This appeared in my e-mail inbox this week.
You’re not fucking nurses. Nurses work with doctors. Psychiatrists are not real doctors. So you’re not real nurses. You’re just trumped up prison guards, in prisons that hold the innocent. You poison peoples’ bodies with toxic drugs against their will. You carry out human rights atrocities every fucking day. How dare you call yourselves nurses. I hope each and every one of you is killed by one of your torture victims. I mean that. Maybe one day you can get a taste of the trauma you cause in peoples’ lives each and every day. Many people could never live the career choice you have made, which is, to hurt people for a living. FUCK YOU. Your site is offensive, your FAQ is offensive, and you people are disgusting.
Okay, which one of you gave Tom Cruise my e-mail address?
I think I’ll use this e-mail as an excuse for some rambling thoughts on the nature of coercion in mental health.
I’m in the process of moving from a ward environment to a a community team. On the community team, none of the patients are subject to the Mental Health Act, on the ward a few of them were, but most were there informally.
That said, I work with children, so issues of consent and coercion are a little more complicated. In some cases consent is devolved to the parents. Some of our patients might well be subject to MHA detention or a Community Treatment Order if they were a little older, but since they’re minors we can often dispense with the Mental Health Act and just get the parents to sign a parental consent form instead.
I don’t expect to be doing much that’s particularly coercive when I go back to the community CAMHS team, apart from occasionally going round to the school or home of an anorexic kid to supervise her lunch. Kids are sometimes hauled to CAMHS unwillingly by their parents, in some cases for Naughty Child Syndrome which they expect us to be able to “sort out” with a bit of anger management CBT. It usually isn’t effective to do CBT on someone who doesn’t want to be there, and if there isn’t a pressing mental health problem these kids are usually quietly discharged.
On the eating disorders unit, there’s a lot more coercion, which I’ve documented in my “The Kid” series, along with the profound ethical and emotional dilemmas that my encounters with The Kid provoked in me. Being an eating disorders unit, the bulk of the coercive side is to do with supervised meal and rest times, and preventing exercise. There’s also some of the coercive elements more traditionally associated with psychiatry at the ED unit – compulsory detention (a fair amount, either under the Mental Health Act or parental consent), physical restraint (occasionally, but not very often) and enforced administration of medication – rapid tranquilisation, depot antipsychotics, nasogastric tube feeding (very rare).
The bulk of the rare occasions where I’ve had to restrain or rapid-tranqiluise someone have been when I’m doing bank shifts elsewhere. Most of the restraint I’ve done has been on elderly wards, where you get to find out just how hardcore your frail, dementing, 77-year old granny can be. Every time I’ve done it I’ve been able to justify my actions as being the appropriate decision.
I don’t enjoy the coercive side of psychiatry, but it’s sometimes necessary in order to protect the safety of the patient, their fellow patients, the public or yourself. I also recognise that it should be a last resort, done according to a principle of least restriction and with all due process being followed.
For that reason I take a very dim view of “pseudovoluntary” (i.e. voluntary until they ask to leave the ward) stays. A patient detained under the Mental Health Act has an automatic right to an independent advocate and a solicitor, and the right of appeal to the hospital managers, to a Mental Health Review Tribunal and to the Care Quality Commission. Somebody who just gets told, “If you try to leave we’ll section you” gets none of that. Don’t tell people you’ll section them if they carry on demanding to leave, just section them. That way they’ll get the legal rights they’re entitled to.
Overall, I’m aware that the coercive side of psychiatry means that a lot of people view my chosen career with the same high regard given to professionals in the seal-clubbing industry. Even so, I still regard that side as sometimes necessary, but to be used responsibly, as little as possible and with the best interests of the patient kept in your mind when you’re doing it. I’m not gung-ho about it, and I’m happy to say that the overwhelming majority of my colleagues aren’t either.
Blimey. And I thought I had unresolved anger issues with psychiatry.
Nuse: “A person educated and trained to care for the sick or disabled”
Seems to fit with what you do quite nicely. I think that’s the opposite of disgusting. Especially the care bit.
Lola x
I often dwell on the coercion tag – not least because I’ve had to use the Mental Health Act with regularity. I agree completely about the pseudo-voluntary hospital stays and certainly in the area I work in (over 65s) we have used the MHA much more since the Deprivation of Liberties Safeguards drew specific attention to that group of people who lack capacity and are ‘required’ to stay on hospital wards.. we are also guided by the Code of Practice which indicates that we can’t threaten someone with sectioning them if they leave – much better as you say, to go through the process and allow appeals.
