Mental health comment

Compassion not compulsion

February 7, 2005

If the government wanted a mental health service based on compassion it would commission an inquiry into the effects of force in psychiatric treatment, argues clinical psychologist Rufus May

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Can we work towards a force free mental health service? As a society I believe we have a moral obligation to struggle for this ideal. This is why on February 14 (Valentine's Day) I and many other former psychiatric patients and our supporters will be taking part in the "Kissit" march in London. A Valentine's card will then be handed to Tony Blair at 10 Downing Street that on the cover depicts a heart and a Cupid's arrow, and when opened up shows the image of two buttocks being penetrated by a hypodermic syringe, with the message 'Have a Heart'.

Originally conceived by the artist Aidan Shingler, the march humourously seeks to raise awareness of and protest against a serious issue; the widespread use of force in psychiatric hospitals (and soon to be extended into the community).

"Psychiatric assault" includes the use of physical restraint procedures, forced drugging (rapid tranquillisation), seclusion, and pain compliance techniques (where the person is hurt to encourage them to comply with the forced chemical or physical restraint procedure).

Many of us on the march will have experienced force in situations where we were not behaving violently. Many of us will have had our bodies invaded by drugs we did not want. Many of us will be workers or family members who have felt obliged to collude with practices we disagree with.

The process of "Acuphase" is one of the most common uses of force on the psychiatric ward. It is used to manage challenging behaviour. Forced Acuphase is where a person is pinned down undressed so that his or her buttocks are revealed. The person is then given a psychiatric cocktail (at present this is usually haloperidol and lorazepam) which is administered by hypodermic syringe into the person's buttock.

The National Institute for Clinical Excellence (NICE) 'Disturbed Behaviour Clinical Guidance' (2004) draft guidelines suggest that all attempts to avoid forced treatment using de-escalation techniques should be tried prior to the use of force. There are however no structures to enforce this recommendation.

If the government wanted a mental health service based on compassion it would commission an inquiry into the effects of force in psychiatric treatment and produce a whole set of guidelines on how to de-escalate challenging situations. This it has not done.

In my experience at what point force is used on a psychiatric ward depends on the staff involved and the dominant ethos on the ward. In every hospital there are hawks and doves. The often high numbers of agency staff tends to make the situation worse, as these staff are often less interested in establishing rapport with the people they are paid to care for. How force is used varies from hospital to hospital and ward to ward, and is influenced by which staff team members are involved on a particular shift and leadership styles.

As someone detained in a secure ward recently described to his mother "At night the bouncers come on". Under the present risk-obsessed culture nurses are often persuaded that in order to avoid harm being caused, restraining and sedating patients early enough will avoid the risk of a harmful incident. This idea of preventive forced treatment (just in case things get difficult) is being most recently being advocated by the government in the form of community treatment orders which psychiatrists will be able to renew every six months.

The long term harm caused by using these procedures is not looked at. I have written in some detail about my experience of forced treatment when I was 18 years old, elsewhere (May 2002). My experience, conversations with other people who have been in-patients and practice as a clinical psychologist, tells me that the use of force has two main negative effects.

Firstly it can set up in the person inflicted with force, a deep resentment toward health care workers. A fundamental trust is broken and the person is likely to be reluctant to seek mental health care support in future crises. Hence we have assertive outreach; whole teams set up to work with this group of dis-affected people and a growing market for secure hospital provision, to take the use of force to its logical conclusion, long-term internment.

The second effect of the use of coercion if it doesn't provoke outward anger and mistrust is these feelings can be internalised so that the person learns not to trust themselves. They give up on their right to an active role in their life assuming a dependent "sick role". One becomes institutionalised. Both scenarios have a negative effect not just on the person but also on the community as a whole. We lose out on the potential of people who have been psychotic to contribute to our society. We guiltily write them off and blame all the passivity or challenging behaviour on the "mental illness".

One can feel like a radical writing about a peaceful and fair approach to mental health care. This is mainly because (since the mid seventies) there has been a lack of literature looking at it. When I facilitate self help groups in community and hospital settings I do not feel radical. In my experience in in-patient settings more than half of the people who receive treatment for psychosis and or self harm are in touch with and unhappy about how they have been treated and have good ideas about how they would like to have been treated. We need to listen to these testimonies.

Force denies the individual dignity and it damages the spirit. It is no surprise that one of the former Guantanamo Bay detainees recently released, now requires mental health care for severe mental health problems. This is the paradox, the use of force creates emotional distress and mental confusion, yet inpatient services designed to care for such states regularly use coercive practice. One of my clients talks about her "secondary mental illness", this is the one created by mental health services and the forced drugging she has endured. She describes it as a shadow in her mind.

