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

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:

• Do you remember your first time?
• Treated like an animal
• Restraint: 10 ways it harms psychiatric patients
• Forced medication: resistance is futile

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

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:

• Forced treatment – 3 recommendations for starting to reduce the harm it causes (Storify of saved tweets on this topic)

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Some reflections by a retired nurse on asylums old and new

 

Earlier this evening, I had a fascinating conversation with a relative who’d trained as a learning disability nurse in the 1960s. She shared her memories as a nurse, visitor and  patient at Coldeast Mental Deficiency Colony, Littlemore Asylum, Digby, Langdon, Tone Vale and other hospitals.She had some interesting observations on the differences between the old asylums and modern psychiatric hospitals.  It was hard to tell if it was pensioner nostalgia or if things really were, on balance, much better in the old asylums. But that was her clear view.

She spoke about the old asylums, on the outskirts of town, each having a home farm where patients would work, have a purpose, be outside and contribute to the life of the institution. Of patients cleaning the wards, nurses helping too, of real hands-on nursing, of vocation, of the matron closely supervising the ward, of strict hygiene standards that meant, for instance, never sitting on a patient’s bed. Of food cooked on the wards, and nurses trained in cooking too in case there was no one else there to do it. Of the value of good routine, of having to boil the needles and bandages, of having to manage patients without drugs, of highly-trained staff.

She spoke of parents being persuaded to abandon their ‘mentally retarded’ children, to leave them behind and get on with their lives. Of how wrong that was and of how people could contribute so much to society if they had routine jobs. That seemed her one regret from those times.

She spoke of nurses needing to get at least two years’ experience before they could go on the wards with the more difficult patients. Of how patients would be matched to particular nurses, as some patients could be violent from time to time and you had to know how to relate to them. Of how the experienced staff, strict routine and a pride in their work created a secure and stable environment for patients and staff alike.

And she spoke of how things had started to ‘go down the pan’ in the 1970s when, for the first time, staff could use drugs to ‘keep patients quiet’. Of how younger staff were recruited, how routine slipped, how patients were left to do as they wanted, neglected and ‘drugged up to their eyeballs’. Of seeing the nurses’ pride in their job dwindling, of staff having affairs with each other, of hygiene standards slipping. She’d seen this in residential and nursing homes too: residents drugged to keep them quiet, one perhaps two staff on overnight, and little care.

And then she compared her time working in the old institutions with her recent experience of care in a brand new psychiatric hospital. She said, when she was a patient herself, the staff were ignorant about mental health, and some nurses were ‘really nasty’. Staff congregated in cliques or in the staff room. They didn’t mix – ie care for – patients. At night, nurses would be on their smart phones and would brush her away when she tried to talk to them. Of how the ward phone was kept locked in the nurses’ office, so patients couldn’t contact the outside world except with staff permission. (That’s a recipe for abuse behind closed doors, if ever there was one.)

She spoke of there being no facilities for exercise – and, when she went in, she was used to walking miles. How she got fatter & fatter. That there was a small internal courtyard but she wasn’t allowed in it in case she ‘climbed over the wall’ and escaped. How she was finally, after several weeks, allowed into the courtyard and would then walk round and round and round. How there was a swimming pool and gym elsewhere on the hospital site, but the nurses wouldn’t take her there. How she badly missed activity. How she came out of hospital far more unhealthy than when she went in, physically.

How nursing had become more technical, and nurses had more status now, but had lost the basic hands-on skills. How nurses nowadays had lower hygiene standards and no idea about cross-infection control. How hospitals needed highly-trained staff but how the staff who’d treated her didn’t have sufficient training. How nursing was just a job now, not a vocation.

It was fascinating listening to her experiences as staff, visitor and laterly patient starting in the 1960s and running right through to the present day, and the comparisons she made.

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Related links:

• My tweets on the subject earlier this evening
• Some reflections of the lovely twitter people
• An old blog post – The economics of the lunatic farm – and farming!
• Reflections of a retired nurse on the history of bipolar disorder going back to when she trained in the 1950s (on Bipolar Blogger’s blog here and here) (2013)

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Do you remember your first time?

My bedspace after one incidence of forced treatment when I was restrained and injected on my bed by six people.

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Patient: When you’re unwell you need care. And what I got was punishment. So when I was unwell I was extremely stressed and I was anxious. And I was taken by the police from my bedroom, unlawfully as it turned out, erm, from my bedroom into hospital where I was assaulted by patients and staff and I was held down and drugged repeatedly. And nobody came and spoke to me and said this is what’s happening, this is the diagnosis you have, we think you’re experiencing this and this drug will help you. Nobody came and spoke to me. And instead what they did was I would just be on my bed, reading a book, or not reading a book, couldn’t read, I would be on my bed, doing something, minding my own business, and I would turn around and there’d be a team of six people with rubber gloves who would hold me down [Starts to cry], pull my trousers down and drug me. They didn’t tell me what the drug was, they didn’t tell me what the effects were, they didn’t tell me what to expect, they didn’t tell me how long it would last, they didn’t tell me what it was for. Nothing. And they would finish and they would climb off my bed and they would walk away. And I wouldn’t know when they would come back. And they did that, erm, over and over and over and over again over a period of several days. I don’t know what they were giving me and I only found out after I left and saw my medical notes some of the drugs they were giving me. Sometimes they’d make a mistake and they’d give me drugs twice. Even though I went to the counter to get my drugs, take them voluntarily, they would still hold me down and give me other drugs. [In a strong voice, stops crying] So in that context I don’t think medication was helpful. The approach was unhelpful. What that approach does is it makes people afraid to ask for help.

