Tag Archives: psychiatric wards

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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“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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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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Do you remember your first time?

16 Nov
My bedspace after one incidence of forced treatment by six people.

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

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Open quotes

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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, Close quoteser. 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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My previous posts on forced treatment (each containing links):

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On restraint, conflict and containment:

 

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Stoptober, supporting lifestyle change and preventing detained patients from smoking

14 Oct

   SLAM smoke free

This month is “Stoptober”, the annual campaign encouraging smokers to stop smoking for 28 days during the month of October. It’s an opportunity I heartily recommend people take, if they wish: choosing to stop smoking for 28 days gives you an increased chance of stopping smoking for good, like I did, a decade or so ago. And that would be a good thing, for all sorts of reasons.

On 1st October, South London and Maudsley NHS Trust (SLaM) went “smoke free”. This means that, across its entire site, no-one – staff, patient, visitor – will be permitted to smoke. The ban covers all of its hospital sites, namely the Maudsley Hospital in Southwark, Lambeth Hospital, Bethlem Royal Hospital in Bromley and the Ladywell Unit at Lewisham Hospital. SLaM, whether on ward or – and this is new – outdoors. And here’s the issue I’m highlighting today: that includes a ban on detained patients who do not have leave smoking. People struggling to cope with a mental health crisis and sectioned will now have have no opportunity to go and have a cigarette designated outdoor areas in the grounds, the ‘garden’ of their temporary surrogate home.

I mention SLaM simply because they are one of the only NHS trusts to introduce a total ban and because I’ve chatted with them on twitter about their policy. It’s funny what I randomly stumble across on twitter.

Stoptober SLAM

Stoptober SectionedStoptober SLAM (2)Stoptober Late Fines

I asked SLaM whether it would be requiring staff to be ‘smoke free’ 24 hours a day; or whether detained patients would be permitted to smoke outside of office hours; after all, if a policy is about health, and both staff and patients have the lungs, the same policy should apply.

Stoptober SLAM (3)Stoptober stillicides

“[S]upport[ing] people who smoke to make healthy lifestyle choces and have access to treatment for nicotene dependency” is something I encourage and does not depend on imposing a total ban. However, while staff were to be encouraged to stop smoking, patients were to be forced to do so. I asked whether, to help make wards healthier, would detained patients have access to exercise, healthy food, fresh air? Would harmful practices like forced medication be banned. No response.

Stoptober Sectioned (3)Stoptober Ermintrude

Extending the ban on smoking on NHS premises is NHS policy. The National Institute for Health and Care Excellence (NICE) issued new guidelines last year, updating those from 2008 which banned smoking indoors. SLaM matron Mary Yates contributed to the development of NICE’s national smokefree guidelines which is perhaps why SLaM is one of the early adopters. But what of psychiataric detainees? Somehow, along the way, the rights of mental health patients to make choices about our own lives seem to have been bulldozed by the familiar patronising undertones that infect the whole of mental health services.

“But smoking is harmful! We have a duty to our patients! We must do everything we can to encourage and support patients to make healthy lifestyle choices!” I agree with all of that. However, smoking is not a medical or mental health emergency: it is a bad habit, an unhealthy habit, a poor lifestyle choice, one to be discouraged – and one where people need every opportunity and support to stop or cut down if they choose. Patients with mental health problems die decades before the general population from conditions such as lung cancer, heart disease and stroke. It’s a serious problem and one which needs to be addressed, urgently, diligently and intensely.

Stoptober Pipsterish

However, no one is sectioned for nicotine addiction. No one is in immediate danger of death from being a cigarette smoker. Being a smoker is not a medical emergency. The presenting problem is a mental health crisis. A mental health crisis is not the time to impose lifestyle changes. To seek to impose lifestyle changes at that time is, as Mark Brown put it, “awesome mission creep”.

What is the reason for extending the ban on smoking into the grounds of psychiatric hospitals? The indoors ban introduced a decade ago had clear aims, but what are the aims of the outdoor ban? SLaM says in its page on it’s new ‘smoke free’ policy that its aims are “[t]o create a healthier environment for everyone] and to “reduce … inequality”. Are those aims – vague as they seem – achieved by imposing temporary abstinence on psychiatric detainees? Is there evidence that enforced temporary abstinence provides sustained behaviour change?

