Peace Talks

Peace talks are about to start, between representatives of Israel and West Bank Palestine.

Meanwhile, the Israelis are making lots of noises about building more settlements; and they are taking steps to forcibly move Bedouin (citizens of Israel) off their own lands.

Perhaps the term “settlements” sounds innocuous.  But settlements are not innocuous: they are permanent; they are on Palestinian lands (often on private property); they consume vast quantities of water and leave little or none for the Palestinians; moreover, the “settlers” are heavily armed – and they threaten their Palestinians from time to time and damage their olive trees.

At the same time, the Israeli army and settlers are taking over the Jordan Valley and, in effect, surrounding Palestinian towns and villages and Arab East Jerusalem, on all sides.  The Palestinians will end up living on “reservations” or “bantustans”.

The move is towards an Israel that stretches from the sea to the River Jordan.  The Palestinians are in the way of this vision.  It would be best, for the hardliners, if they disappeared and joined the existing Palestinian diaspora.

Security?  Israel has total control over land routes, the air-space and the sea; she has aircraft, machine-guns and nuclear weapons; she has a vast military forces and a huge reserve army.  One only has to spend a few minutes in Israel or Palestine to see evidence of this.

So, it does not look as if the Israeli government is serious about peace, at all.  No change there, I’d say.

When will the West in general and the USA in particular wake up to the fact that Israel’s policies are fundamentally racist?  Racism on this scale, in any other country, would be condemned, vigorously and openly, by Western democracies; and real pressure would be put on.

Blame on both sides?  Yes.  But Israel has the power and has the one-sided support of the USA.

Israel has been given a special dispensation for her behaviours, for far too long.

May we have genuine peace talks, please, without further “facts on the ground”?

 

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Thoughts on the interface between the Mental Capacity Act and the Mental Health Act, England and Wales

General

The British House of Lords has appointed a Select Committee to review the workings of the Mental Capacity Act. (The consultation process can be viewed on-line.)  I have submitted written evidence, on the basis of my forty years of practice as a social worker for local authorities.

I believe that the MCA is a good Act.  But in my submission to the Select Committee, I have given it as my opinion that the MCA is still bedding in.  Staff need training and updates on case law (especially as regards the DoL Safeguards).  Indeed, the DoLS procedures need amendment – simplification, in fact.  MCA Schedules A1 and 1A are very complicated and hard to follow.  Schedule 1A in particular is so opaque that it should be re-drafted, to make it more comprehensible.

The referral criteria to Independent Mental Capacity Advocate services may be too tight. I am inclined to think that patients should have access to advocacy, (a) whenever their care plan is being reviewed, not only when a major decision is being made, and (b) even if a relative or friend is involved as the Representative, Donee or Deputy (cf the provisions of the MCA).  IMCAs develop expertise through training and practice.

The relationship between the MCA and the Mental Health Act remains confusing.  Case law has thrown some light on it: roughly speaking, the MHA “trumps” the MCA, so long as its use is lawful.

Training for Best Interests Assessors in Wales is neither prescribed nor compulsory.  The Welsh Government should be urged to address this and raise the standard.  Moreover, Best Interest Assessors should be rewarded, financially, for the additional work they take on.

The interface

My main concern, therefore, is about the DoLS and the interface with the Mental Health Act in general and MHA Guardianship in particular.  Both Acts need to be considered – together.

A patient (I use the word ‘patient’ for convenience) who is:

(a) mentally incapable

(b) in need of psychiatric treatment in hospital

(c) deprived of his/her liberty

should be subject to the Mental Health Act rather than the DoLS procedures – even if he/she is compliant.  The MHA confers on the patient more rights – better safeguards and more reviews.  Guidance on this matter should be issued – in law and/or regulations and or a revised code of practice.  (Note that, although compliant patients are generally dealt with “informally”, in terms of the MHA, nothing in the MHA prevents their detention, in principle.)

Similarly, a patient who is:

(a)  mentally incapable

(b)  in need of a care plan but not hospital admission

(c)  deprived of his/her liberty

should be subject to MHA Guardianship rather than the DoLS procedures.  The law should explicitly allow this.  (See below).

 

As I have already indicated, MHA Guardianship provides more safeguards than the DoLS: for example, it provides for more reviews, by those involved in the care, the hospital managers and the Mental Health Review Tribunal.  Guardianship is appropriate when an impairment of capacity and periods of non-compliance have continued, and are likely to continue, for years.  Moreover, Guardianship has an inbuilt flexibility: it can be converted to a MHA section 3 admission, under section 19 of the MHA.

Practical drawbacks of the present laws

Guardianship does not provide explicit authority for the guardian to detain the patient – in other words, to deprive the patient of his/her liberty.  In his MHA Manual, Professor Richard Jones argues that it provides implicit authority.  I believe that this opinion has not been tested in any court hearing.  The authority should be made explicit in law – or else it should be excluded, specifically.