Interviewer: It’s incredibly brutal. Can I go and get you a tissue?

Patient: No, no, I come prepared. I always have tissues with me.

Interviewer: Are you okay to …

Patient: Yeah, yeah, I’m fine.

Interviewer: And that was your first experience of medication as well?

Patient: Exactly. I don’t, I don’t take … Well, before this experience, I didn’t take anything. I didn’t take aspirin, I didn’t take paracetamol. I didn’t even drink coffee. You know, I didn’t take any drugs. I had a fear of drugs. I had a fear of needles. I have low blood pressure so if you give me a needle I’ll faint. So if you want to give me a needle I need to be lying down, I need to be calm and then … Whatever. So, er. So I’m, you know … Now I know a lot about drugs. [laughs] I know a lot about drugs. Erm, before that, no, that was my, that was my first experience of drugs.

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Do you remember your first time? I do. I remember the first time I was treated by force. I remember it very well. The account above is an unedited segment from the transcript of my February 2012 interview with a researcher. In it, I briefly describe my first time being treated by force. That interview was also the first time I’d been able to speak to anyone in detail about what had actually been done to me in hospital. I knew it would be difficult and emotional, but I forced myself to take that first step in speaking out as part of a research project. It was six months after I’d been discharged from an acute inpatient psychiatric ward but, even so, I was floored for a week by the emotion of the interview.

Then, the following month, I found myself tweeting in bursts, over the course of several hours, about my experience of being treated by force. That was the first time I’d conjured up those images in detail and written them down for others to read. As I tweeted, I shook, cried, felt sick – but kept going. I couldn’t turn it into a full blog post but instead wrote a short one (Treated like an animal) linking to the collated tweets. I hadn’t read them back till just now: I couldn’t. That blog post and collated tweets have since been read thousands of times.

Three months later, in June, mental health charity Mind launched a campaign to end use of face-down restraint on psychiatric wards and that prompted me to write about forced medication again (Restraint – 10 ways it harms psychiatric patients). That post was read even more times than the first, though the toll in writing it was, thankfully, less on me. That was because, this time, I wasn’t conjuring up images of what it was like to be forcibly medicated in order to convey a picture to the public: it was a more considered overview of the topic. Almost a year after discharge, it seemed I’d begun to attain some distance from what was done to me.

Then, in November of that same year, the interview transcript arrived and a mental health charity asked me to write a piece for them about my experience of forced medication for their campaign. I forced myself, again and again, to sit down and bring to mind, in great detail, what it was like, so the reader could envisage themselves there, in the moment, being on the receiving end themselves. It took a heavy toll on me emotionally. Trying to edit it was toughest. Trying to take my raw recollections and shape them into something suitable for a mainstream audience without being overwhelmed by the intensity of the recollections. In the end, I couldn’t submit the written work. (It’s languished on my computer for 2 years, and I’ve only just looked at it. And I’ve only just glanced through the research interview transcript.) What that reinforced for me was that speaking or writing about forced treatment is a part of a healing process for me and something I cannot conjure up to order: it has to naturally arise from me when the time is right. I have a diagnosis of post-traumatic stress disorder as a result of what was done to me in hospital, and that’s just what I’ve got to work with.

It was another four months before I wrote about forced treatment again, in March this year (Forced medication: resistance is futile). I was able to write my first proper blog post describing one aspect of it. Compared to 12 months earlier, I noticed that tweeting about the topic (almost all my blog posts arise from tweets!) had been less overwhelmingly painful and that I’d been able to go back afterwards and edit the tweets into a blog post. It seemed as if I was naturally and instinctively keeping a distance from something that had injured me to the core, gradually circling round it and every now and then being able to touch on the subject. It seemed that, each time, after several months had passed, I was able to return to the subject with a little less terror.

So here I am, 8 months later, over 3 years since I was discharged from hospital, writing about forced treatment again. Circling the subject again, adding a little more depth, noticing that I can now approach it with a little less pain, with fewer flashbacks and  physical responses.

And what is new this time I’m writing about forced medication? It’s not a topic I’ve seen discussed much on social media or in the mainstream media. But then, it’s not something I’ve been able (emotionally) to investigate. However, I have been aware (very much at arm’s length) of campaigns to reduce the use of physical and chemical restraint and seclusion related to what’s called “challenging behaviour”. These include Mind’s campaign to end the use of face-down restraint and Mersey Care NHS Trust’s No Force First pilot to create coercion-free psychiatric inpatient wards. I’m also aware of research on conflict and containment in inpatient psychiatric settings which highlights that it’s staff, not patients, who influence how much of each there is likely to be. There may well be research and discussion on forced medication that’s passed me by, and please do let me know if you come across any.

For me, forced medication is very much a separate topic to use of force in situations of danger (to the patient themselves or others) or conflict (such as verbal abuse or violence). Forced medication is about a psychiatrist deciding on a course of treament (medication) and leaving ward staff to get on with administering that. It seems to me there are no controls over use of forced medication, other than the good will of staff and we already know that, when one group of people is given power over another, it may not always be a benevolent dictatorship. Even with the best of intentions, shortcuts can be taken – and using force to medicate someone is the ultimate shortcut – and staff can become aclimatised to routine use of force.

