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10 Jul

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No visits till the meds kick in 1No visits till the meds kick in 2No visits till the meds kick in 4

No visits till the meds kick in 5

 

No visits till the meds kick in 7

No visits till the meds kick in 8

No visits till the meds kick in 9

No visits till the meds kick in 10

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No visits till the meds kick in part 1 and part 2.

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Justification

12 Apr

 

It’s been a long day: first I had to explain mental illness to a psychiatrist; then I had to explain mental health cuts to my family. They know. Or they should.

That’s the thing with mental health: you’re always having to explain and justify it in a way you simply don’t have to with physical illness. No cancer doctor would see a new patient without making sure they’d read all the relevant documents first; not so in mental health. No-one would tell a relative that the reason they hadn’t got cancer treatment they needed was because they hadn’t been nice enough to the cancer clinic; not so in mental health. If I had cancer, I’d show up at the clinic and know the doctor would (or should!) have checked the slides and results first; not start from scratch. If I had cancer, family would say how awful it was that cutbacks meant I couldn’t get treatment; not that it must be because of something I’d said or done. It’s bad enough having mental health problems without also having to justify their existence – or your own worthiness to receive help.

Link here.

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Who protects the rights of mental health patients?

7 Apr

 

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Police don’t know the ins and outs of mental health law. Doctors don’t understand the difference between clinical judgment (with all its grey areas) and legal reasoning (which is more black and white) nor the limis of their legal powers. AMHPs are supposed to be the experts. But do they really protect the rights of people with mental health problems? Do hospital managers? Even a specialist mental health and criminal law solicitor got it wrong on important points of law and practice. Who is there for us, looking out for our legal rights, our human rights, when we’re at our most vulnerable?

With Martha Spurrier, former in-house council at mental health charity Mind, joining human rights charity Liberty last week as its new director, will the human rights of people with mental health problems be any more protected?

Some thoughts and conversations and more here, here and here.

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Related links

 

 

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“Safe” staffing on mental health wards

5 Feb

Some thoughts on “safe” staffing and what this mean on psychiatric inpatient wards.

 

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A total smoking ban for detained psychiatric patients stinks of coercion

7 Nov

 

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. SmokingWardipedia, 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 1983Code 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 2013Mental 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 guideBritish Institute of Human Rights (2013)

13. What it’s really like to work on a mental health wardIndependent, Dr Sebastian Cook (26 October 2015) 12

 

 

 

Use of force on psychiatric patients – 3 recommendations for starting to reduce the harms it causes

18 Jun

Keep calm and reduce the harm

How is the quality of inpatient mental health care measured? I’m asking a question, because I don’t know the answer and I’d be happy to learn if anyone would like to send me information.

So far as I know, the only nationally-collated and reported statistics for mental health patients are for deaths and self-harm, both of which are physical measures. It’s known that some people coming out of psychiatric hospital have had a difficult time in there, but there doesn’t seem to be much research interest in looking at why that is or how to make patients’ experiences of inpatient mental health care better. Perhaps it’s just part of what seem to be long-standing low expectations of what mental health care can achieve; perhaps it’s just accepted as a natural fact that people will dislike being detained against their will; or perhaps it’s that psychiatric patients are assumed to be a pretty miserable lot by our very nature so it isn’t the role of mental health services to try to show us a good time. I don’t know.

But I do know that I came out of inpatient detention with post-traumatic stress disorder as a direct result of what was done to me behind closed doors. I do know that I have a shoulder injury which I still receive physiotherapy treatment for more than 3 years since it was inflicted on me. And I do know that I want to try to make psychiatric care less traumatic.

To that end, I’m proposing 3 simple measures, modest proposals as a starting point to help shine a light in dark corners, with the aim of uncovering and encouraging best practice and reducing the routine use of harmful practices – a “big data” approach.

Here are my three recommendations for starting to reduce the potential of coercion and forced medication to cause harm:

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(1) Collate and report national statistics on the use of coercion and forced medication

How is use of forced medication not notifiable? Objectively, it’s physical assault on someone, and at their most vulnerable. It would be grotesque if this were considered to be a routine and natural part of mental health ‘care’. It’s such a gross invasion of a person’s human rights that it can’t be treated as nothing. Individual hospitals may keep records, in their own ways, but there’s no uniform definition of “forced medication” & no central recording. There’s no way to know which hospitals or wards use forced medication most, where best practice is, or where injuries occur at the time or after.

