to consider some measure to address the issue of coercive control. It is not very far removed from what people experience in abusive domestic violence relationships.

When women are trying to free themselves, they need a lot of supports in order to break free from the coercion. Everybody I know in Recovery Experts by Experience and who are on mental health forums would tell us that the idea of voluntary patients, involuntary patients and the in-between is almost a paper exercise because once you go into the mental health services, you must comply with what you are directed to do because those services then have the power under mental health legislation to detain you and treat you against your will. We know that electroconvulsive therapy, ECT, is the ultimate treatment that can potentially be held over people.

I request that the committee give strong consideration to simplifying the legislation such that it is easily accessible and understood by people, as well as being easy to apply so that the services can free up more resources to work in person-centred care in trauma-informed ways to help people who come into distress and so that they recognise that for 99% of people it is evident it is past trauma or difficulties that cause them to become distressed and force them to seek mental health supports. I am conscious of the time restrictions. I will conclude with that request for the committee to consider the coercive control element and see if it is possible to bring this into the Bill in order to recognise the utter powerlessness people have vis-à-vis psychiatry.

Chairman

I thank Dr. Brosnan. Our next contributor is Dr. O'Mahony. He is very welcome.

Dr. Charles O'Mahony

I thank the Chairman. I am delighted to have this opportunity to address the committee on this important proposed legislation. In the time allocated to me, I will speak to four issues, the first of which is the intermediate category as proposed under the general scheme. The second is the need for a proper complaints mechanism, which is not currently provided for. I will speak then briefly on the mental health tribunals and the lack of provision in the mental health legislation for people who experience mental ill-health in the context of the criminal justice system.

As regards the intermediate category, the lack of human rights safeguards for persons who are considered voluntary under the Act and have difficulties in making decisions is one of the weak points within the Mental Health Act 2001. The creation of the new intermediate category has the potential to provide a level of safeguard for people who are voluntary patients but de facto detained, with no oversight of their detention. However, it remains to be seen whether the provisions in the general scheme will address this human rights issue. We are concerned there is a potential risk that the introduction of this new intermediate category could widen the net of coercion. Voluntary persons who are considered to lack capacity under the Mental Health Act could be supported by the provisions in the 2015 Act to make decisions. That could be an alternative to this intermediate category. The touted liberty of safeguard processes that are being developed could also support people. One of concerns in respect of the intermediate category is that it could potentially broaden the net of coercion for people rather than addressing this big human rights issue in the proposed legislation.

The next issue I wish to address is that of the direct complaints mechanism. It is a source of much disappointment that the general scheme does not contain any provisions that will support persons subject to the legislation to raise issues or complaints based on their lived experiences of mental health services. It is clear that one of the major deficits of the 2001 Act since it was enacted in 2006 is that it does not provide for a dedicated independent direct complaints mechanism. In the absence of a specific complaints mechanism, people who use mental health services must lodge their complaints with the internal HSE complaints mechanism.

If a complainant is not satisfied with the outcome, he or she may then make a complaint to the Ombudsman. Section 16 of the Mental Health Act provides that a person must be notified of his or her entitlement to communicate with the Inspector of Mental Health Services during the annual inspection. This is not an adequate safeguard because by the time the inspectorate team comes to the approved centre, the person may have been discharged. There are no robust powers for the inspector or her team in terms of responding to complaints. This is a major deficit in the 2001 Act and the Bill.

In addition, although Ireland has now ratified the UN Convention on the Rights of Persons with Disabilities, UNCRPD, it has not ratified the optional protocol that would allow people with lived experience of mental health issues and services to make a complaint directly to the UNCRPD committee. The failure to ratify the optional protocol means an essential layer of accountability is absent. Members of the committee should be advocating for the Government to ratify the optional protocol to the convention.

I refer to mental health review boards which, under the Bill, will replace mental health tribunals. From a human rights perspective, these tribunals or review boards are an essential procedural safeguard for persons who are detained under the 2001 Act. They relate to vindicating the right to liberty, which is lost in these circumstances. However, I draw the attention of the committee to a recent systematic review of international literature in respect of mental health tribunals. It highlighted significant issues with these tribunals, indicating the tribunals are not adequate in protecting human rights but, in fact, can deny human rights, legitimise coercion and restrict access to justice. That is a real problem. The research identified that the participatory potential of the tribunals can be undermined by medicalised and legal cultural practices that dictate and dominate their proceedings. There is also a lack of meaningful involvement of detained persons in the tribunal hearings and they result in a sense of powerlessness and procedural unfairness. Cultural change is required to ensure the tribunals comply with international human rights law. The qualitative research in Ireland on this issue reflects the experience here.

In deciding whether to affirm or revoke an order, the tribunal psychiatrist at these hearings is generally asked for his or her opinion in the first instance. In evidence before the tribunal, the responsible consultant psychiatrist is almost always asked to submit his or her evidence before the person detained has an opportunity to speak at the tribunal hearing. In some cases, the person may wish to speak first but be told by the tribunal to wait until the responsible consultant psychiatrist has given his or her evidence.

In my view, the proposed changes to mental health tribunals as outlined in the Bill are insufficient to make the current tribunal systems effective in vindicating the rights of persons subject to the 2001 Act. The current mental health tribunal process does not adequately protect the human rights of persons admitted under the 2001 Act. The data show that less than 12% of admission orders are revoked at hearing stage. Tribunal composition is heavily weighted towards the medical model and professional opinion, with little or no multidisciplinary or advocacy input. Psychiatrists and legal professionals are dominant within the tribunals and the voice of the layperson is very much marginalised. A layperson cannot be a chairperson of the tribunal. In addition, the psychiatrists and lawyers get paid more than the laypeople. There are several changes needed in respect of tribunals to make them more meaningful for people and for them to be an effective human rights mechanism to review the detention of people.

Chairman

May I interrupt Dr. O'Mahony? We are a little behind on time. We will definitely come back to some of the points he is raising. I ask him to conclude his opening statement because there are four or five more people to come in with opening statements. He will be able to return to some of his points when members ask questions. We are very tight for time today. I thank Dr. O'Mahony.

Dr. Charles O'Mahony

That is no problem. I am happy to speak to points relating to the lack of provision for people who experience mental ill health within the criminal justice system when members come in with questions.

We need a revolution in terms of mental health law and policy in Ireland to comply with our obligations under the UN Convention on the Rights of Persons with Disabilities. The Bill produced by the Department of Health does not represent the required revolution. It is modest and unambitious. The review of the 2001 Act has been a long process marked by delay and deferral and culminating ultimately in a Bill that disappoints in failing to address many of the key human rights issues.

I will speak to a number of other points. My colleague, Dr. Morrissey, and I produced a human rights analysis report on mental health reform. It makes a number of recommendations that would strengthen human rights protections within the Bill.

Chairman

I thank Dr. O'Mahony. He will be able to make further points later. I call Ms Hough.

Ms Jennifer Hough

I thank the committee for the opportunity to address it. Unfortunately, I am participating today because my sister, Valerie, died by suicide in January 2020. She was 42 years of age and spent the best part of 25 years interacting with the mental health services at various points in her life. In spite of all of this, she lived a good life - this is an important point to make - and was well much of the time. She was a preschool teacher, she travelled a great deal, she was a great sportswoman - she played golf and badminton - and she had many great friends and loved ones. She deserved so much more, though, and her life, her potential and her opportunities were seriously hampered by a label of "bipolar", the "medication for life" mantra and the coercive nature of our mental health system. She was just 15 years of age when a professional first described her as having depression and hypomania. By the time she was 19, she had the lifelong label of "bipolar" and had already been given a range of powerful psychiatric drugs that did not make matters any better and undoubtedly made them worse.

The medical model of mental health treatment we are discussing means that, once someone gets a diagnosis, medication becomes the main focus of treatment. My sister was bipolar, so the story that she was disordered told her that she was the problem. Her brain, her make-up and her biology were the problem. Asking for help from such a system is counter-intuitive because the help on offer comes at great cost, including the potential loss of liberty. My sister was sectioned and detained twice, but that is a whole other story that I do not have time to go into today. Other costs are mind-altering medications and traumatising environments with very little therapeutic value, if any, despite the best efforts of those working in them. Talking is almost discouraged in the mainstream mental health system because there is no one there to talk to and, as we all know, real talk therapy takes a great deal of time and investment. Instead, the Band-Aids - the medications - are applied and the trauma for which people are there in the first place and the great stigma around mental health issues continue.

Sometimes, there are not even Band-Aids. I sat with my sister once in an overcrowded accident and emergency department. Later, she was locked into a stroke ward for safety. I suppose people were kept there in case they wandered out. She stayed there for a whole weekend and was then sent home with no mental health intervention at all. She just could not face all of this anymore. She had been there too many times, been traumatised and retraumatised, and been hit by the revolving door on the way out.