The power to move a patient from place to place (eg from their home to a hospital or to a care home), if they are subject to the DoLS, should be made explicit in law.

Three cases

I now move on to discuss three cases.  Two of these I was involved in myself; one (the first mentioned) influenced the practice of social workers and other practitioners while consideration of it went up from court to court.  I think that they throw up interesting, relevant scenarios.

The Bournewood case

The facts are well known to practitioners in the field.  The patient was mentally incapable and compliant (not expressing dissent).  What could have happened was that the care team considered detention under the Mental Health Act.  One of the patient’s informal carers would have been the Nearest Relative, in accordance with section 26 of the MHA – they would have been consulted; they would have refused to go along with the care team’s plan, as they wanted the patient to be discharged to their care; the status of the patient would have remained “informal”; an Approved Social Worker could have applied to the County Court to override the views of the Nearest Relative (or at least to test the strength of the case); the Court would have heard the evidence and come to a decision.  The demands of the European Convention on Human Rights would have been met, as (a) a process laid down in law would have been followed, and (b) an independent review would have taken place.

England and Wales would not have ended up with the complexities of the DoLS, as they stand now, if this option had been explored or if it had been recommended subsequently, in law and in policy directions.  If, as I have argued above, the MHA procedures now came to be preferred to those of the DoLS, the use of the latter would be lessened: they would be confined, more or less, to the protection of patients who are:

(a)  mentally incapable

(b)  in need of physical treatment (generally, in hospital)

(c)  deprived of their liberty.

In my view, this would be a progressive move.

A mother and son

This case came to my attention twenty or more years ago.  I should add that in those days, practitioners had no experience of applying to a court for “declaratory relief” for their actions, when care, rather than treatment, was at stake.  Practitioners were more familiar with MHA Guardianship.

The mother had cared for her adult son (who had Downs Syndrome) for many years, singlehandedly.  When she felt that she could no longer care for him, she decided that he should not be left in the care of anyone else.  She then tried to kill her son, by poisoning him, but he survived.  The eventual outcome was that the son was placed in a local authority residential home and made subject to MHA Guardianship.  The defence of the care team to any objection would have been that we were acting in the best interests of the son, especially as he was at risk from his mother.

The criteria for Guardianship were, I admit, stretched somewhat, given that a patient with a learning disability can only be made subject to a Guardianship application if the disability is “associated with abnormally aggressive or seriously irresponsible conduct” (section 1 of the MHA).  (The care team invoked “irresponsible conduct”.)  This exclusion is appropriate for section 3 but, I would strongly argue, not for section 7 (Guardianship), which is less restrictive.  The law should be changed, to allow for the protection of Vulnerable Adults in similar circumstances.

A patient, discharged from hospital and placed in a care home

This case came to my attention in 2009.  The patient in question had had many admissions – sometimes under section 3 of the MHA – to the local hospital.  On her latest discharge from hospital, the patient was placed in a care home by her local authority.  The regime of the home imposed restrictions upon the residents.  (Did these restrictions amount to a deprivation of liberty?)  The home is situated, not in the patient’s home area, but in the neighbouring area, where I was working as a Best Interests Assessor.  The local authority for the area where the patient had lived for years was going to dispose of her home.  Hence, unless she stayed in the care home, she would be rendered homeless.

The Managing Authority, for the purposes of the DoLS, referred the case of this patient to my local authority, as the Supervisory Body, and I was assigned to the case.  In the course of my enquiries, I consulted the relevant social worker in the neighbouring authority: she stated that she would take responsibility for her share of the DoLS process, in response to this referral; she added that at the expiration of the authority to detain, she would pass responsibility for continued detention to my local authority.

I objected to this transfer of management, as it appeared to me to be an abdication of responsibility, especially given the long term involvement of the neighbouring local authority with the patient.  I proposed that MHA Guardianship would be appropriate, especially as, if the patient relapsed, she could be transferred to hospital fairly smoothly (in accordance with the MHA).  My colleague argued that the patient could not be deprived of her liberty, under Guardianship: she was relying on the advice given in the MCA and DoLS Codes of Practice.  I reminded her that, in his MCA Manual, Professor Richard Jones expressed disagreement with this advice; I tended to agree with Professor Jones; my colleague accepted the advice given in the Codes and stuck to her opinion.  In conclusion: the law needs to be clarified: the MHA should be amended, to allow this, explicitly.  Then, the guidance on the DoLS could be altered, to reflect this change.

I await the conclusion of the Select Committee’s deliberations with interest.

David R Harries

Reflections upon forty years in social work in England and Wales

Context

After about forty years in field social work – mainly in Wales, in local government, in the field of mental health – I am now retiring.  I have decided to put some thoughts together.

