A Voluntary Section

People growing up in the UK learn that we live in a democracy where citizens enjoy basic freedoms and fundamental human rights. The rule of law governs society. So long as we live our lives according to those laws, we are free to live our lives much as we wish.

However, there exist minorities of vulnerable individuals who do not enjoy these basic freedoms. People with mental health problems are subjected to coercive controls which would not be tolerated by other members of society. We may be detained based on a psychiatrist’s assessment of our state of mind. If we are unlucky enough to be detained in a Mental Health facility, our human rights may be abused and we will have little recourse to seek redress.

I have twice been detained against my will during crises. The first time that this happened, I went to the Accident & Emergency Department seeking help for confusion and mild paranoia. Based on the assessment made by a trainee GP with minimal psychiatric experience, I was placed under a Section of the Mental Health Act, physically assaulted and given invasive treatment against my expressed wishes.

The second occasion is the subject of this piece.

 

Preamble

Some 18 months before the main events, shortly after the birth of our first child, I am on paternity leave and we are expecting a visit from the midwife. My wife is having trouble breast-feeding and the midwife has promised to come and give some hands-on support.

The pregnancy went reasonably smoothly and our baby was born at full term. The only hitch was when a scan showed that he was in breach a few days before the due date, persuading the doctors to perform an elective caesarean.

The midwife arrives and I am relegated to tea-making duties while the womenfolk get down to business. Afterwards, with our son successfully latched on and feeding, we chat over mugs of tea.

The midwife has been working for the local authority for 9 months, after returning from overseas where she had been working for the Royal Air Force. She is planning to return overseas. The conversation turns to the recent pregnancy, the elective caesarean and the breach presentation. For most of the pregnancy, everything had been completely normal and several scans had shown that the baby was facing down. Then, one evening, I came home from work to find my wife in tears after a visit to her GP. During a routine appointment to check on the progress of the pregnancy, she had been handled so roughly by the GP that she had left upset and in pain. About one week later, she went for a routine ultrasound scan and the baby was in breach.

By this time, we have become quite friendly with the midwife who has been a constant presence during quite stressful times. During the conversation over tea, we describe these events to her and ask her whether she thinks the baby might have been rotated into the breach position as a result of the rough handling. Her response surprised us both. She asked my wife the name of her GP and then said that this GP was well known within the team of midwives for having multiple complaints made against her during her patients’ pregnancies. In fact, the GP had tried unsuccessfully to get pregnant herself but had never been able to carry a child to full term, owing to multiple miscarriages. Apparently, the GP was married to an influential surgeon at the regional hospital.

A few months later, the GP retired from the practice and returned to her original home in Edinburgh.

We were outraged to learn about this. Outraged that a doctor should continue to practice in spite of multiple complaints. Outraged that a doctor should be allowed to quietly retire with their reputation intact and able to enjoy their pension.

 

Sacked

Some 18 months later, I am finally coming out of a long and protracted depression. My employer has been taken over by an American multi-national corporation.

But today, I feel energised. In the morning, I fire off some emails to some very senior people in Milwaukee. Walking around the factory, I feel part of a dynamic enterprise where everything is possible. Shortly before lunch, I crash. I get into my car and drive home.

Three months earlier, the company doctor had referred me to a private psychiatrist at the Priory in London. In the afternoon, I telephone him and explain my change in mood. He instructs me to stop taking an SNRI antidepressant which he prescribed to me when we last met and to ask my GP for a prescription for Temazepam. He also offers me an appointment for two days later.

I try to get an emergency appointment to see my GP but she is not working that day and I am offered an appointment with the Head of the Practise instead. I have never met him before. He is a large man with a powerful build and dark hair. I briefly outline my situation and explain that my psychiatrist has advised me to get a prescription for Temazepam. The doctor does not like being told what to do and refuses to give me the prescription, saying ‘we shall see about that’. I am feeling extremely restless and have a need to get to my feet, which I do and I leave the consultation room telling him ‘not to bother’.

I have a great need to expend energy. I am also determined to get my prescription for Temazepam. It seems the most natural thing in the world to walk the 8 miles to the nearest hospital. There is an emergency MH facility at the back of the hospital and I am hopeful that I will be able to talk a doctor into giving me a prescription for Temazepam. As I am walking towards the hospital, my mobile rings. It is my boss from work, asking me where I am and when I will be back at work. I tell him that I cannot talk to him just now but that I should be back in a few days. He says that my emails have caused a bit of a stir and he is struggling to defend my corner. He urges me to return to work as soon as I can.

Eventually, I get to the hospital and present myself to the reception of the small MH ward. But they refuse to treat me. By now, it is evening and my wife arrives and gives me a lift home.

