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Good Practice in Adult Mental Health
 Good Practice Series
Edited by Jacki Pritchard
This series explores topics of current concern to professionals working in
social work, health care and the probation service. Contributors are drawn
from a wide variety of settings, in both the voluntary and statutory sectors.
of related interest
Good Practice with Vulnerable Adults
Edited by Jacki Pritchard
ISBN 1 85302 982 3
Good Practice Series 9

Good Practice in Risk Assessment and Risk Management 1

Edited by Hazel Kemshall and Jacki Pritchard
ISBN 1 85302 338 8
Good Practice Series 3

Good Practice in Risk Assessment and Risk Management 2

Protection, Rights and Responsibilities
Edited by Hazel Kemshall and Jacki Pritchard
ISBN 1 85302 441 4
Good Practice Series 5

Good Practice in Working with Violence

Edited by Hazel Kemshall and Jacki Pritchard
ISBN 1 85302 641 7
Good Practice Series 6

Good Practice in Working with Victims of Violence

Edited by Hazel Kemshall and Jacki Pritchard
ISBN 1 85302 768 5
Good Practice Series 8

Good Practice in Supervision

Statutory and Voluntary Organisations
Edited by Jacki Pritchard
ISBN 1 85302 279 9
Good Practice Series 2

Good Practice in Counselling People Who Have Been Abused

Edited by Zetta Bear
ISBN 1 85302 424 4
Good Practice Series 4
 Good Practice in Social Work 10

Good Practice in
Adult Mental Health
Edited by
Tony Ryan and Jacki Pritchard

Jessica Kingsley Publishers

London and Philadelphia
 All rights reserved. No part of this publication may be reproduced in any material form
(including photocopying or storing it in any medium by electronic means and whether or
not transiently or incidentally to some other use of this publication) without the written
permission of the copyright owner except in accordance with the provisions of the
Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the
Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1T
4LP. Applications for the copyright owner’s written permission to reproduce any part of
this publication should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work may result in
both a civil claim for damages and criminal prosecution.

The right of the contributors to be identified as authors of this work has been asserted by
them in accordance with the Copyright, Designs and Patents Act 1988.

First published in 2004

by Jessica Kingsley Publishers
116 Pentonville Road
London N1 9JB, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA

www.jkp.com

Copyright © Jessica Kingsley Publishers 2004

Library of Congress Cataloging in Publication Data

Good practice in adult mental health / edited by Tony Ryan and Jacki Pritchard.-- 1st
American pbk. ed.
p. cm. -- (Good practice in social work ; 10)
Includes bibliographical references and index.
ISBN 1-84310-217-X (pbk.)
1. Mental health. 2. Mental illness--Prevention. 3. Mentally ill--Services for--Great
Britain. 4. Psychiatric social work--Great Britain. I. Ryan, Tony, 1958- II. Pritchard, Jacki. III.
Series.
RA790.G59 2004
362.2--dc22
2004005660

British Library Cataloguing in Publication Data

A CIP catalogue record for this book is available from the British Library

ISBN-13: 978 1 84310 217 5

ISBN-10: 1 84310 217 X
ISBN pdf eBook: 1 84642 053 9

Printed and Bound in Great Britain by

Athenaeum Press, Gateshead, Tyne and Wear
 For our sons:
Kieran Ryan
Nathan Pritchard
 CONTENTS

Preface 11
Tony Ryan, University of Manchester,
and Jacki Pritchard, trainer, consultant and researcher

1. What is Mental Health, Illness and Recovery? 13

Piers Allott, University of Wolverhampton

2. Human Rights and Mental Health Law 32

David Hewitt, Hempson’s Solicitors

3. The Care Programme Approach 55

Lynn Agnew, Trafford Social Services

4. Interventions in Mental Health 72

Promoting Collaborative Working and Meaningful Support
Simon Rippon, NIMHE North West Development Centre

5. Medication Management 90
Jacquie White, University of Hull

6. The Role of Primary Care 108

Debbie Nixon, NIMHE North West Development Centre,
and Tim Saunders, GP and Cheshire West Primary Care Trust
 7. Medical Diagnosis of Mental Illness 127
Rob Poole, consultant psychiatrist, North East Wales NHS Trust

8. Multidisciplinary Teamworking
and the Roles of Members 145
Karen Newbigging, Health and Social Care Advisory Service

9. Supporting Staff 164

Jane Gilbert, independent consultant

10. From Grassroots to Statute 183

The Mental Health Service User Movement in England
Carey Bamber, NIMHE North West Development Centre

11. Mental Health Advocacy

and Empowerment in Focus 202
Rick Henderson, Advocacy Across London

12. Personal Experiences

of Mental Health and Illness 219
Julian and Eric (Son and Father)

13. Carer Perspectives 229

Alison Pearsall, Lancashire Care NHS Trust, and Lillian Yates,
Pennine Care NHS Trust

14. Black and Minority Ethnic Mental Health 245

Melba Wilson, Centre for Mental Health Services Development
England, Linda Williamson and Rhian Williams, Wandsworth Pri-
mary Care Trust, and Sandra Griffiths, The Mellow Campaign
 15. Gender and Mental Health 262
Barbara Hatfield, University of Manchester

16. Substance Misuse and Mental Health 278

Mark Holland and Vall Midson,
Manchester Mental Health and Social Care NHS Trust

17. Towards No Secrets 295

The Use of Multi-Agency Policies and Procedures to Protect
Mental Health Service Users from Abuse
Ruth Ingram, Bradford Social Services

18. Managing Violence 311

Roy Butterworth, Lancashire Care NHS Trust

Glossary 328
List of contributors 335
Subject index 340
Author index 349
 List of Figures

Figure 5.1 Example of a medication review clinic within

a rural CMHT 104
Figure 8.1 A negative experience of multidisciplinary working 151
Figure 18.1 The management of a violence skills network 325

List of Tables

Table 6.1 A summary of problems, severity and available

interventions 119
Table 6.2 Types of psychological therapy 121
Table 8.1 Characteristics of an effective team 154
Table 11.1 Distinctions between advocacy and other informal
support 205
Table 16.1 Reasons reported by dual diagnosis service users
for their substance misuse 281–2
Table 16.2 Comprehensive assessment and treatment in dual
diagnosis 286
 PREFACE

Mental illness affects one in three people in their lifetime and as such is a
major area of health and social care provision. Given the prevalence, and
the limited resources available to support people with mental health
needs and their carers, a wide range of individuals, professionals and
agencies come into contact and provide support to people from all strata
of society. There is a variety of mental illnesses and disorders, some of
which carry more stigma than others. Consequently, there is an array of
interventions and responses available to effectively support people with
mental health needs. Because of the complexity of the range of illnesses
and their effects, the knowledge needed to support people may be varied.
It is not just specialist mental health professionals who come into contact
with people with mental health needs but also a wide range of other
health and social care personnel, including employment support
workers, housing workers, probation staff, care workers in residential
homes, domiciliary care workers and staff working in street agencies.
It is for the above reasons that we decided to edit this book. It is
intended to be read by mental health professionals with experience in the
field through to workers across all sectors who may be required to
recognise a mental health need or problem and to provide some form of
support. The book is also intended to provide such readers with a better
insight into the mental health system in order to help people they are
working with access specialist services and support. It will also be benefi-
cial to anyone who has little or no experience in mental health but who is
considering a career in this area.
Our objective in bringing together this collection is to provide
guidance on good practice in adult mental health. In order to do this a
wide range of issues need to be understood; these include theory,
practice, law, politics and the personal experiences of service users and
carers. To achieve this we felt it was vital to demonstrate the human
nature and impact of mental ill health. Contributors have achieved this by

11
12 GOOD PRACTICE IN ADULT MENTAL HEALTH

using case studies based on their experiences of either working in the field
or being a service user or carer.
The book is designed in such a way that the reader or trainer can dip
in and out of sections as best meets their needs. A variety of materials are
included: case studies, vignettes, questions for group discussion, good
practice points and facts. Contributors have included further reading
materials and useful organisations. A glossary is also provided at the end
of the book, which although not exhaustive, covers all the key terms used
in the book.
The field of mental health and illness has changed dramatically over
the past fifty years; it is dynamic and constantly evolving as we learn more
about how best to support people with mental health needs. The closure
of old Victorian asylums and an emphasis on community-based support
and treatment has brought a greater awareness and understanding of
mental health and illness. Society’s attitude is changing but still has some
way to go. Attitudes have changed because people have become more
enlightened through education, training and personal experience. This
book is an attempt to continue that trend by educating people who are
sympathetic to the issues surrounding mental health and who are in a
position to then raise awareness amongst others – be that in their work
role or their wider social role.
The book has been constructed in a way that takes the reader through
the history and theory of mental illness, the legal and policy frameworks
as applied to current practice, and then describes a number of interven-
tions and methods of delivery across different groups of service users.
Although mental health and illness is a very complex area, and we have by
no means covered all aspects, this text brings together many of the
current key issues that are relevant to professionals working in the field
and to anyone else who has an interest.
We hope readers of this text will be enlightened and inspired in a way
that helps them to work more effectively with those people with whom
they come into contact who have mental health needs.
Tony Ryan and Jacki Pritchard
 CHAPTER 1

WHAT IS MENTAL HEALTH, ILLNESS

AND RECOVERY?

PIERS ALLOTT

INTRODUCTION
This chapter aims to provide an overview of definitions of mental health,
illness, recovery and wellness. To aim to achieve any more within the
space available is all but impossible given that the argument over this
question has raged for at least the last thirty years with some referring to
mental illness as a myth (Szasz 1960). Many people who have been
diagnosed as ‘mentally ill’ also reject such classification and may argue
that they have nothing to ‘recover’ from. It is without doubt that the life
experiences of a significant number of people defined as mentally ill have
often been extremely damaging. Hearing the narratives of many people in
recovery, one is often struck with a sense of awe that they have survived at
all. This includes the experiences of people from black and ethnic
minority communities, from whose cultures there is a great deal to learn.
Many people have not only managed to survive their difficult life experi-
ences but also to survive their ‘mental illness’ and the consequences of an
often less than supportive mental health system in which their life experi-
ences were cast aside because they were perceived to be disturbed in their
feeling, thinking and perceptions of the world. Many people have thrived
as a result of their experiences, demonstrating that adversity can often be
overcome and provide a basis for growth.

