This post is specifically directed at Ted, our occasional representative of Thomas Szasz-esque libertarianism and opponent of all forms of coercive psychiatry.
So, Ted, this is from me, a jackbooted representative of evil psychiatric totalitarian bastardry, to you, brave standard-bearer of freedom and liberty.
And the subject of this post is: eating disorders.
Just recently I’ve been spending time on secondment to our local eating disorders unit. It’s a relief for me to get back to doing what I consider to be true psychiatry (i.e. treating severe mental illness) rather than being at the CAMHS outpatient clinic coming up with a hundred tactful ways to say, “No, your little monster does not have ADHD. Can we interest you in a parenting class?”
The ED unit is a harrowing place where you find anorexic teenage girls (usually girls) who look like something out of news footage from a famine zone, and it’s tragic to watch. These are girls who should be out having fun with their friends, watching Hollyoaks, listening to godawful R’n'B and having their first snog. Instead they’re stuck in the ED unit, locked in a brutal, no-prisoners war against their own bodies.
And they’re in a lot of danger, physically as well as psychologically. Their periods dry up, their blood pressure, white blood cell count and bone density all go through the floor and their electrolyte balance goes all tits up. Their core body temperature drops, causing them to grow lanugo hairs. Small wonder then, that of all the mental illnesses anorexia nervosa is the one that’s most likely to kill you.
This is where coercive psychiatry comes in. The protocol for serving a meal to an eating disorder patient is a no-holds-barred affair. She’s made to come to the table with her hair tied back and wearing short sleeves, wearing no watches or jewellery, so that there’s nowhere to secretly stash food. She’s then made to eat everything – everything – on the plate with a nurse watching her like a hawk. No excuses are tolerated. No “that’s got a bit of gristle on it” or “but that’s just a crumb”. The plate has to be completely cleared. Afterwards she’s made to sit resting for a full hour so she can’t go off and purge or exercise.
If she fails to complete the meal, or doesn’t complete the rest period, then she’s ordered to drink a nutritional supplement milkshake. If she refuses to do that, then she’s restrained while a nasogastric tube is passed up her nose and into her stomach to force-feed her. Nasogastric feeding is so unpleasant that few of the girls have to have it done more than once. As coercive psychiatry goes, you don’t get much more coercive than this.
So, Ted, explain to us that this is inherently wrong, quote Thomas Szasz and Ayn Rand to us, speak of fundamental liberties and responsibilities and of the inherent right of all individuals to do what they like to themselves…and I shall respond by simply saying, “If we don’t do this…They. Will. Die.”
Better yet, come round to the ED unit and explain to their parents why we should just let them starve to death. I’d love to see that meeting, and the response of the parents. Really, I would.
@Ted -
“What does it matter IF (?) they are blind?!
If you think they don’t know they are about to walk off a cliff, then get involved, by all means.”
You have missed the point (again). Being clinically depressed can be as much a failure of perception as being blind. A clinically depressed person about to end their own life can be as “blind” to the reality of their situation as a blind person walking unknowingly towards a cliff edge. (Or are you now agreeing with me that it is OK to intervene with force if necessary in the life of someone who is clinically depressed and a risk to themselves as I would in the life of our hypothetical blind person?)
“Why on earth are you asking me?!”
I thought you might have an opinion what if anything would you say?
@ Azulinebloo
Much as I disagree with Z and many of the others, at least they occasionally come up with some form of an argument. If you think that people who decide not to eat are suffering from a medical illness, then on what basis do you hold this opinion? And even if they were, would you still ignore their wish to be left alone (even if made prior to the onset of the illness)?
@ E
Your decision to put “blind” in speech marks shows precisely that they are not blind to to their situation. The psychiatric patients I talked to who had attempted suicide had *reasons* for their actions, and were often more than happy to discuss them. I’ll assume your question concerning whether I believe in coercive detention is a joke. By agreeing with the for-your-own-good principle, you undercut any criticisms you have of psychiatric practices.
“I thought you might have an opinion what if anything would you say?”
Do you mean in general? Your comment suggested I might have something to say to a particular person that I do not know, which I don’t. I’m not suggesting it is true of you, but in my experience people who favour coercive suicide prevention suffer a) from thinking that such measures are successful, and b) a general poverty of imagination concerning how non-coercive suicide prevention might look.