Helping

What is social work about?  Rather than refer to definitions and codes of practice prepared by others, I shall say what I personally think.

Fundamentally, social work is about helping other people.  It is organised help.

The person who wishes to start helping others, whether as a volunteer or as a paid worker, will benefit from three things: (i) training, (ii) supervision and (iii) working within the framework of an agency (whether this is an arm of the State or a voluntary body).  Indeed, these three things are essential.  They are certainly essential to social work.  They protect both the people receiving help and the helper.  They improve the helper’s practice.  They guard against misguided effort and indeed harm (to either party).

Helping people is rewarding; at the same time, it is actually a hard thing to do properly.  Numerous aspects need to be taken into account, such as these:

  • Does the helper know him/herself?
  • Has the helper any awareness of internal conflicts (perhaps arising from childhood troubles)?
  • Does the helper know the proposed recipient and his/her situation?
  • Does the helper aim to treat the proposed recipient as an equal (as far as is possible)?
  • Is the helper aware of, and sensitive about, the power differential that generally applies, between helper and recipient?
  • Is this helper best placed to help this particular recipient?
  • Is there someone else (eg a relative or a friend), or a different agency, that could help too?
  • Is there scope for two helpers or helping agencies to work together on the issues?
  • Are there matters, arising from the issues, that need to be taken up with managers?
  • Are there matters that should be taken up with government, with a view to policy change?
  • Does the helper make him/herself aware of risk factors and think of ways to deal with them?
  • Is the helper aware of agency policies?
  • Is the helper aware of budgetary restrictions?
  • Is the helper aware of changes in society that will affect the agency and its work?

Here are some rules:

  • Do not discriminate adversely against a recipient because of age, disability, race, gender, sexuality etc
  • Do not abuse your power and oppress the people you are supposed to be helping
  • Do not overplay your hand by attempting to “rescue” people: remember that (a) your remit is limited, (b) your skills are limited, (c) people tend to generate their own solutions to their problems – “rescuing” will sooner or later be perceived as oppressive
  • You may have specialised knowledge and skills that can help; the recipient is the expert on his/her own situation
  • Recognise the strengths of the people you are trying to serve; learn from them
  • Maintain a balance between involvement and professional distance: recipients are not personal friends
  • Think about ending the helping relationship, when it is timely
  • Consider the feedback received from recipients, whether through body language or comments; learn from it.

A triangle

Social work – where an arm of government is the employer – can be seen as having three main aspects:

  1. Direct contact with others – listening and interviewing, assessing and proving care
  2. Advocacy on behalf of others –vis-à-vis government, other agencies, people with power and influence
  3. Representing government and society, upholding laws, making authoritative decisions, sometimes going against recipients’ expressed wishes.

Rewards and frustrations

My experience is that, on the whole, people in the helping professions do their best.  Most are altruistic – they are not in it for the money. 

The helping relationship has its inbuilt frustrations: because there are never sufficient resources to meet all needs (or to meet all demands); and because of personal failings, on the part of recipients (unable or unwilling to make the most of the help offered), or on the part of practitioners (because of a lack of insight, a lack of knowledge, a lack of sympathy, or tiredness or sickness).  Sometimes, recipients are hostile; occasionally, they threaten the practitioner (or others).  Sometimes, someone one has come to know well dies – occasionally through suicide.

The rewards?  It is possible to build up a friendly relationship with most people, on the basis of mutual respect and shared goals.  Sometimes, situations get a lot better.  The good practitioner will give the credit to the recipient rather than to him- or herself; but positive remarks and thanks expressed by the people we serve boost our morale and help us to carry on.

The personal

Social work has meant lots of things to me.  It is stimulating.  It is tiring.  It means warm relationships with many users of the services.  It involves many close working relationships with colleagues, from various backgrounds, ie within and outside local government; it means co-operation, to achieve the best results.  It means accepting that conflicts will arise but also trying to resolve conflicts by means of an organised, sensible approach.

As time has gone on, I believe that social workers have become more sophisticated; but at the same time, the demands upon them have become heavier.  (Has society become more complex?  Well, laws and policies affecting social work have become far more detailed and demanding.)

The wish-list

There are a few things I wish had been in place during my time as a social worker, and that I wish were securely in place now.

Firstly, I wish that social workers as a body had been more skilled and articulate about explaining, to government and employers and the media, (a) their knowledge and skills and professionalism and (b) the limitations of their roles and responsibilities – especially during my first thirty or so years. 

Similarly, I wish that governments and society and employers and the media would avoid denigrating social workers – blaming them for social ills and personal failings that cannot be laid at their door and seeing things only with the benefit of hindsight.

I wish that the management pyramid could be inverted.  In my experience, a great deal of the relevant experience lies with the front-line practitioners rather than with anyone else in the structure.  When this is the case, they deserve appropriate respect. 

