“Safe” staffing on mental health wards

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

 

.

.

.

A total smoking ban for detained psychiatric patients stinks of coercion

 

Following on from my piece ‘Banned by the BMJ’, below is the article which was to be published in the British Medical Journal on 7th November as part of the ‘Head to Head’ series ahead of the Maudsley debate. I was to put the ‘no’ side of the debate. This piece was written in that context with the medical readership of the British Medical Journal in mind – an audience which had never heard of me and which may have been unfamiliar with many of the materials I reference – and to the BMJ’s word limit.

.

I was detained under UK mental health law in 2011. I am a non-smoker.

Arguing that detained patients should be banned completely from smoking is, in essence, arguing that people with mental health problems should not be treated as full human beings but instead as a subset ripe for discrimination.

Everyone, including doctors, makes broad assumptions about psychiatric patients and our ability to make choices and interact with others. When we are locked up, the medical profession assumes it has the moral right to impose lifestyle changes. However, no-one is sectioned for being a smoker: we are sectioned because we’re considered a danger to ourselves or, more rarely, others. Being a smoker is not a healthcare emergency, and a mental health crisis is not the time to impose lifestyle changes.[1]

The ban on smoking inside psychiatric hospitals was introduced a decade ago, a time when people with mental health problems were side-lined far more. The indoor ban had clear aims: to create a safer working environment for staff and to respect the right of non-smoking patients to have a smoke-free surrogate home. The rights of smoking patients were protected by providing access to designated outdoor smoking areas. The aims of the outdoor ban are less clear. For example, the South London and Maudsley NHS Foundation Trust vaguely says that it aims to “create a healthier environment for everyone” and “reduce … inequality.” [2]

A complete ban prevents detained smokers without leave from smoking (or, rather, smoking overtly). It relies on the ward doors being locked. You do not increase patient “equality” by use of force. It is simply a case of “because we can”.

I am very much in favour of making psychiatric wards healthier and bringing about sustainable improvements to patients’ health. When I was fragile and detained, the ward environment was toxic. Food with no fibre, poor sleep hygiene measures, no access to exercise or fresh air, no therapy and nothing to do except sit round eating biscuits and drinking coffee – and avoid being assaulted. I was repeatedly medicated by force. I have since been diagnosed with post-traumatic stress disorder. [3] There was no smoking reduction or cessation help available. There is a great deal of scope for psychiatric hospitals to make wards healthier. [4] [5] [6]

If improving health were the reason for the ban, hospitals would make stopping smoking compulsory for staff too – 24 hours a day, even at home. That, of course won’t happen because staff wouldn’t stand for it. Unlike staff, though, patients can’t vote with their feet.

Behind all this lies a weight of history, law and medical practice which call on the entrenched notion that people with mental health problems need not be considered full human beings. The ability to use force runs through psychiatry like letters through a stick of rock. Coercion is the backbone of psychiatry. Patients experience psychiatric wards as coercive, not therapeutic.[7] [8] I was treated by force. I was locked in seclusion with no water, no food, no access to a toilet and no contact with the outside world, without even my glasses or shoes. Psychiatrists who visit wards do not truly know what goes on behind closed doors. Trusts must make wards better, not more coercive.

Where is the evidence that SLaM’s aims will be achieved by temporary enforced abstinence based on dominance, duress and fear? A ward stay is an opportunity to build therapeutic relationships with staff that may continue afterwards in the community and could lead to sustainable smoking reduction or even cessation and reduce healthcare inequalities. In psychiatry, unlike any other medical specialty, engagement with patients and persuasion are relegated to “nice to haves.” If patients can’t go elsewhere for medical advice because they are locked up and the law gives staff the right to use force, there’s no need to hone these skills.

Law and societal changes are moving towards reducing discrimination against people with mental health problems. [9] [10] [11] [12] With this ban, psychiatry is moving against the trend. This is morally indefensible and goes against patients’ rights to be at the centre of decisions about our care and treatment. Medicine shouldn’t be about imposing a doctor-dictated “fix” but helping patients to find to solutions that work in our lives.[13]

.

References:

1. Smoking and psychiatric wards – Georgia Rambles blog, Dr Georgia Belam (30 September 2014)

2. Stoptober, supporting lifestyle change and preventing psychiatric patients from smoking – Sectioned UK blog, @Sectioned_ (14 October 2014)

3. Do you remember your first time? – Sectioned UK blog (16 November 2014)

4. A smoking ban for mental health workers in the workplace – Nurse With Glasses blog, @nurse_w_glasses (15 November 2013)

5. Smoking – Wardipedia, a World of Ward Knowledge, @WardipediaNews

6. How can psychiatric wards become better, healthier places? – Sectioned UK blog (26 October 2015)

7. On the ward – abuse in the mental health system – Schizoaffected3 blog, @schizoaffected (27 June 2015)

8. Coercion in a locked psychiatric ward: Perspectives of patients and staff. (I asked for helps as to how to cite this link properly)

9. Code of Practice to the Mental Health Act 1983 – Code of Practice to the Mental Health Act 1983 (January 2015) which, for the first time, includes a section on human rights (chapter 3).