Ah Ted, indulge us lesser beings with the benefits of your superior imagination and outline how non-coercive suicide prevention would deal with someone who tells you they are leaving now, this instant to go and jump off Suicide Bridge. You know they have the capacity to do it, they have clearly signalled their intent to do so, they have tried to do so before that very morning. So – what’s the plan, Ted? They’re at the door of the ward right now.
Incidentally, just to give that imagination of yours a proper workout – the person has two very small, pre-school children at home.
@E –
“Your decision to put “blind” in speech marks shows precisely that they are not blind to their situation”
My decision to “blind” in quotation marks was to indicate that I was using “blind” in the case of a clinically depressed person being “blind” to the reality of their situation in a metaphorical rather than a literal sense and to draw an analogy between them and a literally blind person unknowingly walking towards a cliff edge. A clinically depressed person may be “blind” to their situation, you and I as objective observers are not.
I am sure the people you have spoken to had “reasons” for wanting to end their life. But were they good reasons? Were their reasons always rational? I am always willing to discus someone’s reasons for wanting to end their life (It is after all the ultimate question in philosophy) and may even agree on occasion with their reasons for wanting to do do so (although for obvious professional reasons which I am sure you would understand I could never convey this to the patient at least not in a professional setting) but I always reserve the right to disagree with tham and to intervene (with force if necessary) in cases where I think action is justified.
Why does agreeing with the “for your own good” principle” undercut any criticisms I may have of psychiatric practices? Parents intervene in the lives of their incompetent (in a legal sense) children, courts intervene in the lives of people with sever learning difficulties for the same reason, and A&E staff intervene without consent in the lives of people unable to give informed consent. Why is “madness” to use an old fashioned term (and don’t read anything into the use of quotation marks) be any different? The issue is one of competency.
“Do you mean in general?”
In general but also specifically to this one person, what would you do if crazyladywolf65 were stood in front of you now with the pills in her hand about to take them bearing in mind that at the moment you have no knowledge of their reason for doing so and no immediate way of finding out before they do the deed. The choice is to act or not act there is no time to have a philosphical deabte with the woman. Restraining them has moral consequences but so does adopting the moral high ground (if that is what you are doing) and doing nothing.
Anyway I have to go out now and visit someone who thinks their house was broken into last night. Maybe it was, maybe not. What should I do if she wants to end her life because she no longer feels safe in her own home?
that last comment was directed at Ted not at myself by the way.
Hmmmm. Arguing with yourself E, then going into denial about it?
That’s not a good sign.
Hi Ted
Unlike your patient, you get to go home at the end of your shift. If you really disliked it, you could quit your job.
The debate is about the right to die – not about whether I like my job or not. Not that I’ve said I dislike it at all. For the 5% of times I do not agree with the MH service – there’s 95% I do. It’s not all about disempowering people and coercive treatment. For that 5% I stay to try to help change it rather than run away.
[Mr Ian to Squawk] “This is your valid viewpoint”
It seems to me that telling someone their viewpoint is valid while supporting indefinite invasions of their body is not a consistent position to take.
Where did I say I supported it? In the case in question AND given her to be of legal adult age – I see no reason to ignore her advanced directive. However, see below.
If proper psychiatric advance directives were legally binding, I am sure quite a few people would take the time to write one. From what you have said so far, I have a hard time thinking that you actually support them, because you don’t believe that people have a principled right to reject psychiatric intervention.
But I do believe anyone who has capacity to make a decision has that right – I have also stated AD’s should not be obviated by the MHA but only by the MCA. There is no equity in singling out people detained under MHA which circumvents the whole spirit of the MCA.
The MCA is universal to all UK citizens regardless of MH issues.
If decisions are made during someone’s optimum or satisfactory capacity (which also allows people with LD to make decisions without reference to a socially expected level of capacity – but on their individual potential optimum capacity – as they are unlikely to improve that capacity to normal limits) – then those decisions remain valid – but this can only happen until the person’s capacity diminished to a point where they cannot change them.
It is indeed a bind but the catch22 is that a competent person may withdraw an AD at anytime – yet, as Shrink identifies – if someone loses capacity to self-determine, they are deemed mentally incapable to consent or refuse.
How can we be sure they haven’t changed their mind?
If someone has an AD that is legally binding to allow them to die – and whilst ‘mentally unstable’ they become acutely physically unwell – they then say “I want to live – save me” – What do I do?