My sister's right to health and life was denied by a system that did not treat people holistically, medicated human distress over understanding it, and retraumatised them by wielding significant power over their lives. For example, if people do not take their medications, they are seen as not having insight or as being non-compliant. This can mean they have to stay longer in hospital. Even if they are voluntary patients, the threat of being made involuntary is always there. Over the years, my sister learned how to become a good patient and become compliant. That takes people's voices away and makes them powerless. Their voices are seen as not valid or not compliant.

If we want to change how we treat people in greatest need, we must start demanding it. Last year, the World Health Organization released a report signalling the failure of biomedical mental health systems. It stated that mental health systems overdiagnosed human distress and over-relied on psychotropic drugs to the detriment of psychosocial interventions, and that a fundamental shift within the mental health field was required.

We need to face up to the realisation that treating people with drugs is behaviour modification, not treatment. We are giving people drugs to change their state of mind, not to cure some supposed underlying disease or biological abnormality. We have all heard the stories about Kerry CAMHS in recent months. I wonder how many young people are starting on the same path my sister was put on at 15 years of age. Are young people being told they have a mental disorder for life and that they have to take medications for it? Is that really how we are still treating our young people?

It is no longer acceptable that mental health services do not actively seek to get to the root of people's trauma. Above anything else, this should be their raison d'être. At the very least and as a matter of urgency, mental health services must be guided by human rights-based, person-centred principles and provide accurate and objective information.

This is basic informed consent, but it does not happen. Services should seek to understand and address people's life experiences without coercive practices. Again, this does not happen. People should not be maintained on psychiatric drugs without close monitoring and a plan to reduce them as much as possible, but this is not the case. We have to stop medicalising human distress. We need to listen to people's stories and the growing chorus of expert evidence and research that says that mental health systems based on labels and drug treatment are not working and are, in fact, further harming and stigmatising people.

I thank members for listening.

Ms Fiona Anderson

I thank the committee for the opportunity to contribute. I have been with the mental health services for the past 30 years or so under the Mental Health Treatment Act 1945 and the Mental Health Act 2001.

I will start on the subject of involuntary detainment and the proposals relating to medical treatments and electroconvulsive therapy, ECT, under the 2001 Act. The Act requires that the responsible treating consultant psychiatrist explain to the involuntarily detained person in an understandable method and language the benefits, side effects and withdrawal symptoms of any proposed medical treatment or ECT. The detainee should be given a minimum of 24 hours, but ideally 48 hours, to consider the proposed medical treatment or ECT, weigh the pros and cons of the information, make an informed decision and communicate with persons to assist him or her. Where capacity is compromised, the detainee should be permitted to appoint a person whom he or she trusts to assist in any of the three ways listed below, having due regard, respect and consideration for the expressed will and preferences of the detainee and not the "best interests" approach, under which the person has no involvement in the decision-making process and outcome.

The three-tiered system is: appoint a person or persons to assist the detainee to understand the information relating to any proposed medical treatment or ECT so that he or she is in a position to make an informed decision; appoint a person or persons to assist the detainee to understand the information relating to any proposed medical treatment or ECT and make a combined decision with the person; and the courts appoint a representative, preferably somebody close to the person and trusted by him or her, to make decisions on his or her behalf. While enduring power of attorney is an option available to the person, the decision to appoint someone to act on his or her behalf should his or her capacity become compromised requires careful consideration because it is wide open to abuse in terms of finances and property, particularly where older persons are concerned.

It is important to note that it does not automatically follow that an involuntarily detained person also lacks the capacity to make decisions. A reservation is being sought to be placed on Article 12 of the UN Convention on the Rights of Persons with Disabilities, UNCRPD, on legal capacity, especially as regards psychosocial and mental health disabilities, which would be discriminatory and goes against Article 5 on equality and non-discrimination. It is important to note that all individuals, when given the opportunity and option to appoint a person to assist them, even with compromised capacity, are capable of making a decision or a combined decision and of trusting someone to make decisions on their behalf.

Advanced medical directives are not legally binding in mental healthcare as they are in general medical services and the 2001 Act overrides the Assisted Decision-Making (Capacity) Act 2015 in its present format.

Upon admission, an involuntary detainee is provided with a copy of a guide to the Mental Health Act 2001, known as the blue book. This is the most inappropriate time to give the booklet to a person because he or she may be too ill to read and understand the information regarding mental health tribunals or may be medicated to the hilt on admission. The term "mental health tribunal" may lead to a misunderstanding of what a mental health tribunal consists of and should be changed to mental health "review board" rather than a "tribunal panel".

A section 28 hearing should be explained fully to the involuntary detainee. More often than not an involuntary detainment order is revoked prior to the initial hearing. A detainee may not have what is defined as a "mental disorder" at the time of the tribunal and often a detainment order is revoked before a hearing can take place. Many involuntary detainees are not given the opportunity to have their voices heard and their human rights vindicated by a mental health tribunal.

Chairman

Thank you very much, Ms Anderson. I will now invite members to ask questions before returning to the last three witnesses. Deputy Ward is first.

Deputy Mark Ward

I thank all of the witnesses for coming here today. It is very important that everyone's voice is heard in the context of this mental health (amendment) Bill to make sure that the legislation is fully inclusive.

My first question is for Dr. Morrissey. She said we are all potential users of mental health services and I speak as someone who has used mental health services in the past. I speak about it so often and so openly because I want to break down the stigma around mental health. It is very important for people to have their voices heard and to talk about mental health as much as possible. In the context of the heads of the Bill, the report commissioned by Mental Health Reform was very helpful, particularly its human rights analysis of the Mental Health Act. What recommendations would Dr. Morrissey like to see prioritised in the subcommittee's report? There are a number of recommendations in the human rights analysis but which ones would Dr. Morrissey like to see prioritised?

Dr. Fiona Morrissey

I thank Deputy Ward for what is a very good question. We want to prioritise a human rights-based approach primarily. We want to move away from coercion or forcible treatment and taking people's decision-making rights away from them towards a system of support. We want to see something similar to our Assisted Decision-Making (Capacity) Act where people are supported to make decisions for themselves rather than having decisions made for them and being forcibly treated or deprived of their liberty. We want people to be supported to make decisions around their mental health treatment. We need to strengthen the presumption of capacity in the legislation and the requirement to provide people with supports to make decisions around their treatment. That could be through support from a supportive decision maker or through independent advocacy. A right to independent advocacy is quite important.

We need to move away from the ethos whereby it is presumed people do not have capacity to make decisions to a system where we presume they have capacity but they might need support to make decisions when they are unwell. In the legislation we need to strengthen those presumptions, provide people with the support they need to make decisions, and move towards a system where coercion is the exception rather than the rule and is only used in very rare circumstances. That would be a good start in terms of the legislation.

Another important issue is the regrading of power from voluntary to involuntary. Once people are in the system, even if they were initially admitted on a voluntary basis, they can be made an involuntary patient at any time through the regrading powers under the Act. In fact, the Bill erodes people's rights further.

Under previous legislation, people had to express a wish to leave but now they can actually be regraded without even having to express that wish. Coercion pervades the whole system. People are prevented from making decisions for themselves and are not supported to make their own decisions. We need to start from the basis that we presume people have capacity and support them to make their own decisions around their treatment and care. I hope that answers Deputy Ward's question.

Deputy Mark Ward

It does indeed and it leads on very well to my next question which relates to the perspective of the service user. Ms Anderson mentioned the advanced healthcare directives and the contradictions between the Mental Health Act and the Assisted Decision-Making (Capacity) Act. As someone who has used mental health services, what does Ms Anderson think needs to go into this Bill to strengthen the Mental Health Act?

Ms Fiona Anderson

The current legislation is such that it provides a three-month window of opportunity to coerce treatment. This is deliberate as it is considered a sufficient time span for recovery and the person is more likely to co-operate and comply with treatment. After the three months have expired, explicit consent must be obtained to continue with the medical treatment. Should a person make the decision to cease medical treatment, irrespective of how unwise that decision may appear, it must be respected and adhered to.

Deputy Mark Ward

It might be a good idea for this committee to have a briefing on the Assisted Decision-Making (Capacity) Act in the context of our consideration of this Bill. That could be very useful. I thank Ms Anderson for her response.

My next question is for Dr. O'Mahony. In his opening statement he mentioned the Mental Health Act and the criminal justice system. In his written submission he said it is regrettable the review of the 2001 Act, which we are now reviewing, has ignored the issue totally. What would he like to see in this Bill on this issue?

Dr. Charles O'Mahony

In the Green and White papers which informed the 2001 Act, there were proposals to provide for the assessment of people in the criminal justice system at the start of the process, before they are convicted, so they could access mental health services. However, there was quite a lot of backlash to that in the 1990s, particularly from psychiatrists who did not want to see the courts having powers relating to diversion and diverting people out of the criminal justice system into mental health services. When the 2001 Act was going through the Houses, those provisions were dropped, surprisingly, and Senator Mary Henry raised that issue in some of the debates on the 2001 legislation. The Government gave a commitment to revisit the issue but it never did and the review of the Mental Health Act, which went on for more than ten years, did not engage with the criminal law aspects at all.