10. “The UN Convention on the Rights of Persons with Disabilities (UNCRPD) is the first human rights treaty of the 21st Century. It reaffirms disabled people’s human rights and signals a further major step in disabled people’s journey to becoming full and equal citizens.” Equality & Human Rights Commission on the United Nations Convention on the Rights of People with Disabilities (Ratified by the UK in June 2009)

11. Mental Health (Discrimination) Act 2013 – Mental Health (Discrimination) Act 2013 (28 February 2013) This Act removed discriminatory mental health legislation affecting MPs, school governors, company directors and would-be jury members.

12. Mental health advocacy and human rights: your guide – British Institute of Human Rights (2013)

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

 

 

 

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:

.

(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.

.

 

(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.

.

(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!

.

.

.

Related links:

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

.

.

.

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.

.

.

.

.

.

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)

.

.

.

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.

.

.

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.

.

.

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.

 

.

.

.

..

.

.

.

Related web links:

.

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)

.

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)

 

.

.

.

Secrets from the modern day 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.

.

.

.

.

Related links:

.

Mainstream media:

• Guardian newspaper preview
• ITV
  • Press releases on the show with detailed overview (episode 1 and episode 2)
  • Episodes (episode 1 and episode 2)
• Radio Times preview

.

Twitter and blogosphere:

• A memory that haunts me – Skye, the Secret Schizophrenic (@SecretSchizo), writes about one incident on ward
• Restraint and bullying on mental health wards (18th August)
• Thoughts on tonight’s series:
  • Conversations with 3 psychiatrists and others
  • Tweets of others on the hashtag #secretsfromtheasylum
    • Those who think bad things are still happening today and we can’t just look back in shock at long past practices
    • Those who watched it purely as a history programme, shaking their heads at what used to be done to those poor mentally ill people with no concept of what happens today

.

Background – mainstream media:

• Child mental health services ‘stuck in the dark ages’, says Norman Lamb – “Care and support minister says options available to young people are ‘not fit for purpose’ and vows overhaul” – Guardian newspaper (20th August)
• Children’s mental health care at ‘breaking point’ due to council and NHS cuts, charity warns – “Data obtained by YoungMinds highlights extent of spending cuts facing CAMHS teams” – Community Care (June 2014)
• Children’s mental healthcare in crisis, Care Minister Norman Lamb admits – “Children’s mental health services in England are “dysfunctional” and “crying out” for a complete overhaul, the Care Minister Norman Lamb has said, in a stark admission that thousands of children are being let down by the NHS’s “institutional bias” against mental health.“ – Independent newspaper (20th August)
• Hundreds of children ‘detained in police cells’ – “Hundreds of children in England and Wales have been held under the Mental Health Act and locked in police cells because officers did not have anywhere else to take them” – BBC news (January 2014)
• Mentally unwell children sent hundreds of miles for care amid bed shortage – “Community Care and BBC News investigation also reveals hundreds of acutely unwell young people have been detained on adult wards” – Community Care (20th February)
• Scandal of putting mentally ill children in police cells must end, says MP – “Dr Sarah Wollaston condemns use of police stations for under-18s who are having a breakdown rather than taking them to specialist medical units” – Guardian newspaper (14th August)
• Why aren’t we more shocked that people with mental health problems spend time in police cells because we lack beds? – “Wanting to care about mental illness is not the same as caring.” @Glosswitch in New Statesman (02 December 2014)

.

Background – recent experiences of psychiatric hospitals:

• A memory that haunts me – Skye (@SecretSchizophrenic) (August 2014)
• Forced medication: resistance is futile (March 2014)
• Restraint – 10 ways it harms psychiatric patients (June 2013)
• Treated like an animal (March 2013)

 

.

.

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.

.

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.

.

.

.

..

.

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).

.

.

.

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.

.

.

.

.

.

.

• 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!)

.

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.

.

.

Starting a family when you have a mental health diagnosis: unfit to be a mother?

Photo by Bicycle Bill

.

Scroll down to the web links section for links to all the coverage & commentary on the Essex forced caesarean & adoption story

.

.

