Question: What would you like to see in the forthcoming mental health white paper?

Marjorie Wallace : We have long campaigned for more positive rights to care and treatment for people who experience mental illness. Currently far too many of the thousand people a week who call our helpline SANELINE say that they are turned away when they seek help. Families also feel there is nowhere to turn. If a person who is ill fails to keep an appointment or appears not to co-operate with the system they are easily "dropped" from services. We would like to see an obligation on those services to provide more pro-active care, preventing vulnerable people from being lost or neglected in the community.

We hope the new Act will focus on the health and safety of the individual and their longer term well-being rather than the current emphasis on dangerousness. Although the previous Act acknowledged the "health and safety" of a person with mental disorder, it was consistently interpreted to mean the immediate risk posed to themselves or others.

We expect the new Act to include people who have severe personality disorder which is deemed untreatable, who have previously fallen between the Mental Health Act and the criminal justice system.

Question: Is a new Mental Health Act necessary?

Marjorie Wallace : The promised 'root and branch' reform is long overdue. The Mental Health Act 1983 was an update on that written in 1959, at a time when new medications had only just been discovered which could quell the more florid symptoms of severe mental illness. Its primary and highly necessary purpose was to protect the rights of people living in institutions and to safeguard their liberties. Since the majority of people are now living in the community, the Act has become outdated and years of misinterpretation has led to an imbalance between the rights of individuals with mental illness, their families or carers and the public.

Question: Do compulsory treatment orders have a place?

Marjorie Wallace : SANE is not in favour of compulsory treatment except as a last resort. We agree with the Mental Health Alliance that the key aim of the new Mental Health Act should be to reduce the need to use compulsion, and that the least coercive measures are used. We believe that the majority of people would be able to take part in decisions about their own treatment and when well, agree 'advance directives' as to what action should be taken in times of crisis.

We believe that the need for compulsion would be greatly reduced by more imaginative and responsive services, more rigorous risk assessment and more consistent and skilled supervision. If mental health teams or doctors were able to intervene earlier and provide immediate help in crisis before a person become so ill that he or she lost insight there would be less need to treat people against their will.

Compulsion could also be reduced if the medications offered were better tolerated. It has been disappointing that still 84% of people with schizophrenia are given the old 'a-typical' medications with their stigmatising side effects as first line treatment. It is not surprising that young people faced with side effects almost as distressing as the symptoms of their illness fail to take medication and resist future contact with professionals. We accept that all medications have some side effects, but if the most up to date drugs were combined with other forms of therapy the need to force people to take medication could be reduced.

In the few cases where compulsion has to be used we would be concerned that treatment were given outside a clinical setting, not necessarily a hospital, but a unit with professional supervision.

Question: Could compulsory orders, if anything, drive patients away from treatment?

I think the fear surrounding compulsory treatment orders could make people feel very nervous and avoid contact with services. If these orders are to be introduced it must be made clear that compulsion would be used in very exceptional circumstances and apply to a small group of people.

Question: Are there human rights implications here?

We assume the proposals will be in line with the Human Rights Act. There are various ways of looking at human rights, and we are in favour of positive rather than negative rights. We would like to see positive rights written into the new law, however difficult that may be, by imposing on services a duty to provide care and treatment when someone needs it. People with mental illness should be accorded the dignity and respect of being given an option for treatment and a chance to get better.

Question: Do you think enough NHS staff in general, doctors, nurses - are adequately trained to detect and deal with people coming to them with mental health problems?

Marjorie Wallace : That's a very general question. If you take the GPs, there's an intrinsic problem of the time they can spend with patients. We have found from our analysis of calls to SANELINE that it can take up to an hour talking to someone who may be very seriously depressed or psychotically ill before they reveal the extent of their illness.

One of the symptoms of mental illness is the person's ability to mask it. We would not necessarily criticise GPs for failing to detect all mental illness, because they are generalists. We are aware that a number of practices are taking on counsellors or mental health nurses. But there is a severe shortage of mental health nurses - community psychiatric nurses are supposed to have a caseload of 35 patients but in reality some have caseloads of 85-90. This is exacerbated by almost 400 vacancies in consultant psychiatry posts. Many of our callers do not see one psychiatrist regularly but a series of locums, which may not help a patient's own sense of fragmentation.

There is a move to create a new type of generic care worker. It can take quite a lot of experience, if not training, to be able to detect the symptoms of mental illness and know when it may be necessary to intervene. To put emphasis on untrained or partially trained care workers would therefore concern us.

Question: How do you get more of these specialists in? How can you attract people into the professions?

It's not so difficult to attract them, the real problem is keeping them. The burn-out rate with mental health specialists is high - for those at the sharp end, it can be as little as two years. Obviously if there were more resources people would have smaller caseloads, feel less helpless and overwhelmed, and derive more reward from their job.

Question: Do you agree that the old psychiatric hospitals should have been closed?