If I let them die is that negligence?
If I help them live – can they not then equally claim negligence for not abiding by the law of the AD?
What if the AD says they don’t want invasive procedures; but they change their mind and decide they want to live but after they’ve already deteriorated into a stupor and can sense but not communicate?
Perhaps this may apply to only a fraction of a % that may be so placed – and they will die.
But then only a fraction of a % equally suffer the overall consequence of such invasive practice and are forced to live to regret it, as stated by squawk. I acknowledge that chance and I’m sorry it happens – but had that case been one of the ‘other’ % – she may well be dead now and no one would have realised she wanted to live.
Would you say “That’s too bad – should have made your mind up earlier; shouldn’t have been so fickle”?
It’s rather difficult to interview the number of those who are dead and ask them – “Did you really want to die?”
However, I am certainly not averse to listening to the likes of Squawk who will tell me – “Yes, I did want to die” – and then use that to inform my opinion (rather than quoting Szasz et al to validate your opinion).
The reality is – if death were the sole aim, then there are plenty of other options. But it isn’t – it is generally a side-effect of the underlying issues that lead to death’s doorstep.
I simply pose you this:
We permit everyone who wishes to die, to do so, as you would have them be allowed.
But how do you say we justify under this permissive regime to the family, society the services, and even the person – who, given the chance to come back, would say “You know, I didn’t mean it – Can I have another chance?”
@Mr Ian -
“If proper psychiatric advance directives were legally binding, I am sure quite a few people would take the time to write one.”
I can’t help thinking Ted has a point there. If AD’s were legally binding or had some legal force more of our patients would be writing them. As it is they don’t so people tend not to bother.
I’m not that convinced by advance directives. When I was 25, I had absolutely no idea what being 45 would be like, and imagined I’d be all sorted out, fat, middle-aged and content. Well, two out of four isn’t bad I suppose.
I think what I’m saying is how could I possibly know now how I’d feel if I was seriously ill with – say – inoperable cancer? I might think now, with the life I have at the moment, that I couldn’t stand it and would want to die, but I suspect I might feel very differently if I was in the actual situation. And what if, as Mr Ian says, I am unable to communicate my desire to stay alive?
I’m hoping squawk is going to take us up on the offer and may write about AD’s so not wanting to steal all the debate in here – but you’re right about changing minds over time and ADs should be reviewed and re-validated periodically.
If someone came to me aged 65 and unconscious -even for a physical condition – and someone later produced an AD written when they were 25 I’d have to consider it’s validity 40 years on if it hadn’t been re-validated. It’s common for people’s minds to change over time – as you indicated beakie and, other than religious reasons, what was once relevant may no longer be so important.
(Tho this argument does question the validity of donor cards if not similarly re-validated)
@E – The issue with them E is that they only become un-binding in law if someone is detainable under the MHA so for the vast majority of MH patients they remain valid options. Even when detained, it would still be frowned upon to not at least consider an existing AD and review it’s basic principle to the poiunt it should be documented why one wasn’t followed – and not just “cos s/he’s on a section 3″.
@ beakie
First of all, I don’t work in a psychiatric ward, so I wouldn’t be stood near the door of one. Second, who is this person who is “leaving now”? Do I know them? Third, what do you mean by “capacity to do it”? It sounds to me like someone who has a) the ability to know that they want to kill themselves, b) the ability to plan and carry out actions which will lead to this happening, and c) the ability to communicate these plans to someone else, is not suffering from a severe illness which renders them incapable of making decisions. Are you restricting your question to people who you say are mentally ill, or does it apply across the board?
It is very unlikely someone I didn’t know would signal such intent to me. It is possible, but incomparable to the average psychiatric case. In any case, it is apparent from the very act of being informed that the other person does not wish to commit suicide immediately and with no interference. They may wish for help in killing themselves, or they may wish to be persuaded to not go ahead with it. They may be desperate and not really care what happens to them. Whichever it is, it is important that they chose to tell someone.