Here, then, are my recommendations for reducing the use of forced medication and thereby the harm it causes:

1. Collation of national statistics on use of forced treatment – Make it compulsory to record each use of forced medication and to report it nationally. That way, national statistics and a picture of best practice can emerge as the basis for comparisons and for developing evidenced-based interventions. That will necessitate development of standard definitions of forced treatment, particularly since my medical notes record “No restraint employed” in relation to the first incident of forced medication. So, for instance, I would include (but in different categories), where use of force is mentioned to a patient in order to coerce them to take medication “voluntarily”; where the medication “hit squad” attends and stands near a patient to encourage them to take the medication “voluntarily”; and what was done to me (ie the full 6-person take-down). Make use of forced treatment a notifiable process (like a notifiable disease): it’s such an invasive process – state-sanctioned assault on someone at their most vulerable – that there cannot be a justification for treating it in such a slapdash way.
2. Earning the right to use forced treatment – Make use of forced medication a right which must be earned, each and every time, by exhausting every alternative option beforehand. It may suit some ward staff to go straight for forced medication as a short-cut for ward management purposes. However, patients are people who exist beyond the locked ward and will do so once they are discharged, and forced treatment can have damaging effects in the medium and long term. Forced treatment can cast a long shadow. It should never be a first resort. The Code of Practice to the Mental Health Act sets out strict conditions for use of physical restraint but forced medication is nodded through under the guise of general principles. Clearly that approach is not working, meaning that detailed guidance on the prerequisites for the use of forced medication, in the same way as they are for restraint, are necessary.
3. Debrief patients after each use of forced treatment – I’ve seen on documentaries (such as ITV’s recent series Broadmoor) that, when a patient is physically restrained and forcibly medicated, afterwards staff meet to discuss and debrief. All the while, the patient – who’s just been subjected to what, at the very least, could be described as a highly intense experience – is left in their bedroom or bed space alone to try to work through their responses. I recall time and again being left face down, underwear and trousers askew, in sheets covered in bootprints on a bed pushed out from the wall, empty antiseptic wipe packets on the floor. I’d be left shocked, terrorised, humiliated, confused, frightened, to clear up my bedspace, somehow get hold of clean sheets and somehow work out how to, well, be on the ward again. Patients need a debrief just as much as staff. Or perhaps more. After all, they are the vulnerable ones, there to be healed, not brutalised. Witness a patient’s pain. Be there to comfort them. Help them work their way through the experience.

I shouldn’t be left, over 3 years after discharge from hospital, still being triggered into flashbacks by obvious reminders like the photograph above or the word “restraint”, let alone such seemingly innocent stimuli as the flicker of fluorescent lights, the hum of air conditioning or traffic cops chasing a motorist on TV. Treatment is supposed to help patients. No patient should ever leave the ward more harmed than when they went in, too scared to ask for help in future and only referring to “that place” in hushed tones. Good psychiatric inpatient wards exist all over the country. Hopefully these three proposals are a helpful addition to dialogue around ridding the psychiatric system of forced medication by learning from those who use it least.

 

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Related web links:

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My previous posts on forced treatment (each containing links):

• Treated like an animal – My first blog post on forced treatment (March 2013)
• Restraint: 10 ways it harms psychiatric patients – My second blog post on forced treaatment (June 2013)
• Forced medication: Resistance is futile – My third blog post on forced treatment (March 2014)

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On restraint, conflict and containment:

• Mersey Care NHS Trust – ‘No Force First -Changing the culture to create coercion free
  environments and press release (October 2014)
• Mind’s campaign to end face-down restraint (ongoing – various stages since 2011)
• Dr Chris Papadopoulos et al:
  • Events preceding changes in conflict and containment rates on acute psychiatric wards – “Ward staff play a crucial role in influencing the likelihood that conflict or containment events will occur in inpatient psychiatric settings.” (January 2012)
  • The antecedents of violence and aggression within psychiatric in-patient settings – “This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.” (June 2012)
  • Correlation between levels of conflict and containment on acute psychiatric wards – “Wards can make positive changes to achieve a low-containment, nonpunitive culture, even when rates of patient conflict are high.” (May 2013)

 

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Forced medication: resistance is futile

Pacific Northwest Ballet principal dancer Carrie Imler, with corps de ballet dancers William Lin-Yee and Andrew Bartee in Jiri Kylian’s Sechs Tänze (Six Dances). Photo © Angela Sterling.

Someone found my blog today by searching “how to get out of the restraint that psychiatric wards use”. That lead to these tweets on my experience of forced medication on a psychiatric ward (set out below, slightly edited).

I discovered that nothing I did or said made any difference to the use of restraint on me: they were going to carry on and do it, no matter what. It made no difference to them what I said or did. All I could do was try to make a difference to me.

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Someone found my blog today by searching “how to get out of the restraint that psychiatric wards use”. Yeah, no chance there: it’s six to one. I discovered that nothing I did or said made any difference to the use of restraint on me: they were going to carry on and do it, no matter what.