13
14 GOOD PRACTICE IN ADULT MENTAL HEALTH

BACKGROUND
Concepts of mental illness
Until the late eighteenth century, people who had experiences that we
now define as ‘mental illness’ were treated no differently from any other
dependent person referred to as the ‘needy and worthy poor’, a group
that included people with physical disabilities, chronic illnesses and
dementia. The parish provided some financial assistance to enable
people to continue to live in the community and very few ‘dangerous and
troublesome lunatics’ were segregated from society in specialised houses
of correction. The rise of industrialisation brought about very significant
changes in nineteenth-century society with an increasing need for labour
and an expectation that ‘able bodied’ people would work, leaving those
who were not ‘able bodied’ to be supported by the poor houses to the
point at which the poor houses began to overflow. People whose differ-
ences of behaviour set them apart from others in the poor houses began
to be problematic in the overcrowded conditions and this led to the devel-
opment and rise in provision of private care provided by doctors special-
ising in the care of people thought to be ‘mad’. It was in the middle of the
nineteenth century that the development of asylums was mandated and
they, like the poor houses, filled quickly with a wide range of people
whose differences and behaviour could not be tolerated (Jenkins 1994).
The Alleged Lunatics’ Friends Society was established by John Perceval
in 1845 (Frese and Davis 1997).
So original concepts of ‘mental illness’, if defined by those who were
admitted to the asylums, were very broad indeed including people with a
range of physical difficulties, tertiary syphilis, diabetes and even malnu-
trition. There were almost as many classification systems as there were
experts! It was with the publication of the sixth edition of Emil
Kraepelin’s Lehrbuch (1904) that classification of mental disorders began
to stabilise. However, with the establishment of the World Health Organi-
sation (WHO) in 1948 and the publication of an international classifica-
tion of diseases, ICD-6 (WHO 1948), a more internationally recognised
classification was achieved, although only adopted by six nations. The
publication of ICD-8 (WHO 1967) provided a classification based on
new principles proposed in a report commissioned by WHO from the
English psychiatrist Erwin Stengel (1959) and finally achieved broad
international agreement. However, there has always been an issue
between the importance of empirical as opposed to non-empirical
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 15

evidence in classification, with empirical views dominating to the

exclusion of non-empirical views (Fulford 1989).
Recovery narratives strengthen the importance of non-empirical
views that are meaningful to the people whose experiences mental health
services and psychiatry aim to address. Perhaps with the significant con-
tribution now being made by ‘expert patients’, by learning what helps
people on their recovery journeys and by giving greater weight to this
qualitative experience, ICD-11 and DSM-V will see in a new era of
understanding that gives at least equal weight to evaluative information.

The concept of recovery

The experiences of the service users of mental health services, those
people who seek support for their mental distress, have generally been
excluded since the rise of industrialisation, due to poverty or social
exclusion on the basis that people with ‘mental illness’ were perceived not
to have the capacity for sound reasoning. However, there have been many
people with experiences of recovery from mental illness/distress through-
out history whose stories were often not told and, if they were, were not
heard or were discounted. It was not until the rise of the civil rights
movement in the United States and the publication of books like Judi
Chamberlin’s On Our Own (1978) that a new sense of hope among
people diagnosed as having a ‘mental illness’ seemed at all possible.
The 1990s was seen as the ‘decade of the brain’ from the perspective
of biological psychiatry and, in apparent direct contradiction to this
medical philosophy, mental health recovery was seen as ‘a guiding vision
for the 1990s’ (Anthony 1993) from a service user and family perspec-
tive, a more values-based thinking. The concept of mental health
recovery was not taken up in the UK until the mid- to late 1990s when a
few people began to embrace the concept in their work, although in those
early days there was little in-depth understanding of the concept or its
practice. However, with the publication of research into coping and adap-
tation (Hatfield and Lefley 1993) and Accepting Voices (Romme and
Escher 1993), together with the development of user groups and organi-
sations such as the Hearing Voices Network, the development of
concepts of coping with symptoms began to become more prominent
and ‘experts by experience’ began to develop their own writing (Coleman
and Smith 1999).
16 GOOD PRACTICE IN ADULT MENTAL HEALTH

What underpins the development of recovery is a value base that

respects the differences between people. The announcement by the gov-
ernment in July 2001 of the establishment of the National Institute for
Mental Health in England (NIMHE) was accompanied by an announce-
ment that one of the first tasks of NIMHE would be the development of a
national framework of values for mental health. A draft national
framework of values (see Box 1.1) was delivered to the e-conference
hosted by the Mental Health Foundation at the end of March 2003
(NIMHE 2003) and the link between the concept and practice of mental
health recovery and values-based practice connected by two of the partic-
ipants now appointed as Fellow for Recovery and Fellow for
Values-Based Practice at NIMHE. A literature review of recovery that
includes a commentary on the role of values can be found in Allott,
Loganathan and Fulford (2002).

Box 1.1 National Framework of Values

for Mental Health (draft, March 2003)
The National Institute for Mental Health in England (NIMHE)’s
work on values in mental health is guided by three principles of val-
ues-based practice:
1. Recognition – NIMHE recognises the role of values alongside
evidence in all areas of mental health policy and practice
2. Raising awareness – NIMHE is committed to raising aware-
ness of the values involved in different contexts, the role/s
they play and their impact on practice in mental health
3. Respect – NIMHE respects diversity of values and will support
ways of working with such diversity that makes the principle
of service user-centrality a unifying focus for practice. This
means that the values of each individual service user/client
and their communities must be the starting point and key de-
terminant for all actions by professionals.
Respect for diversity of values encompasses a number of specific
policies and principles concerned with equality of citizenship. In
particular, it is anti-discriminatory because discrimination in all its
forms is intolerant of diversity. Thus respect for diversity of values
has the consequence that it is unacceptable (and unlawful in some
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 17

instances) to discriminate on grounds such as gender, sexual ori-

entation, class, age, abilities, religion, race, culture or language.
Respect for diversity within mental health is also:
· user-centred – it puts respect for the values of individual users
at the centre of policy and practice
· recovery oriented – it recognises that in building on the personal
strengths and resiliences of individual users, and on their
cultural and racial characteristics, there are many diverse
routes to recovery
· multi-disciplinary – it requires that respect be reciprocal, at a
personal level (between service users, their family members,
friends, communities and providers), between different
provider disciplines (such as nursing, psychology, psychiatry,
medicine, social work), and between different organisations
(including health, social care, local authority housing,
voluntary organisations, community groups, faith communities
and other social support services)
· dynamic – it is open and responsive to change
· reflective – it combines self-monitoring and self-management
with positive self-regard
· balanced – it emphasises positive as well as negative values
· relational – it puts positive working relationships supported by
good communication skills at the heart of practice.
NIMHE will encourage educational and research initiatives aimed
at developing the capabilities (the awareness, attitudes, knowledge
and skills) needed to deliver mental health services that will give
effect to the principles of values-based practice.

MENTAL HEALTH, POVERTY, CULTURE AND SOCIAL

JUSTICE
Prilleltensky (2001a, p.253) defines mental health as ‘a state of psycho-
logical wellness characterised by the satisfactory fulfilment of basic
human needs’. Prilleltensky highlights that some of the basic human
needs for mental health include a sense of mastery, control, and a sense of
efficacy; emotional support and secure attachment; cognitive stimula-
tion; sense of community and belonging; respect for personal identity
and dignity; and others identified by the Basic Behavioral Science Task
Force of the National Advisory Mental Health Council (1996a, 1996b).
18 GOOD PRACTICE IN ADULT MENTAL HEALTH

Given the above it is not surprising that the experiences we identify as

‘mental illness’ are closely connected with poverty and social injustice
and what might more accurately be referred to as ‘disempowerment’ or
‘losing control over one or more aspects of one’s life’. Prilleltensky
(2001a, p.254) highlights the importance of cultural assumptions on
mental health, particularly cultural assumptions about poverty and social
justice, the way this is framed and society’s response to it. He summarises
his view that:
cultural assumptions exert a direct influence on mental health through
definitions of the good life and the good society and through psychologi-
cal definitions and solutions to problems. Notions of the good life de-
rived from competition and individualism lead to social isolation and
psychological stress. When these problems are defined in individualistic
terms, the person is viewed as responsible for her or his suffering. But
cultural assumptions also exert an indirect influence on mental health
via society’s definitions of social justice. The way we frame justice deter-
mines how we allocate resources, and the way we allocate resources has a
direct impact on the mental health of the poor and the vulnerable.
Psychiatry is part of Western medical science and as such has developed
within the context of Western cultures. When one considers, in addition
to the cultural assumptions identified above, the cultural differences
between nations including differences of ethnicity and race and the way
these issues are dealt with in a multicultural society, concepts of mental
illness become very much more complex. Until relatively recently the sig-
nificance and importance of differences in cultural meanings of mental
health have gone unrecognised, or been ignored, and this has led to con-
siderable social injustice; in particular the fact that many more people
from African Caribbean backgrounds in the UK experience considerably
greater levels of coercion both on entry to and within the mental health
system.
The importance of culture has been recognised since the beginnings
of psychiatric classification (Kraepelin 1904), but the Western societies
in which we now live and our ability to travel and communicate around
the world easily have created a very different context to that experienced
by Kraepelin. Culture within these societies has become very much more
complex. Marsella and Yamada define culture as:
Shared learned meanings and behaviors that are transmitted from within
a social activity context for purposes of promoting individual/societal ad-
justment, growth, and development. Culture has both external (i.e., arti-
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 19

facts, roles, activity contexts, institutions) and internal (i.e., values,

beliefs, attitudes, activity contexts, patterns of consciousness, personal-
ity styles, epistemology) representations. The shared meanings and be-
haviors are subject to continuous change and modification in response to
changing internal and external circumstances. (Marsella and Yamada
2000, p.12)
They highlight the work of Murdock (1980), an American anthropolo-
gist, who separated Western views from non-Western views of disease
causality. He reported that Western models were based on naturalistic
views of disease causation, including infection, stress, organic deteriora-
tion, accidents and acts of overt human aggression. In contrast, among
many non-Western societies, disease models were based on supernatural
views (i.e. any disease which accounts for impairment of health as being a
consequence of some intangible force) including:
1. theories of mystical causation because of impersonal forces
such as fate, ominous sensations, contagion, mystical
retribution
2. theories of animistic causation because of personalised forces
such as soul loss and spirit aggression
3. theories of magical causation or actions of evil forces
including sorcery and witchcraft.
It is considered significant that many people in the United Kingdom who
are ‘experts by experience’ (people who experience mental illness/
distress, their families and friends) and have been diagnosed as ‘mentally
ill’ have adopted a mixture of Western naturalistic models of disease –
including stress, accidents and acts of human aggression, including
abuse – and non-Western models that are more supernaturally or spiritu-
ally based, while rejecting naturalistic biological concepts of infection
and organic deterioration.
Anam Cara is the service-user-run crisis alternative to psychiatric
hospital inpatient treatment reported on in Being There in a Crisis (Mental
Health Foundation 2002). This work and the Foundation’s Strategies for
Living with Mental Illness (Mental Health Foundation 2000) highlight the
importance to experts by experience of Eastern concepts of ‘illness’ and
‘healing’ that have an emphasis on spiritual beliefs and ‘energy healing’:
the use of Bach or Australian bush flower essences, Reike, Shiatsu and
meditation practices, to name but a few. The work at Anam Cara proved
very effective in supporting the recovery of many people and the service
20 GOOD PRACTICE IN ADULT MENTAL HEALTH