The NICE guidelines on "Disturbed (violent) behaviour: the short-term management of disturbed (violent) behaviour in inpatient psychiatric settings" are due out this month. The draft guidelines which came out last year, recommend that every time a person is forcibly restrained, drugged or secluded a review is desirable (but not essential) to look at if any lessons can be learned. When the community (and I say the community because the hospital is part of the community) uses force against a distressed individual there are always lessons to be learned, amongst all parties. As a society we have to see the use of force as a failure of our abilities to carry out a compassionate approach to emotional distress. Where someone is actively violent restraint of some kind is at times necessary. However in my experience the use of force in the psychiatric system is often unnecessary and there lacks a culture of accountability when it is used.

In terms of care for psychosis, force is at the centre of the state's approach to treatment. Neuroleptic drug treatment (under the pseudonym anti-psychotic medication) is presented as the treatment of choice for people with unusual beliefs behaviours or experiences; treatment of choice for those who have no choice.

Most first admissions to psychiatric hospital are characterised by a "try this medication or if you don't we'll have to force you to take it" approach. I am frequently contacted by families who choose to support people to manage their psychotic experiences without the use of forced drugging, they then get no support from mental health services. Maybe we should rename mental health services 'psychiatric drugging services'! This use of neuroleptic drugs as a maintenance (long term) treatment occurs despite evidence that alternative approaches work.

The Soteria project and other similar projects in Scandinavia show that minimal or no antipsychotic treatment combined with a humanistic approach can be more successful than the traditional drug-based approach. Why aren't similar (research) projects funded in this country? Is it the huge influence of the pharmaceutical industry on the medical profession and increasingly other disciplines (including the government's own think tank and policy spreader the National Institute for Mental Health)? This is a human rights issue, as democratic citizens we should have the right to a force-free mental health care. Those of us who believe in compassionate approach to mental health need to come together to struggle for this vision.

Ten years ago I was told by my clinical psychology supervisor I was preaching to the converted, I disagree psychology (like other disciplines) is complicit in these arrangements. For example, if we look at the early intervention (for psychosis) movement, which is spearheaded by psychologists, what they are advocating is person-centred but still neuroleptic drugs are at the centre of treatment. Is this pay-back for all the drug company funding of this movement? For example, one early intervention handbook on how to implement early psychosis services recommends that a person has to be "symptom free" for a year, before professionals should consider cessation of drug treatment. However the Hearing Voices self help movement has shown that people can develop drug-free approaches to living with psychotic experiences. Despite the alternative evidence that is available, even the new early intervention services which pose as innovatory, generally do not give people a choice of a drug-free approach to their difficulties. This is how endemic coercive practice is in the mental health care system.

Aged 19, against doctors wishes I withdrew from my neuroleptic drug treatment. I had to learn to manage my own psychotic experiences and recovery without medication. This is fraught with problems if you do it alone, to be successful you need a group of people who will support you (see Lehmann, 2002 for accounts of the withdrawal process). Part of the culture of coercion in this country is that there are no specific services that will support you if you want to withdraw off neuroleptic medication.

Over the last ten years I have had the privilege of supporting others to manage their disturbing experiences without the use of force, sometimes without the use of medication. Supporting people in a force-free way through their spiritual and emotional crises takes resources. Not more resources, just a different emphasis in how they are used. Such an approach requires structural changes in society, I don't deny this. Mental health crisis care needs to be based much more in the community and involve the community. We need to demand a society that assists a community based approach to emotional crisis. For example, in many cases family members or friends would be able to help more in the care and recovery process if they could take more time off work. We need employers to support this. Supporting someone through psychotic and or distressing experiences can be exhausting. One needs a whole team supporting the process. However in the long term creating this healing environment will reap rich rewards for everybody involved.

In a sense we are all institutionalised into accepting the status quo. A lot of good caring people end up colluding with practices in their hearts they know are wrong and counter-productive. I myself have at times chosen not to challenge practice I felt was unjust and violent. As a junior member of staff I feared repercussions on my career, if I rocked the boat too much. Many staff are in this situation every day. This is why the Kissit Campaign is so important (see the forthcoming special issue of Asylum magazine for detailed coverage).

In this article I have tried to highlight some of the main issues involved. We need a public debate about this. The Kissit campaign is an excellent wake up call for all of us to become more active in the struggle for a compassionate approach to different states of consciousness. We need to challenge the conventional approach to challenging behaviour. All the civil rights movements have had at their root the struggle against violence. Women, black people, gay people; all these groups have in the past, experienced state-sanctioned violence, that at the time was seen as acceptable. The struggle for a mental health care approach that is not violent is just as important as these other egalitarian causes.