With that out of the way (I consider it very important, perhaps you less so) I can get closer to your question. So, if someone did inform me, I would probably bring up the fact that they had told me and ask them what they think this tells them about their stated aim. I would inform them about the relevant governmental and non-governmental agencies they could get attention from, and I’d be sure to let them know any possible consequences of asserting dangerousness to oneself. I would also remind the person that they are responsible for themselves, and for what they do. If they have two small children (how do I know this?), then that might be something to talk about. I would neither agree nor disagree with their stated aim, because it has nothing to do with me. I would tell them that I will not shop them to psychiatry, nor would I use force to prevent them from any non-aggressive act. Nor would I help them in any way to die. I would not lie to them, nor would I tell them unproven assertions about any medical illnesses. If I felt they were manipulating me, I would tell them so and make arrangements to leave the situation (perhaps in the hands of a family member).
I recall reading that Andrea Yates told mental health services that she had wanted to kill herself because “I had a fear I would hurt somebody … I thought it better to end my own life and prevent it.” Of course, she was subject to coercive psychiatry, making such an act more difficult. http://www.usatoday.com/news/n.....titialskip
Does that satisfy your curiosity?
@ E
“I was using “blind” in the case of a clinically depressed person being “blind” to the reality of their situation in a metaphorical rather than a literal sense”
Just as mental illness is an illness in a metaphorical sense rather than a literal sense. Obviously, the mentally ill share some characteristics with those who are medically ill, but they also have many things not in common. One thing they do not have in common is the presence of an objectively identifiable bodily lesion or malfunction. You practically made Szasz’s point for me.
“Why is “madness” to use an old fashioned term (and don’t read anything into the use of quotation marks) be any different?”
Because the groups you compare it with are all legally incompetent.
“what would you do if crazyladywolf65 were stood in front of you now with the pills in her hand about to take them bearing in mind that at the moment you have no knowledge of their reason for doing so and no immediate way of finding out before they do the deed.”
You can read my above response to beakie for some overlapping content. But your example just shows how absurd the principle of coercive suicide intervention is — you define the situation as an emergency (which does not resemble the average psychiatric suicide intervention at all), and then allow whatever is necessary to prevent death. So, recognizing that people who really want to kill themselves will do so, is there anything you *wouldn’t* do to try to prevent a voluntary death?
@ Mr Ian
“Where did I say I supported it [indefinite invasions of the body]?”
What else does “I am certainly not averse to listening to the likes of Squawk who will tell me – “Yes, I did want to die” – and then use that to inform my opinion” mean? If you retain the power to decide whether to allow people to kill themselves, then you support the principle of coercive bodily intervention. If there are some circumstances in which you reject the powers to intervene, then great!
“How can we be sure they haven’t changed their mind?”
They signed the form, and they should take responsibility for it. Moreover, if they are genuinely mentally incapacitated, there is not much of a mind left to change!
“If someone has an AD that is legally binding to allow them to die – and whilst ‘mentally unstable’ they become acutely physically unwell – they then say “I want to live – save me” – What do I do?”
If someone can inform someone they wish to override a previous directive, then does that not make you wonder how “mentally unstable” they are? Another relevant factor: if health care were not free at the point of service, people might think twice (rather than not at all) before agreeing to something they were not sure about.
“But how do you say we justify under this permissive regime to the family, society the services, and even the person – who, given the chance to come back, would say “You know, I didn’t mean it – Can I have another chance?””
I’ve dealt with the person to whom the intervention is forced upon. And it has nothing to do with anyone else. To the extent that it does, the person is a slave.
“I’d have to consider it’s validity 40 years on if it hadn’t been re-validated”
Nonsense. The fact that people have not taken any action to invalidate a previous decision is plenty of evidence that they have not repudiated it. As you say, people change their minds all the time, but yet strangely not enough to have bothered to do anything about their advance directive – something which can have far reaching implications.
Does that satisfy your curiosity?
Yes, it tells me once again that you have absolutely no idea what you’re talking about, and no idea how other human beings work.
@Mr. Ian
“Even when detained, it would still be frowned upon to not at least consider an existing AD”
Still not the same as having that AD enforceable in law but
“Disagreement with the priest is freedom of religion. Disagreement with the politician is freedom of speech. Disagreement with the psychiatrist is irrationality, insanity, and mental incapacity.”
can’t help feeling Ted might have a point there.
@Ted
“Just as mental illness is an illness in a metaphorical sense rather than a literal sense.”