Diversion is a policy that has developed throughout the western world. The aim is to divert people with mental health problems away from the criminal justice system, but we are a real outlier in that we have not developed an overarching policy. We do not have provisions, procedures or legislative provisions to facilitate diversion and have a very piecemeal approach to it. The 2001 Act needs to be amended to maximise the opportunities to divert people out of the criminal justice system and allow them to choose mental health treatment. We need to take a problem-solving approach. A recent report by the Inspector of Mental Health Services, Dr. Susan Finnerty, entitled Access to Mental Health Services for People in the Criminal Justice System, contains some very good proposals, including some law reform proposals that could be implemented through amendments to the 2001 Act.

Deputy Mark Ward

We have seen a number of reports recently on people within the criminal justice system who have mental health issues. Those reports are not good and are very damning of society. This is an issue that must be included in the committee's report.

My last question relates to the complaints mechanism.

Dr. O'Mahony stated both adults and children should be entitled to avail of this complaints mechanism and that is very apt. Representatives of CAMHS appeared before the Joint Committee on Health last week and we heard some heartbreaking stories of children being over-medicated without receiving any other treatments such as psychotherapy, occupational therapy or whatever else might be needed. If Dr. O'Mahony had a magic wand, what would he make this independent complaints mechanism look like and how would it work?

Dr. Charles O'Mahony

There could be provisions that would give a specific mandate to the Inspector of Mental Health Services regarding this. In line with international best practice, there could be a mental health ombudsman, although that would, obviously, require additional resources, as will be the case for the Mental Health Commission and the inspector. It is important that there be a mandate. A number of amendments could be used to extend that mandate to the inspector in order that, when she and her team are carrying out their inspections, they can respond more robustly to complaints and there will be more accountability and oversight. Moreover, they should be able to examine clinical decision-making in order that it will be more robust for people.

When people are detained, significant human rights issues arise, such as loss of liberty, forced drugging and ECT. It is important, therefore, that there be a robust complaints mechanism. The south Kerry CAMHS scandal, which has been in the news in recent weeks, showed what can happen with the lack of a complaints mechanism. Issues may not be reported or responded to because people do not know whom to approach and there is not effective oversight by way of a complaints mechanism.

Chairman

I thank Dr. O'Mahony and invite Ms Lillis to make her opening remarks.

Ms Deirdre Lillis

I thank the committee for the opportunity to speak. I have worked in independent advocacy for more than 25 years. I currently work as an advocacy co-ordinator with the Social and Health Education Project, a community development and training organisation. We provide advocacy support to all disabled people, including people who use mental health services. Critical changes will need to happen if we are to move towards a more humane and human rights-based legislative mental health framework. That is supported by what has been said during this meeting regarding the importance of the UN convention, the special rapporteur, the WHO reports and our assisted decision-making legislation.

I want to raise two points that relate to being a voluntary patient and the protection of my liberty. If I am admitted as a voluntary patient and I remain a voluntary patient, yet I am not allowed to leave, as I have witnessed in my work primarily because people have nowhere to go, I have no protection of my liberty and I am deprived of my liberty. This does nothing to protect my human rights. I do not think the Mental Health Act addresses this. I have witnessed the issue of the intermediate person being of particular concern when a person may be doubly labelled, or diagnosed as having both an intellectual disability and a mental health difficulty. To address this in the current legislation, which is not fully enhanced in regard to human rights, there needs to be access to independent advocacy to support the human rights of the person. I have witnessed service providers struggling to address this matter and the value of independent advocacy in challenging this deprivation of liberty and supporting a person's wish to leave.

Draft safeguarding legislation has been mentioned. It is hoped this might address the matter in some way, although I hold reservations about the paternalism in the general scheme of the Bill. There appears to be no progress on this, only the addition of this intermediate person, and while I fully accept this will afford some access to redress and respect of rights, as other speakers have said, the voluntary position is very similar regardless of the judgment on a person's lack of capacity. I have grave concerns this will not be used because a person requires treatment in an approved centre but rather because people have nowhere to go. I have witnessed cases of people having stayed in units for more than ten years in this position, and I cannot begin to imagine what that must be like.

As regards the statutory right of access to independent advocacy, if I am detained under the Mental Health Act, I should have a statutory right of access to independent advocacy besides the right of advocacy to legal representation. Legal representation, unless it is provided in such a way that fully comprehends a human rights-based approach to mental health that involves going beyond the confines of the medical, does not suffice. Any situation in a civilised world which means that a person is deprived of liberty because of his or her health warrants access to independent advocacy support to ensure our voices will be heard and our rights respected. We have a responsibility to respond to the UN convention and to develop our legal framework to honour our ratification of this convention. Other jurisdictions have embedded a statutory right to independent advocacy in their mental health legislation for many years, and with this comes the requirement to resource independent advocacy adequately. I carry some reservations because, if it is resourced to support a statutory right only where a person is involuntarily detained, that is not good enough. Scotland has overcome this in legislation by making independent advocacy a statutory right for a person at any point in the mental health system.

Those aspects are important to remember at this moment, but the bigger question is when we will move from the inhumane actions of coercion and control in the name of treatment. This legislation is being reviewed in the context of improving a system that we already have and that already fails us in respect of human rights. How can we go beyond the scope of this limited and medicalised model in this legislation? I do not think we can, but the smaller steps would go some way to getting us there. If we enact legislation in the spirt of human rights, this Act should not exist, although that is not going to happen today or tomorrow. We now have legislation that provides a human rights framework to address our health needs, namely, the Assisted Decision Making (Capacity) Act 2015, which we hope will finally replace the Lunacy Regulation (Ireland) Act 1871, in 2022. If, at times, we may need extra support to speak for ourselves about decisions being made about our health and our lives, this Act affords us that support. Why, therefore, do we need the Mental Health Act? Wherever and whenever we are trying to make informed decisions about our own lives in systems where power is inequitable and professionals are not listening, access to independent advocacy is of critical importance in supporting that process.

Chairman

I thank Ms Lillis.

Deputy Neasa Hourigan

I thank all our guests. My first questions are for Ms Lillis, although Dr. O'Mahony might also have something to say. I might explore the issue of independent advocacy and how it might look in real terms. Ms Lillis was clear it is not just about legal representation but that it is a broader issue. In her estimation and that of anyone else who wishes to give one, who would fulfil that role and at what point in proceedings would he or she be triggered into action? At what point would the representative advocate for the person?

Ms Deirdre Lillis

There is some discussion and debate about who would fulfil the role. There is a clear commitment to developing peer-led advocacy, but I am not sure how open the current peer-led advocacy service is to people with intellectual disabilities. There should be a breadth of capacity in respect of the independent advocacy resource in order that it will not restrict itself in regard to whom it might serve, including children and young people aged 16 to 18, who may also be in need of an independent advocate. There is scope for discussion. The National Advocacy Service for People with Disabilities is growing, strong and independent of the HSE but it is not necessarily a peer-led service. There has to be some scope for development and discussion in that regard, although I am just a small cog in a small organisation in this advocacy world. There needs to be space to discuss the issue, or else there will be only competition between forms of advocacy, which does not serve us well at all.

On when the advocacy might be triggered, we have heard during this meeting that it is no good giving the blue book, or whatever it is now called, to a person when he or she is in a state of extreme distress as he or she walks through the door.

An advocate should be available when a person walks in the door. If I am correct, advocacy is referred to in many places throughout the report Dr. Morrissey and Dr. O'Mahony have written with regard to the human rights approach in nearly every section, which talks about rights relating to consent, care planning, support in writing an advanced healthcare directive and mental health tribunals, and its recommendations. I hope Dr. Morrissey and Dr. O'Mahony will tell me if I am mistaken. It needs to be there from the beginning to the end and beyond. In Scotland, people may have access to independent advocacy support before they go into hospital so there is someone to support them and to speak for them in respect of what their advanced healthcare directive says regarding what does and does not help them. It may say that it helps to have somebody who is in the community, a person they can speak to. In the UK, this has been categorised as falling under involuntary detention. It is not sufficient because it happens at the last minute. It has to be across mental health service provision, just as it is in Scotland's legislation.

Dr. Charles O'Mahony

You should be able to avail of advocacy in the community as well. With regard to the general scheme, advocacy needs to be put on a statutory footing. It is recognised in the general scheme but there is no provision made for it and no funding source provided so that is quite meaningless in the current format. It is very clear that, for advocacy to be effective and independent, it has to be independent of the HSE, the Mental Health Commission and the decision-making support service. That should also be specified in the legislation. It also needs to be peer-led. It is a core requirement that people with lived experience lead the advocacy service. There needs to be statutory provisions to ensure that advocates live up to the role and funding needs to be provided. It is also core that advocates receive human rights training relating to the United Nations Convention on Rights of Persons with Disabilities and the European Convention on Human Rights. That is core if we are to have an effective independent advocacy service.