* Rufus May is a clinical psychologist with Bradford District Care Trust's assertive outreach team, and honorary research fellow with the centre for community citizenship and mental health at the University of Bradford. He helps organise a monthly public meeting about different peaceful approaches to mental health called Evolving Minds. To join a network setting up Soteria-style mental health services contact David Marsh at the University of Bradford

kissit.org
moshersoteria.com
Asylum magazine
Rufusmay.com

References:
Lehmann, P.(2002) Coming off Psychiatric Drugs, peter-lehmann- publishing.com
May, R. (2002) Over Our Bodies. Mental Health Today, August edition.

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Those I've restrained are a risk to themselves

Comment from: A Smith, nursing student and nursing auxillary, Manchester
Date: November 19, 2007

This is rubbish. Firstly, acuphase is not lorazepam and haloperidol - it's an antipsychotic drug (clopixol acuphase). It is extremely hard to get a doctor to consent to this treatment and prescribe it, and it is only for patients who are extremely unwell and who have have no other option.

The question I would ask you is what are the alternatives? Many of the people whom I personally have restrained are not only a danger to the staff and other patients but are a huge risk to themselves.

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Ignorance and bitterness

From: Richard Nisbet, assistant ward manager, Bradford District Care Trust,
Date: April 25, 2008

I agree entirely with A.Smith's comments above, having worked in acute hospitals for the last six years.

Mr May seems to be of the opinion that psychosis and acts of violence towards the self and others are mutually exclusive.
Wrong.

I find it equally, if not more ill conceived, his apparent opinion that being an RMN excludes one from being compassionate, particularly if one has ever had to make the decision to restrain, detain or forcibly medicate anyone.

These three options are a last resort, but essential components of a ward-based nurse's broad range of therapeutic tools. Mr May has clearly never had to take responsibility for a ward of 21 male patients, and three or four other staff members, with a view to maintaining the safety, security and physical, emotional and social wellbeing of all.

Mr May's ignorance, bitterness at his own experiences (with which I empathise) seem to have coloured his judgement to such a degree that I do not understand how anyone can take his mantra of "no drugs good, all drugs bad" remotely seriously.

Empire building and flagrant self promotion to indulge one's grievances at the expense of others is not an attractive quality.

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Not bitter - part of a movement for change

From: Rufus May, clinical psychologist with Bradford District Care Trust's assertive outreach team,
Date: May 13, 2008

Richard, perhaps I can clarify how I see this area differently to you. I am not against drug treatment. I am for people having a choice about treatments and having access to alternatives to drugs. I do think psychiatric nurses are often very compassionate people. I think the system of care that is in
place means many good caring people end up engaging in practices they did not go into a caring profession to do.

I am guessing that by talking about my personal experiences of coercive treatment 21 years ago in the film 'The Doctor Who Hears Voices', I have opened myself up to the accusation of being driven by bitterness to criticise traditional psychiatric approaches. So its good to be able to address this. I was bitter about the way I was treated in the psychiatric system 21 years ago. I would say the bitterness lasted two to three years. I then turned it into a more productive outrage as I started studying sociology and psychology and developed my vocation as a care worker. I think for most of my twenties I did have occasional nightmares about finding myself back in
hospital against my will. These disappeared when I started to speak out about the psychological impact of this aspect of psychiatric treatment. I recently met someone in their twenties who still has nightmares of being forcibly medicated at the age of 16 in a West Yorkshire psychiatric hospital. I think the psychological impact of forced treatment is denied by those who practice it, so I welcome the opportunity to debate about its merits and necessity.

I think we need more research on the psychological effects of compulsory or forced treatment, particularly with the government planning to extend compulsory treatment into people's lives in community settings.

I think that I have turned my anger about my own 'treatment' and the 'treatment' I witnessed others receiving, into a passion for reforming mental health services. My own experiences and observations of psychiatric treatment and my professional experiences of working in mental health services for the last 13 years suggest that the violent practice of forced treatment is over-used. I believe that violent interventions such as making someone submit to a depot injection or 'a rapid tranquillisation' often has a deep alienating impact on the individual. My approach is not fuelled by bitterness rather it is fuelled by optimism that a genuine person-centred approach that really listens to what people in crisis are going through (and gives them a range of ways of coping) is far more likely to contribute to the person's psychological recovery.

My work with self help groups and individuals who have experienced acute ward admissions suggests people are much more responsive to holistic approaches, being listened to compassionately, meaningful activities, hearing about other's recovery journeys than they are to an over reliance on psychotropic medication. My work is fuelled by the fact I see a holistic approach having a much more positive impact than a drug-centred approach.

I am in agreement that it is likely to be difficult to manage a twenty-one bedded male ward without using forced treatments. Therefore I think we need to rethink how we provide crisis care to people. A recent Mental Health Act
Commission report described acute wards as "frightening and dangerous" that they were "tougher more scarier places" than ten years ago. Such findings also suggest we need to think again about how we provide care and support to people in crisis.