As I think I argued once before, Psychiatry is no less a science or a valid branch of medicine for treating the concept of mental illness as a “metaphor”. The idea of an electron is a metaphor (is it a wave or a particle? When did you last see, taste, hear, or feel an electron?) But this does not stop us making a valid prediction of what will happen when we flick a light switch.
“Because the groups you compare it with are all legally incompetent.”
So are those deemed to be suffering from a mental illness of a type and degree that renders them irrational to the point where it is justified to intervene against their will if need be. Competency is a concept; a social construct if you will that can be applied to minors, those with a learning disability, acquired brain injury and if we choose to a mental illness.
“is there anything you *wouldn’t* do to try to prevent a voluntary death?”
Yes there is plenty I wouldn’t do but in cases where I would intervene I don’t consider the intended actions of a suicidal person to be “voluntary” any more than I would consider a blind man walking off a cliff edge to be “voluntary” where the blind man is unaware of the cliff edge and is just out for a walk but has forgotten to take his guide dog with him. What would you do in such cases where persuasion has failed and the individual is clearly acting on faulty information or a misconception/ misperception of reality?
I’ve only got one thing to say as regards Ted’s prevaricating about the hypothetical person off to visit the bridge on the A1.
Over a decade ago, I was a patient on an acute ward. Another patient, who was a friend of mine from previous admissions and with a history of multiple, serious suicide attempts, confided in me that when she was getting discharged at the end of the week she was going to take twice as many pills as she had before and kill herself.
I, being either too ill to realise this wasn’t a good idea on her part (I was actually jealous I couldn’t do the same and thought life sucked and everyone was better off dead blah blah), or just a moron, didn’t tell anyone.
Luckily, her mum happened by her flat that day and found her, so she didn’t die.
I’m never doing something that assinine and negligent again. Jesus. She could have died. Her ODs weren’t self-harm, she just seemed to have a bionic liver. Her consultant said as much.
So Ted, in your case, I recommend sex and travel in that order (ie please f**k off).
@Ted – <i?What else does “I am certainly not averse to listening to the likes of Squawk who will tell me – “Yes, I did want to die” – and then use that to inform my opinion” mean?
It means I do what is the consensus until it becomes obsolete. I did not choose coercion nor did I invent it. It was there and has been a long time before I joined mental health. To arrive into a (westernised) global situation and simply do different on a whim would be considered irrational. To validate and evidence my decisions to be different would be more sensible.
They signed the form, and they should take responsibility for it. Moreover, if they are genuinely mentally incapacitated, there is not much of a mind left to change!
And that is a reason to ignore the potential? Because they might be temporarily unable to do otherwise – so basically, it’s their loss – too bad, too sad?
If someone can inform someone they wish to override a previous directive, then does that not make you wonder how “mentally unstable” they are?
No. For they may also tell me they are Jesus Christ and God told them to change their AD and now accept the ECT as it’s a way of being crucified and serves as a sign of faith to Zeus; in which case they may be deluded (as God was discharged two weeks ago).
I’ve dealt with the person to whom the intervention is forced upon. And it has nothing to do with anyone else. To the extent that it does, the person is a slave.
You totally missed the question – what of those who aren’t coerced against suicide – who actually would rather you had?
Nonsense. The fact that people have not taken any action to invalidate a previous decision is plenty of evidence that they have not repudiated it.
I would still use my judgment as to the nature and extent of the decision(s) within that directive because, and regardless of absolutely anything, I still have a moral and legal obligation to serve the best interests of the person.
I’m keen for you to answer my dilemma tho; if you can I will concede to your position quite readily:
There are categories of those who explicitly voice suicidal ideation –
1. Those with long term and probably unresolvable chronic issues who repeatedly want to die and escape.
2. Those as above but repeatedly seriously self harm – and risk accidental death
3. Those who are similar to above but options exist to ameliorate the underlying suffering who are simply drained by the waiting for a cure or dislike the treatment options
4. Those who are more transiently and immediately dysphoric – say their long term relationship has recently ended or they are having a brief psychotic espisode – and suicide is only a transient reactive state of mind to seek immediate relief to the immediate problem.
Now I have no problem with those who fit #1 category taking their own life. They have weighed the balance and givcen their circumstances – death is less painful. It’s sad and I wish we had support to cure them – but we don’t always have everything. “Care” would suggest we keep trying – a cure may come up and the underlying issues become resolved; but that’s just human nature to be woefully hopeful.