On starting a family when you’re managing a mental health problem: reality and scare stories

Earlier today, a story about a mother with a diagnosis of bipolar disorder broke which was so utterly grotesque that it has caused a storm of protest on twitter and elsewhere. Questions are to be asked in the House of Commons. Although so far we only have a story reported in the Telegraph newspaper (based on incomplete information), there appear to be 2 main aspects. These fall into familiar media narratives:

1. “Evil social workers steal our children.” And, in this instance, rip a baby from it’s mother’s womb in an enforced caesarean the mother didn’t know about till she came round to find the scar in her abdomen. As reported in the Telegraph, a woman with a diagnosis of bipolar disorder, visiting the UK for two weeks from Italy, was sectioned and taken to a psychiatric hospital. Without informing her, social workers went to court and a judge made an order that a caesarean section could be performed on the woman and the baby taken away. Without warning, the woman was forcibly sedated and, when she woke up, a caesarean section had been performed on  her and her baby removed. She has never seen the baby.
2. “Women with mental health problems are unfit mothers.” The Telegraph reports that, subsequently, the mother went to court to seek the return of her baby. The judge decided against returning her baby because – despite the fact she was currently well – he said her lifetime risk of relapse meant she was an unfit mother.

There are other troubling aspects to the news story too, but these are the two that relate to mental ill-health. I comment below on these aspects. In summary:

1. We don’t yet know all the facts around the caesarean section in 2012. It seems so grotesquely barbaric and traumatising that there must be more to it. A c-section is a medical matter, not one for social services. Other seemingly plausible explanations have been put forward and what’s been reported doesn’t ring true. Court of Protection cases are not routinely reported, so we may never see the judgment in this case and the local authority involved may be unable to comment. The main source of information for media coverage is the original Telegraph report, which is based on information provided by only one source (the mother’s solicitor). As a comparison, the Telegraph report refers to a “panic attack”, whereas other commentary refers to a psychotic episode. And the Telegraph story is  written by a journalist who has been criticised for writing misleading court reports in pursuit of his cause. He is a journalist with an agenda. At best we can say for certain that the information we have is incomplete.
2. As written, it appears that the fact that the woman had a diagnosis of bipolar disorder was the judge’s justification for refusing to return the child to its mother.  This is appalling. This – and the real problems women managing mental health problems face in accessing the support they need – are the real issues for debate.

This scare story contrasts sharply with the reality of women’s experiences of managing a mental health problem and wishing to start a family (for instance this by Erica Camus, 33, diagnosed with paranoid schizophrenia and contemplating whether she can become a mother; or these comments by Seaneen Molloy, in her twenties, diagnosed with bipolar disorder and also wishing to become a mother).

Many women’s mental health problems will start during child bearing years – so there are a lot of us affected. Women and couples make decisions every day about sex, contraception, psychiatric medication and abortion. With so many of us living this reality daily, the real conversations should be about the following issues:

• The provision of supportive mental health care in partnership with women, so they don’t fear asking for help in case they risk losing their autonomy or children
• The provision of sufficient specialist maternity mental health services, both outpatient and inpatient, so mother and baby or babies can be cared for together, no matter how unwell the mother is  (it was recently reported that, “Only 50% of areas have any kind of specialist perinatal mental health services“)
• Ensuring worst case scenarios are planned for in advance, in partnership with the woman (to hopefully reduce the risk of such heartbreakingly sad events as the deaths of Daksha and Freya Emson)
• Researching the effects of psychiatric medications on unborn babies (this research project is currently recruiting women participants for a study on pregnancy and antipsychotic medication)

Let’s hope that the furore generated by this seemingly sensationalised scare story provides a window of opportunity to discuss these real issues women face daily. And let’s hope that women who are wrestling with these very issues now will not decide to have a termination, or to not have children, or to not seek help with mental health concerns as a result of such scare stories.

Allesandra Pacchieri with her youngest daughter, Baby P (Daily Mail, 4th December 2013)

.

.

Here are my thoughts (tweets edited only slightly due to the lateness of the hour) in response to the initial Telegraph story:

The Telegraph reports that a judge ordered – without even telling her – that a mother could be forcibly sedated & her baby delivered by caesarian section then taken. And that a new judge has ruled that a bipolar diagnosis – just the diagnosis – makes a mother unfit to have her child with her.

Can you imagine a mother with Crohn’s disease who experienced a relapse being forcibly sedated and having her baby removed by secret caesarean? Just like bipolar disorder, doctors diagnose Crohn’s as a lifelong relapsing and remitting condition. At times of relapse, a parent with Crohn’s may be unable to take care of their child. Would anyone say that a mother with Crohn’s was, by virtue of that diagnosis alone, unfit to keep her child just in case she relapsed? No. That judgment seems reserved for those of us with a mental rather than physical health diagnosis.

