Compassion not compulsion
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
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'.
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
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).
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
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
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
join a network setting up Soteria-style mental health services contact
David Marsh at the
University of Bradford
P.(2002) Coming off Psychiatric Drugs, peter-lehmann-
May, R. (2002) Over Our Bodies. Mental Health Today, August edition.
restrained are a risk to themselves
A Smith, nursing student and nursing auxillary, Manchester
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.
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.
Richard Nisbet, assistant ward manager, Bradford District Care Trust,
April 25, 2008
I agree entirely with A.Smith's comments above, having worked in
acute hospitals for the last six years.
May seems to be of the opinion that psychosis and acts of violence
towards the self and others are mutually exclusive.
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.
building and flagrant self promotion to indulge one's grievances
at the expense of others is not an attractive quality.
- part of a movement for change
May, clinical psychologist with Bradford District Care Trust's assertive
May 13, 2008
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.
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.
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.
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.
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.
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.
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
going in wider society about how we spend resources on mental health
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
deficiencies of acute care
Ross Hughes, homeless hostel manager, Avon, Somerset
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!
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
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.
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!
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.
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.
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.
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,
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.
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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