In #2 accidental death is a side effect of the risk they take. I advise and educate that such actions run the risk of death. The patient tends to dismiss me with “so what?” attitude – but the fact they aren’t directly attempting suicide does not mean they are trying to die (note – extreme sports etc are not suicidal – yet they are aware of the risks to self)
In #3 I am happy to try all the other options before broaching the unacceptable ones. When it comes to it – the suicidal state can be resolved and the question would have to be “at what cost to the person?”
In #4 however, such reactions are not uncommon yet do not last. Grief is resolved and people come to terms with their new status. Yet under the permissive regime of Ted, they should be allowed to kill themselves at whatever time they make their decision to do so and under whatever circumstances.
It is these in #4 who are more likely to be grateful for intervention at a later date when perhaps they are still able to function as a parent or find a new relationship or even re-ignite the old one.
What do we do about these #4 people who are making rash decisions in the heat of the moment?
Just allow it and say “Well – too bad s/he didn’t get over it. They coulda had a life”?
Do you simply allow them to die?
Here’s a better example under the pseudonoym Rachel Brand:
http://www.guardian.co.uk/life.....eing.women
I tried to kill myself for the first time around eight weeks after Susie was born. At that point I was mainly focusing on trying to get some sleep. We went to stay at Dave’s parents’ house while they stayed at our house with Susie so we could be in a peaceful environment. On one of these occasions, while Dave was asleep I walked into the kitchen and took tablets belonging to his mum. I just wanted to go to sleep and never wake up.
OK post-natal depression – it’s defined as a “mental illness” and often is considered responsible for the irrational thoughts that lead to mothers becoming capable of commiting infanticide. But let’s not intervene coercively eh?
After her third attempt she was compulsorily admitted – but only after displaying “I became convinced that everyone was out to get me on a governmental level. I thought Dave was a robot or someone pretending to be him. In the hospital there was a sign saying the floor was slippery and I imagined that they had deliberately made it dangerous to kill me so I began trying to navigate the room using just chairs”
So what should have happened for Rachel?
She should have been left alone to die and her husband told – Sorry but that’s her choice – you deal with it? I’m sure he could also explain to Susie that mummy only went a bit bonkers after she was born but don’t blame yourself for your mother’s death and not ever knowing her.
I need a better option than this for the ones we will be abandoning Ted.
Sorry.. I should add she was ultimately diagnosed with puerperal psychoses and her personal evaluation of the intervention:
I have spent the past month simply getting to know my baby and acting like a real mother at last. It’s wonderful to have come out the other side.
E – Tube feeding comes under particular rules just for it – most people on the unit who needed a section were under ‘Section 6′, not seen that elsewhere. The ‘Keyes experiment’ is the classic for this – starving a group of COs during WW2 to learn about how to re-feed refugees. A lot experienced cognitive symptoms overlapping anorexia.
Will think about a guest post, won’t be for a week or so though.
Ted – ‘You assume the right to prevent non-aggressive persons from using their bodies as they see fit’
Nope, not the first time round. I wasn’t ‘using my body as I saw fit’, that implies much more choice than I had. I couldn’t have chosen to eat (when I did decide I wanted to learn to eat normally again, it was very very very difficult and I needed a lot of help).
‘If you can offer up anything to show that people who do not wish to eat for a prolonged period of time are somehow stripped of the ability to choose having become a slave to a severe medical illness, then I’m all ears.’
This completely sums up my experience. I didn’t have a choice to eat or not eat, I had a choice to eat and spend the next few hours overwhelmed by complete hatred for everything I was, and then go through it all over again four times a day every day without fail for the rest of my life, or not eat and feel safe and just drift away from it all. Even when I was out of hospital I used to spend most of the day crying and hating every breath I took for keeping me alive. Ever been around a recovering anorexic?
There is absolutely a case for placing EDs in a broader socio-political context – I ‘discovered’ feminism during recovery, and understanding the way young women in particular but increasingly everybody have their sense of self fucked around with by culture and consumerism was helpful. It’s hard to understand though just how much your world-view shrinks during a severe ED & low weight. There just isn’t room for anything besides the ED in your head.