Stoptober Sectioned (2)

For instance, do detainees prevented from smoking whilst on ward remain abstinent on discharge – or, say, 6 months post-discharge? We don’t know because, as the NICE guidelines acknowldge, there are huge gaps in the evidence. This is an evidence-free zone. It is a policy based on a toxic combination of public health moralising about smoking and paternalism about people with mental health problems.

And it is a dangerous policy too. Not only is there no evidence that enforced temporary abstinence improves health outcomes post-discharge, there is clear evidence that, in the short-term, bans are potentially dangerous for patients. This is because smoking impacts on the levels of medication patients require. Most inpatient stays are short-term – two to three weeks on average – and, for a short-term stay, stopping smoking suddenly can mean a dangerous rise in in the levels of medication in the bloodstream that will need to be monitored (which does not happen). And, on discharge, any levels of medication established during detention will be impacted on the (likely) resumption of smoking on release.

Smoking is just about the worst thing anyone can do to their body apart from, say, sticking their head into a giant mincer & pressing the on-button. I am a non-smoker and wish everyoe else was too. I wish smoking had never been invented. It breaks my heart when friends smoke (and makes me turn up my nose and back away from the smell); I want them to be around, not die prematurely early from smoking-related disease. That’s why I want all the help in the world made available to people with mental health problems who wish to stop smoking. But I don’t for one second think that unevidenced temporary enforced abstinence should be any part of the solution. There’s a difference between saying “Smoking is harmful” (which clearly it is, and has a disproportionately large impact on people with mental health problems) and saying “This new policy is the most best & effective way to reduce that harm” – which clearly it isn’t, because there’s no evidence base.

Stoptober pesserine

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web links 5Background information:

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Storify stories

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Input from patients:

  • Here I’ll put links to all the patient consultations I come across *taps fingers* *checks watch* *waits*

Secrets from the modern day asylum

20 Aug
Actor Ray Winstone in episode 1 of ITV's new series Secrets from the Asylum

Actor Ray Winstone in episode 1 of ITV’s new series Secrets from the Asylum

 

This evening, episode 1 of ITV’s new family history series Secrets from the Asylum aired. It delves into the murky world of dreaded Victorian lunatic asylums through the eyes of celebrities who make emotional discoveries about relatives incarcerated in the distant past. With a doom-laden commentory and spooky music, viewers were invited to be shocked that people with senile dementia were condemned as lunatics, to gasp at disturbing treatments like chaining or hosing with cold water (“treatments which now seem crazy themselves”) and to shake their heads at “sickening attitudes towards the mentally ill”.

I’ve often said that one of life’s cruel ironies is that, whilst nowadays we condemn with obvious horror what was done in the name of mental health care in the past, we don’t recognise the horror of some of what is being done now, today, in modern psychiatric hospitals. What is going on now – behind locked doors, out of sight, to the country’s most vulnerable people, sometimes by the most brutal of “carers” – goes unremarked. I’ve said before that, in the future, we will look back at some of today’s practice of mental health care with horror, just as we now look back  in horror on the lunatic asylum. How long will it be before we do that? And why can’t the general public see it now?

Because it is happening now. This minute, as I write this piece, as you read it, horrors of commission and omission, of things done and not done, are taking place in the name of mental health care. And yet the damage they cause – the lack of job satisfaction of good staff, the lives half-lived through inadequate treatment and support and even the lives cut short – go largely unremarked. It’s a secret from the modern day asylum, because no one is looking.

Only this morning, government minister Norman Lamb announced he was establishing a new mental health task force to look at the state of children and young people’s mental health care. Some of the papers ran the story. There was an excellent feature on the morning news. But, by lunchtime, it seems it had all been forgotten. What – if not hundreds of sick children detained in police cells for want of treatment of hospital beds, of sick children bussed from hospital to hospital, hundreds of miles from their parents – what could make the wider public see the utter inhumanity of the way in which people with mental health problems are treated today? If even sick children won’t make the public – and hence politicians – sit up and reach into their back pockes for some serious money and some serious thought how those in need of help can best be supported, then what hope is there, really for things to improve in mental health services in this country?