I was talking about the Act to a student social worker who was milling around our offices earlier in the week, the only way it can be justified is by looking at longer term necessity and best interests.
Incidently, I’d be really worried if anyone enjoyed the coercive nature of the work..
“Your site is offensive, your FAQ is offensive, and you people are disgusting.”
It is nice to know we have managed to reach out and affect someone so deeply. Also nice to know that people actually read the FAQ.
That reminds me, we really ought to get around to updating the FAQ.
Would it be a little insensative to suggest that the emailer ‘keep taking the tablets’?
[PS Please ignore pur spellign]
That e-mail is horrible and untrue.
Should we just let people suffer?
All I can say is that the writer has clearly never had any MH difficulties because then he would understand everything that nurses do is to CARE. People don’t get detained for no reason.
I wonder that the writer would do if one of his relatives had a psychotic episode? Presumably allow them to suffer. How very human rights minded of him.
We have spent years trying to get this site to offend someone. I think the least people we offended were the Nursing Standard but that was a long time ago.
Anyone got any FAQs for us so we can update?
And Z is disgusting.
I think we’ve occasionally offended Dr Crippen and a few psychotherapists.
We also got (briefly) mentioned in NMC News a while. Rather boringly, it seems their view of us is that what we’re doing isn’t unethical so long as we don’t breach confidentiality or bring the nursing profession into disrepute.
I think we’re all pretty careful about not breaching confidentiality, since we anonymise and semi-fictionalise all clinical anecdotes.
As for bringing the nursing profession into disrepute…
Ted suddenly doesn’t seem quite so extreme in his views any more…
For a second there I thought I was back at work…
Z, why are you OK with using parental consent with minors, but not ‘pseudovoluntary’ admissions for adults?
There’s much less protection for someone who’s admitted under parental consent, particularly as the decision there isn’t being made by trained professionals with a right of appeal, but by the family who may be implicated in fucked-up-ness.
I find this particularly worrying on an adolescent ED ward, where most of the patients would be likely considered competent if they weren’t ill, or for non-ED related decisions – I was allowed to consent to participating in research, and to all sorts of minor physical health stuff, whilst an inpatient under parental consent.
BTW I’m rather suspecting you were working on my old ED ward, there’s not many to choose from.
Good question, Squawk, and I suspect I’m going to open up a can of worms, but my answer would be that society doesn’t grant children the same level of autonomy that adults have. Children are compelled to do all sorts of things – for example, to stay in school – and being compelled to remain on an ED unit and have their meals and exercise supervised has become an extension of that.
In the current legal, ethical and social climate, children are not afforded the right to deliberately malnourish themselves.
I’m not entirely comfortable with going by parental consent alone. I think it’s probably sufficient for, say, supervised mealtimes, but for the more extreme interventions such as nasogastric tube feeding I’d prefer something more stringent. That said, on the (very few) occasions that an NG tube was used while I was on the ED unit, the kids involved were clearly experiencing the cognitive effects of starvation, and as a result were nowhere near Gillick-competent to make decisions about their healthcare.
I don’t think I was on the same ED unit that you were on. I could tell you why, but not in a public forum as that might give away my identity.
Incidentally, Squawk, your invitation to do a guest post on MN is still open.
Yeah, but… just being on a psych unit when you’re 14 is a REALLY BIG DEAL even if you aren’t going for the far end of physically coercive actions – and even just requiring someone to remain on the unit is only meaningful if you know & they know you know that you are prepared to back that up by physical force if necessary. IMO this isn’t something that’s made enough of a big deal. Asking a patient nicely ‘will you please stay here and finish this sandwich’ is ontologically equivalent to rugby-tackling them for running away & tube-feeding, if that’s what the implied sanction is, be it ever so distant.
Being on a psych ward for months at a time, & if it’s an adolescent ED specialist unit then often very far from home so you can’t maintain effective social contacts, is a lot different from the social near-universal of school. The ‘hard coercion’ for me is not nearly as much of a jump as taking someone out of their social framework, taking away everything that’s important – not just the illness, but friends, family, school, almost everything that gives your life shape – and then telling someone that you’ll be held for an indefinite period until they’ve been forced to give up what makes life bearable, and won’t be free ’till you don’t even miss it any more, and even when you’ve been allowed to go you can & will be brought back at any time if you go back to being who you are now. Compared to that, and compared to all the physical shit that an ED does to you, then tube feeding really isn’t much of a jump further.
