Friday, 24 August 2012

24 August 2012 - Collusion and Control - The Reality of Mental Illness

The unholy trinity of restraint, seclusion and forced treatment in the psychiatric system can lead to collusion by agencies who should be protecting the rights of vulnerable people.  In an attempt to keep control, on the slippery slope of patriarchal power.  Where patients are treated like children and real family are sidelined, surplus to requirements.

Investigations into adult protection can be like shutting the gate after the horse has bolted.  Too late too little.  Diversionary tactics of blaming others.  Non system others.  Keeping up the appearances.  That force is justified if a person is mentally ill.  Does that mean they deserve it?

Families left to pick up the pieces.  Put their reputations back together again.  Shake off the disappointment but retain a modicum of distrust.  Learning from the experience that not everything does what it says on the tin.  Older and wiser and stronger.  Ready for the next round.

Where I live in Scotland the statutory agencies say that they are the guardians of welfare.  "Fife Council Social Work, NHS Fife and Fife Constabulary are working in partnership to keep people safe from harm."  According to the adult protection information on the Fife Council website.  I'm wondering how this translates into the psychiatric setting where restraint, seclusion and forced treatment are ways of working with vulnerable people?

Where locked wards and seclusion rooms within locked wards mean that vulnerable people/patients are out of sight and out of mind.  Where carers, family members and named persons are not allowed to go, except by permission and even then it could be by the back door.

What constitutes safety in the psychiatric ward?  Does it mean taking the pills and doing what you're told?  Being compliant and not questioning the decisions of professionals.  Accepting that they know best even if they don't know you.

Or should it mean person centred care, getting to know the patient and carer and family members?  Mutual partnerships and shared decision making.  Like it says in the new mental health strategy for Scotland.  But isn't happening where I live.

There are a number of safeguards in the Mental Health Act Scotland 2003, for people with a 'mental disorder' and under the Act, to "make sure your rights are protected".  The main ones are the Mental Health Tribunal, named person, advocacy, advance statement, Mental Welfare Commission.  In theory these pillars, along with the Principles of the Act, should ensure fair and just treatment for people in mental distress and under detention.  In practice it depends on the safeguards having the power and place they are meant to have, in my opinion.  (taken from recent blog post 'Mental Health Acts - Protecting Rights or Not?')

I have been concerned for some time about the gulf between the theory and practice, of safeguards keeping people safe, in the experiences of patients, carers and family members engaging with the psychiatric system.  Locked wards and the use of restraint, seclusion and compulsory/forced treatment are high risk places and procedures. Where basic human rights are in danger of being overlooked or ignored.  The right to adequate food, housing, water and sanitation; the right to freedom of expression.

As a 'named person' and carer I had limited rights of access to the psychiatric locked ward.  Advocacy was difficult to obtain and, in our opinion, not a voice for the locked-up patient.  The advance statement required more content to be taken seriously.  Another 'bulletproof' one has been written (we may be deluding ourselves).  The Mental Health Tribunal seemed to be on the side of the system and not the patient, having little impact on patient safety, staffed by ex-professionals.  As for the Mental Welfare Commission I want to believe it's a watchdog (with teeth) and a guide dog, helping shape policy, develop services and safeguard rights.  See MWC 'Influencing & Challenging'.

But in light of a report received this week, written by statutory agencies months ago, that attacks my character, motives and reputation, accusing me of "psychological harm", for daring to stand with the person I care for, I am left reeling from the shock.  A psychiatric system and its cohorts colluding to lay the blame at my door.  And I wasn't even there.

When the restraint, seclusion and forced treatment happened.  Resulting in injury and trauma.  The lock-ins for hours at a time in a seclusion room without toilet or water.  No recorded observations until they were caught out.  Freedom of expression denied.  Policies and procedures non-existent or made up as they go along "according to the patient population".  The forensic psychiatrist saying that people without capacity don't require advocacy.

This is the reality for people with mental illness in the psychiatric system when they dare to resist the treatment or challenge the status quo or criticise the practice.  I might have recovered, be a survivor, off all the psychiatric drugs, participate in national mental health groups, run events with international speakers, write blogs and websites that are read by many people.

But I am still the ex-mental patient (wrongly) diagnosed in 2002 with schizoaffective disorder or schizophrenia, depending on who's the scribe.  It's in the medical notes to this day so it must be true.  And no doubt helps to reinforce the stigma and discrimination when agencies are looking for somewhere to lay the blame, for system failure.

Sunday, 5 August 2012

5 August 2012 - Mental Health Acts - Protecting Rights Or Not?

I want to believe that the Mental Health (Care and Treatment) (Scotland) Act 2003 is there to protect the rights of people with mental ill health (mental disorder).  Who may find themselves taken into a psychiatric hospital against their will, given compulsory treatment and their freedom restricted.  The difficulty for me is that my own experience of involuntary psychiatric detention and forced treatment made me feel vulnerable, frightened and at risk.  And I know of others who have experienced the same, in the years since the new Act came into being.  There still seems to be a gulf between what should be happening and what is happening.

The Scottish MH Act has safeguards in place, to protect the rights of mental health service users, the main ones being the Mental Health Tribunal, named person, advocacy, advance statement, Mental Welfare Commission.   In theory these pillars, along with the Principles of the Act, should ensure fair and just treatment for people in mental distress and under detention.  In practice it depends on the safeguards having the power and place they are meant to have, in my opinion.  Independent advocacy that is free from conflict of interest and supports freedom of speech, which may mean challenging statutory agencies.  Advance statements that are recognised, and promoted, by psychiatric professionals.  Named persons given their place, informed and included.