My impression is that society, doctors and the courts infantilise women who are pregnant. And that certainly happens to people with mental health problems. That’s a double whammy for pregnant women who are managing mental health problems if their case comes before a court.

One question that arises in reading the Telegraph story is where was the perinatal psychiatric service? The point of perinatal psychiatric services is to support mothers through pregnancy and delivery. Since pregnancy is linked to bipolar relapse, it’s all the more important for women to get proper perinatal psychiatric care. That doesn’t seem to have been the case with this mother, though there is a perinatal psychiatric service in Essex.

However, the scary message from these two legal cases, as reported, seems to be this: if you have a bipolar diagnosis, you shouldn’t tell anyone that you’re pregnant because, if you do, you could lose your baby. That you should steer clear of mental health services at all costs.

Wouldn’t a better message be that, if you have a bipolar diagnosis and you want to become pregnant, you should get in contact with a perinatal mental health service so you can plan the pregnancy? Wouldn’t a better message be that, if you’re already pregnant, you should make contact with a perinatal mental health service so they can support you during and after your pregnancy? Wouldn’t a better message be that, if a woman gets a bipolar diagnosis – or any other mental health diagnosis – she is still a full human being. She is not merely a womb. She is not merely a piece of meat to be sedated and sliced open without her knowledge. She is not merely a risk to children. She is a full human being.

At the moment, we know only a partial view of what has happened. The report is based on instructions the mother gave her solicitor. We don’t know why the caesarean was performed. There must have been some medical reason. We are told that the mother wasn’t warned about the planned caesarean and that the child was taken away without the mother seeing it. We are told that the child hasn’t been returned to the mother for the apparent reason of the mother’s bipolar diagnosis and therefore possibility of relapse.

Let’s hope this is just some really, really badly reported media story that’s actually a bit dull. That would be better than the alternative. It will be interesting to see what comes of this story when it’s reported fully. I wonder if either journalist has relevant expertise. I wonder if either has form for whipping up a storm of controversy for a story that turns out to be far more straightforward.

But basically, if you’re a woman with a bipolar diagnosis, you’re an unfit mother. What a sweeping generalisation that infantilises women & reduces us to no more than our diagnoses.

I can guarantee that, when this story is picked up more widely tomorrow, there will be people who will defend the court’s decisions purely on the basis that the woman had mental health problems. Some – who see a diagnosis, who see risk, rather than a person – will see mental health as a trump card, a byword for dangerousness and unpredictability.

Does a bipolar diagnosis make a mother unfit? No, not in and of itself. No more than would a diagnosis of another relapsing and remitting condition like Crohn’s disease. Yes, the mother might relapse. Maybe relapse is not a possibility but a certainty, so the only question is when the next relapse will happen, not if it will.  That’s equally true of Crohn’s disease.

If a mother has a bipolar diagnosis, that’s an argument for supporting the family, not removing her children. Supporting the family is a far cheaper option than taking children into care of putting them up for adoption. Both are astronomically expensive options financially. If a mother has a bipolar diagnosis, that’s an argument for supporting the family, not removing the children. That’s the humane and compassionate response.

Let’s hope this case receives such an outcry that women with a bipolar disorder will be viewed more realistically. Not infantilised.

.

[15th April 2014] The final chapter for mother and child; and the Guardian

.

.

.

.

.

.

.

Related web links:

The following topics are covered:

• Statements from the parties involved – including court judgments (including the judges’ reasons), Essex County Council, the mother’s solicitor & MP, and the hospital where she was treated
  
• Other court cases related to pregnancies
• Mainstream media coverage
• Commentary and blogs – Birthrights charity, British Association of Social Workers, blogging barristers & others
• Other relevant material – Eg research, perinatal mental health, Court of Protection, twitter conversations

.

.

Statements from the parties involved:

• Mr Justice Mostyn, Court of Protection – August 2012 caesarean judgment – Includes  (a) preface by judge (b) judgment (c) transcript of hearing and (d) copy of the Order made – Court of Protection, Mr Justice Mostyn, Re AA (Thursday 23rd August)
• His Honour Judge Newton, Chelmsford County Court – February 2013 child placement judgment – The judge’s reasons for why baby (P) should not be returned to her mother –  (A) – His Honour Judge Newton in the matter of  Re: P (a child) – Chelmsford County Court judgment (February 2013)
• Essex County Council – Essex County Council responds to interest in story headlined “Essex removes baby from mother” – Key dates, context and statement (Monday 2nd December)
• Brendan Flemming, solicitor – Statement of the mother’s UK solicitor on his website – Brendan Fleming, solicitor, was “unable to discuss the facts, evidence or information in this case” and had “a duty to ensure information relating to ongoing proceedings remains confidential. As such, we are unable to offer any comments or information relating to this case.” (Monday 2nd December)
• North Essex Partnership NHS Foundation Trust– Statement on Caesarean Case (the hospital where the mother was treated) (Wednesday 4th December)
• John Hemming MP – Various statements on Hemming’s blog
• Mr Justice Charles, High Court – Reporting restrictions link (prohibiting the identification of the child or her carers) (Wednesday 4th December) Here’s the reporting restrictions order (version 2 – version 1 named the child) & here’s the judgment transcript (erronerously dated 2012)

.