So today, the day that Norman Lamb announced that children’s mental health services were “in the dark ages”, ITV launches a new two-part series, Secrets from the Asylum. We gawp at the outdated practices of the old lunatic asylums. We gasp at the people locked away without proper treatment. We shake our heads in judgment at the barbaric treatments in days gone by.

And yet, it wasn’t until very recently that there were any effective treatments for mental distress and mental illness. Those running the old Victorian asylums had, in a way, an excuse. They did the best they could. In the words of the title to episode 1 , those trying to help people with mental health problems in the past had the “best intentions”. Nowadays, we don’t have that excuse.

Nowadays, there are treatments, help and support that can make a real difference to people’s lives. And yet … they are not employed. And, worst still, sometimes – in fact, far too often – practices that we know – through logic, humanity and research studies – are actively harmful to people are employed instead.

Why is that? It’s hard to explain. In large part it will be down to the resources allocated to NHS mental health care: with few staff on wards and paperwork to complete, there isn’t enough time to spend building therapeutic alliances with patients. There isn’t enough time to show the care and compassion, kindness and support so vital to helping people in mental health crisis. With wards that are badly designed and ill-equipped (as was the one on which I was detained), staff will be struggling from the outset.

But, also, it seems that there is something to do with the training of mental health professionals that creates a barrier, preventing staff from recognising human suffering. On ward, it seemed to me that the priority of even well-meaning staff was ward management. “Order and control took precedence over care,” said the commetator in episode 1: it seems that nothing has changed.

I speak as someone who was so traumatised by my experience of inpatient psychiatric care that I came out with the gift of PTSD (post-traumatic stress injury). Tonight’s episode refers to people in the past – before the advent of Victorian asylums – being chained, caged and beaten: I have been “chained” by means of the chemical cosh, a cocktail of drugs intended to quell me; I have been “caged” by being held in seclusion; I have been “beaten” by staff who assaulted me (in the criminal sense) and many more who physically restrained me, six at a time, for forced treatment and by patients from whom the staff did not protect me. Based on my experience of modern day inpatient psychiatric care, it doesn’t seem to me that there’s any obvious reason for us to pick over the bones of history and gloat about how far we’ve come.

And how is it such practices are allowed to continue, without a public outcry? Several powerful reasons. One is that there is still an enormous stigma to mental health problems. There is a shame to having been treated in a psychiatric hospital. It’s not something people speak out about readily. Another reason is that psychiatric patients lack almost any credibility. In an NHS system which we know is hard for even staff to raise concerns about and which has, it seems, a culture of closing ranks and covering up, what hope for patients’ complaints to be dealt with? And of course these things go on behind closed doors, out of sight. No one sees apart from those incarcerated in the strange world of the psychiatric ward, whether they are staff or patients.

It isn’t just me who thinks that some of what goes on on inpatient psychiatric wards is wrong. Here are a couple of examples from this week:

  • Here is a conversation that took place a couple of days ago when a psychiatrist, a psychiatric nurse and I discussed our experiences of physical restraint and bullying on mental health wards. The strong impression is that what I experienced is the norm, rather than the exception, which is heartbreaking.
  • Here is a post by Skye, the Secret Schizophrenic, about an upsetting incident that happened to her on ward recently. It illustrates how what happens on wards now can confound humanity and logic.
  • Here are some tweets on the hashtag #secretsfromtheasylum comparing modern day practices with those in Victorian asylums and questioning whether it really all is in the past.

I do know people who have had excellent experiences of psychiatric inpatient care that has transformed their lives for the better. It gives me hope. It should be the norm. Especially now that we there are effective treatments available to help people recover from  or manage mental health problems.

What is the hook? What is it that makes people want to watch programmes like Secrets from the Asylum but not care about the way mental health patients of today are neglected and mistreated? And how can some aspect of that be harnessed to our benefit, so that the lessons of the past are learned? Those are questions I wish I had the answer to but don’t.

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Background – recent experiences of psychiatric hospitals:

 

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Forced medication: resistance is futile

19 Mar
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.

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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Hospital inspections and dashed hopes

13 Mar

Green tick list

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My weekly updates on waiting to hear from the hospital inspectors in response to my report. Months later, I’ve still heard nothing apart from automated email responses.