Make it compulsory to record each use of forced and to report it nationally. That way, national statistics and a picture of best practice can emerge as a basis for comparisons and for developing evidenced-based interventions.

Big data is only as good as the input it’s based on, which will necessitate developing standard definitions of coercion and forced medication, to include:

  • Where force or some other form of coercion is mentioned to a patient in order to coerce them to take medication “voluntarily”.

There was a nurse on the ward where I was detained who seemed to be able to find out what patients were most afraid of then threaten them with that in order to get them to comply. In front of me he threatened one friend, who’d been moved from another ward after having been assaulted by another patient, with being sent back there if she didn’t take her medication immediately. Knowing I wanted to be seen to be complying, he twice threatened to report me to the psychiatrist if I was back late from leave.

  • Where the medication “hit squad” (called the rapid response team where I was detained) attends and stands nearby to encourage a patient to take medication “voluntarily”.

That same nurse would call the all-male rapid response team to stand outside the room of a friend whose culture kept men and women largely segregated, in order to “encourage” her to take the prescribed medication immediately. Each time, she would’ve been anxious about taking the medication and simply needed time to settle, but instead staff would become impatient and try to hurry her, making her more anxious.

  • What was done to me, namely the full 6-person take-down).

Even that may need to be spelled out because, for instance, the first time I was forcibly medicated, it states in my notes “No force used” which is simply a lie.

Such definitions will need to be worked on carefully to make it more difficult to fail to record incidents by accident, meaning any failure to record would have to be quite deliberate.

Use of forced medication is such an invasive process – state-sanctioned assault on someone at their most vulnerable – that there cannot be a justification for treating it in such a slapdash way and not even recording it. Make use of forced medication notifiable.

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(2) Having to earning the option to use coercion or forced medication

Make the option to use of force something which must be earned, each and every time, by exhausting every alternative option beforehand, each and every time. It may suit some ward staff to go straight for forced medication as a short-cut for the purposes of ward management, but forced treatment can have damaging medium and long term effects. I remember each and every time I was medicated by force, or restrained, or held in seclusion. It is not nothing, especially when you are struggling in mental health crisis. Using force on people at their most vulnerable can cast a long shadow. It should never be a first resort.

In my case, force was the first resort every time. Not once was I offered medication and given the chance to take it voluntarily: instead, I was ambushed and drugged. I never knew when the hit squad would turn up and do it again. Even when my solicitor had advised me that the quickest way to get out of psychiatric hospital was to “comply, cooperate and engage” so I’d been first in the medication queue and had taken medication voluntarily, I was ambushed again by the hit squad the very next day. No warning, no discussion, no chance to comply. Ambushed. Repeatedly.

The Mental Health Act Code of Practice prescribes strict conditions for use of physical restraint, but not so use of forced medication. Perhaps it’s presumed that the general “least restrictive” principle will mean that forced medication will always be used as a last resort but, in my case, it was very much a first resort.

Staff haven’t just “done the right thing” because it’s the right thing to do, so it’s become clear they must be made to do so. Detailed guidance on the prerequisites for use of forced medication (and sanctions for contravention of procedures) are necessary.

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(3) Debrief patients after each use of forced medication

After each use of forced medication, I’d simply be left, abandoned in dirty sheets. The first time it was done to me, I got up, pulled up my trousers to cover my buttocks then ran down the hall after the departing staff asking them what they’d just injected me with, what it was for, what I could expect to feel, how long it would last – but received no response. They continued walking away down the corridor without responding to me once. Not one of them even so much as turned their heads to acknowledge I was speaking. And in the meantime they chatted away to each other. I was left to return to my bed space feeling confused, humiliated, anxious, violated, not knowing what had been done to me or why or what would happen next. I’d been violated in my bed but had no change of clothes or change of sheets. None of my questions was ever answered. I only learned what drugs had been administered to me when I received a copy of my medical records, months later.