Richard also comments on my 'self promotion' and suggests I am 'empire building'. Media interviews I take part in and the recent film I contributed to (The Doctor Who Hears Voices) focuses on me as a 'special individual'. But if you go to my website www.rufusmay.com (or come to Evolving Minds public meetings I help organise) you will find my work is all about group-work and community development (as much as individual work) and I see myself as crucially linked in to many networks and emancipatory movements (in particular the hearing voices movement). So I see myself as part of a movement for change rather than an individual merely seeking power for its own sake. In Bradford and Hebden Bridge I can easily name many other colleagues operating from a similar perspective to myself. Many more are keen to hear and learn about different ways to approach emotional distress and confusion. So as well as a mental health worker, I also see
myself as an activist who is part of an emancipatory movement. I have decided to engage with the media to generate wider awareness and debate about our society's approach to distress and confusion. This does mean I am
presented as a 'special individual' in the media at times, which plays down the work of others. A good example is two years ago, when I agreed to do an interview with the Independent about the Brighton to London Bed-push (see www.bedpush.com) and the story was headlined 'One man and a bed' despite me telling the journalist about the fifteen other people involved. However I have come to the decision that this special treatment by the media is a price worth paying (and something I can clarify later) to get a dialogue
going in wider society about how we spend resources on mental health services.

Traditionally the media has not been interested in the rights of people to a peaceful approach to their mental health problems, so we have to be creative to engage their interest. Anybody, including Richard is welcome to continue this dialogue at my Blog which is in association with my NHS employers Bradford District Care Trust.

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Tackle core deficiencies of acute care

From: Ross Hughes, homeless hostel manager, Avon, Somerset
Date: May 20, 2008

I write as someone who has recently left a mental health NHS trust, where I worked as a service user involvement manager, I have been a patient on a psychiatric acute ward and had a period of time seconded as a ward manager on a busy acute psychiatric ward. One lunatic did get a chance to run at least part of the asylum!

I think it needs to be recognized that a lot of people do come into hospital very unwell, in huge states of distress and often at high risk to themselves and others. I was never terribly convinced by the idea that Machiavellian psychiatrists were in the business of lifting slightly arty and eccentric members of the public off the streets, as an act of malign social control. This is partly because in order to get into many acute wards these days one often needs to be in such distress that one cannot be left in the community without severe risk. Given the fear many trusts have of homicide investigations, I suspect it is often sadly risks to others, rather than risks to the service user themselves, that tend to increasingly feature upper most in community team’s minds, when considering admission.

I am increasingly saddened by how many service users are left in the community in high levels of distress with almost no support at all. Many of the client group I now work with, who experience street homelessness and have complex mental health and substance misuse issues fall into this category. Like Rufus, I would much prefer a much wider set of treatment and support options to be available and people are often left with either medication or abandonment.

Rufus recently began one of his famous bed pushes from our local acute psychiatric hospital which was intended to give the impression of patients fleeing from psychiatric oppression. Given the usual pressures on admissions I was surprised his bed wasn’t requisitioned by hospital managers to admit someone!

Sometimes I suspect service users are admitted in such high levels of distress, often tormented by trauma-related psychotic symptoms, that compulsory medication may be in the short term, the most humane option. In fact there are several service users who would wish this to happen should they become very unwell. However, continued use of coercion to enforce medication compliance, without in anyway opening up a dialogue with patients to develop less medication intensive coping strategies, is also too often the norm.

There are lots of features of acute care which massively increase an over-use of coercion. For instance, inpatient staff not being well supervised and the fact that caring for very unwell people and the difficult emotions that arise from doing so are often not discussed. Psychiatric inpatient care often involves two sets of mental health casualties - those on the shop floor and those in the nursing office.

Secondly, poor debriefing of patients after difficult control and restraint incidents have taken place in order to repair relationships and develop less coercive strategies. If one is going to use forcible medication in an emergency, then this is essential, as there is indeed the very real danger of re-traumaticing patients who are often abuse victims.

Thirdly, completely unscientific bio-medical understandings of mental health distress where diagnoses such as ‘schizophrenia’ tend to encourage nursing staff to view service users as genetically-diseased organisms rather than driven ‘mad’ by trauma and abuse. The latter model of psychosis, while distressing, is something that at least places the patient as inhabiting the same human space as the nurse and acts as an empathetic bridge between patient and nurse,

Fourthly, boredom where patients are encouraged to relinquish any skills and insights they might have in terms of getting better and assume a resentful but passive role in their care. Fifthly, the failure to develop effective ‘advance directives’ where acute staff can be guided by service users in what types of nursing strategy might prove helpful when trying to support a patient and de-escalate a situation in a crisis.

It would be by addressing some of the core deficiencies of acute inpatient care that might help move someway to reducing the levels of coercion on many of our wards.

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