In my experience of restraint, once there’s a tick on the chart saying “forced medication”, it’s going to be done to you, no matter what. Once there’s a tick in the box saying “forced medication”, it doesn’t matter where you are or what you’re doing, you’re getting it.

It made no difference that I’d never been asked whether I’d like pills or an injection. The forced med squad just turned up and did it to me. It made no difference that I’d never been asked which drug I’d prefer to take. They just climbed on top, pinned me down and stuck it in me. It made no difference that I’d never had a discussion about symptoms or potential diagnoses or treatments. They just carried out orders.

It made no difference that I was sitting on my bed, reading quietly, minding my own business. They’d turn up mob-handed & do their business. It made no difference that I’d stepped out of a meeting with the IMHA to get a letter from my bedroom she’d asked to see. They came in as I sat on the floor, document wallet in hand, surrounded by papers. They did it to me there, then walked off chatting, leaving me to wander back to the IMHA, disheveled and dazed.

It made no difference when I pleaded with them to explain what they were doing, what was in the syringe (or syringes – it varied), what effect it would have on me. None. It made no difference when I talked calmly to them, speaking to each by name, asking them to explain why they were injecting me. None. It made no difference when I repeatedly called out a friend’s name, calling to mind someone who cared for me, who heard my words. None.

It made no difference whether it was night or day. They could turn up any time, stick it in me, roll off, leave me lying in dirty sheets. It made no difference when (realising nurses wouldn’t speak to me) I wrote notes and handed them to the nurses. The notes asked the nurses to explain what drugs they were injecting, what the effects were, what they were for and what the plan was going forwards. No response. They just handed each note back to me later, unopened.

It even made no difference when I was first in the drugs queue so I could take the pills instead: they still came for me again. I had a double dose that day.

The staff weren’t monsters. Far from it. They’d chat away to each other, coordinating between themselves who was going to take which limb; who was doing what when; and then when to let go as one.

They’d chat away to each other as if the person beneath them was not a person who spoke their language but a wild and senseless beast. They’d leave behind a bed pushed out from the wall, sheets trampled under their boots, empty swab wrappers on the floor, lumps and bruises on my arms and legs. They’d leave behind a person who didn’t know what had just been done to them, or why, or when it would happen again, or how to make it stop.

I learned that, when they come for you, there is no escape. You are locked in and cornered. It is going to happen. It makes no difference what you say or do.

I learned that, when they come for you, there is no escape. You are locked in and cornered. It is going to happen. It makes no difference what you say or do. You can’t reason with people who won’t listen to you. You can’t persuade people who don’t hear you. You can’t resist them when it’s six to one, even if (unlike me) you knew how. You can’t reason with people who are just carrying out orders. You can’t persuade people who don’t think you’re worth asking.

It’s like being in a science fiction novel. Resistance is futile. Your life as it has been is over. Comply, cooperate and engage. Resistance just prolongs the process. The quickest way to get out is to comply, cooperate & engage.

I found that there was nothing I could say or do to stop them using restraint on me. But things I said and did helped me cling on to me. Little things I did and said as they did their business on me helped me to cling to my sense of being a person, a human being not an animal.

It made no difference to them what I said or did. All I could do was try to make a difference to me.

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Related links:

• Earlier blogs:
  • Treated like an animal – The first time I wrote about forced medication (March 2013)
  • Restraint – 10 ways it harms psychiatric patients – Comments on forced medication and physical restraint (June 2013)
• Code of Practice to the Mental Health Act – contains provisions about use of restraint of people who are violent or aggressive but rubber stamps its use for forced medication
• Good psychiatric practice – Code of Ethics of the Royal College of Psychiatrist (March 2014)
• My tweets on the topic earlier today – It made no difference to them what I said or did. All I could do was try to make a difference to me – and some responses from the lovely twitter people
• We are the Borg (Star Trek) (video – 50 secs)
• A year as a mental health advocate at South London and Maudsley NHS Foundation Trust (SLaM) – 27 minute video by Jake. He talks about what he saw working at SLaM as an IMHA, including the routine use of forced medication, threats and restraint of people who are not being violent or aggressive (and other topics) (see particulary the first 12 minutes).

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Hopefulness

I’m a little bit in shock. I’m still not sure how to put it. It seems too good to be true. It’s taken nearly 3 years to be able to say this:

I’m being seen by a psychiatrist who seems to relate to me as a human being, wants to get to know me as a person and work with me in partnership.

What’s puzzled me so far is why all the psychiatrists I’ve seen haven’t been like this. I know they’re intelligent, caring professionals. So it’s been a genuine puzzle to me why the mental health care I’ve received so far has been so bad or inadequate, and in so many different ways. It’s one thing having one bad experience of care: it happens. But for it to happen repeatedly, with different professionals? It’s a puzzle.

I had no idea that, two years after joining twitter, I’d still be banging on about bad experiences of care. (It’s not because I like them!). I never thought I’d still be going on about what was done to me in hospital. (I’d much rather have had treatment for the resulting PTSD.) I never imagined I’d still be moaning about my bad experiences of community mental health care. (I thought I’d learn how to work the system to get what I needed.)

In fact, just so you know, I don’t do nearly as much moaning on about my supposed “care” as I could. (It would sound way too negative!) I’d summarise my experience of mental health care as having been brutalised, traumatised then parked on welfare benefits and sedating meds. Mental health nurses & doctors who’ve treated me so far have been akin to veterinary staff: they’ve observed, diagnosed and neutralised me.