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I’ve spoken before about my experiences in hospital: I was brutalised at my most vulnerable to the extent I came out with post-traumatic stress disorder (PTSD). I recently found out that the hospitals inspector had given the place where that was done to me full marks. And not for the first time.

It seems as if the inspection system is a rubber stamp, reassuring people outside that everything is just fine. We can all relax and look away.

I hadn’t been able to contact the inspectors before: I’m still traumatised by the hospital experience (and I’m still waiting for PTSD treatment). But, when I learned that the inspectors were going in again, I made myself make contact with them.

It was hard, but I did it. I’d known for a while that it was possible to report concerns (anonymously, if you wish) via the hospital inspector’s website. That seemed a good way to give the inspectors a heads up on some things to look out for: little signs and subtle clues that things might be amiss (if they still were). To encourage them to join the dots, to look and see where the hints might lead – rather than dismissing them as individual, isolated issues of little importance. To follow the trail to find out whether, to use their phraseology, the hospital might not be meeting all of its essential standards.

I tried several times to make that report, before eventually succeeding. First, there was the challenge of steeling myself to do it: to bring to mind the poor care I’d received (without setting off too many flashbacks) and think about how to phrase it in a way the inspectors might find constructive. Any number of times that barrier was too much for me. Then there was the difficulty in navigating the website. Often I would go there, try my hardest to get to the right spot, fail and leave. It took a lot of effort – emotional and practical – but, finally, I was able to make contact.

However, other than automated responses, I have received no reply from the hospital inspectors. No response to say that my query was awaiting attention, and perhaps a timescale within which I might hear back. To this day, I’ve had no reply.

And now, the opportunity to make a difference has passed. The inspection has taken place. The inspectors have published their report. They gave the hospital full marks, as if to say, “Relax everyone, it’s safe to look away again.”

But it is? Reading the report, I can see little clues – remarks at the end, comments by patients, concerns mentioned briefly – that have seemingly been brushed aside. It’s as if they’re saying, “Move along now. Nothing to see here.” Despite these niggles, the hospital was still given full marks. An unbroken list of green ticks. All essential standards were met, apparently. So the message seems to be: this is the standard of care we expect the hospital to give. This – what was done to you and what may still be being done to others now – is good enough. This hospital need not change. This hospital is good enough. All is well.Hospital inspection standards

It’s hard to know what to think about that or how to process it.

In a way, it’s a vindication of not having raised any issues before (which would have come at some personal cost to me): because, clearly, they would not have been a cause for concern. I knew I wasn’t strong enough to stand up to the hospital and raise concerns direct: as my dad said to me, “You can’t break concrete with a feather.” I assumed that I’d be strong enough eventually, after treatment (other than drugs) – but I’m still waiting for that. I felt it was my duty to do what I could to try to make a difference.

Now, though, it seems it didn’t matter after all. Because, according to the inspectors, the hospital is doing fine. Or, perhaps, no on really wants to know what’s going on.

“The hospital is doing just fine, thanks for asking. And we’ll be back in another 3 years, to give it full marks again. Have a nice day now!”

When I searched under “hospital inspections” for an image to head this piece, up came a picture of one of the Winterbourne View residents being dragged by the arm. It seemed apt. If hospital inspections were effective, it wouldn’t need undercover reporters filming secretly (as they did at Winterbourne View) to expose abuses. That’s if we want to find them.

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Some weird conversations with the CQC’s Kay Sheldon

  • June 2014 – In which Kay Sheldon asks for my details TEN times in a row.
  • June 2014 – Some conversations arising.
  • November 2014 – Kay wades in again with victim-blaming.

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Hopefulness

11 Mar

Daffodils at the allotment

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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Patients or prisoners? Late back or escaped?

25 Feb

The Great Escape film poster

Have you ever been an “escaped prisoner”? Or, to be more specific, have you ever been in a mental health hospital and been more than half an hour late back from leave? I’ve done the latter. And, according to last night’s BBC London News lead story, these two are the same thing.

