Learning Disability is Not a Mental Disorder
Author: Robin Jackson
On Wednesday 24th June 2015 members of the Scottish Parliament debated Stage 3 of the Mental Health (Scotland) Bill. An amendment to the Bill had been tabled by Jackie Baillie to insert a legislative commitment to review the position of people who have a learning disability under the terms of the Mental Health Act, as in current legislation in Scotland learning disability is unambiguously included as a form of mental disorder.
The situation south of the border is different. Under the terms of Section 1(2A) of the 2007 Mental Health Act a learning disability does not constitute a mental disorder unless it is “associated with abnormally aggressive or seriously irresponsible conduct” on the part of the patient.
In the Holyrood debate, Jackie Baillie made reference to the fact that in 2001 the Millan Review of Mental Health Legislation in Scotland had recommended that: ‘there should be an expert review at an early date of the position of learning disability within mental health law.’ In the meantime it recommended that the continuance of the three categories of mental disorder: mental illness, learning disability and personality disorder.”
Eight years later, the McManus Review (2009) in discussing the inclusion of learning disability within the Mental Health (Care and Treatment) (Scotland) 2003 Act, noted the Millan Committee’s recommendation that this matter should be reviewed. It was the opinion of the McManus Review Group that it was time for such a review to be undertaken.
The case for excluding learning disability from any definition of mental disorder was supported by a large coalition of bodies representing people with a learning disability - Enable Scotland, Inclusion Scotland and People First (Scotland).
Four principal points were advanced to support exclusion from the category of mental disorder:
- Inclusion of people with a learning disability in an Act that clearly has its focus on the treatment of people with mental ill health has a detrimental impact in the public perception of learning disability;
- People with a learning disability are not mentally ill. Unlike mental illness, learning disability is a lifelong condition that cannot be cured or ameliorated by medication. It is an intellectual impairment rather than mental disorder;
- People with a learning disability may require care and support and - except where a mental illness is also present - psychiatrists are unlikely to take the lead role in providing care and support for people with a learning disability;
- There is evidence that people with a learning disability are subject to compulsory treatment as a result of their learning disability alone. More than 11% of those in mental health institutions are people with a learning disability, when they represent just 2% of the population and their stay is longer than average.
Notwithstanding the strength of the arguments advanced by Jackie Baillie and for reasons which are not at all clear, the proposed amendment was voted down by all SNP SMP members at Holyrood.
The question arises as to why this issue has remained unresolved for so long. A number of possible reasons can be advanced.
1. Too insignificant
Greig (2015), Chief Executive of the National Development Team for Inclusion in England, has recently drawn attention to the fact that over the past twenty years learning disability has not registered as an issue of particular importance in government circles, as the number of people with a learning disability in the general population is seen to be too small to warrant action. In other words, learning disability does not register as a politically significant area which is in urgent need of attention.
2. Too difficult
As Malcolm Chisholm, a former Labour Party Minister for Health and Community Care at Holyrood, conceded in the debate, any change in definition would necessitate changes in other Scottish mental health legislation - Mental Health (Patients in the Community) Act 1995; the Adults with Incapacity (Scotland) Act 2000; The Mental Health (Care and Treatment) (Scotland) Act 2003; and the Mental Health Act 2007. However, changes in definition would also have implications for UK-wide Acts and regulations and in a variety of different fields (e.g., local government and social security (BPS, 2000).
3. Bureaucratic inertia
The continuing lack of movement in resolving this issue may also result from a disinclination on the part of the relevant sections of the civil service to engage in extensive changes to legislation which are not perceived to be essential. In such a situation, retention of the status quo tends to be the preferred option, as Sir Humphrey Appleby in ‘Yes Minister’ demonstrated on countless occasions!
4. Influence of psychiatrists’ lobby
One of the most significant barriers to change has been the standpoint of psychiatrists who see intellectual (i.e. learning) disability as being an integral and important part of their professional domain: indeed the Royal College of Psychiatrists has within it a Faculty of Intellectual Disability. Psychiatrists also tend to be well (over?) represented on government enquiries and reports relating to learning disability, with the result that they can exercise an undue influence on the deliberations, conclusions and recommendations. There may also be a tendency to accord a degree of deference and weight to their professional opinion as opposed to the views of lay people (e.g., voluntary organisations; advocacy groups; parent groups).
5. Lack of professional consensus
The fact that there is no professional consensus regarding a definition of learning difficulty can be used as an excuse for inaction. There are some clinical psychologists who take a quite different stance to that of psychiatrists (Webb and Whitaker, 2012). In their view a person may be regarded as having a learning disability, if s/he:
- is judged to be in need of community care or educational services due to a failure to cope with the intellectual demands of their environment and are suffering significant distress, or
- is unable to take care of themselves or their dependants, or
- is unable to protect themselves of their dependants against harm or exploitation.
6. Absence of unified independent voice
The absence of a strong and unified voice representing people with a learning disability has probably contributed to the delay in securing an agreed definition. As the recent Centre for Welfare Reform report ‘Who cares?’ indicated, most of the major charities in the UK have become too closely identified with the government policy machine and in the process have lost their ability to take a strong and independent standpoint (Jackson, 2015).
The need for action
The past two decades have witnessed not only a serious contraction in high quality services for people with a learning disability but also the growth in society of a lack of acceptance and tolerance for people who are perceived to be different. The perpetuation of the view that learning disability is a form of mental disorder which is promoted in existing legislation makes the social inclusion of people with a learning disability that much more problematic.
The point needs to be re-stated, if only for the benefit of the SNP party at Holyrood, that there is a distinct difference between a person having a mental illness and a learning disability. Mental health problems are inappropriate feelings and behaviours that usually (although not exclusively) develop after childhood, and can change over a period of time and may only last temporarily. Learning disabilities, on the other hand, almost always permanently affect intellectual function and are usually evident from birth or early years. They are quite separate and distinct conditions.
There is a compelling case for charities and voluntary bodies representing the interests of people with a learning disability in Scotland engaging in a high profile and, if necessary, protracted campaign aimed at achieving a re-definition of learning disability. It should be a source of national embarrassment that such a re-definition has not taken place.
Atkinson, J. and Patterson, L. 2001. Review of literature relating to mental health legislation. In New Directions, Report on the Review of the Mental Health (Scotland) Act 1984, SE/2001/56. (Millan Review), pp. 458-465.
Greig, R. 2015. The policy construct behind community care, International Journal of Developmental Disabilities, 61(2), 61-67.
Jackson, R. 2015. Who cares? The impact of ideology, regulation and marketisation on the quality of life of people with an intellectual disability, Sheffield: The Centre for Welfare Reform.
Scottish Executive. 2001. New Directions. Report on the Review of the Mental Health (Scotland) Act 1984. SE/2001/56. (Millan Review) https://www.mhtscotland.gov.uk/mhts/files/Millan_Report_New_Directions.pdf
Scottish Government. 2009. Limited Review of the Mental Health (Care and Treatment) (Scotland) Act 2003: Report. (McManus Review) http://www.gov.scot/Publications/2009/08/07143830/0
Webb, J. and Whitaker, S. 2012. Defining learning disability, The Psychologist, 25, 440-443.
The publisher is The Centre for Welfare Reform.
Learning Disability is NOT a Mental Disorder © Robin Jackson 2015.
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