Non-medically trained staff have related to me with humanity. But, ultimately, they’ve all had to defer to the doctors and nurses. It’s almost as if mental health training gets in the way, prevents staff from seeing the human being experiencing human distress right in front of them.

Does training prevent health care professionals from seeing that what’s in front of them isn’t a diagnosis but is a human being experiencing distressing symptoms? Is the human experience so broad and varied that mental health staff steel themselves to stick rigidly to assigned roles and designated boxes?

Let’s be clear. When I’m in mental distress, it’s not about mental health staff being “nice” to me. It’s not about them being my mate. I don’t need a new friend.

I need a competent professional who’ll work with me in partnership: I’m the expert in me; they’re the expert in mental health care.

No matter how unwell someone is, they’re still a person with thoughts, feelings, quirks, preferences, friends, family and a life to return to. They’re not a puzzle to be solved, a problem to be fixed. They’re a human being, not an animal.

I want to be able to write about good psychiatric care, I really do. I have a vested interest, after all! It’s just not been my experience. I’d much rather have been able to write about fantastic treatment by great nurses and doctors; and about how much better I was in myself. I’d even have settled for half decent care and a bit of respect, mediocre care with a modicum of interest. What I got instead was damaging.

I have seen excellent psychiatric care elsewhere: caring, effective, transforming treatment and support. (Though still with no talking therapy.) I’ve just not received it myself. The comparison is bitter sweet.

Is now my time? Am I on the threshold of receiving effective help? Can I get excited about it yet? Am I on my way to living a full life? I’m not silly. I’m not going to pin all my hopes on one busy professional “fixing” me. I know it doesn’t work that way. But … I feel a sense of anticipation.

I’m hopeful the new psychiatrist and I can come up with a plan that will achieve good results going forwards. I’m hopeful the plan we come up with will include meaningful support and help going forwards, so I’ll be able to get back on my feet. And, this time, it feels as if my hopefulness could be a realistic. I’ve been getting by on wishful thinking for too long.

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• Collated tweets (Storify) – My tweets (and some initial responses from the lovely twitter people)
• Twitter conversations – Responses and conversations with the lovely twitter people (these are really interesting – take a look!)

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Trust, respect and coercion in mental health services

Trust, respect and coercion: Can people who use mental health services ever really trust staff when coercion is always an option?

Some thoughts of mine on the subject.

Some responses of the lovely twitter people.

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Madsplaining … as it was mansplained to me. On offering advice to people with mental health problems

The Yolkr – teach your granny a new way to suck eggs (or at least to suck yolks from whites)

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Madsplaining: Offering unsolicited advice to someone on how they should manage their mental health (especially by peers and mental health professionals)

On twitter (and no doubt on other social media platforms), we mental health folks share a lot of detail about our lives. We talk about our good and bad experiences of mental health treatment, medications, symptoms, cheese sandwiches, our lives in general. Sometimes, when someone’s sharing a problem they’re experiencing with managing their mental health, other tweeps – those with lived experience or mental health professionals (or both) – will chip in with helpful tips.  We can be a sharing, caring bunch.

“Oh, I tried X and it works wonders for me. Why not give it a go?” “I saw a documentary about this new thing the other day that I thought would help you with that thing you mentioned.” Sometimes this moves towards more generic helpful tips, along the lines of, “Have you tried a nice cup of tea / hot bath / going for a walk / phoning a friend?” Advice and tips on all sorts of things. It happens offline too.  It can be good advice. Generally it’s well-meant. But …  is it welcome? Well, maybe yes. And maybe no.

The thing is, if someone is managing a mental health (or physical) condition, especially if they’ve been doing so for a while, they’ve probably had a good old go at trying the various drugs, treatments, therapies, supplements and diets on offer. They may be working their way through them with their healthcare team. They may be researching in the library or online. They may have joined a self-help group or forum. They may even have tried any number of hocus pocus remedies that make it into the Daily Mail or documentaries. So, when someone tweets about their condition and you’re tempted to mention something off the top of your head, think: are they asking for advice?

If it’s an offline friend or family member you know well, do they see a doctor and take medication regularly for their condition? Do they have a self-management plan? If someone is managing a long-term condition, the likelihood is they’re keeping some sort of track of how they’re doing. “Are you sure you’re not doing too much and, you know, starting to go hypo?” “Isn’t it time to go to bed now?” “Did you forget to take your medication today? You seem a bit … you know.”

Such comments can be helpful: sometimes we can ignore our own self-management early warning signs and only pay attention when we hear it from someone we trust. If you know someone well enough, or if they’ve asked you to be part of their self-management team – an early warning ally, as it were – it may be appropriate to chip in. But otherwise?

Unsolicited advice to someone managing a long term health condition can be seen as patronising. It may feel like criticism. It can be viewed as a sign that the advice-giver does not respect the person’s ability to manage their own healthcare needs properly. It can be seen as a suggestion that the person does not know their own mind … which, in the context of managing a  mental health problem, puts the advice-giver in really dodgy territory. Really dodgy.

