Sarah Markham: Dealing with iatrogenic harm in mental health

When the prime minister Theresa May commissioned the current independent review of the Mental Health Act (MHA), she committed to dealing with “the burning injustice of mental illness.” One aspect of this injustice is the iatrogenic harm which patients may experience during detention under the MHA.

Iatrogenic harm refers to the harm caused inadvertently by the process of treatment. This may manifest as uncertainty and anxiety caused to the patient by a failure of staff to provide them with important information regarding diagnosis, treatment, or discharge planning; adverse reactions to drugs; negligence; or unnecessary treatment resulting from a psychiatrist’s decision. 

The media often report on cases of patients who have raised concerns about their treatment at the hands of mental healthcare services. The interim report of the MHA review acknowledges that these concerns go beyond the harms mentioned above, and states that there are “serious issues” with the use of the Mental Health Act.

Awareness of the need to protect the human rights and social rights of those with mental illness is seemingly ever present in the news. Such concern is not limited to the MHA, but also the Mental Capacity Act (MCA). In July 2018, the government published a Mental Capacity (Amendment) Bill, which if passed into law will reform the Deprivation of Liberty Safeguards (DoLS), and replace them with a scheme known as the Liberty Protection Safeguards. In its current form the bill fails to include reforms around supported decision-making and best interests, as proposed by the Law Commission. These omissions have proved controversial, with practitioners anxious about what this could mean for them in practice.

The independent review’s service user and carer group, of which I am a member, is raising awareness of the very real need for an effective means of dealing with iatrogenic harm. We need a way to manage perceived harms that helps patients have their experiences validated, and helps services to learn from these experiences, so that clinical practice and service provision can be improved.

A possible means that I have suggested is a truth and reconciliation process of restorative justice, known as restorative practice. Restorative practice brings those harmed by conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward.

There are already positive evidence-based examples of the value of restorative practice in meeting the needs of victims and reducing reoffending. Restorative practice isn’t limited to the criminal justice system and can be used anywhere, including within healthcare systems. The focus of restorative practice within a mental healthcare setting would be to facilitate a full exchange of testimonies and experiences in a manner which ensures that the recipient of harm is able to express all their concerns and opinions to the healthcare provider in order for them to learn from the process, and implement necessary changes in their clinical practice or the service provision.

Integrated working between a restorative justice practitioner and a regulator, such as the Care Quality Commission (CQC) would allow the implementation of learning gained from the restorative practice to be tracked and monitored.

In their 2017 paper “Exploring the case for truth and reconciliation in mental health services,” Spandler and Mckeown suggest that healing and restitution may not be achieved until the full extent of service user grievances has been acknowledged. Hopefully the current Independent Review of the MHA, is a start.

Sarah Markham is an academic mathematician and patient representative currently pursuing a second PhD in theoretical computer science. She is a member of the BMJ Patient Advisory Panel.

Twitter: @DrSMarkham

Competing interests: None declared