Other court cases relating to pregnancies:

Case 1 (1998): Forced caesarean was unlawful, despite High Court judge’s ruling

• Summary: Court-ordered caesareans in the UK – Sheila Kitzinger’s Letter from Europe in Birth – Issues in Perinatal Care (September 1998, Vol. 25.30) –
• Full court judgment: Louize Collins, Pathfinder Mental Health Services NHS Trust & St Georges Healthcare NHS Trust ex part “S”

Case 2 (May 2013): Court upheld autonomy of woman with bipolar diagnosis who had changed her mind and wanted abortion

• Full court judgment:Re SB (a patient; capacity to consent to termination)
• Mental capacity, mental illness and pregnancy – Miss B and the “bipolar abortion” case (May 2013) – My commentary <== This post includes links to other commentary and coverage

.

Mainstream media coverage:

Saturday 30th November:

• ‘Operate on this mother so that we can take her baby’ – “A mother was given a caesarean section while unconscious – then social services put her baby into care” – Telegraph newspaper, by Christopher Booker – the original story
• Woman has child taken from her womb by social services – “Essex social services have obtained a court order against a woman that allowed her to be forcibly sedated and for her child to be taken from her womb by caesarean section” – Telegraph newspaper, by Colin Freeman – follow up a few  hours later

Criticism of Christopher Booker:

Christopher Booker is the journalist who wrote the original Telegraph piece.

• Must journalists attend court hearings to report accurately? “I posted last week on a judgment given by His Honour Judge Bellamy in a family court case involving a mother’s abuse of her baby The judge took the unusual step of criticising media reporting of the case. He said the Telegraph’s Christopher Booker’s reporting was “unbalanced, inaccurate and just plain wrong”.“ – UK Human Rights blog (May 2011)
• The superhuman cock-ups of Christopher Booker – “The journalist makes so many errors that you would be forgiven for thinking he did it deliberately to waste everyone’s time” – Guardian newspaper (October 2011)

Sunday 1st November

• ‘Am I crazy to want a baby when I’m schizophrenic?’ After a decade-long struggle, one woman tells of her fears as she contemplates starting a family. “Erica Camus, 33, has lived with paranoid schizophrenia for ten years.She manages her mental illness with daily medication and therapy.When she was first diagnosed she was convinced she was a fugitive. She is now pondering how her schizophrenia would affect a child” – Daily Mail newspaper
• Baby taken from mother by UK social services in ‘forced caesarean’ – RT.com (Russia Today)
• Council forces caesarean on mother – Sunday Times newspaper (£)
• Forced C-section was ‘the stuff of nightmares’ – “Social Services condemned for forcibly removing unborn child from woman” – Independent newspaper
• MP queries ‘forced’ caesarean section – “Child still in Essex social services’ care 15 months after Italian woman with mental health problems had baby removed” – Guardian newspaper
• Pregnant woman has unborn baby girl forcibly removed by caesarean after social workers obtain court order because she had suffered a mental breakdown – “Italian woman claims she was not warned she would be given a ceasarean. Essex council obtained order allowing them to sedate her against her will. The case has now escalated into an international legal row” – Daily Mail newspaper
• Social Services forcibly remove unborn child from woman by caesarean after she suffered mental health breakdown – Independent newspaper
• Woman’s Baby Taken From Womb By Court Order – “An MP is to raise the case of a woman whose baby was taken from her after she suffered a mental breakdown.” Sky News
• Woman’s baby taken from womb by social services – video – “A pregnant woman from Italy, in Britain on business was given a Caesarean section against her will, and had her baby removed by social services. The child is now in the process of being adopted.” – Channel 4 news, with Katie Razzall (twitter @katierazz)