Dr. Fiona Morrissey

Dr. O'Mahony covered some of what I was going to say but it should be an automatic right and it is critical that advocacy be independent. Even the legal representation people have at mental health tribunals is not adequate. They should also have an automatic right to an independent advocate because the legal representation does not always represent people's wishes, views and preferences. Human rights training is critical. This is also a key support under the UN Convention on Rights of Persons with Disabilities to support people to make their decisions. We need to give people the support they need to enable them to make decisions for themselves. Independent advocacy is a key part of that.

Dr. Liz Brosnan

This is a very good question. I agree with everything that has been said. It is very important that independent funding and independent sources be provided to build up the capacity of a group that can actually step up as an independent advocate. It should be people with lived experience but people with lived experience need an awful lot of help to overcome many of the barriers faced by marginalised groups such as ours. Creating places and mechanisms to train people in human rights and in the values and principles of the UN Convention on Rights of Persons with Disabilities and ensuring we can translate them into the Mental Health (Amendment) Bill is important. It is only when we get the resources and supports needed to build a strong independent user movement in this country that things will begin to change and that people will be able to step in and step up as peer advocates and peer support workers with the ability to resist capture by the mental health service and the whole ethos of coercive control I mentioned before. We need supports to build the strength of a movement that can help people. We are one of the last marginalised groups of people in this country. We are not recognised and not helped to step out of the chains that many of us are in. We want to believe the mental health services are doing things in our best interest but, in fact, they are actually keeping us captive.

As Ms Lillis said, independent peer advocacy at the time can help and support people not to need involuntary treatment. Every one of us wants to keep people out of the services and for those who go into the services to get the best support and help possible, but we also want to help people to step beyond the cognitive capture that happens within services. I echo everything. It is very important we build in strong supports. I thank the Deputy for the question.

Ms Fiona Anderson

I will just come in on the question of mental health tribunals. A section 28 hearing should be explained fully to the involuntary detainee. More often than not, an involuntary detainment order is revoked prior to the initial hearing. Many involuntary detainees are therefore not given the opportunity to have their voices heard and their rights considered and vindicated. Neither do they have the opportunity to stand their ground and defend their corner. Many do not have the skills, the confidence and the voice to speak on their own behalf. When legal representatives are appointed by the Mental Health Commission, they are there to protect the patient's interests, but they do not really know the story behind the person. A person is not just to be listened to but to be actively heard. I will leave it there.

Deputy Neasa Hourigan

I thank Ms Anderson very much for that. I will go back to the issue Dr. O'Mahony raised with regard to the criminal justice system and diversion mechanisms. He mentioned things like proposals for law reform. A body of work seems to have been done on that. Does Dr. O'Mahony envisage that as something that would live within the current legislative work or does it require separate and different work?

Dr. Charles O'Mahony

It depends on the pace at which the legislation goes forward. Proposals were developed previously and there have been recommendations from the inspector, who envisages a number of different powers for the courts to refer people for assessment and treatment with the mental health services. That would require a new part in the legislation if it was to be included. It was very regrettable that, even though it was raised as part of the review process, this oversight and massive gap was not addressed. It may delay the legislation but it would require a specific part within the legislation if it was to be included.

Deputy Neasa Hourigan

That is an important point for all of us. It should live in this legislation although it may need other supporting pieces down the road. I will turn to Dr. Morrissey who, at the beginning, spoke a little bit about stigmatising language. We are trying to be very aware of those things but it is a live issue and moves all of the time. Will Dr. Morrissey outline her concerns in that regard to us?

Dr. Fiona Morrissey

The language in the current Act is improved somewhat in the Bill but these improvements do not go far enough. We need to use the language used in the UN Convention on the Rights of Persons with Disabilities. Using terms like "mental disorder" suggests people are disordered. We need to start focusing on people's strengths rather than on their deficits. The change from "patient" to "person" is very welcome, but we need to move away from terms like "mental disorder" and even "mental illness". The UN Convention on the Rights of Persons with Disabilities refers to people with psychosocial disabilities and people who experience psychosocial distress. We need to move away from that language because language is very powerful. It can label a person and such a label can be a great burden. Once you have that diagnosis or label, everything you do in your life is questioned. We need to be very aware of the language we use in respect of people. It is primarily a question of talking about people as equal human beings, the same as ourselves, rather than talking about them as being disordered in any way.

It is just different degrees or levels of human distress that we all experience. We need to move away from that language throughout the Act and the proposed draft Bill. We need to get rid of terms such as "mental disorder" for sure.

Deputy Neasa Hourigan

I thank Dr. Morrissey. I will finish with a short discussion around the issue of coercive control. It overlaps a little with the discussion around involuntary treatments. Our guests have done a brilliant job of outlining the concerns around coercive control and how it relates to issues such as involuntary treatments. Is that a larger or separate piece of work or something they would see threaded through this legislation? It is back to the question whether coercive control is something that goes beyond the scope of when a person is an inpatient, whether is similar to independent advocacy in that it should be a consideration throughout a person's experience of service provision, and where that would best live and how we would address that. I do not know who wants to answer that. It is an open question.

Dr. Liz Brosnan

I want to come in on this point because it is a critical point. I thank Deputy Hourigan for raising the question.

Everything that permeates the culture and ethos within services revolves around coercion. To make a difference, I would like to see some thought given to whether it could be mentioned as a concept that is now emerging in legislation to support women - incidentally, a happy International Women's Day to my sisters here - where I understand some efforts are being made to address the issue of people experiencing coercive relationships by providing for a code for criminal coercion in that area of law. Perhaps it is possible for the creative minds of people on the committee and within Government, people who experience this and us to be creative and to capture it within the guiding principles or the opening statement, being mindful that it is something we need to find ways to address. There should be a strong emphasis on freedom and supporting people in terms of independent advocacy and their rights and providing funding to strong peer-developed projects. We have projects around the world, such as Soteria and the Leeds peer-run crisis houses, to which I hope others will speak. We have examples around the world of places where people can find alternatives to the control that happens within services.

It is not a direct answer. It is a plea for us to begin to think more and to divert more funding into alternatives to the system we have. I do not believe it is possible to replace it but let us please find some way to divert more funding and resources into building up the capacity of the independent peer-run and peer-support services.

Dr. Harry Gijbels

Following up on the points that Dr. Brosnan made, control and coercion are, of course, two separate issues. They are connected but they are separate as well. Coercion can certainly be organised through legislation; I am not quite sure about control. We have heard about abuse of power. We have heard Dr. Brosnan talking about a very different type of service. Control is also a cultural, and not only a legislative, issue. A cultural shift and a cultural change is a much more difficult thing to address. They are two separate but connected issues.

I certainly support what Dr. Brosnan has said about alternative services because there are good examples of services where there is hardly any control and no coercion at all.

Chairman

I thank Dr. Gijbels. Does Ms Lillis want to come in there?

Ms Deirdre Lillis

Yes, please. I refer to the Assisted Decision Making (Capacity) Act 2015. At this moment in time, can there be some further look at how the two Acts interact and how, if we are working to a system of supported decision-making, that immediately shifts the culture and the legislation in relation to coercion? The idea of a briefing on the 2015 Act sounds wonderful. That is really important at this moment, especially as it is now coming, hopefully, into full operation in the summer of this year. That may help the current draft.

Chairman

Does Deputy Hourigan have any other questions?

Deputy Neasa Hourigan

Did Dr. Morrissey want to come back in there?

Chairman

Apologies. Go ahead, Dr. Morrissey.

Dr. Fiona Morrissey

I thank Deputy Hourigan and the Chairman. The issue there around cultural change is critical. We need to effect cultural change in practice and human rights training within our services. The WHO now has an equality rights training programme, which we need to implement in our services to help people to move away from coercion and challenge the assumptions that we all have around coercion. We need to use it towards a system where we are supporting people.

We do not need to use coercion. It is a practice that has built up over time. We need to move away from coercion and control under the legislation within our services as well.

Deputy Neasa Hourigan

I thank the Chair.

Chairman

Is Senator Hoey under pressure for time? Does the Senator have to leave? I will call on Dr. Gijbels to make his statement if the Senator has time.

Senator Annie Hoey

I would prefer that Dr. Gijbels would make his statement. I have to go at 12 o'clock but I have plenty of time. That is no problem.

Chairman

I welcome Dr. Gijbels. Thank you for your patience. I hope I am pronouncing your name correctly.

Dr. Harry Gijbels

It is not easy to pronounce. It is a Dutch name. I thank the committee for inviting me to speak here this morning.