I provided advocacy for a male patient in a forensic ward 10 years ago.  He had been transferred to the ward from prison and had narrowly missed being transferred to the State Hospital.  The advocacy he wanted was help in writing letters to hospital professionals about his treatment, so that he had a voice despite being locked in.  I believe the advocacy support helped him to be listened to, to be fairly treated and to eventually be discharged out into the community as an active citizen (he became a volunteer at the project I worked for).

Recent experience of trying to access advocacy for a relative in a locked ward was not so positive.  There was no continuity of advocacy relationship, difficulties in accessing an advocate when needed, and a reluctance on the part of the advocacy project to challenge statutory provision.  As a named person I was not kept informed or always included, by professionals.  The advance statement had some power but was no defence against forced treatment, the result being that a more bulletproof statement has since been created.  Time will tell if this has power.  Again I want to believe that it is possible to be empowered even when locked up and receiving compulsory treatment.   I use the word compulsory rather than forced.  Ever the optimist.

Some of us by nature or circumstance are non-conformist, non-compliant and questioning of the status quo.  I have found this to be a useful stance in normal society as it makes sense to have an inquiring and critical mind.  But in the psychiatric system this independence of mind and non-compliance can be perceived as a lack of insight (anosognosia), proof of mental illness and a reason for compulsory treatment.  In my experience.  Professionals who didn't know me when in good mental health made decisions about me when in mental distress.  Which resulted in detention, compulsion and paternalistic prognoses.  Making the road to recovery a longer and more challenging one, than it might have been if I'd been listened to.

There is a list of approaches and alternatives, much of them from American sources, in the Scottish Government's Review of Literature Relating to Mental Health Legislation, Ch 10, Least Restrictive Alternative, one of the underlying principles of the new Act  "... because of its relationship with two new provisions to the new Act that have generated considerable interest, namely, compulsory treatment in the community and advance statements.".   Food for thought.  Discussions about chemical and/or physical restraint, which is the least invasive, that willingness to take medication doesn't mean the patient isn't feeling coerced.  In the summary it states "There has been a tendency to assume that LRA means treatment out-with an institutional setting, but a different approach would suggest that it means treatment in accord with a patient's wishes.".  That's more like it.  Person-centred treatment for mental distress.  Preferably with alternatives that didn't involve compulsion or force.

There are proposed changes to the 2003 Mental Health Act Scotland, following the McManus Review Report and the government's response to the review.  Relating to advance statements, advocacy, named persons, medical matters and tribunals.  From reading the report and responses I can see attempts to increase the uptake of advance statements and the availability of advocacy.  Also for more clarity on the named person role.  I would like to see more power given to the patient/service user, requiring a releasing of power from the psychiatric professional/establishment.  Ron Coleman, in Recovery: An Alien Concept? says "“... it is not the professionals’ role to give power to clients.  Their role should be to renounce their power and influence over service users, and by doing so create the conditions in which service users can reclaim power for themselves." (p66).

In conclusion, mental health acts are laws under which people with mental disorders can be admitted, detained and treated against their will in hospital.  The first principle in the MH Act Scotland 2003 is "Non-discrimination – People with mental disorder should, wherever possible, retain the same rights and entitlements as those with other health needs.".  Therefore there is an expectation that people under compulsory treatment should have their rights respected.  This respect also stretches to carers under the Scottish Act.  The problems and tensions arise, in my opinion, when the expectations of the patients and their carers, regarding treatment, are not the same as the psychiatric professionals.  When the only choices are chemical or physical restraint, neuroleptics, forced treatment and seclusion.  Control rests with the system.  Human rights become secondary.  The mental health act safeguards seem powerless in the face of diagnoses, medication and detention (or labels, drugs and forced treatment).

Thursday, 2 August 2012

2 August 2012 - Notes And Other Fairy Tales In The Land Of Make Believe

Once upon a time there was a psychiatric establishment called 'The Land of Make Believe'.  Where some people wear uniforms (I'll call them the Uniform) and the others don't (I'll call them the Others).  The Uniform write notes (Notes) about the Others.  Sometimes at the time or sometimes after.  These Notes are very important to the Uniform.  They have undergone copious amounts of training on writing Notes, storing Notes, carrying Notes around.  And meet in a big room to have discussions about the Notes, the Others and The Land of Make Believe.

The Others are more interested in talking about themselves to others, both Uniform and Others.  However the Uniform seem to have little time available for talking, or listening or anything that isn't to do with the Notes.  Therefore the Others find themselves taking up smoking as an activity and sitting with Others in the smoking area.  Even the smoke resistant sit with the smokers, to have human contact.  Meanwhile the Uniform get on with their Notes.  Changing them if necessary.  To fit the story of the Uniform.

Labels are another important factor in the writing of Notes.  The Others can't just be distressed or anxious or worried.  They've got to be given a diagnosis or two that equates to a mental disorder.  Otherwise the Others shouldn't have come through the looking glass into the Land of Make Believe.  Where Notes are like the Jabberwocky to the uninitiated or non-Uniform.

"Beware the Jabberwock, my son!
The jaws that bite, the claws that catch!
Beware the Jubjub bird, and shun
The frumious Bandersnatch!

The Uniform write in the Notes when the Others are misbehaving (according to the Uniform) and this may result in a visit to the Land of Dame Slap, a school for bad pixies and fairies, at the top of The Faraway Tree.  Or forced treatment in Jabberwocky language.  Bad medicine or a necessary evil, according to whether you are the Others or the Uniform.  The Notes will justify the actions and the end will justify the means.  Which is another uniform, compliant, harmless, emotionless, humourless outpatient.

Of course this is only a fairy tale.  Isn't it?