was valued by both its ‘guests’, who reported 100 per cent excellent satis-
faction with the service, and the staff that worked alongside the Anam
Cara ‘recovery guides’ from the local home treatment team. The national
MIND survey (Baker and Strong 2001) confirms that ‘spirituality’ was
important to roughly half of the respondents. This reflects the fact that in
1997 42 per cent of the UK population used alternative therapies, an
increase from 34 per cent in 1990 (Eisenberg et al. 1998), with 70–90 per
cent of all episodes of illness managed outside the established health care
system – through self-care and alternative therapies (Melmed 2001).
Each one of us has a different background; our personal upbringing
has unique characteristics. The cultural context provided by our family,
our local community and the wider society in which we grow up has a sig-
nificant impact on the way in which each of us views the world. In
Western societies the development of biological medicine has led to the
belief that the functioning of mind and body are separate, whereas in
Eastern societies beliefs are much more holistic in nature and there is a
recognition that mind and body are interrelated. In fact, Western
medicine is reported to be only the fourth most commonly practised
system of medicine in the world today, preceded by Chinese medicine,
homoeopathy and herbal medicine (van Kooten-Prasad 2000); and if
studies of recovery from serious mental illness, including schizophrenia,
report that recovery rates are significantly higher in developing countries
than they are in Western countries (Warner 1994) then, in terms of our
definitions of mental health, illness and wellness, we must, at least,
consider what we can learn from different cultures as well as begin to
understand how people from different cultures in Western societies may
experience difficulties with Western ways of conceptualising ‘mental
illness’.

SEEKING DEFINITIONS
What we call ‘mental illness’ in Western society describes differences of
perceptions, feelings and behaviour that are perceived to vary signifi-
cantly from those of the majority population. At the simplest level, mental
illnesses can be defined as severe disturbances of behaviour, mood,
thought processes and/or social and interpersonal relationships. In psy-
chiatric diagnosis these experiences are grouped under a range of
common headings that enable the use of similar responses and treat-
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 21

ments to be offered to people with the same diagnoses. The most

common groupings are anxiety, affective disorders, psychotic disorders,
including schizophrenia, and personality disorders.
However, it is argued that what is more important to the individual is
a description of the issues as perceived by the person rather than a
diagnosis. This is because people can only begin to look for solutions to
issues that are identified by them, whether with or without professional or
non-professional assistance, and can then begin to contextualise, under-
stand and perhaps find meaning in the experiences (Bracken and
Thomas 2001). If diagnoses are given within a Western medical context
and the response, as is often the case, is only to prescribe medication, then
there is an assumption that both the problem and the solution can be
simply dealt with by the ‘third party’ rather than the person seeking
solutions that are considered effective and have meaning to him or her.
This is a common course of action within Western medicine that is com-
fortable for both the person and the general practitioner or psychiatrist,
although it is one through which personal growth of the individual may
well be impeded. This is not to argue that diagnosis is unimportant but
rather that it has less relevance for the person than for the professional,
and that at least part of the solution rests with respecting the values of
individuals who approach services for support.
Mental health and mental wellness are more than an absence of
mental illness. All of us have experiences of mental distress at some points
in our lives and the experience of mental illness or even clinically
diagnosable psychosis is much more common in our societies than has
previously been identified. Van Os et al.’s (2000) study of a population of
7076 people in the Netherlands found an occurrence of psychosis in the
general population of 17.5 per cent, some fifty times more than expected.
This suggests that a significant proportion of the population may have
experiences of ‘the psychosis phenotype’ that indicates the continuum of
‘mental illness’ in our communities and that even those forms of mental
disorder considered the most serious are significantly more prevalent
than previously identified. Therefore, if some 17 per cent of people with
clinically diagnosable ‘psychosis’ are not in contact with mental health
services, we must assume that a person who can be clinically diagnosed as
having a ‘mental illness’ can also be ‘mentally healthy’. This will be par-
ticularly so if in addition to their symptoms of ‘mental illness’ they experi-
22 GOOD PRACTICE IN ADULT MENTAL HEALTH

ence ‘a state of psychological wellness characterised by the satisfactory

fulfilment of basic human needs’ (Prilleltensky 2001a, p.253). They may
have high self-esteem and feel good about who they are, they may have
loving relationships and family lives and be successful in their chosen
occupation, in spite of diagnosable symptoms. So the presence of
symptoms, in themselves, is not sufficient to determine ‘mental illness’ or
to exclude ‘mental health’. This view is supported by Repper and Perkins
(2003, p.viii), who contend that approaches that focus on deficits limit
our view of people who experience mental health problems. They point
out: ‘People whose symptoms continue or recur can, and do, live satisfy-
ing lives and contribute to their communities in many different ways and
the alleviation of such symptoms does not necessarily result in the rein-
statement of former, valued, roles and relationships.’ Mental wellness or
well-being might be defined by each of us within our own culture, experi-
ence and expectations of life, so that what is mental wellness for one
person may well not be for another.
Prilleltensky (2001b, p.7) defines mental wellness as ‘the simulta-
neous, balanced, and contextually-sensitive satisfaction of personal, rela-
tional, and collective needs’ and particularly identifies the importance of
‘relationality’. Two sets of needs are considered to be essential in
pursuing healthy relationships among individuals and groups: respect for
diversity, and collaboration and democratic participation. Respect for
diversity ensures that people’s unique identities are affirmed by others,
while democratic participation enables community members to have a
say in decisions affecting their lives.
This has been clearly demonstrated in the Department of Health’s
(DH) Black and Ethnic Minority Drug Misuse Needs Assessment completed
in May 2003 (Winters and Patel 2003) that highlights the benefits of true
democratic participation and community engagement, referred to by the
author as ‘community recovery’. The project defined ‘community
engagement’ as ‘The simultaneous and multifaceted engagement of
supported and adequately resourced communities and relevant agencies
around an issue, or set of issues, in order to raise awareness, assess and
articulate need and achieve sustained and equitable provision of appro-
priate services’ (Patel, Winters and McDonald 2002, p.12) – so much so
that a community engagement approach is now being considered to
address the mental health issues of black and minority ethnic communi-
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 23

ties. It is thought that the outcome of such a process will significantly

support and extend the views expressed in this chapter and confirm
approaches underpinned by the concept of recovery and values-based
practice.
There is much to learn from this experience and the developing
methodology of engaging people from different cultures, black and
minority ethnic communities. People from these communities have expe-
riences of exclusion through prejudice, discrimination and racism. New
approaches to addressing these issues and their consequences, as well as
other community issues, must have meaning to these people in ways that
enable them to take control of their lives and to take the actions they
believe necessary for their communities. The process of development and
consultation adopted in producing Inside Outside (DH 2003), like the
above, clearly demonstrates this in the true and meaningful engagement
of some 4000 people from local communities.
Respect for diversity and democratic participation are essential prin-
ciples for enabling concepts of mental health, illness and wellness to be
understood and are encapsulated in the developing NIMHE National
Framework of Values for Mental Health (see Figure 1.1).

RECOVERY AND VALUES-BASED PRACTICE

It has been argued that the concept of recovery is not new (Roberts and
Wolfson 2004), although what might be referred to as the emerging
‘recovery movement’, that is enabling significant potential change in the
way services are delivered, is new. This follows a decade of writing,
research and identification of emerging best practices in mental health
recovery in a number of states in the US (United States Public Service
Office of the Surgeon General 1999), New Zealand (Mental Health
Commission 1998) and Canada (Everett et al. 2003).

What is recovery?
‘Recovery’ is a concept that has been introduced primarily by people who
have recovered from mental health problems often in spite of and outside
of the ‘mental health system’. At its simplest ‘recovery’ can be defined as a
subjective experience of having regained control over one’s life. ‘Recov-
ery’ is not simply a reframing of current professional approaches, such as
rehabilitation or psychosocial intervention. Recovery is in the control of
24 GOOD PRACTICE IN ADULT MENTAL HEALTH

each person. The achievements of those who have recovered embrace

hope, empowerment and social connectedness.
In the UK, the West Midlands Regional Health Authority commis-
sioned a piece of work in 1997 that led to the development and publica-
tion of a series of five directional papers with the intention of ‘helping to
articulate the direction of the mental health system of the future’. The
first paper set out a vision of a modern community mental health system
that ‘is rooted, first and foremost, in the desired goal or outcome for the
individuals it seeks to support: service users and their families’ (Carling
and Allott 1999, p.1). The core concept within the series of directional
papers is therefore the concept of recovery that:
refers to an active, ongoing and highly individual process through which
a person assumes responsibility for his/her life, and develops a specific set
of strategies not only to cope with symptoms, but also to address second-
ary assaults of the disability, including stigma discrimination and social
exclusion. (Carling et al. 1999, p.1)
However, it appears to have taken some five years for the concepts
contained in the directional paper series to begin to become more widely
known. The changes in services demanded by these new concepts, even
though now underpinned by national policy, Modernising Mental Health
Services: Safe, Sound and Supportive (DH 1998), The National Service
Framework for Mental Health: Modern Standards and Service Models (DH
1999), and the NHS Plan: A Plan for Investment. A Plan for Reform (DH
2001), will still take time to be accepted requiring, as they do, the need for
new ways of thinking and approaching issues of respect for difference,
personal autonomy and power.
In New Zealand there is a clear policy for the adoption of recovery in
the blueprint that states:
Recovery is a journey as much as a destination. It is different for every-
one. For some people with mental illness, recovery is a road they travel on
only once or twice, to a destination that is relatively easy to find. For
others, recovery is a maze with an elusive destination, a maze that takes a
lifetime to navigate. Recovery is happening when people can live well in
the presence or absence of their mental illness and the many losses that
may come in its wake, such as isolation, poverty, unemployment, and dis-
crimination. Recovery does not always mean that people will return to
full health or retrieve all their losses, but it does mean that people can live
well in spite of them. (Mental Health Commission 1998, p.1)
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 25