Why am I writing this post now? Because only today I was reminded of how quick I can be to offer unsolicited advice. To leap in with handy hints and tips about how they could make their life better … if only they’d do as I suggest.  Partly that comes from my work background; partly because, being fairly long in the tooth, I (think I) know a lot of stuff; and party because I have a caring nature & like to help. Once, in response to a tweet from veteran mental health writer and thought leader Mark Brown (twitter: @MarkOneinFour), I tweeted “helpful advice” about light boxes. Of course, he’d tried that back at the dawn of time. Luckily he let me off the hook graciously.  Earlier today, I spotted a tweet about a medication issue I had faced myself. I replied with several helpful practical tips … Or so I thought. Because then I remembered … no advice had been sought. And that’s when I coined the term “madsplaining“. Let me explain.

I first came across the term “mansplaining” (with an “n”) when tweeter Phil Dore (twitter @thus_spake_z) used it.  When I did an online search, this (from Urban Dictionary) was on the first page that came up:

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“Mansplaining: To explain in a patronizing manner, assuming total ignorance on the part of those listening. The mansplainer is often shocked and hurt when their mansplanation is not taken as absolute fact, criticized or even rejected altogether. Named for a behavior commonly exhibited by male newbies on internet forums frequented primarily by women. Often leads to a flounce. Either sex can be guilty of mansplaining.

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A lot of the terribly clever online debate passes right over my head, and that’s as far as my knowledge of “mansplaining” goes (though I understand it’s been used online in feminist discourse for several years).  As it happened, it fitted perfectly with an encounter I’d recently had with a trainee psychiatrist: he was very new to twitter, had dived into an ongoing conversation with a patronising explanation, and was then flumoxed when I pointed that out. The “flounce” went on for quite some time.

And so what do you think happened when I first tweeted the word madsplaining …? Yes, you guessed it: I got mansplained!

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So after “mansplaining”, do we have madsplaining? ie offering unsolicited advice to someone on how they should manage their mental health (My tweet)

I think that would be psychsplaining. mad folks being splained to. but i notice your rhetoric is from feminist & poc activism… – Erick Fabris (twitter: @exic)

Oh hi Erick, are you mansplaining to me what I mean when I say madsplaining …? (My tweet)

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Priceless. Well, thanks for asking, Erick, but I do mean just that: madsplaining. As other tweeps chipped in:

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This is perfect! madsplaining gets right on my tits! “Have you just tried….?” “Everyone worries…” Hahahahaha my new word! – Molly Teaser (twitter @mollteaser36)

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Always fascinated about how much they know about their advice and how little they know of me. It’s the assumption that just because their advice works on their own neurosis, it works for everyone else. – MH Extremist (twitter @wildwalkerwoman)

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“You mean: “Snap out of it” “cheer up!” It’s all in your mind” “What have you got to be depressed about?” YES. Can you imagine this: “Cancer? You don’t look like you have cancer. Pull yourself together, get over it.” Ect” – MScarlet Wilde (twitter @wilde)

 

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I draw a distinction between madsplaining and what I call “patienting“, which is when someone uses your status as a “mental patient” to try to shut you up. An example would be (as has happened to me several times on twitter) a mental health professional will say to me something along the lines of, “Think you’d better take your meds now, love”.  Perhaps that’s a topic for another blog.

And, finally, here’s a little interchange to bring a smile to your face:

Or will this all turn meta and become splainsplaining? – Phil 

I blame you entirely, Phil, for introducing me to the word “mansplaining” … which you can take any way you like ;-D (My tweet)

The concept of splainsplaining is kinda blowing my mind – Dr Sarah Knowles (twitter: @dr_know)

Don’t worry, I’ll splainsplainsplain it to you – Phil

*head explodes* – Sarah

 

Sometimes I love twitter. And sometimes I need to take my own advice.

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• My twitter conversation on Storify:
  • Madsplaining (a short one this time!)
  • Follow up – Sanesplaining and psychsplaining – my online research on the origins & use of these terms (another short one)
• What have you got to be so depressed about? – Men Will Pause blog by Scarlet Wilde (twitter: @wilde), written in response to the madsplaining twitter conversation
• Eric Fabris‘s website – Mr Fabris is a Canadian researcher, artist and writer. Amongst other things, he lectures at the Ryerson University School of Disability Studies.

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But we’re not all like that …

“But we’re not all like that!” We’ve all said it, haven’t we? Read or heard something that seems to criticise a group we belong to or feel part of and said, “But we’re not all like that!” I know I have. It’s instinctive. Especially so for those working in social care or the NHS, perhaps even more so for those working in mental health which seems to get criticism from every angle. There are many committed, hard-working, professional, compassionate staff who do the best they can in difficult circumstances, make a  positive difference to people’s lives and do a really good job.

So when a dedicated  GP or mental health occupational therapist hears a story on the news about terrible care in a service elsewhere, he might say, “But not all of us are like that!” A compassionate doctor or psychiatric nurse will read a story about a patient abused in another hospital and say, “We don’t all do that!” A social worker will see a story on a soap about a child being taken from its mother and say, “Not all social workers!” A psychiatrist or mental health healthcare assistant will read a patient describing their experience of poor care and tweet back, “But we’re not all like that!” It’s true: we’re not. But … And there is a but.