Each time after that, the pattern was the same except that I no longer ran after the staff trying to ask questions but would just be left stunned in my bed space, having been subjected to ambush medication yet again. Left in soiled sheets with my bed pulled out from the wall, having to somehow try to piece together my dignity and try to get some clean sheets and clean clothes, so shocked I’d quietly creep around in slow motion, trying to process what had just been done to me. Shocked again, brutalised again. I think the worst time was the time they came for me even when I’d taken the medication voluntarily; it seemed that nothing I said or did would make them stop.

I learned after coming out of hospital that it’s routine practice for staff to be debriefed after having been involved in a use of forced treatment. Staff are professionals at their place of work, but patients on a psychiatric ward are at our most vulnerable – so why aren’t patients debriefed too? It’s common sense. At the very least, the forced medication process is a very intense experience for people who are poorly, more so than for trained staff who are healthy. It’s clear that forced medication has the potential to harm patients. Good mental health staff want to reduce the harm caused to patients. Let’s do it.

People who choose to train as mental health nurses, occupational therapists, doctors or healthcare assistants don’t for the most part choose their career in order to leave people so traumatised they come out of hospital vowing never to go back into “that place” again, terrified to ask for help, even with post-traumatic stress disorder. Of course, in every profession, there will be a few rogues and, just as professions giving power over children attract sexual predators, so psychiatry will attract some people who want to exert power behind closed doors over vulnerable people who won’t be believed if they speak up about what’s been done to them. People with both good and bad intentions go into mental health services; knowing that to be the case, how can mental health services, especially inpatient wards, be designed so that the good intentions of the former are the most practical option to express but the bad intention of the latter are harder to express? At present it seems that inpatient wards facilitate bullies and brutes, encouraging those who are like that to start with and pushing those who went in with good intentions to become bullies and brutes to or at the very least inured to cruelty and lack of compassion.

In order to challenge endemic use of forced medication, first the evidence of its use must be gathered.

If you’re wondering what I mean by “forced medication”, this’ll give you a flavour:

There is no measure of quality of mental health care but, just as statistics for pressure ulcers are gathered as a signal that

From the Stop the Pressure 2014 slide presentation

From the Stop the Pressure 2014 slide presentation

something’s going wrong on a physical healthcare ward, so statistics about the use of coercion and forced medication can be used as an indicator that something’s not quite right in mental health care. I don’t know all the healthcare or NHS jargon but comparing use of force in psychiatric care to pressure ulcers, where are the CQUIN goals to reduce use of force? Should each use of force be recorded as a ‘serious incident’? The above are modest recommendations intended to be simple, doable steps to reduce harm to patients of forced medication. How can these steps be brought about? Are there better ones and if so what are they? What needs to be done? What’s the first step in making this a reality? Put your thinking caps on and let me know!

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Related links:

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Mental health and human rights: Why aren’t human rights groups interested in mental health folks?

17 Mar

Healthcare is a human right.

Why aren’t human rights groups interested in the human rights of people with mental health problems, especially when there’s so much for them to get their teeth into? Is it just the same ol’ ignorance and prejudice?

When a human rights story is in the news, you’ll see me banging on about it on twitter and asking where the coverage of the human rights of mental health folks is. I’ll ask why human rights organisations don’t seem interested in this group of people, who can in many cases genuinely be classed as some of society’s most marginalised and vulnerable: sometimes locked up behind closed doors, often out of sight, with little credibilty and subject to state powers to impose forced treatment on people even when they have mental cacpacity. Why don’t we hear about that all day and all night from human rights organisations?

Lancet Psychiatry human rights

This silence from human rights groups is puzzling when mental health issues are receiving more publicity and prominence and where there is so very much for human rights groups to get their teeth into. That leads me to ask all sorts of questions. For instance:

  • The Convention on the Rights of Persons with Disabilities

I’ll ask why human rights organisations don’t seem to be interested in a brand new developing area of rights, namely those under the Convention on the Rights of Persons with Disabilities (CRPD) which has been described as a paradigm shift in disability rights. Don’t they want to get in on the action on this hot new area, rather than sticking doggedly with familiar human rights aspects? Are human rights organisations bound to stay in the familiar niches they’ve carved for themselves, or will they look further afield?