The concept of recovery within professional circles in the United States

became more widely recognised following the publication of ‘Recovery
from mental illness: The guiding vision for the 1990s’, in which William
Anthony synthesised the writings of people with experience of recovery
into his definition:
…a person with mental illness can recover even though the illness is not
‘cured’… [Recovery] is a way of living a satisfying, hopeful, and contrib-
uting life even with the limitations caused by illness. Recovery involves
the development of new meaning and purpose in one’s life as one grows
beyond the catastrophic effects of mental illness. (Anthony 1993, p.15)
People who have experienced mental illness/distress and been treated by
the mental health system have been writing about recovery for many
years, even if the word ‘recovery’ has not been used. This has occurred
particularly since the 1980s, including works written in the UK such as
I’m Not a Bloody Label, I am Graham Myerscough (Myerscough 1981).
The author wrote:
My perception of myself and the world around me has almost completely
reversed. I have abilities now that as far as I was concerned those years
ago did not exist. I have uncovered creative thinking and abilities, a cre-
ative perception to go with those abilities that I did not have, was buried.
In the process I have exploded many myths about human behaviour
through my own thinking and experiencing, for myself that is… I can say
and do, that Manic-Depression is not an illness, on the contrary it was for
me a fundamental part of my growth process; from my experiences.
(Myerscough 1981, p.14)
Many stories of recovery have a very positive sense of discovering self,
finding meaning and personal growth as described in the quote from
Myerscough above. The benefits of a recovery approach appear to be
very significant and we must ask why, if we have known about these expe-
riences, have we not explored, researched and implemented ways in
which these recovery experiences can be supported for the majority of
people who experience mental illness/distress?
The growing recovery movement is not anti-psychiatric since it
recognises and respects differences between people, and many people
choose to take medication and even have ECT. There is tension between
traditional views and approaches to mental illness and alternative views
and approaches that exists in all groups, both professionals and people
with lived experiences of distress themselves. It is the freedom to make
informed choices that is considered of central importance. This requires
26 GOOD PRACTICE IN ADULT MENTAL HEALTH

a different relationship with services, one in which true collaboration and

partnership are acknowledged and individual differences respected.

Values-based practice (VBP)

In order to manage the tensions mentioned above, it is essential that we
adopt a values process that can enable this. ‘Values-Based Practice (VBP)
is the theory and practice of effective healthcare decision-making for situ-
ations in which legitimately different (and hence potentially conflicting)
value perspectives are in play’ (Fulford, forthcoming).
VBP, like recovery, starts from respect for the values of each individ-
ual (in this VBP differs fundamentally from ‘ethics’, in so far as ethics aim
to tell people what is right); VBP, like recovery, emphasises the impor-
tance of strengths and positive values rather than focusing on deficits and
negative values; VBP, like recovery, is concerned as much with process as
with outcomes, building on skills of communication, awareness and
engagement; VBP, like recovery, provides options in care, genuine
choices that are built on the diverse skills and resources of different disci-
plines, and that reflect the strengths and resources of each individual
rather than the demands of ‘authority’ (professional, ideological or
political); and finally, VBP, like recovery, puts decision-making firmly in
the hands of those most directly concerned, individual users and
providers working together in the real-life contingencies of day-to-day
care (Allott et al. 2002).

PRACTISING IN RECOVERY-ORIENTED WAYS

On the one hand, changing practices requires what appear to be small
and cost-limited investments, but on the other, they are changes that
Western societies seem to have had great difficulty implementing and
sustaining over the last thirty years or so. In the early 1970s Paul Polak
and his colleagues (Polak and Kirby 1976, p.13) in south-west Denver
delivered a service that ‘reduced the need for total adult psychiatric
inpatient beds to less than 1/100,000 population’. This, described as a
‘total community care system’, has a bearing on current discussions
about ‘whole systems of care’. In south-west Denver the structure of
mental health services began with ‘citizen participation and community
control’, in what today we might refer to as ‘citizenship’ but in fact is
much more than this. The service system included a network of small,
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 27

specific community environments, such as Anam Cara, as well as private

homes, called family sponsor homes in Birmingham (Mental Health
Foundation 2002). This was supported by an ‘intensive observation
apartment’, ‘home day care’ and ‘back-up hospital beds’. The primary
treatment approach was ‘social systems intervention and crisis interven-
tion’ with a philosophy based on the ability of the person’s ‘social system’
to take control and for individuals within the system to be empowered
and to learn to deal with and resolve their crises.
The messages then are clear; it is possible to do things differently but:
Recovery requires the right atmosphere or organizational climate in your
mental health organization – one that is sensitive to consumers, and
values [the] independence of the individual. It allows consumers to risk,
to fail. It holds that every consumer has a right to the same pleasures, pas-
sions, and pursuits of happiness that we have. It looks at potential, not
deficits. (Weaver 1998, p.1)
For practitioners, Weaver advises what mental health provider staff might
need to think in order to assist a service user with recovery:
1. I will stop trying to control the consumer’s life.
2. My professional success is based on the consumer’s recovery
progress.
3. I listen to, believe, and value what the consumer says.
4. I will not treat a consumer any different than anyone else.
5. I have in-depth knowledge about and sympathy for the
consumer’s disability.
6. I will not allow a consumer to become overly dependent
upon me.
7. I can give a consumer hope or helplessness – it is my choice.
8. I see potential in the consumer.
9. I serve as a ‘coach’, not as an authoritative mental health
professional.
10. I will not become discouraged when a consumer fails or
rejected when a consumer succeeds.
11. I will take care of my whole being – dealing truthfully and
realistically with the spiritual, mental, emotional, and physical
aspects of my life.
(Weaver 1998, p.4)
28 GOOD PRACTICE IN ADULT MENTAL HEALTH

IMPLICATIONS FOR EDUCATORS AND SERVICE

COMMISSIONERS
If we are to implement recovery concepts and practices in all of our
services, then we need to find ways of commissioning services that will
enable the process to begin and developing education programmes that
recognise that this is a new way of thinking about what is diagnosed as
mental illness.
There is no simple or single answer to commissioning services or
educating and training the workforce. As with the individual recovery of
people who experience distress, the pathway to recovery for each profes-
sional and service will be different and services too must be allowed ‘to
risk, to fail’ and to learn from these experiences.
Each service should have clearly stated and active vision and mission
statements underpinned by an agreed values process that will provide the
foundation on which to build. These must include recovery as the core
vision driving the system. Recovery measures should be used to identify
the effectiveness of the system. In particular, these measures must
include quality of life and empowerment. In order to deliver effective
outcomes for people with lived experiences in these domains a compre-
hensive framework is provided in the Emerging Best Practices in Mental
Health Recovery (Townsend et al. 1999), developed by people with lived
experience. The core set of service domains are:
· clinical care
· family support
· peer support and relationships
· work/meaningful activity
· power and control
· stigma
· community involvement
· access to resources
· education.
It is important that the role of each stakeholder is identified: this will
include the person with lived experience, the clinician and the
community in each of these service domains and at each of the four stages
of recovery:
 WHAT IS MENTAL HEALTH, ILLNESS AND RECOVERY? 29

1. dependent/unaware
2. dependent/aware
3. independent/aware
4. interdependent/aware.
In order to achieve such a service, significant interagency and interdisci-
plinary collaboration is required, demanding investment in training and
education of the current workforce as well as redesign of basic profes-
sional training courses to include recovery as a core concept.
We need to ensure that all educational programmes address the issue
of values and adopt a process that recognises and values differences
between people, particularly differences of culture and race. Emphasis
should be placed on training that can support people to self-manage,
develop their resilience and contribute their skills and abilities.
Essential to delivering this major change, which will bring significant
benefits for people with lived experiences of mental distress, will be truly
putting the service user at the centre of everything we do. To achieve this
we need to ensure significant investment in peer operated services,
initially in the region of 15 per cent of overall mental health spend, as well
as developing a workforce that values lived experience of recovery from
mental distress as well as experience by training.
To conclude, the following quote from Octavio Paz (1967, accessed
via web) challenges us all:
What sets worlds in motion is the interplay of differences, their attrac-
tions and repulsions. Life is plurality, death is uniformity. By suppressing
differences and peculiarities, by eliminating different civilizations and
cultures, progress weakens life and favors death. The ideal of a single civ-
ilization for everyone, implicit in the cult of progress and technique, im-
poverishes and mutilates us. Every view of the world that becomes
extinct, every culture that disappears, diminishes a possibility of life.

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 CHAPTER 2

HUMAN RIGHTS AND MENTAL HEALTH LAW

DAVID HEWITT

INTRODUCTION
This chapter will consider how the Human Rights Act 1998 (HRA 1998)
has affected mental health law in England and Wales.

The Mental Health Act 1983

At the moment, practitioners must use the Mental Health Act 1983
(MHA 1983). The main provisions of the MHA 1983 are set out in Box
2.1.

Box 2.1 Mental Health Act 1983

· Admission for assessment (max 28 days,
non-renewable) s2
· Admission for treatment (6 months, renewable) s3
· Holding power (doctor, 72 hours) s 5 (2)
· Holding power (nurse, 6 hours) s 5 (4)
· Emergency admission (max 72 hours) s4
· Guardianship s7
· Leave of absence s 17
· Transfer s19
· Renewal of detention s 20
· Discharge s 23
· Supervised discharge s 25A–J
· Nearest relative: appointment s 26

32
 HUMAN RIGHTS AND MENTAL HEALTH LAW 33

· Nearest relative: displacement s 29

· Criminal detention ss 35–55
· Consent to treatment: general ss 56–64
· Consent to treatment: medicine for mental disorder s 58
· Consent to treatment: urgent s 62
· Consent to treatment: other forms s 63
· MHRT*: general ss 65–79
· MHRT*: applications ss 66 and 67
· MHRT*: discharge criteria ss 72 and 73
· Aftercare s 117
· Removal to a place of safety – from a private place s 135
· Removal to a place of safety – from a public place s 136
*Mental Health Review Tribunal

The government plans to introduce new mental health legislation (De-

partment of Health 2002a, b, c).