Have you read much on the methodology of the psychologists working at Guantanamo?
I’m thinking particularly here of what the ‘Mind Hacks’ blog described as:
‘What the interrogators want… is not learned helplessness, but where the detainees know and can demonstrate that co-operation is the only method that allows them control over their environment’.
( http://www.mindhacks.com/blog/.....throu.html )
I appreciate it’s an emotive comparison, I don’t particularly like comparing MH staff to military interrogators (remember I work in MH-related area). But sometimes I think that MH staff don’t appreciate the impact of living in a total institution – or have spent so long around it as to be institutionalised themselves. The tools used are in some ways less important than the head-space they put you into.
IMO there’s not been nearly enough of the long-term follow-up looking at how to allow people not just to stop displaying ED behaviour, but how to lose the sense that hospital gives you of being totally lacking in agency, controlled by the environment, having no valid thoughts or opinions… it’s a dangerous way to leave people. But anyway, that’s the important bit in involuntary treatment, what you do to people’s minds, not whether it takes force-feeding to break them so they can be rebuilt.
BTW, should you have a spare couple of hours & want to read up on the psychs at Guantanamo: http://documents.propublica.or.....curity#p=1
Possibly the creepiest bit is that as a psych grad myself, I can absolutely follow their reasoning, it’s very much what I’d be doing in the same situation…
I agree with you entirely about the damaging effects of keeping kids on psych units for long periods. As it happens, CAMHS in my area has, for that very reason, been reorienting itself away from inpatient care towards assertive outreach teams providing intensive support to kids in their homes and schools. We’ve been very successful at keeping kids out of hospital (or, failing that, drastically shortening their stay) as a result. I’ll do some posts on this when I’ve got my thoughts together.
Thanks for the links on Guantanamo. I’ll have a browse.
Good
Be interested also to know how you’re looking at supporting families then, if you’re moving towards more severely ill patients staying at home.
I spent over three years (total, cumulative, distributed over 5 admissions) as an inpatient between the ages of 9 and 17 for ED treatment. Included plenty of restraint, RT, NG and PEG tube feeding, as well as other, even less pleasant interventions… Just wanted to say thanks Squawk and zarathustra for your insightful comments. Agree with at lot of what you say. It’s good to see some of the issues being discussed.
Em
Just thought I would say we don’t all hate psych nurses! Yeah, there are some shit ones, just like there are in any job, but there are also some great psych nurses out there, who seem to genuinely care about their patients. I am lucky enough to have a CPN who is in the second camp, and have also known some great psych nurses when in hospital. Obviously there are bits of your job that aren’t so nice, but I think that most of us mentals, if caught in a reasonable state of mind, would agree that you do a pretty good job, which is probably thankless a great deal of the time. So next time you are sectioning someone and they are screaming that they hate you and that you are evil incarnated, it probably isn’t actually true. Unless you are one of the shit ones, in which case it probably is.
And moving on, I would rather be pseudovoluntary than on a section thanks. Yeah, I might miss out on a few appeals etc, but at least I won’t have being sectioned on my record for the rest of my life. And if I am really desperate to be put on a section so I can have those appeals, I will just leave, or attempt to. Then I will either be free, or sectioned
I might print out that email to show my shrink, so he can see what actual mindless hatred looks like, and maybe he’ll stop whining about how I’m so uncooperative and ungrateful.
Most of the restraint I’ve done has been on elderly wards, where you get to find out just how hardcore your frail, dementing, 77-year old granny can be.
True dat. We were all secretly relieved when my grandmother’s walking-stick was replaced by a zimmer frame that, crucially, she couldn’t lift up and swing.
I’m guessing the L Ron Hubbard quote at the top didn’t help either…
Why? Looks like useful advice to me …
*ahem*
An interestingly angry email, doesn’t fit well with my personal experiences, having been both a service user (i.e. patient) and a mental health nurse of long standing. Clearly the writer doesn’t comprehend the use of ‘irony’ ‘humour’ in the FAQ. Perhaps when you re-write the FAQ you should bung something in about insight.
Not the warmest language, but clearly the email has a point. The response by zarathustra seems to confuse actual incompetence (eg young and old folk) with fake incompetence (eg most adult psychiatric patients). That said, I agree that the boundaries of coercion should be clearly defined. This refers not just to sectioning, but to the whole psychiatric enterprise. Some unfortunate people have no idea what mental health professionals can legally do. In any case, sectioning someone to ensure their legal rights are upheld is particularly insulting.
