Following on from my piece ‘Banned by the BMJ’, below is the article which was to be published in the British Medical Journal on 7th November as part of the ‘Head to Head’ series ahead of the Maudsley debate. I was to put the ‘no’ side of the debate. This piece was written in that context with the medical readership of the British Medical Journal in mind – an audience which had never heard of me and which may have been unfamiliar with many of the materials I reference – and to the BMJ’s word limit.
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I was detained under UK mental health law in 2011. I am a non-smoker.
Arguing that detained patients should be banned completely from smoking is, in essence, arguing that people with mental health problems should not be treated as full human beings but instead as a subset ripe for discrimination.
Everyone, including doctors, makes broad assumptions about psychiatric patients and our ability to make choices and interact with others. When we are locked up, the medical profession assumes it has the moral right to impose lifestyle changes. However, no-one is sectioned for being a smoker: we are sectioned because we’re considered a danger to ourselves or, more rarely, others. Being a smoker is not a healthcare emergency, and a mental health crisis is not the time to impose lifestyle changes.[1]
The ban on smoking inside psychiatric hospitals was introduced a decade ago, a time when people with mental health problems were side-lined far more. The indoor ban had clear aims: to create a safer working environment for staff and to respect the right of non-smoking patients to have a smoke-free surrogate home. The rights of smoking patients were protected by providing access to designated outdoor smoking areas. The aims of the outdoor ban are less clear. For example, the South London and Maudsley NHS Foundation Trust vaguely says that it aims to “create a healthier environment for everyone” and “reduce … inequality.” [2]
A complete ban prevents detained smokers without leave from smoking (or, rather, smoking overtly). It relies on the ward doors being locked. You do not increase patient “equality” by use of force. It is simply a case of “because we can”.
I am very much in favour of making psychiatric wards healthier and bringing about sustainable improvements to patients’ health. When I was fragile and detained, the ward environment was toxic. Food with no fibre, poor sleep hygiene measures, no access to exercise or fresh air, no therapy and nothing to do except sit round eating biscuits and drinking coffee – and avoid being assaulted. I was repeatedly medicated by force. I have since been diagnosed with post-traumatic stress disorder. [3] There was no smoking reduction or cessation help available. There is a great deal of scope for psychiatric hospitals to make wards healthier. [4] [5] [6]
If improving health were the reason for the ban, hospitals would make stopping smoking compulsory for staff too – 24 hours a day, even at home. That, of course won’t happen because staff wouldn’t stand for it. Unlike staff, though, patients can’t vote with their feet.
Behind all this lies a weight of history, law and medical practice which call on the entrenched notion that people with mental health problems need not be considered full human beings. The ability to use force runs through psychiatry like letters through a stick of rock. Coercion is the backbone of psychiatry. Patients experience psychiatric wards as coercive, not therapeutic.[7] [8] I was treated by force. I was locked in seclusion with no water, no food, no access to a toilet and no contact with the outside world, without even my glasses or shoes. Psychiatrists who visit wards do not truly know what goes on behind closed doors. Trusts must make wards better, not more coercive.
Where is the evidence that SLaM’s aims will be achieved by temporary enforced abstinence based on dominance, duress and fear? A ward stay is an opportunity to build therapeutic relationships with staff that may continue afterwards in the community and could lead to sustainable smoking reduction or even cessation and reduce healthcare inequalities. In psychiatry, unlike any other medical specialty, engagement with patients and persuasion are relegated to “nice to haves.” If patients can’t go elsewhere for medical advice because they are locked up and the law gives staff the right to use force, there’s no need to hone these skills.
Law and societal changes are moving towards reducing discrimination against people with mental health problems. [9] [10] [11] [12] With this ban, psychiatry is moving against the trend. This is morally indefensible and goes against patients’ rights to be at the centre of decisions about our care and treatment. Medicine shouldn’t be about imposing a doctor-dictated “fix” but helping patients to find to solutions that work in our lives.[13]
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References:
1. Smoking and psychiatric wards – Georgia Rambles blog, Dr Georgia Belam (30 September 2014)
2. Stoptober, supporting lifestyle change and preventing psychiatric patients from smoking – Sectioned UK blog, @Sectioned_ (14 October 2014)
3. Do you remember your first time? – Sectioned UK blog (16 November 2014)
4. A smoking ban for mental health workers in the workplace – Nurse With Glasses blog, @nurse_w_glasses (15 November 2013)
5. Smoking – Wardipedia, a World of Ward Knowledge, @WardipediaNews
6. How can psychiatric wards become better, healthier places? – Sectioned UK blog (26 October 2015)
7. On the ward – abuse in the mental health system – Schizoaffected3 blog, @schizoaffected (27 June 2015)
8. Coercion in a locked psychiatric ward: Perspectives of patients and staff. (I asked for helps as to how to cite this link properly)
9. Code of Practice to the Mental Health Act 1983 – Code of Practice to the Mental Health Act 1983 (January 2015) which, for the first time, includes a section on human rights (chapter 3).
10. “The UN Convention on the Rights of Persons with Disabilities (UNCRPD) is the first human rights treaty of the 21st Century. It reaffirms disabled people’s human rights and signals a further major step in disabled people’s journey to becoming full and equal citizens.” Equality & Human Rights Commission on the United Nations Convention on the Rights of People with Disabilities (Ratified by the UK in June 2009)
11. Mental Health (Discrimination) Act 2013 – Mental Health (Discrimination) Act 2013 (28 February 2013) This Act removed discriminatory mental health legislation affecting MPs, school governors, company directors and would-be jury members.
12. Mental health advocacy and human rights: your guide – British Institute of Human Rights (2013)
13. What it’s really like to work on a mental health ward – Independent, Dr Sebastian Cook (26 October 2015) 12
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