Yesterday, as I was working on the computer, I had the BBC on in the background. My ears pricked up when I heard that a story on a mental health unit would lead the news that night. But not for a good reason. Of course, it was a story about mental health and violent crime. I tuned into the news bulletin on iPlayer later on. And it was worse than I thought.

The story was about patients at the John Howard Centre, a mental health hospital in London. A request under the Freedom of Information Act had revealed that patients had been recorded as being over 30 minutes late back from leave over 200 times in the past 13 years. Patients coming back late to their ward? Not that interesting a story, you’d think.

That is until you replace the words “late back” with “escaped” and “patients” with “prisoners”. BBC journalist Jean MacKenzie had translated that into a report that over two hundred prisoners had escaped.

For extra frisson, MacKenzie delivered her piece to camera outside the high chain link fence surrounding the centre (a medium secure unit), and the story was illustrated with the unsmiling photograph of one such “escaped prisoner”, who had been convicted of murder. The message to the public? Behind these high security fences is a seething mass of unpredictable and potentially dangerous prisoners; and two hundred violent, deranged prisoners have escaped and are loose on the streets of London.

Somewhat different to the picture revealed by the Freedom of Information Act request. But far more lively for the evening news audiences, playing, as it did, to stereotypes and prejudices linking mental health and violent crime.

The way this story was reported, I would once have been recorded as an “escaped prisoner”. Who’d have thought it? When I was sectioned, I was once late back from leave. Why? Because I’d been at the funfair with my neighbour and her children (one in a pushchair) having been told by one nurse before we’d left for my two hours leave that I had half an hour’s leeway so long as I rang to let them know. We spent a wonderful time on the dodgems and other fairground rides and still had tokens left to spend when I noticed the time and realised I’d be back late unless we left immediately. I rang the ward right away, as I’d been told to do. This time, unfortunately, I got through to another nurse – the ward’s enforcer – who said no, I had to be back on time or I’d be reported to the consultant. I looked at my neighbour, she looked at me, we grabbed the children and ran all the way to the hospital. The elder child was dragged, howling with disappointment and hunger; the younger one pushed at high speed in the pushchair. I was delivered back to the ward just after the 30 minutes leeway had expired. Some “escaped prisoner”.

Here are some of the responses of the lovely twitter people:

Clairus (@Hellsbell) tweeted BBC London News to say:

“Why did Jean MacKenzie call mental health patients late back from leave “prisoners” who’d “escaped”?” apology needed!

Doris (@isthismental) did the same, but added more detail:

“Shocking repeated error BBC London News. Patients at John Howard Centre and any mental health hospital are patients not prisoners. If I’m 35 minutes late back from leave from hospital, it is right that this is recorded as AWOL [absent without leave]. It would be neglectful not to. Usually I’m late because my bus was late and [there is] only 1 irregular bus [that] actually goes to the hospital (that screams of stigma). All your report has done is whip up misguided fears and stigma about mental health and given Majorie Wallace a platform. I’ve been late back from hospital leave so I can get a take away. H&S [Health & Safety] rules say hot food can’t be kept so it’s take away or starve. Once I was technically AWOL from a ward, but on site. I ‘refused’ to return to the ward until homophobic abuse was sorted.”

Earlier today, I (and several others) received the following response from Antony Dore, Editor, BBC London TV News weekdays:

“You’re right – we shouldn’t have used ‘prisoners’. Have discussed this issue with those involved.”

To which I responded:

“Thank you. Will there be a correction broadcast in the same news bulletins tonight?”

Several others raised the same point, which is that, if a prominent report is incorrect – and the story lead the 6:30pm bulletin and was story 2 of 2 in the 10:30pm bulletin – a correction should be issued with equal prominence. The incorrect impression given must be corrected.

It’s stories like these – presenting mental health problems and mental health units purely in the context of violent crime and escaped prisoners – which help to perpetuate ignorance, prejudice and discrimination against people like me. Stories like these create shame and stigma. Stories like these belong to the past. It seems the John Howard Centre is portrayed in stories like this as almost equivalent to a Broadmoor in the heart of residential London.

I’ll be watching the news tonight to see BBC London News does broadcast a correction.

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There was no correction on the evening’s news bulletin.

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The BBC is not alone in the way it reported the story:

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