I personally would rather be sectioned than under psuedovoluntary. There is something inherently dishonest about that and I despise that. I do understand the point, however, that some make that they would rather be able to choose voluntary status. In order to preserve voluntary status, we need to handle the transition better from voluntary to involuntary once someone asks to leave. Perhaps, once you ask to leave, the 72 hour hold starts ticking, and if they don’t have a court order by then, they have to let you go. (Well, that is my scenario based on American laws.) But this business of persuading someone who asks to leave while voluntary to stay, or of pretending not to hear them, or of simply not taking any note of their request, has to stop. That would all be frustrating and maddening to someone who is able to stand up for herself, but for a patient who may not be able to stand up for her rights, that is abusive.
I think persuading someone to stay has its merits, as long as it’s not “if you try to leave we’ll form/section you”. In my unit at least, all the patients are voluntary so making someone involuntary necessitates a transfer to an authorised and probably less nice unit.
Do you have a problem with “I really think you benefit from being here, I think you’re safer in hospital” etc.?
I don’t think any reasonable person can deny the existence of abuse/torture in some psych wards. I sometimes think it would be etter to say “no coercion at all” than to have coercion and have such places. Even if it meant allowing some people to choose death. That’s not because I agree with all thet Thomas Szasz (sp?) silliness, but because I think it’d better to err on the side of protecting the vulnerable from others than the side of protecting the vulnerable from themselves.
It’s a horribly difficult line to draw.
I have a friend whose life almost certainly saved by being put on section when she had severe anorexia (and depression, anxiety, PTSD and loads of physical health probs).
I have another friend who was forced to take meds that almost killed her.
The fear of coercion has, at times, stopped me getting help when I was in potentially lethal situations. Ironically, I would have been more likely to get help if I hadn’t believed people would try to force me.
Just to clarify – there are LOADS of great people working in mental health system the and we don’t need “protection” from them. The trouble is that those who ARE abusive are good at covering their tracks.
This can not be a proper email. There is correct usage of your and you’re and apostrophes and grammar and … stuff. Not even a decent use of the triple exclamation mark!!! Caps are used with a delicate touch.
I love that he defines nurses as “people who work with doctors”. Telling.
I can see how someone may have had a negative experience with MH services. As a mental health nurse I have often felt compromised as a human being when I have felt that what my job entails violates people’s human rights (in my and other’s opinion, but obviously not in the outdated mental health service’s eyes)and many times I have felt I should try and leave nursing. The only thing that keeps me here is that I can see a better way that is more humanistic and i think that more and more mental health nurses have similar views and that we will be able to chip away at the system and lead by example.
ie. I have been saying for years that older people with dementia, and many without, in acre homes and at home, should not be given anti-psychotic medication and there are other ways to support them and usure their wellbeing and it is only just in the mainstream news now and only talking about care homes. In the future we will see exposed the disgrace of people who don’t need anti-depressants (yeah, I know some do benefit from them and if informed properly wish to take them, I mean the many who aren’t and don’t need them) being prescribed them by gung ho consultants and GP’s and I’m sure in my lifetime that people will look back at enforced injections and ECT without complete information and free consent with horror. Many of my mates, in their late 20′s/30′s, who are not nurses are amazed that ECT still exists, many say ‘I though they stopped that in the 60′s) and most patients I know who have had it, by un-coerced choice or otherwise, don’t realise the long term effects on memory (yeah, I’v seen the reaserch, but I’ve also seen the reality of people wjho’ve had it having long term memory problems and trauma).
And don’t get me started on the forensic system and prisons in general.It’s WRONG and society is an uncaring, backwards, mess, not intelligent and compassionate. t’s uncool to be a ‘leftist’ now, but someone is making money out of psychiatry and keeping some barabaric practices in place as it keeps them in work and because they can’t and won’t change things to benefit the ‘service users’.
Some days i feel ashamed that I am part of this backwards service and all I can do is trust my morals and not engage in any activity that compromises that and stick up for my rationale as to why. This causes me to be somewhat of a rebel, but what’s the alternative, be a sheep and keep the evil old ways alive. I wouldn’t be able to sleep at night if I did that. here;s to a better, more caring, understanding, loving and compassionate future for mental health care.