I will be brief because most of what I intended to say has already been said. It feels as though I am at a conference that I and others organise every year which is called the Critical Voices Network Ireland conference. Everything that has been said here this morning I have listened to over the past 14 or 15 years. Unfortunately, we have not made much progress. I will say a little about Critical Voices Network Ireland and then I will say a little more about the WHO guidance report, which came out last year and has been mentioned already.

Critical Voices Network Ireland, of which I am a representative here today, is a broad network of service users whom we have heard today, carers about whom we have heard today, professionals about whom we are hearing today, and academics and national campaigning and advocacy groups all of which are looking for a mental health system not based on the traditional biomedical model. The concerns expressed here this morning capture well some of the concerns that individuals, groups and communities have been expressing about mental health care in Ireland for many years.

Such concerns refer not only to coercive practices and lack of treatment and care choices, but also to abuse of professional power, over-reliance on and excessive use of medication, discrimination and stigmatisation, inhumane physical conditions in hospital units and lack of meaningful community-based alternatives to hospitalisation. We have heard references to that this morning.

Critical Voices Network Ireland provides a broad platform to discuss and debate concerns and share new initiatives and ideas. Every year, we get about 500 people coming to Cork for two days to discuss themes such as recovery, medicalisation, meanings of madness, trauma and distress, the value of psychiatric diagnosis, the therapy industry, activism and acts of resistance and safe spaces. This year's conference is on 16 and 17 November. I hope members can come to Cork to discuss issues around the notion of self-experience. What does "self-experience" mean? We talk so much about it. It is a common theme and term. Whose "self-experience" is referred to? That is my plug about Critical Voices Network Ireland.

It is not easy to influence policymakers, as we are trying to do this morning. The campaign to delete section 59(1)(b) of the Mental Health Act 2001 had limited success. We were able to get rid of the word "unwilling", but "unable" remains in the legislation, so concerns about involuntary treatment remain. People can still have ECT against their will if they are deemed to be unable but no longer where they are unwilling.

In the wider context of transforming mental health care provision in Ireland, the attention of members has been drawn to the WHO guidance document, which they may have in their possession. If they do not, I urge them to get hold of it. It is entitled Guidance on Community Mental Health Services: Promoting Person-Centred and Rights-Based Approaches and affirms that mental health care must be grounded in a human rights-based approach, as is clear. At the launch last June, Dr. Michelle Funk stated:

This comprehensive new guidance provides a strong argument for a much faster transition from mental health services that use coercion and focus almost exclusively on the use of medication to manage symptoms of mental health conditions, to a more holistic approach that takes into account the specific circumstances and wishes of the individual and offers a variety of approaches for treatment and support ...

We have heard that reflected this morning. It is all set out in the CRPD. A few countries have established the frameworks necessary to meet the far-reaching changes but many more have not.

The guidance is intended primarily for people with responsibility for organising and managing mental health care. It presents details of what is required in areas such as mental health law, policy and strategy, service delivery, financing, workforce development and civil society participation in order for mental health services to be compliant with the CRPD. The guidance report contains examples of good practice. I will offer an example with which members may be familiar. Ireland is represented by an example of a community-based mental health service that has demonstrated good practice in respect of non-coercive practices, community inclusion and respect of people’s legal capacity. That is the Home Focus project in west Cork.

That is all I wanted to say and it reflects what I have been listening to for the last 15 years. It is interesting that it has moved to a different arena and, hopefully, we can stay in that arena for a bit longer because that is where the influences can be made.

Senator Annie Hoey

I thank the witnesses. It has been useful and powerful and has given us things to think about.

Early in the presentation, reference was made to stigmatising language. Will the witnesses tease out the correlation between the stigmatising language used in legislation and the direct impact on patients? Sometimes people can see things as just words. Will the witnesses draw the link between the two so we can understand it when we think about the language used in this legislation?

Dr. Fiona Morrissey

That is a good question. I think Deputy Hourigan was talking about it as well. That stigmatising language is important because when discriminatory language is used, it affects a person's identity and role in society and it devalues them. When you talk about people with a mental disorder, it becomes an othering. You are talking about these other people. That is why at the beginning of the session I said this applies to all of us. It is not some people out there with mental disorders. It is just human beings who experience mental or human distress. When we use language that makes people different or equates to othering, we start dehumanising people and talking their human rights away.

Language is important and that is why the CRPD did not use any of that medicalised language. It used terms like "psychosocial disability". It did not define "disability" because there can be different levels of human distress and of disability. I have heard people talk about having a mental disorder and, therefore, not being able to do certain things in their lives, such as getting married or making decisions for themselves, and having no control over their lives.

When you undermine somebody's value in society by labelling them in stigmatising and discriminatory language, you undermine their identity and society's perception of them. It is important to move away from such language to more human rights-based language where people are seen as equal human beings with the same rights we all have. That is why it is critical that we allow people to make decisions for themselves and that we do not take rights like their legal capacity away from them. We all need different supports to make decisions and we should give them the supports to do that. The language in the legislation is powerful in terms of society's perception of people experiencing mental distress. We need to move away from that sort of language if we want to move to a society where it is accepted and people are treated with respect.

Dr. Liz Brosnan

I echo what Dr. Morrissey has said and will add a point that is not legislative but is something to bear in mind. People with lived experience of mental health issues and service users experience a form of discrimination that has no name. Every other form of discrimination and stigmatised behaviour has a label, whether sexism, racism, Islamophobia or any other aspect of people's identity by which they are marginalised. Language is important. Many of us are silenced and it is difficult to find words to speak about the way people are set up as subjects under mental health law.

I urge in the strongest possible terms that we use the word "person", bearing in mind that any person can, due to the vagaries of life, end up requiring mental health services. Finding respectful language helps us to build that sense of value and worth to combat the discrimination that has no name.

Some people use the word "sanism". Everybody is presumed to be sane unless he or she comes into contact with mental health services but it is not a very comfortable word and we are trying to find a new way to speak about it. I will leave it at that.

Dr. Charles O'Mahony

One of the positive things in the Bill is the alignment of the guiding principles with the Assisted Decision Making (Capacity) Act 2015. One of the regrettable things about the 2001 Act was that the notion of best interests in respect of adults was used by the courts to let some mental health services off when they did not comply with the legislation. The courts took a very paternalistic approach in a number of cases where individuals had challenged the legality of their detention. It is very important that there is a push back against any attempt to undermine those revised guiding principles in the Bill or any suggestion that these principles be changed.

The language is very important. Head 5, section 4(9) limits the scope of the revised guiding principles with a caveat that the provision of mental health services is subject to the availability of resources. This should be deleted because it could undermine the more positive guiding principles that are now included in the Bill. I encourage the committee to take a look at that and recommend the removal of that caveat to the revised guiding principles.

Senator Annie Hoey

That is very helpful. It is always useful for us to have specific issues to focus on and chase after. A couple of weeks ago, doctors and medical professionals appeared before the committee. One witness spoke about a colleague who, as a GP in Australia, prescribed medication for about 30% of patients with mental health difficulties whereas in Ireland, she found herself prescribing for nearly 100% of such patients. I asked the witnesses whether she thought we were overprescribing and there was broad acceptance that we are because of the lack of other supports and resources. I know we had a conversation earlier about the biomedical model and mental health systems where we are prescribing for behaviour modification but not dealing with more significant issues. Could anyone comment on what was said from the perspective of GPs, overprescribing, including prescribing for up to 100% of patients, and what we are talking about today, which is from a more patient advocacy perspective? I do not want to make correlations or links between the two that are not there but I would be interested in hearing the witnesses' thoughts and the impact that would have.

Dr. Charles O'Mahony

We have not developed community mental health services in Ireland. No alternatives have been developed. There is a funding stream into a very biomedical system, which might explain why there is a different approach in different jurisdictions. One of the recommendations in our report on mental health reform was that consideration be given to a right to community mental health services. A Vision for Change, which is largely unimplemented, was predicated on the notion of developing community mental health services but we have not seen the development of those services. A right to community mental health services in the amending legislation would be welcome. It would signal a commitment to moving to alternatives and away from coercion, which is something that should be given serious consideration.

Dr. Liz Brosnan

The Senator asked a great question and I am glad she did so because it is core to part of the fundamental difficulties we have with mental health services as they are constituted in Ireland. We know from experience that when a doctor does not have time to listen to people even in general practice and to explore the issue bringing the person to seek help, the easy solution is used because of the weight of medical education, theory and all of the funding from the pharmaceutical industry in terms of research.