Monday 2nd December

• British Social Services Sedate Woman, Take Child from Her Womb, Confiscate It Indefinitely – National Review (USA)
• Caesarean case mother denied chance to keep baby in hospital – “Doctors’ suggestion that baby forcibly removed from mother’s womb by court order should stay in hospital with her was rejected by court” – Telegraph newspaper
• Child taken from womb by social services: it’s not always wrong – “We must not get distracted by vilifying the Court of Protection when children’s rights are at stake. The system needs to be respected and supported, argues solicitor-advocate Sophie Khan” – Telegraph newspaper
• Council claims concern over risk to mother and child led to forced Caesarean – “Concerns about “risks to mother and child” led a health trust to apply for permission to deliver an unborn child by Caesarean section, a local authority said today.” – Independent Ireland
• ‘Forced caesarean’ mother ‘sends message of thanks’ – Video with MP John Hemming – ITV news
• ‘Forced’ caesarean case – Italian mother in talks with MP – “John Hemming says he hopes to raise matter in parliament, and has been in touch with Italian officials to see if they can help” – Guardian newspaper
• Judge intervenes in case of mentally-ill mother whose baby was delivered by caesarean section after court order – ITV news (2 min video)
• Judge intervenes over woman made to have caesarean – “Britain’s top family judge has taken over the case of an Italian mother whose baby was taken into care after an enforced Caesarean section.” – Times newspaper (£)
• Social workers ‘seize unborn baby from the WOMB’ after mother has panic attack – “Italian woman visiting UK on work training trip subject of bizarre legal action – it is claimed social services obtained High Court order for enforced birth by caesarean section” – Daily Mirror newspaper

Tuesday 3rd December:

• Caesarean and adoption mum’s treatment ‘brutal and invasive’ – “Stefano Oliva’s client was forced to undergo a Caesarean section and give her baby up for adoption because of fears for her mental health” – BBC news

• County council explains actions amid storm over caesarean section case – “The county council at the centre of the media storm after the baby of an Italian woman was delivered by enforced caesarean section has issued a statement explaining the background to its actions.” – Local Government Lawyermagazine
• Explain why you snatched baby girl at birth: Judge’s order to social workers behind forced caesarean – “Sir James Munby has demanded answers in extraordinary case. The child was taken from the 35-year-old Italian in forced caesarean. The case shines light on murky secrecy of Court of Protection” – Daily Mail newspaper
• Father of forced caesarean child is ‘over-stayer’ in Italy – ITV news
• Forced caesarean case: Italian woman ‘suffering like an animal’ – Guardian newspaper
• The forced Caesarean case proves that light must be shone on social services and the courts – Spectator magazine
• It’s not the caesarean but the adoption that is an act of violence – “The sedation of a bipolar woman for a caesarean is a medical issue. It’s what happened next to her baby that’s truly alarming” – Guardian newspaper, by Zoe Williams
• Italian woman who was given forced caesarean section: I want my baby back – Guardian newspaper
• Pregnancy and mental health & here – BBC Woman’s Hour, including an interview with Sarah (@HackneyBird)

Wednesday 4th December:

• Caesarean case mother ‘was six weeks off due date when baby was forcibly removed’ – “The lawyer of an Italian woman whose baby was removed by caesarean section and put up for adoption says the procedure was done weeks before she was due to give birth” – Telegraph newspaper
• Corrections and clarifications – Guardian newspaper correcting factual inaccuracies in earlier pieces
• Essex caesarean pregnancy ‘not full term’ – “Stefano Oliva’s client was forced to undergo a Caesarean section and give her baby up for adoption because of fears for her mental health” – BBC news
• Forced caesarean was ‘manifestly’ in Alessandra Pacchieri’s interest, says judge – “Papers from secretive Court how that a forced caesarean section on the Italian mother Alessandra Pacchieri was allowed because of fears for mother and baby” – Telegraph newspaper
• I could feel my baby kicking inside me. I was crying as I begged them not to cut me open: Mother whose baby was snatched from her womb by the State talks to the Mail – “Alessandra Pacchieri’s baby was taken into care from forced caesarean birth. Sinister decision was approved by shadowy Court of Protection. The distraught mother says her body was ‘invaded’ and her baby ‘stolen’.” – Daily Mail newspaper
  

Thursday 5th December:

• Court: forced C-section was medically justified – Las Vegas Sun
• Court judgment: Cesarean section forced on Italian woman in UK justified medically – Ottawa Citizen
• Caesarean case mother: Italian government to step into Alessandra Pacchieri adoption battle – “Italian government stepping into British legal battle over Alessandra Pacchieri and her baby delivered by forced caesarean” – Telegraph newspaper
• How the court ruled caesarean of Italian mother whose baby was snatched from the womb must be kept secret – “Girl was born to mother, who has bipolar disorder, by court-ordered caesarean 15 months ago. Her Italian mother, 35, says she has suffered ‘like an animal’ at having child she wants to raise taken away from her.” –Daily Mail newspaper
  