As for treating the family network – I’ve worked a fair bit with children with disabilities, and it just doesn’t make sense to treat that without treating the ‘context’ of the disability (social model). An important part of that is helping the family come to terms with the child’s impairment – I particularly like Jim Sinclair’s ‘Don’t Mourn For Us’ wrt autistic spectrum disorders: http://www.autism-help.org/sto.....-mourn.htm . the children I’ve worked with mostly aren’t ‘curable’, and some of them have degenerative conditions and will die (and some will go on to live full, meaningful and happy lives, surrounded by people who care about them, but that’s another discussion). Parents of children with chronic, unstable, or degenerative illnesses are supported by professionals to accept & live with their condition. Families of people with anorexia aren’t, although 2/3rds of those who live will have a chronic ED (and some of those who ‘get better’ will have long-term physical illnesses). There’s so much emphasis on ‘getting back to normal’, & IMO even for those few who do manage ‘normal life’ again, things will be very different, the child the parents used to have won’t be the same person who’s been through an ED & out the other side.
Zarathustra: ‘Erm, most people don’t die of a toothache.’
Before modern dentistry, it was a common way to go.
I do agree with you on personality disorders though. I recently had to deal with a (male, final yr medical student) friend who needed hospital admission for depression triggered by the loss of a parent & academic pressures – he was told by the psychiatrist that if he didn’t take a specific antidepressant the psychiatrist would give a diagnosis of personality disorder. The psychiatrist then went on to compare my friend to Harold Shipman & Beverly Allitt. There’s never been a suggestion that my friend is a risk to anyone else, despite lots of Occ Health assessments. Diagnoses shouldn’t be used as a threat or punishment.
Mr Ian: ‘If someone has an AD that is legally binding to allow them to die – and whilst ‘mentally unstable’ they become acutely physically unwell – they then say “I want to live – save me” – What do I do?’
My AD is written so it only kicks in if I refuse treatment whilst well and *then again* refuse treatment whilst ill. If I decided whilst ill that I was going to consent to hospitalisation, and then decided that consenting to tubefeeding would be easier than struggling with eating myself, I could be tubefed. IMO this is analogous to children being allowed to consent but not to withhold consent. Agree is tricky.
I don’t want to die, and at worst I was ambivalent about staying alive – if I’d wanted to die enough there are more certain ways to do it and not be stopped than refusing food & eventually fluids when I’d just had enough of it all. I didn’t want invasive treatment, & knew that death would be a consequence of that, and didn’t think that was the worst option of all the bad ones available. It’s not quite the same thing as being actively suicidal.
Beakie – I’m well aware of research which suggests that even winning the lottery, being on kidney dialysis, or becoming paralysed doesn’t have that much impact a few years down the line on happiness. ISTM that MH does pretty much by definition. I agree that it’s not possible to foresee one’s own wishes exactly (which is why I’d probably go for positive consent when incapacitated to over-ride an AD), but I probably have more insight into what it’s like for me to be hospitalised for an ED than anyone else, having been there once already.
FWIW I date my AD to last 5 years, try to re-sign & update every 3.
Squawk> That’ll be the Minnessota Starvation Experiment. I first read about this in a book about eating disorders, unfortunately I can’t remember which one. The whole thing is FASCINATING (and horrifying). The volunteers were conscientious objectors (mostly Mennonites, Brethern and Society of Friends) whose religious beliefs forbade military service. They did this as civil service instead of the army, as far as I remember.
The wikipedia entry is here:
http://en.wikipedia.org/wiki/M.....Experiment
A more detailed account is here at junkfood science:
http://junkfoodscience.blogspo.....-that.html
The latter is a size acceptance blog. You need to skip down to find the study description. I haven’t read the whole article here, but it is likely to strongly emphasise the aspects of the study that would correlate with the size acceptance movement’s views. Just as an fyi.
I can recommend taking the time to dig up comprehensive information about this study because it makes gripping reading.
@Squawk –
“he was told by the psychiatrist that if he didn’t take a specific antidepressant the psychiatrist would give a diagnosis of personality disorder. The psychiatrist then went on to compare my friend to Harold Shipman & Beverly Allitt.”
Sounds like it was the psychiatrist was the one with the personality disorder.
Unfortunately E in that situation, the psychiatrist has all the power and you have none. So you have to go along with it. I’ve been threatened with having something unpleasant (“resists treatment”) written in my notes as well if I didn’t play ball. It doesn’t matter if you think he’s an arse. He can still do whatever he likes and there’s nothing you can do about it.