This powerful lobby makes it far easier for people to give drugs than to spend time listening to people. This is not to say that on some occasions, although very rarely, with somebody presenting in a state of extreme distress, some medication could be used to alleviate that. In effect, the drugs are called antipsychotics, which are usually given to people with long-term conditions. They have a lot of metabolic side effects that are very often not spoken about and they have consequences for physical bodies so people end up more likely to die younger. They often put that down to the fact that many people smoke and they attribute increased mortality rates of people who use mental health services to that. They rarely look at the effect of the drugs on people's bodies because they are very powerful drugs and are used far more than they need to be. Joanna Moncrieff, a psychiatrist in the UK, would speak very strongly to the fact that these are very powerful medicines that are overused and often used in combination so there is polypharmacy. To be fair, I have come across some concerns about this discussion among professionals in mental health services.

There is a push to develop more access to talking therapies within mental health services. That is what people want. They want access to a safe space to talk about the underlying issues. It could not have been clearer from what Ms Hough said earlier about what she felt her sister did not get. Doctors are under too much pressure with too little time, too many people to see and too few resources. Community mental health teams need to be fully resourced and they need to be multidisciplinary because each and every discipline in mental health has a unique and important aspect to offer people who use the services. Owing to the dominance of psychiatry, quite often the first position that is filled is that of psychiatrist and it then trickles down so it is very hard to rebalance the power of psychiatry. Often when psychiatrists do not know what to do or do not have the time, falling back on overmedication is a human response to the pressure they may be under because of lack of resources for mental health services. Services are so underfunded. I know that during Covid, the first aspect of services to falter involved the community teams that had been developed because staff working in teams were pulled back into trying to cope with the acute units as these are the services that are currently legislated for under mental health legislation.

Ms Jennifer Hough

I echo what Dr. Brosnan said. The minute someone in Ireland comes into contact with mental health services or even a GP, drug treatment is the first line treatment. It does not matter whether it is depression, bipolar disorder or schizophrenia.

No matter where a patient's ailment falls on the spectrum, drug treatment is the answer. My sister was on four or five different medications at one time. We talk about access to services. My sister was lucky enough, if that is the right phrase, to access private services in Ireland, which meant she was put on even more drugs than she would have been in the public service. It is crazy. She was left walking around unsupervised and unmonitored while on four or five antipsychotic medications. We call them antipsychotics but they are really just tranquilisers. An antidepressant could be thrown in too. Those medications are seen to be working if the person plateaus back to a baseline. They are working the way they are meant to work. They dampen the person's emotions, numb them and make them able to be a normal person who can walk around in society but that is not getting to the core problem. Of course, that is why we have a revolving door system. People are taking drugs that are only maintaining them. It is an enormous problem and unless we get to grips with it, people are never going to achieve their human rights. Some people are lucky enough to recover but it is very difficult. One cannot challenge accepted notions and say the drugs are a problem because there is no mechanism for patients to taper off their drugs within the current system. The British Psychological Society produced an excellent paper last year intended to help professionals to help people taper off their medication. We have nothing like that in Ireland yet. We need to be able to support people to come off their medication but, of course, other resources are then required to support them, including talk therapies and all of that. This is crucial. It is a topic about which I am very passionate. It is at the core of everything. We just give people medication and that is it. I could go on but I will leave it at that.

Ms Deirdre Lillis

One of the pieces of work with which Dr. Gibjels and I are involved in, as part of an advocacy group, is around our rights and medication. That is an area that people, even independent advocates, are reluctant to touch because it is seen as the territory of the clinicians. The work we are doing is trying to address that issue within a human rights context. We are developing workshops and dialogue sessions relating to informed consent to deliver to people using services and healthcare professionals. There is language of shared consent and shared decision-making in the clinical world that I am familiar with but we want to move to a place where people are empowered to ask questions about their medication, to ask whether a review has happened, to ask about the side effects of a medication and to ask whether there are any other options. Stemming from work conducted in the UK, we also want to encourage service providers to sign up to a pledge to honour a human rights-based approach to the prescribing of medication. We would be happy to talk more about that to the Senator if she is interested.

Dr. Fiona Morrissey

Advocacy is key because it can help people to explore alternatives that they might not get to explore otherwise or which the clinicians might not have time to explore with them. Advocacy could support those patients to taper off their medications in consultation with their clinicians. We are looking for that kind of supported decision-making. We must remember that we have resources but they are all going into the area of medication and not into the alternatives and other supports. That does not cost a lot of money. The problem is that all of the resources at the moment are going into one area when we need to provide other supporting resources, such as independent advocacy and other supports, so that people can be supported to make decisions around medications. Such a system does not exist at the moment but it is critical.

Senator Annie Hoey

I thank our guests for their responses. I would be interested to learn more. In the same way it is for Deputy Ward, this is a very personal topic to me, especially issues around tapering the use of medication. When I was a very young woman, there were many complexities around those issues and perhaps some day I will be more confident to speak about my experiences more publicly. The human rights framework and informed consent elements are very important. Sometimes, particularly in crisis situations or dire situations, one is told there is only one way. Perhaps that is sometimes the case in a crisis moment but it cannot be the only way forever. At some point, a patient will come off the bottom. A patient is told there is only one way and at no point does someone ask the patient if he or she would like to have a conversation. I am particularly interested in that aspect of the matter and I would be interested to hear more about it because, as I said, it is a personal topic to me.

I will ask a question that I also asked of some medical professionals who were before the committee a few weeks ago. We are working on a piece of legislation and our guests' job is to come in and point out the flaws and problems with it and suggest ways in which we can improve it. Are we on the right track with this legislation? Is it fit for purpose? We have been talking about this for the past ten or 15 years. Are we on track to having a gold standard or world-class standard of service, or even just good legislation, that would protect, support and provide care and compassion for the people who will be affected by it? This legislation will affect fewer people than some other pieces of legislation we look at. Are we going in the right direction in terms of how we need to treat or support our patients with mental health issues? I am talking specifically about this Bill. We all know our thoughts about the mental health supports sector overall.

Dr. Fiona Morrissey

It is an improvement to be talking about a person rather than a patient and things like that. Moving away from the "best interests" approach is an improvement on what we have had before. However, we still have a long way to go and there are many things we need to change. We really need to enshrine the UNCRPD approach into the legislation to make it human rights-based. That needs to permeate the whole legislation and that is not the case at the moment. Once we have powers within the legislation whereby people are deemed unable to make decisions and their capacity to make decisions about treatment and other matters is taken away from them, we are going in the wrong direction. No matter what oversight we provide through, say, multidisciplinary professionals or an independent consultant psychiatrist, it does not provide the human rights protections people need. Neither do mental health tribunals. I know that because I remember those tribunals. In some cases, tribunals can legitimise coercion. We need to be careful about the direction we are going in terms of human rights. Are we putting our resources and money into the wrong area? Do we need to fundamentally change our focus to support people and not take away their decision-making capacity? The underlying theme of the legislation is that we are still taking decision-making away from people and we are not treating them in accordance with their will and preferences. We need to move more towards putting the person's will and preferences at the centre of everything we do in the legislation and when we do that, we are then going towards a supported decision-making model and putting those supports in place.

This legislation is an improvement but it needs to go further and to move more towards the model in the Assisted Decision-Making (Capacity) Act. We also need a cultural change in practice and to educate people. We need to enshrine that throughout the legislation. We are moving a small bit in the right direction but we have a lot further to go in terms of the supports we put in place. Things such as advanced healthcare directives must ensure services are equally available for everybody, including independent advocacy and all the other projects we have talked about at this meeting. We need to go further, to be honest.

Dr. Charles O'Mahony

I agree with everything Dr. Morrissey has said. There are positive elements in the Bill as published but there are also many deficits. The UNCRPD requires us to abolish mental health laws because they are discriminatory. It is clear we are not going to do that. We are going to retain those laws and try to enhance the procedural safeguards. That does not sufficiently address our human rights obligations and that is why, in the recommendations we made in that report, there are many practical suggestions on how the Bill can be refined to allow for better procedural safeguards. For example, as Dr. Morrissey said, tribunals are not a meaningful or effective mechanism to review detention. There is a lack of independent advocacy and other mechanisms. All those components are core in the absence of abolishing mental health laws to make sure people's rights are vindicated and that effective procedural safeguards are in place.

Chairman

Dr. Gijbels has raised his hand. I know he also wanted to respond to the previous question.

Dr. Harry Gijbels

I thank the Chairman for pronouncing my name correctly. I will make a couple of points about the tapering off of medication. There is an absolute need for a structural approach to the tapering off of medication.

People in this country are desperate for help and assistance with that. That is one point.

We in the our rights and medication group would love to meet Senator Hoey. Second, I am surprised - maybe I do not know enough about it - but does anybody know about the WHO guidance document? Is that not the guiding document that should drive policy in Ireland on mental health development and services? Is it going to end up on the shelf? It contains so much information. There is so much guidance, including technical guidance and everything. It should drive matters. Is it going to end up on the shelf? I do not know. Anyway, that is my point.

Chairman

I thank Dr. Gijbels. Does Ms Lillis wish to say something?