The Human Rights Act 1998

HRA 1998 came into force on 2 October 2000. It introduced into
domestic law the European Convention on Human Rights and Funda-
mental Freedoms (ECHR).
As far as mental health law is concerned, the main implications of the
HRA 1998 are as follows:
· all ‘public authorities’ – including NHS bodies and local
authorities – must interpret legislation in a way that is
compatible with the ECHR
· the ECHR can be enforced in every court and tribunal
· the victim of an act that is incompatible with the ECHR can
sue for damages and/or seek judicial review
· if an Act of Parliament is incompatible with the ECHR, the
courts can make a formal Declaration to that effect.
So, HRA 1998 introduces the ECHR into domestic law. But what does
the ECHR say?
34 GOOD PRACTICE IN ADULT MENTAL HEALTH

The European Convention on Human Rights

For present purposes, the most significant parts of the ECHR are set out
in Box 2.2.

Box 2.2 European Convention on Human Rights

· The right to life Article 2
· The prohibition on torture and inhuman and
degrading treatment Article 3
· The right to liberty Article 5
· The right to a fair trial Article 6
· The right to respect for one’s private and
family life Article 8

PSYCHIATRIC PRACTICE UNDER THE ECHR

Although the ECHR has been available in the English courts only since
HRA 1998 came into force in October 2000, UK citizens have been able
to appeal to the European Court of Human Rights (ECtHR) in
Strasbourg since 1966. So, the ECHR has been influencing domestic law
for several decades.
The purpose of this chapter is to consider what the ECHR requires –
and what it permits. It will do this by looking at various significant
features of psychiatric care.

REGULATIONS
Mental health law isn’t all contained in the MHA 1983. Various regula-
tions have been made under the Act, such as the Mental Health
(Hospital, Guardianship and Consent to Treatment) Regulations 1983,
and some government departments issue directions that affect psychiat-
ric patients. Now HRA 1998 is law, such regulations and guidance must
be interpreted so as to comply with the ECHR (HRA 1998, s 3).
What this means was considered in Ex parte L, which came before the
High Court in December 2000 and was the first significant mental health
law decision since the coming of HRA 1998 (R.(L) v Secretary of State for
Health 2001). The case involved ECHR, Article 8 (1), which is set out in
Box 2.3.
 HUMAN RIGHTS AND MENTAL HEALTH LAW 35

Box 2.3 Article 8 (1), European

Convention on Human rights
Everyone has the right to respect for his private and family life, his
home and his correspondence

Significantly, Article 8 (2) says this right can be interfered with in certain
circumstances. Those circumstances are set out in Box 2.4.

Box 2.4 Article 8 (2), European

Convention on Human Rights
· National security, public safety or the economic well-being of
the country
· The prevention of disorder or crime
· The protection of health or morals, or
· The protection of the rights and freedoms of others

In L, a patient challenged new restrictions on visits by children to high

secure hospitals (Directions and Guidance for Visits by Children to Patients in
High Security Hospitals, HSC 1999/160). However, the Court found
against him. It said that although the restrictions breached Article 8 (1),
the breach was justified on some of the grounds in Article 8 (2).
Shortly afterwards, in R. (N) v Ashworth Special Hospital Authority
and Secretary of State for Health (2001), a patient tried to challenge
security arrangements in the high secure hospitals that allow staff to
monitor patients’ telephone calls (Safety and Security in Ashworth,
Broadmoor and Rampton Hospitals Directions 2000, Dir 29 (1) and (3)).
Again, the High Court held that any breach of Article 8 (1) could be
justified under Article 8 (2) (R. (N) v Ashworth Special Hospital Authority
and Secretary of State for Health 2001).
These cases show why some people have argued that the ECHR is of
little help to psychiatric patients: its key provisions, including Article 8,
are subject to a large number of very wide exceptions.
36 GOOD PRACTICE IN ADULT MENTAL HEALTH

DETENTION
Although Article 5 of the ECHR gives everyone the ‘right to liberty’, it
does not apply when someone is detained because of mental disorder.
The relevant parts of Article 5 (1) are set out in Box 2.5.

Box 2.5 Article 5 (1), European

Convention on Human Rights
Everyone has the right to liberty and security of person. No one
shall be deprived of his liberty save in the following cases and in ac-
cordance with a procedure prescribed by law:
[…]
(e) the lawful detention of persons for the prevention of the spread
of infectious diseases, of persons of unsound mind, alcoholics or
drug addicts, or vagrants

The most significant case on this point is Winterwerp, in which the

ECtHR imposed further conditions (Winterwerp v Netherlands 1979). It
said that, except in an emergency, someone of unsound mind might be
detained only in the circumstances set out in Box 2.6.

Box 2.6 The Winterwerp conditions

(i) The patient has a true mental disorder that can be proved by
objective medical expertise; and
(ii) the mental disorder is of a kind or degree that warrants
detention; and
(iii) detention can only continue while the disorder persists

The domestic courts have accepted these conditions (e.g. Anderson, Reid
and Doherty 2002). What do they mean?
 HUMAN RIGHTS AND MENTAL HEALTH LAW 37

A true mental disorder

Generally, MHA 1983 complies with this Winterwerp condition:
· the detention provisions – e.g. ss 2 and 3 – can be used only
on someone suffering from mental disorder (MHA 1983, s 1
(1))
· Winterwerp said that a person isn’t ‘of unsound mind’ simply
because his/her behaviour is different to other people’s; MHA
1983 says the same thing (MHA 1983, s 1 (3)).
Article 5 also requires that a detained person’s ‘unsoundness of mind’ is
shown by ‘objective medical expertise’ – in other words, by medical
evidence. That evidence:
· needn’t come from a psychiatrist, and may be provided by a
GP (Schuurs v The Netherlands)
· will usually involve an examination, although a review of the
medical records may suffice (X v United Kingdom 1981)
· will have to be up to date (Varbanov v Bulgaria 2000).
A patient detained in hospital by order of a criminal court may subse-
quently be given a ‘conditional discharge’. However, the Home Secretary
may recall a conditionally discharged patient to hospital, and English law
doesn’t require him/her to have medical evidence before doing so. This
probably does breach Article 5.

A kind or degree warranting detention

This part of the Winterwerp test is replicated in MHA 1983, which asks
‘whether it can “reliably be shown” that [a person] suffers from a mental
disorder sufficiently serious to warrant detention’ (R. (H) v Mental
Health Review Tribunal 2001). If not, s/he cannot be detained.
English legislation says detention will only be justified if it represents
the ‘least restrictive alternative’ (MHA 1983, ss 2 (2) (a), 3 (2) (c), and 37
(2) (b); MHA Code of Practice, para 3.6). The ECtHR has said the same
thing (Litwa v Poland 2001).

The persistence of the disorder

Under Winterwerp, a patient can only be detained for as long as s/he is ‘of
unsound mind’. However, the ECtHR and the English Court of Appeal
have each held that a person doesn’t stop being ‘of unsound mind’ merely
because his/her symptoms have disappeared (R. (H) v Mental Health
Review Tribunal 2001).
38 GOOD PRACTICE IN ADULT MENTAL HEALTH

The ECtHR court has also accepted that a patient needn’t be dis-
charged immediately his/her unsoundness of mind comes to an end, and
that s/he may continue to be detained while appropriate aftercare facili-
ties are put in place (Johnson v United Kingdom 1999).

Other conditions
The detention of persons of unsound mind is subject to more restrictions
than those established in Winterwerp. Some of them are as follows:
· someone of unsound mind must be told why s/he has been
detained in simple language (Van der Leer v Netherlands 1990;
Fox et al. v United Kingdom 1991), otherwise there will be a
breach of Article 5 (4) (Conka v Belgium 2002; X v United
Kingdom 1981)
· a person lawfully detained under Article 5 retains the Article
8 right to respect for his/her family life (Messina v Italy 2000)
· a patient retains all the Article 5 rights where s/he agrees to
enter hospital for psychiatric treatment and isn’t detained
there (De Wilde et al. v Belgium 1971)
· a patient may be ‘detained’ even though the authorities don’t
regard him/her as being so (Ashingdane v United Kingdom
1985)
· a child may be admitted to a psychiatric hospital with the
permission of his/her parents, and will not be ‘detained’ even
if s/he objects to that admission (Neilsen v Denmark 1989)
· a child who is detained has the added protection of the
United Nations Convention on the Rights of the Child (R.
(SR) v Nottingham Magistrates’ Court 2001).

THE TREATABILITY TEST

In order for someone to be detained under MHA 1983, s/he must be
suffering from ‘mental disorder’. In section 1, the Act refers to four
classes of mental disorder:
· mental illness
· severe mental impairment
· mental impairment
· psychopathic disorder.
 HUMAN RIGHTS AND MENTAL HEALTH LAW 39

Anyone suffering from either of the first two may be detained under
MHA 1983 without a ‘treatability test’ being met; those from either of the
last two may be detained – and the detention of anyone with ‘mental
disorder’ may be renewed – only if treatment ‘is likely to alleviate or
prevent a deterioration of his condition’ (MHA, s 3 (2) (b) and s 20 (3)
(b) and (4) (b)). This ‘treatability test’ is very controversial.
After R. v Canons Park Mental Health Review Tribunal, ex parte A
(1994), the treatability test could have been summarised as follows:
· a patient is ‘treatable’ if hospital treatment will stop his/her
condition worsening, even if it won’t alleviate it
· the condition will be alleviated if the patient gains insight or
becomes less uncooperative
· the alleviation of a patient’s condition will be sufficient even if
it is only likely in the future.
The case of R. v Secretary of State for Scotland (1998) added the following
further principles:
· a patient is ‘treatable’ if treatment will affect his/her
symptoms, even if it won’t affect the illness itself
· many things amount to ‘treatment’, and it ‘may extend from
cure to containment’.
Some commentators have suggested that as a result of these cases, and
the very broad definition of ‘treatment’ they create, virtually every psy-
chiatric patient is ‘treatable’.
Nevertheless, the new Scottish Parliament found it necessary to
abolish the ‘treatability test’ in certain circumstances. In 1999 it intro-
duced legislation to ensure that patients with severe anti-social personal-
ity disorders about whom there are public safety concerns may continue
to be detained in hospital even though they are not ‘treatable’ (Mental
Health (Public Safety and Appeals) (Scotland) Act 1999, s 1).
That legislation was soon challenged, on the grounds that it must
breach the ‘right to liberty’ in Article 5 of the ECHR. The challenge
failed at every stage:
· the senior Scottish Court said that detention would comply
with Article 5 (1) (e) even if the patient wasn’t ‘treatable’,
provided it is necessary to serve a legitimate social purpose,
which may be the protection of the public (A v The Scottish
Ministers 2000)
40 GOOD PRACTICE IN ADULT MENTAL HEALTH

· on appeal, the Privy Council in London held it was lawful to

detain a patient for medical treatment or public protection (A
v The Scottish Ministers 2002)
· and the ECtHR agreed (Alexander Lewis Hutchison Reid v
United Kingdom 2003).
The current position with the ‘treatability test’ is as set out in Box 2.7.