@DeeDee Ramona
Which is where Ted is coming from I think.
However E this only holds in the case where the psychiatrist is a completely unethical and abusive arsewipe. There are numerous members of the profession who urgently need to have their P45 inserted in their nether regions and then be drop-kicked to the nearest job centre. That doesn’t mean that everyone who has ever been sectioned has been simply as part of someone’s power games.
And there are things you can do about an abusive psychiatrist. You can complain to his clinical director, for starters. If you’re not happy with that, there’s a whole other formal complaints procedure that you can pursue – the local PALS service should be able to help you navigate it.
What Beakie said. If a psychiatrist is rude or unreasonable, you do not simply have to sit there and accept it. You have the right to make a complaint and to demand a second opinion. I’ve been involved in cases before where behind the psychiatrist’s back I encouraged the patient to do exactly that.
In this country, certainly, I agree. In the UK, you’re considered a person who actually matters and if you complain someone will listen. This is good. Anyway you know how much Ted and I see eye to eye….
On t’other hand, you are risking complaining being interpreted as a ‘behaviour’ or a ‘symptom’, which can be used to confirm a diagnosis.
I’ve only once made a formal complaint – a pair of CPNs made their first contact with me through an uninvited & unannounced visit to my house, my housemates were worried by being approached by these people with name-tags from the local psych hospital who were looking for me. I wasn’t impressed by the breach of confidentiality, since I’ve been trained not even to leave answerphone messages in case they are picked up by someone other than the patient. I raised it with the CPN concerned at my next appointment, she wouldn’t discuss the matter & would only say ‘You’ll just have to make a complaint’ & wouldn’t tell me how, but since I already knew about PALS then I did anyway. It came up at my next review meeting with the psychiatrist, not as a ‘how do we improve care so this isn’t a problem’, but as a ‘symptom’.
On a somewhat related note – once you’ve got a diagnosis, does it stay on your file forever? When I see my GP now, he’s got a brown paper folder and / or computer screen with diagnoses on top – things like ‘eating disorder’ ‘self-harm’ and even ‘aggression’ (the last from when I was 6 – I have an unrelated developmental disorder & was treated for a patch of ‘challenging behaviour’ at primary school, but with that on the front of my notes I’m always a bit worried the receptionist will think I’m about to hit them).
Alas, where I’ve been at uni for the last few years then there is no choice whatsoever about seeing the one psychiatrist (who I will call ‘Dr Scary’), even if you ask to be referred to someone else or get a second opinion. Uni counselling describe her as ‘difficult to work with’, uni GP says she ‘doesn’t always get on so well with people’, CPN described her as ‘difficult’, & other local psychiatrists who I happen to know through church or work don’t have a great opinion of her either.
When a friend refused to have Dr Scary involved in her care any more, the response wasn’t to transfer my friend’s care, but for Dr Scary to continue to oversee my friend’s treatment without ever actually seeing my friend. I don’t know why this is, Dr Scary works out of the local psych hospital where there are other psychiatrists people could see, but I have never ever known anyone who lives this side of town be able to see anyone NHS but Dr Scary, despite asking, advocacy services, PALS, sympathetic GPs, quoting the rules, and just refusing to turn up to appointments. n=7 who I have accompanied to Dr Scary appointments, plus many more anonymous uni Nightline callers – *all* 7 & most of the Nightline-ers didn’t want to see this particular Dr Scary, maybe if they let everyone swap she wouldn’t have any patients left? I think she should have to re-train as a pathologist or drug researcher or something that doesn’t involve patients.
DeeDee – I’ve also heard about the Keyes / Minnesota study from the POV of some of the COs involved, having been involved in ‘peace churches’ for a while. It’s both fascinating and horrifying in a ‘history of science’ way, as well as incredibly interesting for what it says about the role of food deprivation in EDs & more widely.
I hear what you’re saying Squawk. I recently had the misfortune of working alongside my very own Dr Scary, except I call him Dr Cretin. This is him.
Psychopathology should not be used a means to dismiss complaints. Unfortunately it does happen. I think I may open up a fresh post on this subject.
Incidentally, if your friend’s complaint hasn’t been handled satisfactorily by the local trust, you might want to suggest to her that she take her complaint to the Healthcare Commission. If the Healthcare Commission don’t respond effectively, she can then go to the Health Service Ombudsman.
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