  • United Nations investigation into violations of the rights of disabled people

I’ll ask whether human rights organisation are looking at the fact that the UK is the very first country to be investigated by the United Nations for violations of the human rights of disabled people under the CRPD. Doesn’t that sound like an interesting and important human rights topic?

  • Human rights section to the new Code of Practice to the Mental Health Act

I’ll ask what human rights organisations are doing about the brand new section at the front of the new Code of Practice to the Mental Health Act on … human rights. Isn’t it significant – something of note, something to promite – that the new CoP has at its very beginning a brand new section on human rights? I think so. Is it only me?

  • Care Quality Commission’s new human rights-based approach

Are human rights organisations interested in the human rights-based approach all Care Quality Commission inspectors are to take to inspecting hospitals and other healthcare facilities?

  • Restrictions placed on psychiatric detainees

Do they take an interest in the recent NICE guidance that all NHS hospitals should prevent smoking on their premises, even in the case of detained patients without leave and are there no human rights implications of that blanket policy (spoiler: yes)? And what of the blanket policies of some hospitals to remove patient phones or prohibit them from accessing social media whilst on ward?

  • Routine use of force medication

Forced medication is used on some psychiatric wards as a matter of routine, as a first resort rather than a last resort, even when people have the mental capacity to make medication decisions for themselves. Aren’t the human rights of people subjected to forced medication in psychiatric detention of interest to human rights groups?

  • Voting rights of psychiatric patients

Voting rights are meat and drink for human rights organisations. So why no campaigns or even interest in the voting righs of people with mental health problems?

Mia Vee human rights votin

Why is it? Why don’t human rights groups take an interest in those topics when there’s so much for them to get their teeth into and when mental health is such a hot topic at the moment, often in the news?

Mental health folks don’t seem to get a mention – unless we fall into an existing favoured category such as prisoners, death row inmates or deaths in custody

When I see human rights organisations talking about human rights, I notice time and again that, whilst all sorts of different niche groups and causes are trumpeted, mental health folks just don’t seem to get a mention – unless, that is, we fall into an existing favoured category, such as people in detention in prison or on death row, or deaths in custody. Why is that? And what – given important developments in human rights and current social and political changes giving mental health much more prominence – can be done to get violations of the human rights of mental health folks more of a focus and the enforcement of the human rights of mental health folks made into more of a priority?

Why am I told mental health folks are “too speciailst” when all sorts of other specialist groups are chosen for human rights campaigns?

I’ve tried to follow up with various human rights organisations to find out about the work they do on the human rights of mental health folks. I’ve tried. However, I’ve typically been ignored or, when I do get a response, I’m fobbed off with the line that people with mental health problems are a niche group that’s “too specialised” for them. This doesn’t seem to accord with campaigns run in respect of other “niche groups”, such as refugees, prisoners, LGBT people, trades union members, military personnel. Not at all. And it goes against the premise that human rights are most needed by those people who are most vulnerable – and people with mental health problems can be in very vulnerable postions. It’s niche groups who most need human rights.

Justice Hub human rightsEurorights human rightsHuman rights nicheWhy the seeming lack of interest from human rights organisations? Why are people with mental health problems being marginalised, even by those organisations and individuals who purport to champion society’s most marginalised and vulnerable people? Why – at a time of expanding human rights provisions for people with disabilities including mental health problems, at a time of increasing promimence for mental health issues growth, development and prominence of issues surrounding people with mental health problems – why are human rights organisations not swinging into action and grasping the opportunties available to do good, high profile work and make a real difference to the lives of mental health folks?

Human rights stigma discrimination

Could it be that human rights organisations are simply prey to the same ol’ same ol’ stigma and discrimination that blights the lives of mental health folks every day? Is it a case of priorities and people managing mental health problems just aren’t as important as other groups – even though we make up such a large minority of the population? I’m still trying to find an answer.

I’ll keep on trying. The human rights of people managing mental health conditions are too important to overlook.

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Related links

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Some human rights organisations
BIHR mental health advocacy guide

BIHR course for mental health workers FEB 2015

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Some human rights laws and conventions

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Some twitter musings on human rights for mental health folks:

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