What happens when someone – such as a patient who’s had a brutal experience of mental health care or been badly let down by the NHS when she needed help – describes their experience and gets the response, “But we’re not all like that!”? What happens? The conversation stops being about the person who’s describing their own difficult experience and becomes … all about the person who’s interrupted. It becomes all about the interrupter talking about me,  me, me.

Now that’s understandable … to an extent. We all have our own experiences and perspectives. We all have our own hot buttons or soft spots. Many working in the mental health field have, I’ve come to learn through twitter, their own personal experience of mental health problems – whether directly or through family members. It really isn’t them and us.

It’s always easiest to see our own perspective. But … there is a time and a place for raising it. When someone is describing their own experience of pain, abuse or neglect it may, I’d suggest, not be the time to butt in defensively and talk about yourself. Sometimes, a sense of perspective is needed. This is well illustrated, it seems to me, with this simple anecdote:

Me: Someone driving a blue Toyota just hit and killed my four year old child.

You: I drive a blue Toyota. Not everyone who drives a blue Toyota hits four year old children.

What does this do? I was talking about having been recently bereaved: you turn the conversation around to … you being a good driver. No doubt that’s true or, if not, you sincerely believe it to be the case, are a conscientious driver and are genuinely offended at any suggestion you might not be. Perhaps there have even recently been stories in the press about bad drivers. But … was I criticising drivers of blue Toyotas? No. Was I criticising drivers? No. Was I criticising you? No. I was talking about the painful personal experience of bereavement.

Or, as mental health researcher Dr Sarah Knowles tweeted:

“I broke my leg :(” “Okay, but not all legs are broken. Why do you generalise? For example my leg is intact.” “I … what?!”

Put like that, it should, I hope, be obvious why the response, “But we’re not like that!” is inappropriate. And how responding or butting in with, “But we’re not all like that!” derails the conversation and belittles the experience of the person describing it.

It’s not about you.

Why do I raise this now? Because the “But we’re not all like that!” argument was raised earlier this evening in a twitter conversation. The conversation did – as these sorts of things so often do on twitter – broaden out to include many other tweeps and move on to other debating gambits, such as victim blaming, “if you can’t stand the heat, stay out of the kitchen” and the “them and us” culture. Read on for some fascinating insights and well-made points.

As Charlotte Walker (twitter @BipolarBlogger) tweeted:

“If someone has a terrible experience, I am going to honour that experience. There is no point in saying to someone who’s waited 18 months for CBT, ‘Oh don’t be harsh, in other Trusts it’s better.’ No use at all.”

And as NHS doctor Elin Roddy (twitter: @elinlowri) tweeted:

“I always remember you saying – just because you don’t work in a bad service doesn’t mean they don’t exist … It stuck with me and stops me getting too defensive (I hope) when people criticise health care.”

Next time you’re tempted to butt in and say, “But we’re not all like that!”, take a breath, pause and think … Maybe it’s not the right time to interrupt and hijack the conversation. Maybe  it’s time, instead, to listen.  Maybe it’s not about you. And, next time someone tries to stop you in your tracks with a “But we’re not all like that!”, maybe send them a link to this blog!

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• My Storify stories:
  • This evening’s twitter conversation
  • A continuation of the conversation on twitter (But we’re not all like that – part 2)
  • Some twitter comments on the blog piece (But we’re not all like that – part 3) – it’s funny how how much push back I got to a blog piece on being defensive!
  • But we’re not all like that (again) – 17th October
• The Racism School website (which I found a hard but illuminating read), where I first read the “blue Toyota” anecdote – HT @stavvers
• The positive effects of social media (mainly twitter!) on my mental health – My Journey Down the Road Less Travelled blog – read more about her here for another insight into why, sometimes, it might be inappropriate to butt in and disagree when someone is describing a painful personal topic – Simply Positive (twitter – @positivesimply)
  
• Reflections on “But we’re not like that!” – twitter, criticism & PPI – by Dr Sarah Knowles (twitter @dr_know) (19th August) – An excellent example of the learning that can come through engagement on twitter
• Derailing for Dummies – A how-to guide for trivialising and dismissing someone else’s perspective and experience. “After reading this guide, you’ll be able to marginalise anyone!”

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Let’s talk about poo! It’s tweet chat time …

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Here’s the transcript & fab wordcloud from the tweet chat on 1st August – patients & nurses all talking about poo!

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This Thursday 1st August at 8pm, We Nurses will be hosting a tweet chat about constipation problems, at my suggestion. Here’s my earlier blog on constipation induced by psychiatric medication, including 25 tips you can try for yourself. It is my most read blog piece ever. I guess that makes me some sort of Poo Queen. Hmm …

However, if it gets people talking about an important but often overlooked or covered up topic, that’s all to the good. Let’s break the taboo about poo and make a date in our diaries for this Thursday’s poo chat!

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Background reading:

• My blog on the topic:  Constipation: embarrassment, discomfort … and Poo Pride!
• From We Nurses:
  • link to the guide on the upcoming tweet chat: Talking about poo
  • Tweet chats made simple – handy guide to tweet chats if you’re a newbie
• NHS Choices: Constipation
• What is the Bristol stool form scale anyway …? A brief overview

The Bristol stool tart cake!

 

Additional information on constipation:

• BUPA: Constipation
• Cancer Research UK:
  • Symptoms of constipation
  • Causes of constipation
  • Assessing your constipation
• Patient UK:
  • Constipation in adults
  • Constipation in children
• Royal College of Nursing: Management of lower bowel dysfunction

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Mental health nurse & patient tweet chat: what do newbies need to know?