Ms Deirdre Lillis

All that Dr. Morrissey and Dr. O'Mahony have put in their document on recommendations goes some way, but it is not enough. The special rapporteur asked whether we want reform or a revolution. Do we want this proposed legislation to be a gold standard? It is purported that the Assisted Decision-Making Act is because the position has shifted from best interest to will and preferences. If it can be aligned with that, then we are moving more towards a gold standard.

Chairman

I thank Ms Lillis.

Senator Annie Hoey

I thank our guests. I apologise to Dr. Gijbels for smushing his first name and surname together. I ran over myself trying to get his name out. Those are all the questions I have. I thank all our guests so much. I would love to speak to them offline about the matters I have raised. If they want to reach out to my office, I would love to talk to them about that. I thank the Chair. I am going to hop off the meeting now if that is all right.

Chairman

I thank the Senator. Deputy Buckley is next.

Deputy Pat Buckley

I thank the Chair and all our guests. I enjoyed reading their statements this morning when coming up to Dublin. Much has been covered. I hear what they are saying about the assisted decision stuff, the advanced healthcare directives and the coercion, which is very difficult to control or police, should we say, at the moment.

I am very interested in what Dr. O'Mahony and others said about this being advocacy- and community-led. In this country we normally have two options. We are reactive instead of proactive when it comes to addressing problems. We do a great job of burying them more so than sorting them. Dr. O'Mahony mentioned community-led mental health services. Even though we are talking in technical terms and about the general scheme of the mental health (amendment) Bill and what we can do to strengthen it, we have members within the mental health service who are trying to move away from community-led mental health services. Thus, in terms of where we are starting today and where we have started before, we have constantly met resistance. I do not know what it is. I was very interested in the advanced healthcare directives and advocacy groups. I have a situation at the moment, if I am allowed to say it, with the Owenacurra Centre in my own town. It is a mental health respite centre. It has been working. It is a model of consistency and excellence. Is there a way for the likes of an advocacy group to represent the members and the patients - or should I say the residents, because many of them are there long-term and are very happy there - and their views?

The other point I want to address is the overprescibing of medicines. This has been a bugbear of mine for years. I will not mention the company or anything but I remember an anti-depressant on which the patent was running out. The company was going to discredit this old anti-depressant because it was bringing out a new one. I actually have the paperwork in my possession. What amazed me in this case was it was the company that was pushing this. It was supported by a payment by a doctor to sign off on it to vindicate it. We were talking about trying to reduce the level of medication. The statement issued by the company stated that one is no good, that it would admit what it would not admit in the past, namely, that there were side effects but that this one is so good you do not even have to wean yourself off it and you can go straight onto it.

There is one major problem because it is industry-led when it comes to prescribing medicines. On this side, we are trying to work on mental health issues and be patient-centred, which is very important, but I am worried about being rights-centred. We all have experience within the mental health services, whether we worked in them, used the services or visit people within them. Do not get me wrong, it is not in every sector but it seems to be top-heavy with management. If management do not have control then those on the advocacy side of it will not be welcome because they are stepping on the management's patch. There is one centre and one problem. The other side of it I am looking at is how we can work together. Working with groups like those represented by our guests, I am interested in how the advocacy can get into the community faster. How large are our guests as a group or entity? What can we do to help each other, working within the mental health services?

As a final point, even though we are working on the general scheme, should there be specific rules included such that when the Mental Health Act is done and people within that system fail to keep those standards, there would be repercussions for them as well? There is a lot there.

Chairman

Who would like to come in first?

Deputy Pat Buckley

I would say it is my Cork accent, Chair. Do I have to say it again?

Chairman

Does Dr. Morrissey wish to reply?

Dr. Fiona Morrissey

I apologise. I got some of it. On the last part, we need to support people who are working in the system. We need to educate them on human rights. I suppose we do not want to punish people who are working in the system who just may not realise the impact of the things they are doing on people. This is about educating everybody and working together. It is about collaborating with people with lived experience as equal partners and having user-led services and working together with all partners as equal partners. I do not think it is a good idea to punish people. It is important to support people with lived experience but also to support those working in the services to protect human rights and educate them on the impact of some of the decisions they are making or approaches they are taking. The more we hear the voice of lived experience and put it to the forefront of our services, the more we can do that.

The Deputy mentioned advanced healthcare directives. They are really important tools for opening up the conversation with professionals and people with lived experience so you are forced to have that conversation, listen to the person and respect his or her will and preferences. If you do not have that conversation, you do not know what the person's wishes are. How then can you respect his or her wishes if you do not even know what they are because you have not had that conversation? We need to have continuity of care around that as well so the person is dealing with the same people and that his or her wishes are written down in this legally binding statement. It is important we work together and try to move forward together rather than alienating or demonising any one group of people.

Chairman

Does Ms Lillis want to come in?

Ms Deirdre Lillis

Yes. On the first point about advocacy supporting people who may be in residential situations, our small group SHEP is very poorly resourced but over the past ten years we have been supporting people in congregated settings to have a voice in the process of moving away from those. Some of those people would have been moved from Our Lady's, sent to places that are other institutions and been told they were there from three months and then been there for 20 years, so there is space for advocacy to facilitate that kind of collective voice in the community as well.

There is a danger sometimes - this is happening in other places - that one-to-one, independent, issue-based advocacy takes away the space to provide collective advocacy spaces. I am aware that the Irish Advocacy Network has tried to offer that in other spaces, but all advocacy is very poorly resourced, wherever it is. One advocate could serve all psychiatric inpatient units and then try to serve populations of people collectively. I am not speaking for advocates but I am speaking of what I witness here. I hope I am not speaking in the wrong way. It is from my understanding. If there are spaces for facilitating collective advocacy in the sphere of independent advocacy, specifically with regard to community, we can enhance the collective voice.

Deputy Pat Buckley

I am very happy with that.

Chairman

Ms Rosy Wilson could not get in to the meeting due to technical issues. She has asked that Dr. Morrissey read out her statement. Would that be possible?

Dr. Fiona Morrissey

That is fine. I do not have her poem in the statement that she sent but I can read out what she sent to me. I am happy to do so. Does the Chair want me to do that now?

Chairman

Yes.

Dr. Fiona Morrissey

I am very sorry Ms Wilson could not be here today because she is a brilliant advocate and has lived experience. This is Ms Wilson's statement:

This presentation is my story of my ... mental health episodes treated in Irish hospitals. I don't like remembering and disclosing these periods of “Deep Depression with Psychotic Symptoms”. Symptoms which included overwhelming guilt.

Ms Wilson's statement reads that she does it to use her voice in solidarity and to help to counteract stigma.

My first breakdown was in 2001 when I was 63. This came as a shock to me and my family, my first mental health episode in my hard-working life rearing 4 children and working full time as a lecturer in London Colleges and for the Open University. I was committed to the County Hospital, my clothes were removed for 10 days ... my husband and sister were told ECT was the best treatment, I was not told anything, the how and what and why of it.

Ms Wilson wrote a poem on ECT soon after. I do not have the attachment because it did not come in. Her statement reads that one consultant told her it was her brain chemistry and was probably genetic and that she should talk to her four children, as they may also be affected. The statement also reads that no one considered the underlying factors probably related to her childhood and that the consultant's words made her feel branded and even guiltier and more fearful.

Again in 2017 I became very depressed, and my doctor arranged my admission to another hospital as I had moved house. I was there for six months; my psychotic symptoms were very severe and I was not improving ... My consultant told my family he needed to use ECT as a last resort and they agreed but I didn't. A tribunal was set up where I argued my case with a lawyer appointed to support me. However, the tribunal agreed with the consultant, and I was made an involuntary patient and given 12 sessions of ECT. For the last one the consultant asked me to take it as a voluntary patient and I agreed. Although I can remember my psychoses there is a lot about the hospital that I don't recall. For me ECT wipes my memory ... Because I am under Old Age Psychiatry, I receive very good after care mainly by visits from Community Nurse Team.

In light of the above, Ms Wilson argues strongly that the human rights model enshrined in the CRPD should replace the hierarchical medical model that gives doctors the power to decide what is in the best interest of patients. Her advanced healthcare directive states:

Any mental health care that I require is to centre on rest, counselling and minimal short-term medication (preferably in my own home). In any episode treatment will assume my recovery and return to normal living. I specifically never want to be subjected to ECT again unless medical advice deems it absolutely necessary.

Ms Wilson's statement continues:

I have given copies of my advanced healthcare directive to my GP and Community Psychiatric Consultant ... They both welcomed the document ... and will put them in my files. Their response was an affirmation of the Human Rights model we're all working towards. Even so I am every day [still] frightened that I may have another breakdown and age 83 be sent to a nursing home and given medication against my will.

I apologise. Ms Wilson did not send me her poem and I do not have it. She is a very accomplished poet and has written a poem on ECT. Maybe we can share it with the committee afterwards.

