The Nearest RelativeJoan Rapaport PhD

Tutors

Professor Shula Ramon ARU

Professor William Bingley UCLAN

Overview

• Provide brief background history

• Describe its shaping up

• Explain some recent history & current developments

What is the Nearest Relative?

• Can influence a relative’s hospital detention

• Identified under legal hierarchy

• Principal early origins: Madhouse Law

Brief historical background

• Statute de Prerogative Regis (medieval - ‘Chancery Lunatics’)

• Madhouses Act 1774

• Madhouses Act 1828

• Lunacy & Lunatics Asylum & Paupers Act 1845

• Lunacy Act 1990

Gestation & birth

• Royal (Percy) Commission 1954 - 1957• Relatives: different definitions & roles• Tensions - disaffected relationships• Standing Committee E - hierarchy & procedures• Mental Health Act 1959• NR powers includes application for admission

(also MWO) • Court procedure re admission abolished

Dr Edith Summerskill

‘There is another point I want to make about the nearestrelative. It is easy to dismiss this, but it is quite conceivablethat the nearest relative is not necessarily the person mostconcerned to promote the welfare of the patient … At the moment we are discussing imponderables, but I confess thatI find it difficult to suggest an alternative. No doubt we areall thinking of our nearest relatives and that “but by thegrace of God there goes …” some of us. We should be quitecontent that our relatives should be there to look after ourwelfare, but can that be said of all people?’HC 598 736

Hierarchy & Rules

• Husband or wife

• Son or daughter

• Father or mother

• Brother or sister

• Grandparent

• Grandchild

• Uncle or aunt

• Nephew or niece

• Highest on the list• Age of majority 21 (18)• Eldest at each level• Father before mother• Divorce, separation &

partnerships• Full blood over half• UK• Sexual Offences Act

(removed by 1983 Act)

NR powers

• To make the application

• To object to a treatment section (civil cases)

• To seek discharge

• To delegate role (under memorandum)

‘What do you want, Mam?’To be hung. You won’t send me away, will you?’‘No.’But as Laing and Co. might smugly note, ‘No’ meant ‘Yes’and in due course she was back in hospital.… I was always nervous of discussing anything but thematter in hand with my mother’s various psychotherapistsfor fear they were taking notes on me too, and whatever Isaid, however lightly, would be taken down in evidenceagainst me; I was part of the equation’.

Alan Bennett - Untold Stories p 107

THEORETICAL IMPACTS

Mental Health Act 1983

• New power to ask SSD to send an ASW to assess a close relative with a view to hospital admission (S13(4))

• Hierarchy modified: priority to relative who cared for the pt; person living with the pt 5 yrs included; mother and father equally eligible

NR problems

• MHAC 1991 - ASW reports - abuser NRs - MHAC recommendations re displacement ignored!

• NRs involved in sexual abuse

• Pt challenges where wrong NR had been identified in the admission process

• NRs blocking treatment sections

Rise of carer - NR demise?

• Carer movement• Community care policy - carer shortages• Carers Act 1995 - carer right to own

assessment of need• Psychiatric homicides & media response• 1995 MHA amended - supervised discharge

- NR loss of applicant role (also ASW)

Late 1990s - MHA reform

• Proposals to replace NR with NP & carer

• NP appointed by the pt

• NP - rights to be involved in care plans, make an application of pt’s behalf to MHRT

• Carer - rights to be involved if pt agreed

• Assumed/hoped that NP and carer would be the same person

Proposed MHA reform - professional discretion to exclude carers from consultations about care planning

Where ‘consultation will be inappropriate or counter-productive, for example where there is conflict of interestbetween the patient and carer’. DH MH Bill 2002 Notes

‘It is very dubious whether it is ever possible to divorce theinterests of the individual entirely from the interests of thecarer.’ Brazier (1992).

NR research: main findings

• NR role little known by service users & carers

• Powers seldom used

• Potential for ASW/NR reciprocation for pt benefit

• Role’s positive potential overlooked

• Major problem with the ID process

From reform to amendment

• MHA 2007

• NR survival - intact

• Remedies to displace inappropriate relatives

• Same sex relationships recognition (formalises case law)

Practice concerns - comparisons

• Professional prejudices

• Assessment of care and social context

• Carer information and risk assessment

• Interpretations of person-centred care

• Case law (Bristol case) - interpretations

• The case for psychodynamic approaches?

NR story

• Evolution

• Birth

• Existence

• Near demise and resurrection

• Research and Ethics - do-able now?