• The mother, the C-section baby and ‘secret British court’: the reality behind an ‘inhuman’ legal case is now emerging – Independent newspaper
• ‘Social workers stole my baby’: Forced caesarean mother tells of horrific ordeal – Independent newspaper
• ‘They have stolen my baby,’ insists Caesarean mother – Times newspaper (£)

Friday 6th December

• Court approved caesarean section for mentally ill woman because of two previous caesareans – BMJ (British Medical Journal (£)
• Court judgment: Cesarean section forced on Italian woman in UK justified medically – The Province (Canada)
• The inhumanity of a forced caesarean – “The Italian woman forced to have a c-section was effectively treated as a fetal container.” – By Barbara Hewson for Spiked
• I was tricked into having a caesarean – Essex Echo (twitter @essex_echo)
• The mother, the c-section baby and ‘secret British court’ a secrecy scandal – or the birth of a scare story? – Independent newspaper
• What about the mental effects on the mother of a forced caesarean? – “After a week of revelations about the Italian mother whose baby was snatched from the womb by social services, Beverley Turner speaks to a bipolar mother and a human rights lawyer about the broader ramifications.” – Telegraph newspaper

Saturday 7th December:

• Judge must unravel saga of baby snatched from womb – “In the shocking case of an Italian mother whose child was removed by caesarean, the head of Britain’s family courts will be looking closely at social workers’ actions.” – Telegraph newspaper, Christopher Booker. He’s back.
• Father of caesarean scandal woman: Why I DON’T believe she should keep the baby – “Alessandra Pacchieri’s baby was taken into care from forced caesarean birth. Controversial decision was approved by secretive Court of Protection. Father Marino has backed the court’s decision to put child up for adoption. Says daughter is a ‘threat’ to the baby because she suffers ‘manic delusions’.” – Daily Mail
  

Sunday 8th December:

• Father of woman forced to have caesarean backs British court’s decision – “The father of a woman forced to have a caesarean so her child could be put into care has backed the decision by British courts over fears of his daughter’s mental condition” – Telegraph newspaper

Saturday 14th December:

• I’m not scared by the forced caesarean row, I’m reassured… and I’m bipolar and pregnant, too – “Kerry Hudson suffers from a bipilar-type mental illness. She is pregnant and has come off medication for the duration. Kerry is reassured she has doctors to help her make decisions.” – Daily Mail newspaper
  

 

.

Commentary & blogs:

Sunday 1st December:

• Pregnant woman has unborn baby girl forcibly removed by caesarean after social workers obtain court order because she had suffered a mental breakdown – A Conservative Edge blog (Philadelphia, USA)
• Hemming helps woman in forced Caesarean and adoption case – Liberal Democrat Voice website

Monday 2nd December:

• BASW hits out at social worker scapegoating in Essex caesarean row – BASW (British Association of Social Workers)
• Forced caesarean: a legal perspective – Birthrights (“Birthrights is the UK’s only organisation dedicated to improving women’s experience of pregnancy and childbirth by promoting respect for human rights”)
• Italian woman continues legal battle for return of her child after court-ordered caesarean birth – Marilyn Stowe blog
• Italian mother: Statement by John Hemmings – Statement by the MP in contact with the mother
• A mother was given a caesarean section while unconscious – Obiter J blog
• Media portrayals of social work  – By David Niven (twitter @davidniven)
• Never let the facts get in the way of a good story eh? – By Pink Tape blog (family law barrister Lucy Reed)
• Opinion: Child taken from womb by social services. Really? – Lib Dem Voice by Evan Harris (part of Hacked Off)
• Our response to media reporting on forced caesarean and continued separation of mother and child – “The forced caesarean and continued separation of mother and child is, we believe, unprecedented.” – Bipolar UK (national bipolar charity)
• Untimely ripped – Suesspicious Minds blog (an overview of the legal points) (twitter @suesspiciousminds)

Tuesday 3rd December:

• ‘Essex council should be commended for speaking out on the forced caesarean case’– “It’s time for councils to reconsider their position of not commenting on individual cases” – Community Care (twitter @communitycare)
• Forced caesarean case: Italian mum ‘suffering like an animal’ after baby taken by social services – “She was heavily pregnant when she fell ill at an airport, taken to a psychiatric hospital where her baby was delivered against her will” – Daily Mirror newspaper
• Forced caesarean: the mother’s story and the judge’s – Heresy Corner blog by Heresiarch (twitter @Heresy_Corner)
• Forcible caesarean section authorised for Italian national present temporarily in England – 39 Essex Street Chambers newsletter (barristers) (page 9)
• Lessons learned from the ‘Forced C-section’ case – UK Human Rights blog (by human rights barrister Adam Wagner)
• More questions than answers – on the ‘forced caesarean’ case – The Small Places blog by Lucy Series (twitter @thesmallplaces)
• A piece that is not about forced caesareans – Mental Health & Mental Capacity Blog – by Dr Nell Munro of Nottingham University Law School
• When we don’t know what we don’t know: the “forced C-section” case – “What concerns me about the reporting of this case is the lack of detail surrounding legal issues. Without detail speculation fills a narrative vacuum, resulting in some possibly unfounded conclusions – and frightening people, especially women with mental health issues, in the process.” By Charlotte Walker (twitter @bipolarblogger)
• Why The “Forced Caesarean” Story Was Wrong – “The case is complicated, unusual and tragic. But social services did not force a woman to have a caesarean so that they could take away her baby.” – Buzzfeed by @flashboy

Wednesday 4th December:

• Booker, Hemming and the ‘forced caesarean case: a masterclass in Flat Earth news – Head of Legal blog by Carl Gardner (barrister) (twitter @carlgardner)
• Caesarean sections, autonomy and consent – Practical Ethics, University of Oxford
• The judgment from court of protection in the caesarean section case – Suesspicious Minds blog – a quick overview of the legal points following the publication of the judgment – (twitter @suesspiciousminds)
• A post which is about caesarean without consent – Mental Health & Mental Capacity Blog – by Dr Nell Munro of Nottingham University Law School
• Update on the Essex c-section case – By Pink Tape blog (family law barrister Lucy Reed)

Thursday 5th December:

• The Court of Protection and the new Family Court: can publishing judgments prevent moral panics? – Cardiff Law School, by Julie Doughty and Lucy Series
• Comment: Forced C-sections and stolen babies – “The Alessandra Pacchieri case looks like the ‘stuff of nightmares’, but the problems it highlights are real.” By Jennie Bristow for BPAS (British Pregnancy Advisory Service)
• One flew over the Hemmings nest – Ministry of Truth blog (twitter @Unity_MoT)
• Views on the forced cesarean judgment – Birthrights (“Birthrights is the UK’s only organisation dedicated to improving women’s experience of pregnancy and childbirth by promoting respect for human rights”) by barrister Elizabeth Prochaska ‏(twitter @eprochaska) – “All in all, a depressing case for anyone concerned with modern maternity care and the rights of people with mental illness. The comment by Lucy Series on twitter best sums up my reaction: “If you were trying to convince somebody the Mental Capacity Act was progressive, empowering, person-centred, the caesarean judgment would not help you.””

Saturday 7th December:

• A forced Caesarean? Concerns still linger – Diary of a Political Hack blog by Martin Shapland ‏(twitter @MShapland)

Sunday 8th December:

• Caesarean Escalation, Judges on Human Rights and Happy Birthday – the Human Rights Roundup – UK Human Rights blog

Monday 9th December:

• Turning realisable rights into real rights – Mental Health & Mental Capacity Blog – by Dr Nell Munro of Nottingham University Law School

.

Other relevant material:

The Court of Protection:

• Revealed: How UK justice is dispensed out of hours down the phone line – “The Court of Protection is facing fresh questions about transparency, as The Independent reveals that its judges are making life-or-death decisions over the phone, with incomplete evidence, in proceedings that are not always recorded.” – Independent newspaper (June 2013)

Perinatal mental health:

• All Babies Count: spotlight on perinatal mental health – NSPCC (June 2013)
• Guidance for commissioners on perinatal mental health – Royal College of Psychiatrists
• We are recruiting women for a study on pregnancy and medication – “Have you used psychotropic medication and had a child in the last three years? If so, we would like to speak to you” – McPin Foundation (27th November)

Research:

• McPin Foundation – Recruiting women participants for a study on pregnancy and anti-psychotic medication – “Have you used psychotropic medication and had a child in the last three years? If so, we would like to speak to you. When women with a severe mental illness want to start a family, or find that they are pregnant, they may have to make decisions about whether to keep using medication, change it or stop it altogether. This can be a difficult decision. We want to find out more about how women decide what they want to do and what could have helped them to make that decision.”

Twitter conversations:

• Bipolar disorder and pregnancy: unfit to be a mother (Saturday)
• Bipolar disorder and pregnancy: unfit to be a mother (Sunday)
• Starting a family when you have mental health problems (Sunday 1st December )
• Starting a family when you have a mental health problem (part 2) (Sunday 1st December)
• My tweets on the subject on Monday 2nd (with links)
• My tweets on Tuesday 3rd
• My tweets on Wednesday 4th
• My tweets on Thursday 5th
• My tweets on Friday 6th

.

.

.