Box 2.7 Treatability – The current position

· The ‘treatability test’ is still relevant because the MHA still
contains it, but
· almost any health care will be ‘treatment’, and
· the fact that an untreatable patient can be detained won’t
breach the ECHR

THE NEAREST RELATIVE

Under MHA 1983, a patient’s ‘nearest relative’ has a significant role to
play (MHA 1983, ss 11 (1) and (4), 23 (2), and 66 (1) (g) and (h)).
However, s/he is chosen according to rigid criteria in section 26, which
take no account of the patient’s wishes. This can make a patient vulnera-
ble to abuse (Mental Health Act Commission 1998, para.10.10.3, and
2000, para.4.46).

Abusive nearest relatives

In JT v United Kingdom (2000), a woman claimed that MHA 1983
breached Article 8 of the ECHR because it imposed upon her a nearest
relative who had abused her, and allowed her no say in his selection.
Before the case could come before the ECtHR, the UK government
admitted the breach and promised to amend MHA 1983.
The government first set out its proposed amendments in its Draft
Mental Health Bill (Department of Health 2002a, Part 1, Chapter 7).
However, it has still not made a change, and in the spring of 2003 the
High Court formally declared that the nearest relative provisions in
MHA 1983 breach Article 8. It noted that, although the incompatibility
had been identified ‘a considerable time ago’, it hadn’t yet been removed
(R. (M) v Secretary of State for Health 2003).
 MANAGING VIOLENCE 41

However, practitioners should resist the temptation to anticipate the

government’s amendments, because:
· if they stick to the MHA 1983 (even though it breaches
Article 8), they will have a defence to any claim
· if they take a different route (for example, by allowing a
patient to choose his/her nearest relative), they won’t.

Same-sex cohabitants
Until recently, although one heterosexual cohabitant would be the
‘husband or wife’ of the other – and therefore qualify as his/her ‘nearest
relative’ after six months – the same was not true of homosexual
cohabitants (MHA, s 26 (1) and (6)). This has changed.
In Ex parte SSG (2002), the High Court made a declaration to the
effect set out in Box 2.8 (R. (SSG) v Liverpool City Council and the
Secretary of State for Health 2002; see also Cho 2002).

Box 2.8 The declaration in Ex Parte SSG

· The homosexual partner of a MHA 1983 patient may be
regarded as ‘living with the patient as the patient’s husband or
wife’ under section MHA 1983 26 (6); and
· provided the two have lived together for six months, each may
therefore be the ‘nearest relative’ of the other within MHA
1983, section 26 (1)

The Department of Health has confirmed that all public authorities

should respect this declaration (see www.doh.gov.uk/mhact1983/
consentorders.htm).

THE CONDITIONS OF DETENTION

It is very hard for a patient to succeed in a claim that the conditions in
which s/he is being detained breach the ECHR. The relevant articles are
Article 5 (which is set out in Box 2.5) and Article 3 (set out in Box 2.9).
42 GOOD PRACTICE IN ADULT MENTAL HEALTH

Box 2.9 Article 3, European

Convention on Human Rights
No one shall be subjected to torture or to inhuman or degrading
treatment or punishment

Strasbourg has repeatedly said that for Article 3 to be breached, the con-
ditions have to reach a minimum level of severity. That level is so high that
it wasn’t reached where:
· a patient was detained in a high secure hospital in what he
claimed were tense, overcrowded, uncomfortable and
insanitary conditions (B v United Kingdom 1984)
· a patient who required hospital psychiatric treatment was kept
for seven months on the hospital wing of a Belgian prison
(Aerts v Belgium 2000).
However, where someone is mentally ill, the following factors will apply:
· the conditions may breach Article 3 even though s/he can’t
point to specific ill-effects (Keenan v United Kingdom 2001)
· s/he must not be subjected to distress or hardship over and
above the suffering unavoidably caused by detention
· s/he must be given all necessary medical assistance (Kudla v
Poland 2002)
· anti-therapeutic conditions may breach Article 5 even if they
don’t breach Article 3
· detention will only comply with Article 5 if it takes place in a
clinical setting (Aerts v Belgium 2000).
No UK psychiatric patient has yet succeeded in a claim under Article 3,
and anyone wishing to complain about the conditions in which s/he is
detained will have a better chance if they use Article 5.

MEDICAL TREATMENT
General
The decisions summarised in Box 2.10 show that the ECHR provides
only limited protection for psychiatric patients. Although the required
standard may be getting higher (Selmouni v France 2000), most current
psychiatric practice is probably consistent with ECHR, Article 3.
 HUMAN RIGHTS AND MENTAL HEALTH LAW 43

Recently, there has been a suggestion that patients who are mentally
capable cannot be forced to accept psychiatric medication, even if they
are detained under MHA 1983.

Box 2.10 The European Convention on Human

Rights and Medical Treatment
· It won’t breach Article 3 to force-feed someone who is
mentally competent (X v Germany 1984) (this would be
unlawful in the UK, where a capable adult who is not
detained under MHA 1983 may not be forcibly treated
against his/her will)
· Provided treatment is clinically necessary, it won’t breach
Article 3 (Herczegfalvy v Austria 1993). So, it was permissible
to force-feed a psychiatric patient, sedate him against his will,
handcuff him and tie him to a bed
· Psychiatric treatment won’t breach Article 3 merely because it
has side effects; and any interference with Article 8 may be
justified by the need to protect the patient’s health or preserve
public order (Grare v France 1992)

This suggestion was made in the Wilkinson case, by Lord Justice Simon
Brown (R.(Wilkinson) v RMO,SOAD and Health Secretary 2002; see also
Hewitt 2002b, pp.194, 195). It wasn’t binding, and neither of the other
two Court of Appeal judges who heard the case adopted it. In any case,
Simon Brown LJ has subsequently adjusted his view (see R. (B) v
Ashworth Hospital Authority 2003). However, the Courts have accepted
that now the HRA 1998 is in force, compulsory treatment will be permis-
sible only if it doesn’t breach a patient’s ECHR rights. At the very least,
this has given patients the right to have the reasons for their treatment
explained to them (see R. (John Wooder) v Dr Graham Feggetter and the
Mental Health Act Commission 2002; R. (N) v Dr M and others 2003).

SECLUSION
Before the HRA 1998 came into force, the practice of secluding patients
was thought to be vulnerable to challenge under the ECHR. However, as
44 GOOD PRACTICE IN ADULT MENTAL HEALTH

a result of two recent cases, it is now more strongly established, and the
safeguards for its use are far weaker, than for some time.
It was already known that:
· Article 3 might be breached where a detained person is
removed from association (Koskinen v Finland 1994)
· there will be no such breach where seclusion is for security,
disciplinary or protective reasons (Dhoest v Belgium 1987)
· but the arrangements made for each secluded patient must be
reviewed continuously (McFeely v United Kingdom 1981).
That seclusion is now incontestably lawful is the result of two cases that
were made possible by HRA 1998.
Following R. (Munjaz) v Ashworth Hospital Authority (No 2) (2002)
and S v Airedale NHS Trust (2003; see also Hewitt 2002b) the position
with regard to seclusion is as follows:
· Even though it contains no express provision, the power to
seclude a detained patient may be implied from MHA 1983
(R. v Bracknell JJ, ex parte Griffiths 1976).
· Seclusion doesn’t breach ECHR, Article 3, even where it is
something other than a short-term, emergency measure (A v
United Kingdom 1980).
· Article 5 is not relevant, because patients who are detained
have been deprived of their liberty, even before they are
secluded and even if that step is never taken.
· Seclusion may be ‘medical treatment’ under section 145 of
MHA 1983, and if it isn’t, the decision to begin or end it, and
the management and review of its conditions, is (B v Croydon
Health Authority 1995).
· An NHS trust must consider the MHA Code of Practice
when drafting its seclusion policy, but it may lawfully depart
from it if it has sensible reasons for so doing.
The Munjaz and Airedale cases show that as far as the management of
psychiatric patients is concerned, the standard set by the ECHR is not
particularly high.
 HUMAN RIGHTS AND MENTAL HEALTH LAW 45

MENTAL HEALTH REVIEW TRIBUNALS

Introduction
The Mental Health Review Tribunal (MHRT) is the body through
which the state fulfils its obligations under ECHR, Article 5 (4), whose
provisions are set out in Box 2.11.

Box 2.11 Article 5 (4), European

Convention on Human Rights
Everyone who is deprived of his liberty by arrest or detention shall
be entitled to take proceedings by which the lawfulness of his de-
tention shall be decided speedily by a court and his release ordered
if the detention is not lawful

Because this burden does not fall upon the ‘hospital managers’, their pro-
ceedings need not comply with Article 5 (4).
But what does Article 5 (4) require?

The right to review

All patients detained under MHA 1983 – whether they are unrestricted
(MHA 1983, ss 66 and 69) or restricted (MHA 1983, s 71) – have the
right to challenge their detention in a MHRT. Therefore, it is likely that,
at least in theory, the MHRT system complies with Article 5 (4).
However, in practice, the situation is a little less clear.

Delay
Anyone of ‘unsound mind’ is entitled to a ‘speedy’ review of his/her
detention. What ‘speedy’ means has been examined in a number of cases,
which may be summarised as follows:
· a gap of eighteen weeks between application and hearing is
not speedy enough (Barclay-Maguire v United Kingdom 1981)
· a delay of five months is ‘excessive’ (Van der Leer v
Netherlands 1990)
· a wait of four months is ‘unreasonable’ (although a hearing
may not need to be arranged as quickly upon a subsequent
review as upon initial detention) (Koendjbihaire v Netherlands
1990)
46 GOOD PRACTICE IN ADULT MENTAL HEALTH

· the current benchmark is eight weeks (E v Norway 1994).