Marjorie Wallace : It was absolutely right that we closed the old hospitals as they had been run. With new medications there was no need to keep people in institutions. Community Care works for the vast majority. In closing the hospitals we have lost 50,000 beds in the last twenty years and with them the backstop of a place to go when a person is no longer able to cope on their own or living with their family. We have also lost the concept of 'asylum'; a place of refuge that recognises that people at some points in their lives and in their illness may need time and space away from the multiple stresses they feel.

We have failed to replace the old hospitals with a sufficient number of nursed beds or supported housing, and no amount of intervention by assertive outreach teams can resolve a crisis if there is literally nowhere for a person to go. What we now have, as one doctor has described to me, is acute wards more like battlefields where clinicians are forced to 'hot-bed' patients because they may have 14 people to 10 beds. This poses the dilemma whether to discharge a patient who is still extremely ill or admit someone who urgently needs to come in for assessment. On top of that you have the problem that the wards are so full of people who have come through the courts. In the last ten years we have more than doubled the number of people who are receiving compulsory treatment in hospital, many being detained because they do not want to stay voluntarily in such appalling conditions.

What we need is different wards and units to cater for the variety of conditions, with more emphasis on treating than containing. A comment from the Mental Health Act Commission last year best illustrates this: "The shift in the provision of mental health care from hospital to the community has resulted in hospital admission wards providing care for patients with more acute symptoms and high levels of disturbance. There are indications that problem behaviour on wards, such as threatening language and behaviour, racial and sexual harassment and abuse of alcohol and drugs, is a growing concern."

Question: Would this refuge be a kind of long stay hospital?

Marjorie Wallace : People vary tremendously. We must recognise that there are different needs: some people do not respond to any form of medication or therapy and may need longer term care; there are some whose condition is episodic. Many people call us saying they know that they are getting worse and that if nothing happens they will become so ill that they can no longer look after themselves, they will no longer eat their food, or go out and see anyone. It is these people on the cusp of relapse for whom there is nowhere to go because they have not yet done anything, so everyone waits for them to do something - which may well be an act directed against themselves. We need not only hospitals, but also trained and skilled staff in units in the community.

Question: Are mentally ill people violent?

It is extremely rare for people with mental illness to be violent, and any violence is much more likely to be committed against themselves. There is no evidence that the number of violent acts committed by mentally ill people has increased. But in the few cases where there is an act of violence, either suicide or homicide, it tends to be the result of untreated symptoms and neglect of the person's needs, not just for medication but for consistent, holistic care. Families, friends and neighbours can see for months that a person is deteriorating, that they are becoming more distressed, that they are talking about voices that are battering them, that they are becoming more irrational or more depressed. Yet professionals feel unable to intervene.

At the core of the problem is the failure of risk assessment. No-one blames the professionals because it is difficult to make these judgements, but what seems to be happening is that assessments are being made on the basis of a 'snapshot' of how a person is at a specific time, with dangerousness as the criterion. In such a snapshot assessment nobody is taking account of the overall health and well-being of the patient, so their physical health may also be at risk. We hope the new law will have as its prime focus the health and safety of the individual rather than the immediate risk to others.

Assessments should, where appropriate, include the views of the family or other carers, as they are the people with the closest knowledge of the individual.

Question: What will happen to civil liberties?

Marjorie Wallace : We hope the new Act will better balance the long term liberties of an individual with their short term liberty so that they can lead more fulfilling lives in the community. But the rights of the individual must be balanced with those of their families and carers - and those of the public.

We also need to look at the deeper implications of liberty. Liberty isn't living in a bedsit or a bed and breakfast, looking at four walls and believing the television is speaking to you, or not daring to go out because you believe people are whispering about you. Liberty is care and treatment, and the path to a richer life.

Question: What about the 'treatability test'?

Marjorie Wallace : We expect the new laws will remove the 'treatability test' in relation to people with severe anti-social personality disorders. SANE has campaigned for the law to be broadened to allow treatment for this group, who can pose the greatest risk to themselves or others. Currently, those who are deemed untreatable fall outside the Mental Health Act and may be turned away from care, only to be picked up by the prison system if they have committed an offence.

Question: A new Mental Health Act - will it solve all the problems?

Marjorie Wallace : A new Mental Health Act will not solve the problems unless it is backed up by new resources. There's no point in saying that somebody has to be detained if there is nowhere suitable to detain them, or in saying that a person has to have treatment if it has to be given in such a way that it is going to be more distressing and disturbing to them than not having treatment.

We hope the legislation will recognise that the landscape of mental health has changed dramatically, that it is no longer a question of institution versus the community. The reality is that people have to move between hospitals, supported accommodation and the community, and may need to go back to hospital. We have to cater for all levels of independence, supervision and security. We hope the new proposals will recognise this. If they do, it should make it easier for people to get hospital care voluntarily and with less stigma, and reduce the need for compulsion.

We need more acceptance that people with mental illness are no different from the rest of us; they are neither ill nor well: they can be ill sometimes and well sometimes. That means much more flexibility running through both the law and services.