Chairman

That would be very helpful and we would love to see it.

Deputy Mark Ward

I thank the witnesses. Their testimonies are gold dust for all members of the committee. They are very informative and very much help us going forward. I thank Ms Hough for talking about her sister Valerie.

Ms Jennifer Hough

I thank Deputy Ward.

Deputy Mark Ward

I am sure she is a very unique person to Ms Hough. Unfortunately, and I do not say this to disparage, Valerie's story is not unique. I have heard many times about overmedication with powerful drugs, the importance for medical experts of giving a label and a diagnosis, and the lack of alternative therapies such as talk therapies. Valerie's experience in emergency departments is similar to what I hear on a regular basis, as well. I have spoken to liaison psychiatrists who work in hospitals. Unfortunately, there are just not enough of them to see everybody who comes into emergency departments. They are under-resourced.

I am very interested in what Ms Hough and others mentioned about their views on tapering and the right to taper. In other health areas, there is a right to taper. I have worked in addiction services for numerous years and there is a right to taper. It is called detoxification. The word detoxification literally means removing a toxin from one's body. If somebody was put on a methadone substitute for heroin treatment, he or she has a right to taper off that with the help of a GP or a prescribing doctor. A number of people over the past 20 years have been presenting to addiction services with an addiction to prescribed medication. Benzodiazepines and codeine are two of the medications that regularly feature. How does Ms Hough see the right to tapering working? What structures need to be put in place? Would it be advocacy with someone speaking on behalf of the person who seeks to taper off his or her medication? Does this need to be legislated for? I do not know the answer to that either. Will Ms Hough answer some of that? If anybody else has any questions, that would be very useful.

Ms Jennifer Hough

I will make a quick comment and then leave it to the professionals to say how it could be done in legislation. The issue of medication and tapering or coming off it challenges the biomedical notion of a person having a disorder in his or her brain and needing to take medication for life. All of a sudden saying one can taper off medication and will be okay with the right supports challenges psychiatry and everything in which it believes. In the UK, the British Psychological Society has developed a paper that recognises the right of people and gives guidance for professionals on how to do this.

It is very challenging because it challenges what psychiatry believes and the medical model that medication essentially corrects a brain disorder. I remember my sister and my family were told when she was 16 years of age that she had a chemical imbalance - that she needed to take medications and would be grand. However, we know now that this story about the chemical imbalance is not true. There is no science behind it. It is a false narrative that helps to explain, potentially, how medication might work because it is not known how it works.

Bipolar is just a construct that explains behaviours. It is not a scientific term that says this is what goes on in a person's brain because nobody knows that. Nobody ever tells the person. Nobody comes back to say that new research shows these medications do not work the way we thought they used to. Nobody comes back to the family and updates them on evolutions in research or science.

Some 20 years ago, we did not know that these medications did not work very well or were damaging. We know now. The research is very clear on antidepressants and antipsychotics but it never filters down to the person.

In my view, it is a scandal. I will leave it to the professionals to say how we can legislate for that.

Ms Deirdre Lillis

I want to support Ms Hough and I am very grateful for all she has said about that experience. It is not enough to have an independent advocate available to go in with somebody to an appointment with a psychiatrist because some psychiatrists do not let in independent advocates. It is not enough. Something stronger is needed. As Ms Hough said, it is challenging the entire system. The our rights and medication group is challenging the system. Everybody knows the quote from the special rapporteur that we need to move away from addressing a chemical imbalance to the power imbalances in psychiatry. I wonder what it would be like to consider legislative pieces with respect to conditions to taper. I wonder how that would happen and whether it would work.

Dr. Fiona Morrissey

It is a good point and we could have a position of statutory reviews of people's medication, or they would have to be reviewed at different periods. There is no statutory obligation or regulation around that. The question we must ask is why in mental health are we treating people without their consent. Why is this the only area in which we forcibly treat people or treat them without consent? Why is mental health different from general health care or other areas of health, including drug treatment? In any other area of health, we do not forcibly treat people. Why, then, are we doing it here? There is no evidence to suggest that people have any less capacity in the mental health system than they do in the general health system, and a recent Irish study compiled in the past year or so proves that. There is no evidence of increased risk of violence or danger so we must consider why we are continuing to treat people the way we are doing it now, without their consent or forcibly treating them? They have no pathway to come off medication once they go on it either. When we bring people into the system by treating them without their consent, there is no pathway out or a statutory review mechanism either.

We must question the justification of this non-consensual and forcible treatment. There is no evidence to show coercion works. People might continue with medication for a long time, which can have very damaging side effects for the person. We must question all of that. Why are we still doing it given that international human rights law now obligates us to move away from it as well? What is the justification for continuing with this? We have the opportunity to be a world leader and a model of best practice in the same way our capacity legislation is looked at by other countries. Why can we not do this for mental health as well?

Dr. Harry Gijbels

I recall a recent discussion in the our rights and medication group about a new psychiatrist in an area who went through all the medications of the patients and persons, noting a vast array of overprescribing. What sort of control or review is there on individual psychiatrists when they prescribe medication? There is none, by the sounds of it, and I am not quite sure if there is any legislation around it. It is an example of the power of individual psychiatrists and nobody knows what they are prescribing. That was until another psychiatrist came along and asked what was going on. I just wanted to make that point.

Deputy Mark Ward

It is a really important point as we saw it happening recently with the CAMHS in south Kerry. Another psychiatrist came in and asked what was going on. Only for that whistleblower, as he is being called, being brave enough to ask the question, the issue could have gone on much longer than it did. It is really important for people to ask what is going on. I thank Dr. Gijbels.

Chairman

I have one or two other questions I wish to ask. First, however, I should say that I cannot thank the witnesses enough for their contributions and statements. I totally agree with Deputy Ward's comments. It is like gold dust for us to receive this information, particularly with regard to legislation.

Is there a country that uses the best-practice model in this area that the witnesses think Ireland should adopt? Could they recommend any best practice model to take on? What are their thoughts on countries that are doing really well in the mental health area?

Dr. Harry Gijbels

It is difficult to say if there is a particular country doing well in all areas. There are countries that are doing well in particular areas, including legislation and practice. I refer again to the WHO guidance, which has many examples from different areas right across the globe. It is a very comprehensive document. I mentioned a good example in Ireland with the West Cork Home Focus team that has been going for years. There are good examples in Norway, which has drug-free mental health units. It is difficult to point out a country that is expert at everything and different countries are expert at different things. Italy, of course, is known for community-based healthcare. The committee should really look at examples of good practice right across the globe, and again I refer to the WHO document.

Dr. Fiona Morrissey

I agree with those comments. There are pockets of best practice all over the world that we can bring together. A manual has recently been compiled of examples of good practices at both European and international level. That is a manual we could look at. The WHO has published guidance in the area advocating a move towards human rights-based approach to mental health services. There is the good practice manual and examples like the personal ombudsman scheme in Sweden. There are independent advocacy examples all over the world. As Dr. Gijbels has said, there are medication-free wards in Norway and in Trieste they have made an initial move to a community treatment-based approach. In the United States there are examples of good practice.

We could bring all those together into our system and we are ready with the capacity legislation moving to a model of best practice that other countries are looking to with respect to supported decision-making. Why can we not move towards something like that in mental health? We have already done it in the capacity area so why should mental health be different from capacity law? Why can we not move towards the same model? We could bring together everything we have spoken about today. There is no one country I would look to but I would certainly look to all those examples of best practice, along with the manual and WHO guidance. It is important that these are led by the Convention on the Rights of Persons with Disabilities.

Dr. Harry Gijbels

The area of crisis services has not been mentioned. We have spoken for many years about setting up crisis houses. We have good examples from the United Kingdom in Edinburgh and Leeds, with peer support-led crisis services. Here we have absolutely zilch and nothing at all. We need crisis services as well.

Chairman

Is there anything the witnesses wish to say before we finish or do they feel they have covered everything today. Are there any final points or is it all good?

Dr. Harry Gijbels

It is all good.

Chairman

I thank all our guests very much for coming in. This has been a really informative session. I am glad they could all make it. I thank Dr. Morrissey, Ms Wilson, Dr. Brosnan, Dr. O'Mahony, Ms Anderson, Ms Hough, Ms Lillis and Mr. Gijbels. Did I pronounce that last name right?

Dr. Harry Gijbels

It is Dr. Gijbels.

Chairman

Apologies.

Dr. Fiona Morrissey

I thank the Chairman and the members for the opportunity to present to the committee today, because these voices are often silent. It has been a unique opportunity for us to have our voices heard. We need to move towards doing that more and more within the provisions of our legislation and our services.

Dr. Harry Gijbels

Absolutely.

Chairman

I thank you all again. The joint sub-committee is adjourned sine die.

The joint sub-committee adjourned at 12.31 sine die.