I spend a restless and sleepless night and am up again at the crack of dawn. I need to keep moving and wander aimlessly around the streets. An email arrives in the morning in which an American HR representative refers to one of the emails I sent the day before and informs me that they are ‘accepting my resignation’. That’s it, they have sacked me. I phone around the local pharmacies, explaining my predicament and asking if they will sell me some Temazepam. Of course, they all refuse.

 I have been thinking about the Head of the Practise, reminding myself that this is the man who allowed my wife to be mishandled during her pregnancy. If only I had been prescribed some Temazepam, as my psychiatrist had advised, perhaps I would still have a job.

I decide to go over to the doctor’s surgery and confront the Head of the Practise. I enter though the main entrance, traverse the spacious reception area and go through a door to a corridor which gives access to the consultation rooms. I walk to his door and open the door without knocking. A lady patient is having a consultation. I cross the room to where the doctor is sitting behind a desk and give him a firm smack on his right cheek. Then, I turn around and leave the surgery.

 

A ‘Voluntary’ Section

Late that evening, there is a loud knock at our door. Outside, two policemen, a psychiatrist and a social worker have gathered on my door step. I motion for them to come in. When they move towards the living room, I tell them the baby is asleep and to come upstairs instead. They are not very happy with this arrangement but I am damned if I am going to be ordered around in my own home. When we reach the bedroom, I sit on the side of the bench and leave them to gather uncomfortably on the threshold. I’m hardly going to make them feel welcome.

The policemen remain in the background and the psychiatrist comes to the fore, while the social worker looks like she’s just there to make up the numbers.

The psychiatrist asks me about my current situation and about my mood state. I explain that my psychiatrist instructed me to stop taking the antidepressant but that I have been having trouble getting some Temazepam to help with the sleep disturbance. She explains that they want me to accompany them to a nearby mental health facility where I can stay overnight and be assessed in the morning. When I ask her whether I have a choice, she says that they would prefer that I come voluntarily, in which case I would be an informal patient. I am rather tired of the partial answers so I ask her directly what will happen if I refuse. She says that they would prefer to avoid that situation but they do have the necessary powers to take me in under a Section. I say that I would come in ‘voluntarily’ but that I was doing so under duress.

After quickly packing an overnight bag, I follow the police officers downstairs and get in the back of the police car next to one of the officers.

 

Escape

We drive across Oxford and up to the Warneford Hospital at the top of Headington Hill. The ward is a locked facility and we have to wait and be let inside. The staff check my possessions and then I am led to a waiting area. Eventually, a doctor carries out a quick assessment and prescribes me with some Temazepam. Eventually, my room is ready and I walk through with my bag. The nurse explains that I must keep the door open at all times, even when I am getting changed for the night. In the room next to mine, a large man is lying on the bed moaning, only partly aware of what is going on around him.

I get changed, take my medication and lie back waiting for the pills to kick in. But after three days without medication, it is too late. The dose is strong enough to knock out a horse, but after a couple of restful hours, I am awake again and alert and restless. I attempt to meditate, to remain grounded and manage to stay in bed for another restless night.

At 5:00 am, I am unable to stay motionless any longer. I get up out of bed and quickly change back into my clothes. I look at the grass lawn outside my window which has a fine mist hanging over it and imagine walking through the damp air with the dew condensing on my forehead. I examine the sash window and realize that the only thing securing it are 6 long screws, three down each side. I creep through to the kitchen, open a drawer and find a metal knife with a rounded tip is which will serve as an improvised screw-driver.

Back at my window, the most difficult bit is getting each screw to start moving. Then it is necessary to unscrew them multiple revolutions as they are several inches long. By now, it is 5:20 am and I reckon I should try to get the job before 6:00 am when the morning shift is likely to start. It takes me about 7 minutes per screw and forty minutes later all six screws are removed.

I pack my possessions into my bag and tidy the knife and screws into a pile in one corner of the room where they are not visible to someone entering the room. Then, making as little noise as possible, I slide the window open. The window has not been opened for some time and makes a grinding sound. Then I drop my bag onto the ground outside, crawl through the opening and walk quietly across a path to the grass beyond.

At first, I walk slowly and purposefully, but when I get to the middle of the lawn I cannot resist the urge to break into a run and quickly cover the distance to a wall that encloses the hospital grounds. The stone wall is about eight feet tall and the mortar is cracked and forms natural footholds where there are gaps. I quickly climb to the top, drop my bag down the other side, and climb down. I have a delicious sense of freedom as I make my way to the top of South Park and look out over the spires of Oxford. The sun is coming up, it is going to be a clear day with bright blue skies. It is good to be alive.

 

Rebuilding the Medical Team

Although I might be free, I am still faced with one or two challenges. I am the bread-winner in a family with a one year old baby. We have a mortgage taken out on the house. And the day before, I lost my job.

But my first priority is to stop the interference from medical people.