These decisions have led the state to seek to speed up MHRT procedures.
However, where it tried to do so by listing all unrestricted cases for
hearing after a fixed eight-week period, that was held to breach Article 5
(4). The High Court said that each application should be heard as soon as
reasonably practicable, and in any event within eight weeks (R. (C) v
Mental Health Review Tribunal 2002).
More recently, eight English psychiatric patients won a claim that the
MHRT hadn’t heard their cases ‘speedily’ enough (R.(KB and 6 others) v
Mental Health Review Tribunal and Health Secretary 2002; B v Mental
Health Review Tribunal and Home Secretary 2002; see also Hewitt 2002c).
The High Court held that the delays, which were as great as twenty
weeks, were due to a shortage of MHRT staff for which the government
was responsible. Subsequently, six of these patients were awarded
damages of between £750 and £4000 in respect of the delays (R.(KB and
others) v Mental Health Review Tribunal and Health Secretary 2003).
As far as conditionally discharged patients are concerned, Strasbourg
has found a breach of Article 5 (4) where it has taken, respectively, six
months (X v United Kingdom 1981) and five months (Kay v United
Kingdom 1994) to arrange a MHRT following their recall to hospital. A
further challenge (Pauline Lines v United Kingdom 1997) resulted in the
UK government amending the MHRT Rules 1983 to impose a limit of
eight weeks between recall and hearing (SI 1998 No 1189; see r 2 (4)).

The regularity of review

The ECHR also guarantees anyone detained because of ‘unsound mind’
the right to challenge detention ‘at reasonable intervals’ (Megyeri v
Germany 1993).
Every patient detained under ss 2, 3, 7 and 37 of MHA 1983,
together, in some circumstances, with the ‘nearest relative’ of an unre-
stricted patient, may apply to the MHRT for release at least once in every
period of detention (MHA 1983, ss 66 (1) and (2) and 70). This probably
complies with the ECHR.
Some patients have their detention under MHA 1983, section 2,
extended indefinitely because an application has been made to displace
their ‘nearest relative’ (MHA 1983, s 29 (4)). The Secretary of State has
indicated that he will use his power to refer those cases back to an MHRT
 HUMAN RIGHTS AND MENTAL HEALTH LAW 47

(MHA 1983, s 67 (1)), so that patients are able to go before the tribunal
once in every 28-day period for which they are detained under section 2.

The medical member

Each three-member MHRT will have at least one ‘medical member’
(MHA 1983, Sched 2, para 4).
Because s/he both interviews the applicant and determines his/her
application, it is sometimes argued that the medical member is witness
and judge in the same case.
Although the High Court has dismissed this argument, it has said that
if the medical member is going to take into account a view that s/he
formed after meeting the patient, or if s/he is going to discuss it with other
MHRT members, s/he should disclose that view to the patient (R. (H) v
Mental Health Review Tribunal 2001).
These safeguards may not be sufficient. The ECtHR has held that a
tribunal’s impartiality may be called into question, and Article 5 (4) may
be breached, where it has to assess evidence given by one of its own
members (DN v Switzerland 2002).
In R. (S) v Mental Health Review Tribunal and Health Secretary
(2002), a patient argued that, because he had to be examined by the
MHRT medical member (MHRT Rules 1983, r 11), there was a breach
of Article 5 (4). The High Court held:
· the medical member shouldn’t use the examination of the
patient to form a settled view of his/her mental state
· provided the medical member keeps an open mind until the
conclusion of the hearing, s/he may express a provisional
view.

The burden of proof

The coming of the HRA 1998 forced the government to adjust the
grounds upon which a patient may be discharged from detention by a
MHRT.
A patient may be detained if s/he can be shown to fulfil the relevant
admission criteria (see, for example, MHA 1983, ss 2 (1) and 3 (2)).
However, a patient who sought discharge had to show that s/he now
satisfied different discharge criteria (MHA 1983, ss 72 (1) and 73 (1)).
48 GOOD PRACTICE IN ADULT MENTAL HEALTH

The purpose of a patient’s right of access to a court under Article 5

(4) is to ‘take proceedings by which the lawfulness of his detention shall be
decided’, and it was not the reasonableness of discharge that should have
been in issue.
In R. (H) v Mental Health Review Tribunal (2001), the Court of
Appeal held that the relevant provision of MHA 1983, sections 72 (1)
and 73 (1), breached ECHR, Article 5 (1) and (4). The Court made a
formal declaration to that effect, and in response the UK government
introduced the Mental Health Act 1983 (Remedial) Order, which
requires those who detain a patient to show why s/he should not be dis-
charged (SI 2001 No 3712).

Conditional discharge
In the case of ‘restricted’ patients, who will have been detained in hospital
by order of a criminal court, an MHRT may grant discharge subject to
conditions (and the patient may be recalled to hospital if those conditions
are broken).
A conditional discharge may be deferred so that the necessary
arrangements can be made (MHA 1983, s 73 (7)). Those arrangements
would form part of the aftercare services to which a patient would be
entitled under MHA 1983, section 117. In some cases the inability to
make them has been the subject of legal challenge.
· In Johnson v United Kingdom (1999) a patient had received a
conditional discharge on four occasions, and each had been
frustrated because no suitable hostel accommodation could
be found for him. The Commission ruled that the ‘lack of
adequate safeguards […] to ensure that [his] release from
detention was not unreasonably delayed’ violated ECHR,
Article 5 (1).
· In R. v Mental Health Review Tribunal and others, ex parte Hall
(2000), a patient continued to languish in prison because a
requirement of his conditional discharge could not be
satisfied. The High Court had ruled that his discharge had
been unlawful, saying that the MHRT should have taken
steps to police the conditions it had imposed. However, the
Court of Appeal ruled that the MHRT had no such power.
The Courts have followed this line in most subsequent cases. The
decisions of the High Court and the Court of Appeal in R. v Camden and
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Military Brush Cases for above,
2/0 2/6 2/9

Ebony Military Hair Brush.

Ebony Bonnet Brush. 2/6 2/11 3/6 Concave Back, 9/6 11/0 12/9
14/6 21/0 to 23/6 per pair.
 Gent.’s Ebony Hair Brush.
4/0 5/0 5/6 7/0 8/9 9/9 10/9 11/9

Handled Hat Brush. Ebony Whisker Brushes.

0/9 1/0 1/4 1/7 1/11 Soft or stiff Hair, 1/6 2/0

Satinwood Balloon Shape Hair Brush.

3/6 4/6 6/0 6/11 8/6 9/6 10/9 11/9 12/9

Gent.’s Satinwood Hair Brush.

2/3 2/6 2/11 4/3 5/6 6/11 7/6
8/3 to 10/9 11/9
Hinde’s Wire Hair Brushes, 0/9½, 1/6, 2/0, 2/8, 3/6
 Pointed Hat Brush.
1/6
Roached Back Cloth Brush.
Medium 1/0 1/6 1/11 2/4 2/6
Best 2/11 3/3 3/9 4/3
Extra Stiff 4/6 5/0 5/6 6/6
Zampo Ivory Cleaner. Per packet, 0/9

Handled Cloth and Splash Back.

Solid Screwed Rosewood Backs.
Medium 2/6 3/0 3/3 4/0 4/11
Best 5/9 6/9 7/3 7/11 8/9
Combined Hat and Cloth Brushes,1/9, 2/6, 3/3

Satinwood Military Hair Brush.

1/11 2/3 2/6 2/11 3/6 4/0 6/3
7/3 to 11/9 each
Leather Cases for do.
Prices 2/0 2/6 2/9 extra.
 Lady’s Ebony Hair Brush.
3/6 3/11 4/6 5/0 5/6 6/6 7/9 8/9 9/9 11/9 12/9 13/9

Lady’s Satinwood Hair Brush.

2/3 2/11 3/6 4/3 4/9 5/0 5/9 7/6 8/9 9/6 10/9 11/9
12/9
Lady’s Whalebone Hair Brush,
2/11 3/6 4/6 5/0
Brush Powder, for Cleaning Toilet Brushes per box, 0/4½

Bonnet Brush, Curved Hat Brush. 1/6

Satinwood, 1/0 1/6

Handled Cloth Brush.

Medium .. .. .. 2/3 2/6 3/3
Best .. 3/11 4/11 5/3 5/9 6/9 8/6

The above are delivered Carriage Free, subject

to the Conditions set forth on pages 3 and 4.
[1100]
SPECIAL DESIGNS OF SILVER MONOGRAMS, &C.

No. 51. 1/0

No. 74. 1/6 CUSTOMERS’

OWN DEVICES
No. 61. 1 Letter, 2/6 CARRIED OUT.
2 ,, 3/6
3 ,, 4/6

No. 48. Fully carved, 7/3

Cheaper style, 3/9
No. 73. Silver Shield.
SILVER 1 letter, 3/0; 2 letters, 4/0;
MONOGRAMS ARE 3 letters, 5/0
SUITABLE FOR
IVORY, EBONY AND
TORTOISESHELL.

No. 58. 1/6

No. 57. 1 letter, 2/6; No. 69. 2/3
2 letters, 4/6; 3 letters, 5/6
 No. 60. 1/0

No. 43. 1 letter, 3/3; 2 letters, 6/6;

3 letters, 8/6
No. 43. Cheaper style, 1 letter, 2/3;
2 letters, 4/6;3 letters, 5/3

No. 62. 1/3

No. 63. 2/6 No. 49. 1/6. Smaller, 1/3

 No. 64. 1/6

Florence
No. 71. Fully Carved, From 5/0 to 7/6
Cheaper Style, From 3/6 to 4/9

No. 53. 1/6

The above prices include fixing to Ebony or any Wood articles.

Tortoiseshell or Ivory articles will be charged slightly more for
fixing.
Any of these Letters or Monograms can be supplied in Gold.
Prices on application.
STYLES OF ENGRAVING FOR IVORY, EBONY, OR IMITATION
IVORY.
 Beatrice
No. 1. 1/6

CAS
Charlie No. 3. 0/9 per letter.
No. 2. 1/3 per letter.
No. 4. 1/0 the name.

C.F.S.
No. 5. 0/9 per letter.
ABC
No. 7. 0/9 per letter. CONSTANTIA ET HONORE
AIG No. 8. From 4/6,
No. 6. 0/6 per letter. according to style.

C.H.R. FSD
No. 9. 0/4 per letter. No. 12. 0/6 per letter.

2
E.D.B. J.M.P. LIFE GUARDS
No. 10. 0/6 per letter. No. 13. 0/6 per letter No. 14. From 4/6,
according to style.

William
No. 11. 1/0 the name.
No. 15. 0/9 per letter.
VIRTUTE ET VALORE
No. 16. From 4/0,
according to style.

No. 18. 0/9 per letter.