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The tweet chat took place on Thursday 20th February 2014 with We Nurses – catch up with the discussion by taking a look at the full transcript!

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I’m planning my first one hour tweet chat in a couple of weeks (date to be announced). (Check out my quick guide to tweet chats for more on what they are – this and other helpful links are below). Here’s what I have in mind, for an inpatient mental health nursing tweet chat:

• Patients: Are you a patient who’s experienced inpatient mental health nursing? What would you like the newbies to know – the student nurses about to start a placement or the newly qualified mental health nurse. What things that nurses did – good or bad – made a difference to your experience on ward?
• Students: Are you about to qualify as a mental health nurse? Are you a student nurse about to start your mental health placement?  What is the balance between fear and excitement? What would you like to know? What practical concerns do you have? What do you want help with to make your first days on ward a success?
• Nurses: Are you a qualified mental health nurse? Are you a student nurse who has completed your mental health placement? What tips would you like to pass on to newbies about to qualify or about to undertake a placement? What are those little insider tips that really helped? What would you have liked to know when you were a newbie?

I’d like to be able to share some really useful tips to help new mental health nurses and nursing students make their best start on ward, because that benefits both staff and patients. Here are some example questions I’ve thought up that students might want to know the answer to:

“How can I prepare for my placement so I get the most from it?”

“How can I put the knowledge I’ve learned at university into practice on the ward?”

“How can I settle in as quickly as possible so I fit in with my nursing team and ward life?”

“How can I switch off after a shift?”

“What should I do if I see another nurse doing treating a patient unkindly?”

Here are some examples of useful tips to pass on:

“The Bic 4-colour pens are really useful for filling in your paperwork.”

“Remember to always respect the patient as an individual and see past the diagnosis.”

“Don’t make assumptions or have preconceived ideas based on what you’ve been told before. Remain open-minded and make your own judgments based on your own personal experiences.”

As I’m not a nurse and haven’t run a tweet chat before, I’ve invited @MHnursechat – associated with the awesome We Nurses website and tweet chats – to run a joint tweet chat with me. We’re going to be discussing how this will work and, hopefully, setting a date. Very exciting!

In preparation for the tweet chat, I’m asking you to please share your tips and questions. That will help set the agenda to be followed and the areas we’ll focus on in the tweet chat – so it covers the most burning questions and drills down to the most useful tips. It may be that there will be more than one tweet chat on this topic – perhaps one covering what nurses need to know in their first few days, and another for when they’ve been there a few weeks. We’ll see. A tweet chat needs to have enough of a focus to engage people without overwhelming them, but at the same time enough breadth so it doesn’t peter out prematurely! If there are other topics you think would be good for tweet chats then please let me know!

You can comment below or tweet me (please don’t try to pack more than one query or tip into each tweet ) @Sectioned_ (please remember the underscore). It’s helpful if you could say whether you’re offering your comment from your experience as a patient, nurse or student. Look forward to hearing from you!

Why a tweet chat? I’m often interested in discovering what other tweeps think about topics and then sharing those insights. So, quite a few times, I’ve tweeted questions then collated the responses into a Storify story which I’ve sometimes turned into a blog. (I was rather excited to learn that this is called “crowd sourcing” and “curating the chat”.) This time I thought I’d try making it a bit more organised & involve more people: I’m beginning to learn just how valuable Twitter is as a way to bring together groups of people to share views openly in a way they might not otherwise do. (I’m told this is called “disruption” – disrupting the natural order of things and mixing it up, like mental health peeps and staff learning together.) (Thanks to Victoria Betton for all the cool jargon!)

Why this topic? After all, I’m not a nurse. As a child, however, I remember being taken to one of the big long-stay psychiatric hospitals of the sort portrayed in the film One Flew Over the Cuckoo’s Nest. I remember the high ceilings, big windows and long corridors. Happily I wasn’t being booked in myself. I was visiting family friends who worked there as psychiatric nurses. Members of my family also worked on psychiatric wards and in nursing.  When I was sectioned a couple of years ago, my inpatient experience fell far short of the care I would hope all psychiatric nurses aim to deliver. You could say that everything that could go wrong did go wrong. But, as I’ve been around nurses my whole life, I know that the image and practice of mental health nursing has come a very long way since the fearsomely controlling figure portrayed by Nurse Ratched. For me, nurses are (or should be) an essential part of the team that helps get me well. So I’m all for sharing tips and best practice to help nurses be their best. I’m hoping this tweet chat will be one small way to do that.

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• Guide to tweet chats – all you need to know to join in your first tweet chat or get more from them
• Mental health jargon buster and acronym buster – please send yours in! We’ll try to avoid jargon during the tweet chat itself, but if the jargon’s in the jargon buster, I can just tweet a copy of that by way of explanation

For the nurses and student nurses amongst you, here’s some nurse-focussed content:

• We Nurses website
• Archive of We Nurses tweet chats
• We Nurses guide to tweet chat netiquette (etiquette for nurses using tweet chats)
• Transcript of the tweet chat with all the participants’ tweets collated – take a look at this fascinating and wide-ranging discussion with lots of different perspectives!

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