I wish that social workers were not constrained by useless, time-consuming bureaucratic demands and inappropriate computer systems.  These often have to do with counting numbers (measuring quantity): you can make numbers mean anything.  What is important is the quality of the work.  A quality assessment results in a quality service.  Time limits imposed on assessments are arbitrary and unhelpful – they get in the way of good work.

I wish governments and employers trusted social workers more.  Train them, supervise them, pay them, make reasonable demands upon then – then listen to them and trust them (within reason) and (on occasions) praise them.  Concentrate your attention on those who (for whatever reason) are not making the grade.

A word of advice to inspectors of services: ask the users of services, and the people who have taken on informal caring responsibilities, for their views.  It is their feedback that is the most valuable and informative.

So:

I think that social work remains rewarding.  It always remains hard.  Not for the faint-hearted, perhaps.

David R Harries

 

Reflections on fifty years of membership of the Religious Society of Friends (Quakers) in Britain

Worship

Friends commence worship in silence.  It is better to experience this than to listen to or read a description of it.

Worship is the process of listening for the word of God.  It works best in a group setting. When a Friend hears a clear message, meant for the group, then he or she will stand up and convey it to all.  Friends speak about being impelled by a powerful force to stand up and speak.  This is a force that must not be resisted: it is a right and indeed a duty to speak.  Sometimes, more than one Friend sitting in a Meeting for Worship will receive a similar message; and one spoken message will be followed by another.  A Friend who speaks should not aim at a polished performance, or a long one, but, relying on the inspiration of the spiritual force, should use simple words, straight from the heart.

A Meeting for Worship may remain silent throughout – this is acceptable.  (But Friends may wish to share the fruits of their contemplation, subsequently.)

Ethos

Friends say that each human being has to take responsibility for what he or she believes and how he or she acts.  Reference is often made to the “spiritual journey”.  (During this journey, change can occur.)  This means that each Friend must speak for him- or herself, and choose his or her own words. 

Words have limitations; they are subject to misunderstanding; although they can aid communication, they can also hinder it.  Friends look behind the words – to the spirit behind the words.  We have no creed.

Some leaders promote a doctrine (religious or political), at the expense of the welfare of their fellow human beings: those who resist are punished.  For Friends, people come before doctrine.  It is wrong to persecute anybody because the beliefs they hold are “wrong”.

Although each Friend must speak for him- or herself, a characteristic of Friends is that they are in constant communication with one another – exchanging experiences and ideas. This how an ethos is sustained; this is how spiritual unity is maintained.

Friends are open to new “light” from wherever it comes.  In other words, they are open to change, in accordance with new insights.  Changes can happen as society changes.  This is not a matter of following society, only, but also leading it.  Friends are interested in positive social change.

Belief leads to action; and action reinforces or modifies belief.  But an intermediary process needs to be inserted between the two: namely, discernment.  Friends make an effort, as a group, to discern the way forward before engaging in action.  If ever Friends are not in unity, then they wait until the way forward is revealed to them.  (We do not resolve disagreements through voting.) There may be delay, but once clarity is attained, then the required action is pursued whole-heartedly.

Values

To me, all life is sacred.  Life and nature are so valuable that they must not be depreciated or wasted.  Friends promote peace rather than warlike conflict, social justice rather than inequality, simplicity rather than luxury, earning and deserving rather than gambling, moderation rather than excessive drinking or smoking, sustaining our world rather than over-exploitation of resources and pollution. 

Many Friends are vegetarians because of their respect for animals and also the cost to the environment of farming animals for meat.

Friends believe that all people are equal – equal in the eyes of God.  All are priests; all can communicate directly with God; there are no paid clergy. Therefore, for example, women are equal with men; and the equal status is recognised in our writings.  A second consequence is that any Friend can be asked to serve in a capacity (for a time-limited period), eg as clerk, overseer, elder, treasurer, committee member. 

Commitment

Friends’ ways take time to learn about and to understand: they have to be experienced rather than studied as an academic subject; they make demands upon one’s time and energy.  Some people (even followers of other faith traditions) choose to share their spiritual journey with Friends, as fellow travellers; they are welcome.  

The personal

What effects has membership of the Society had for me?  I have attended about three thousand Meetings for Worship, in various places, in my time; and Meeting for Worship has become an integral part of my life (if I cannot attend, I miss it).  I have been asked to serve in numerous capacities, and I have found all these experiences rewarding.  I have been served and helped too, especially when in some personal difficulty, and for this I remain grateful.  The constant dialogue among us – especially about their experiences and what they have learnt – is stimulating and deepens our faith. 

I appreciate both the freedom of the individual that is part of our ethos; but I also respect accept the discipline that my membership of the Society requires.  This freedom, within a discipline has proved to be the right way for me on my spiritual journey through life.  

 

David R Harries

August 2013