No. 17. 1/2 per letter. Circle 0/9 extra.
0/9 per letter, cheaper style.

No. 20. From 1/6

Maud. According to style.
No. 19. Facsimile of writing.
From 1/6
 DJS
CWB
No. 21. 0/6 per letter.
No. 22. 1/0 per letter.

SANS DIEU RIEN

No. 23. From 14/6, according to design.
[1101]

TOILET REQUISITES.
RAZOR STROPS.

PORPOISE HIDE
No. T U 72. Prices, 1/0, 1/3, 1/6, 2/0, 2/6, 2/11

THE GRADUATING STROP.

GRADUATING RAZOR STROP.

RAZOR PASTE. No. T U 68. Prices, 3/3, 3/9, 4/6
Per tube 0/5½
ROACH WHISK CLOTH BRUSHES
Veneered or Velvet Backs.
0/8, 0/11, 1/1, 1/3, 1/6, 1/10

Tail Combs, Horn or Indiarubber 0/6½, 0/9½, 1/0, 1/3

,, ,, Tortoiseshell 2/6, 3/0, 4/0, 5/6, 6/9

“OGEE” STROPPER
The “OGEE” AUTOMATIC RAZOR STROPPER.
Price 5/0

Rake Dressing Combs, White or Buffalo

Horn 0/9½, 1/0, 1/3, 1/6, 2/0
,, ,, ,, Indiarubber 0/9½, 1/0, 1/3, 1/6, 2/0
,, ,, ,, Tortoiseshell 5/0, 6/0, 7/0 to 15/0
Comb Cleaning Brushes, with Steel Comb, 0/4½, 0/8½
Pocket Combs 0/4 and 0/6
,, ,, with Looking Glass 0/8

Dressing Combs, Stained Horn 0/6½, 0/9½, 1/0, 1/3, 1/6

,, ,, White or Buffalo
Horn 0/6½, 0/9½, 1/0, 1/3, 1/6
,, ,, Indiarubber 0/6½, 0/9½, 1/0, 1/3, 1/6, 2/0
4/0,
,, ,, Tortoiseshell 5/3, 7/6, 9/0 to 15/0

Tooth Combs 0/4½ and 0/5½

,, ,, Ivory 1/0, 1/3 and 1/6

BENT OR STRAIGHT-HANDLED FLESH BRUSH.

Polished and Pinned.
Prices 1/11, 2/6, 2/9, 3/0, 3/3, 3/6, 3/9, 4/6 and 4/11
 Webbed Flesh Brushes.
Prices, 1/9½, 2/0, 2/3, 2/9, 3/0, 3/6, 4/6

Handled Whisk Cloth Brushes. Veneered or

Velvet Backs.
Prices, 0/9, 1/0, 1/2, 1/4, 1/7, 1/10, 2/1, 2/4

THE “BELGRAVE”
The “BELGRAVE” TOOTH BRUSH. Our Own Special Make. Assorted
Patterns. Strongly Recommended, 0/9½
Large Assortment of other Patterns Stocked, 0/4½, 0/5½, 0/6½, 0/8½
Badger Tooth Brushes, 0/7, 0/8½, 0/10½, 1/0
All Tooth Brushes 0/6 less per dozen Children’s Tooth Brushes, 0/3, 0/4½
Indiarubber Tooth Brushes, price 0/6½ Metal Tooth Brush Cases,
0/6½

The above are delivered Carriage Free, subject

to the Conditions set forth on pages 3 and 4.
[1102]
 Bone Nail Brushes. Bent Back.
4 5 6 Rows
0/7½ 0/9½ 0/11½

Concave Handled Bone Nail Brush.

Prices, 0/9 0/11½, 1/1, 1/3
Hand Mirrors, Mahogany Frames. Best Silvered Plate Glass.
0/11, 1/4, 1/5, 1/7, 1/10, 2/0, 2/3, 2/6, 3/0, 3/6, 4/0, 4/11
Heavy Plate, Bevelled Edge.
6½ in. 3/0, 7 in. 3/3, 7½ in. 3/6, 8 in. 4/3, 8½ in. 4/9
 CASE. STUMP.

Cased Bone Shaving Bone Shaving

Brushes, Badger Hair. Brushes, Badger Hair.
2/0, 2/6, 3/0, 3/9, 1/8, 2/0, 2/6, 3/0,
4/3, 4/11, 5/9 3/3, 3/9, 4/6, 5/6, 6/6
Cheaper quality.
1/0½, 1/3½, 1/6½,
1/11½
Metal Shaving Brushes, Hog Hair, price 0/7½, 0/11½, 1/3
Best Badger Hair, price 4/9
 Bone Nail Brushes. Straight Back.
4 5 6 7 8 9 10 Rows
0/7½ 0/9½ 0/11½ 1/1 1/11 2/3 2/11
Cheaper quality 4 5 6 7 8 Rows
0/6½ 0/8½ 0/10½ 1/0½ 1/3½
Extra Stiff 5 7 Rows
2/9 3/11
Satinwood Nail Brushes.
4 5 6 7 8 9 10 Rows
1/0 1/3½ 1/6½ 1/11 2/3 2/6 3/3
Unbleached Stiff Bristle.
Nail Brushes, Wood Backs and Fibre.
Prices, 0/1, 0/1½, 0/3, 0/4½, 0/6½, 0/9½

RANKIN’S CORK MATS

A REAL COMFORT
Recommended by Medical Men
Of All Furnishing Houses
No. T U 29.
Rankin’s Cork Bath Mats.
Prices, 4/6, 4/11, 5/11, 6/11, 7/11, 8/11, 9/11, 10/9
Cheaper quality,
2/6, 2/11, 3/6, 3/11, 4/11,5/11, 6/11
 RUBBER
TOILET BRUSH
PATENTED
India Rubber Nail Brush,
0/8½, 1/6
STEVENS’ SILICON
India Rubber Complexion
JEWELLERY REVIVER,
TABLET Brush, 2/3
Jewellery Reviver. Per Box, 0/9½, 1/6

Shampooing Brush. There is no more delightful

addition to a bath. Large size, price 1/3
Cheaper quality, 0/9

No. T U 571. Ebony Hair Pin Boxes.

3 Divisions, 4/11; 4 do., 5/11; 5 do., 7/6;
Ebony Hat Pin Boxes. Price 6/6
 TURKO
WASHING GLOVES
LONDON
Sponge Nets.
No. T U 4. Bath Gloves.
0/3½, 0/4½, 0/6½, 0/8½ per pair. 0/7½, 0/9½, 0/11½, 1/0½,
Ditto, Loofah one side, 0/5 each. 1/3½, 1/6½
Loofah both sides, 0/7
Loofah Back Strap, 0/8½, 0/10½
Loofah, Natural Flesh Rubbers,
0/2½, 0/4½, 0/6½, 0/8½

Ebony Hand Mirrors.

3/6, 3/11, 4/6, 5/6, 6/6, 7/3, 8/3, 9/3
Brush Racks. 0/9½, 1/0

Ebony Shoe Lift. 1/0, 1/2, 1/6, 2/0

Ebony Paper Knives, 1/6 each.
Ebony Puff Box. 1/6½, 1/9½, 1/11½,
2/3½, 3/0, 3/6, 3/11, 5/6, 6/6 each
Boxwood Puff Box. 0/9½, 1/1, 1/3, 1/4
Nickel Puff Box, 1/11½, 2/3½, 2/6
Fancy Patterns, 0/6, 0/8, 0/10 1/2

Ebony Glove Stretchers.

1/0½, 1/3½, 1/11½, 2/3½, 2/6

India Rubber Bath Brush. Price 3/9

Handled Bone Nail Brush, Prices 0/4½, 0/5½,

0/6½, 0/7½, 0/8½, 0/10½, 1/0½, 1/3½
Ebony Shoe Lifts and Button Hooks. 1/0, 1/6, 2/0, 2/6
Ebony Button Hooks 0/8½, 1/0, 1/3, 1/6
Bone Button Hooks, 0/4½, 0/8½

Brush, Comb and Glass,

0/10½, 1/0, 1/3, 1/6, 1/9
[1103]

NICKEL TOILET MIRRORS.

 No. T U 4359.
Nickel Triple Toilet Mirror on Stand.
Price 69/6
 No. T U 2000. Nickel Hand Mirror.
Prices, 2/3, 2/10, 3/6, 3/11, 4/6, 5/6

No. T U 306. Travelling Mirror, in

Leather Case, with Metal Folding
Handle. 2/11, 3/6, 4/0, 5/6, 6/6
 No. T U 603/1. Shaving Set,
comprising Soap Bowl, Hot Water
Cup and Brush. Price 8/6

No. T U 4517. Nickel

Shaving Set, with Brush No. T U 608. Oblong Panel
complete. Price, 4/11 Nickel Telescopic Mirror, on
Stand, 62/6
 WITH PLAIN AND MAGNIFYING GLASSES.
No. T U 4380. Nickel Shaving Mirror, without Razors.
Price 29/6, 32/0 Larger size. Price 43/9
No. T U 10 P. Reversible Nickel Shaving Mirrors.
Plain and Magnifying Glasses. Will fold flat.
Prices, 6/3, 7/3, 8/3, 9/6, 10/6, 11/9, 13/9.
Cheaper quality, 3/7, 4/4, 6/9

No. T U 152. Most Useful and Compact Travelling

Shaving Mirror. Nickel reversible shaving mirror,
in solid leather case complete, 12/3, 14/0, 15/6,
17/3, 19/9
No. T U 1074. Nickel Swing Mirror.
Sizes 7 × 4½ in. Price 4/6
,, 8 ,, 5½ ,, ,, 5/11
,, 10 ,, 7 ,, ,, 7/11
,, 13 ,, 7½ ,, ,, 9/11
,, 13 ,, 9 ,, ,, 12/9
,, 15 ,, 11 ,, ,, 18/6
 No. T U 604.
Shaving Set with Telescopic Mirror. Solid
Nickel base and fittings, with Reversible
Plain and Magnifying Glasses, opal-lined
Soap Bowl and Shaving Brush.
Size of Mirror 6 in. T U 604/15 Price 14/6
Size of Mirror 7½ in. T U 604/18 Price 17/6
No. T U 4277. Nickel Triple Mirror, Price 43/9

The above are delivered Carriage Free, subject

to the Conditions set forth on pages 3 and 4.
[1104]
 No. T U 280.
Nickel Shaving Set on Polished Wood Base, with Lamp
complete. Price 42/6, without Drawer, as illustrated.
With Drawer, Price 53/9
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