I walk down South Park, over the Plain and up the High Street to the city centre. After eating a quick breakfast from Costa, I make my way up Banbury Road. My plan is to catch a bus but in the end it just seems easier to continue up to Summertown and beyond by foot.

When I get home, I telephone the hospital to tell them I am safe. I explain that, just as I agreed to come in voluntarily yesterday as an informal patient, so I decided to leave voluntarily this morning. The nurse reprimands me but it is fairly obvious that she won’t be doing anything further. Next, I make an appointment later that morning to register with a new GP practise. The new GP seems perfectly reasonable and I explain that I have an appointment with my psychiatrist in London the next day.

I am unsure what the local mental health team will do next and whether they will reconvene the team in order to bring me back in. But I am not going to wait to find out. I pick up my overnight bag and set off to London by car. That evening, I arrange to stay with a cousin in Central London and the following day I attend my appointment with my psychiatrist. We have a 30 minute session, he writes out a prescription for some Olanzapine and return home.

My previous medical team has now been neutralised and I can now start rebuilding a trusting relationship with a new group of doctors.

Now it is time to rebuild my career.

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Accident & Emergency

The Accident & Emergency Department is often the first point of call for someone in crisis. Often, this is where someone in urgent need of medical attention receives treatment. Although there may be complaints about the speed of treatment, the vast majority of people attending Accident & Emergency with a physical health problem are grateful for the care and treatment received. The experiences of people with MH problems attending Accident & Emergency are in marked contrast. The care and treatment is often considered of unacceptably low quality. There are numerous complaints made against the attitudes of medical staff, particularly by patients with self-harming behaviours or suicidal tendencies.

In 1996, I went to the local Accident & Emergency Department experiencing confusion, disorientation and mild paranoia. This is what happened.

 

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Assault

It had been a long wait in the Accident & Emergency department after we arrived at about 6 pm one evening in November 1996. Earlier that day, I had been feeling confused and disoriented and had left work after feeling a little paranoid in the rather febrile atmosphere of a company being restructured.

Then, suddenly, the pace increases.

I am taken behind a small curtained off space and told to sit. A doctor and nurse ask me about my symptoms and take a quick medical history. Halfway through the assessment and without warning, the nurse asks me to hold out my right hand and pricks my index finger with an epi-gun. In the 1990s, these were a recent innovation and I have no idea what she is doing.

I am left on my own while. I can hear the procedures being conducted in the curtained cubicles adjacent to my own. Short conversations, groans, murmurings.

After about 20 min, a young female doctor barely out of her teens enters the curtains and explains that she needs to conduct a psychiatric assessment. Later, I learn that she is still in medical training to become a GP but is the only doctor available with psychiatric experience.

She asks me some standard questions. What is my name? What is my occupation? Am I married? Do I have children? What are their names? What has been going on at work? Who is the Prime Minister of the country? Apart from stumbling with the Prime Minister as a new Prime Minister – John Major is so unmemorable I can’t even remember his name – I provide coherent answers to her questions. She also dwells on the fact that I experienced several depressive episodes in my teens and early twenties. There are some rather open-ended questions which seem rather meaningless and loaded with assumptions which I struggle to engage with.

Then the doctor leaves through the curtains and I am left again to listen to snippets of conversation and groans and moans.

After another 10 min, the first nurse returns. She explains that they are still deciding what to do. Then she leads me back out through the curtains and asks me to wait again in the waiting area.

After another 40 min, the nurse reappears and tells me and my wife to follow her. By this time, my mother and sister have arrived and they join the group. We follow the nurse up two levels to a treatment area with some beds at the back and doors to treatment rooms along one wall. It is not possible to see what is inside the treatment rooms and I do not see any signs to tell me the name of the ward. I am told to sit on a chair and, eventually, the first doctor enters the area and stands in front of me.

The doctor is in his mid-thirties, only a few years older than myself, and says that he is a Registrar which I understand to be quite a senior grade just below Consultant level. He explains that they are exploring several possible explanations and want to confirm or rule out a diagnosis of encephalitis which would account for my feelings of confusion and disorientation. To do this, they are proposing to give me a lumbar puncture to extract a sample of my cerebrospinal fluid and then a simple analysis will show if this contains an infection.

To me, this seems like a very bad idea. By now, my symptoms seemed to be relieving of their own accord. I was young and fit and still had ambitions to climb in the Himalaya. Any procedure which carried risks however small of permanent paralysis seemed like a very bad idea.

A few years before these events, there had been an epidemic of mad cow disease in England and for several months the news was full of stories of the devastating effects of bovine spongiform encephalopathy (BSE) and its human analogue variant Creutzfeldt–Jakob disease (vCJD). In my confused state of mind, I recognised the Ancient Greek root enkephalos and conflated bovine spongiform encephalopathy (BSE) which decimated herds of cows in the North of England with the encephalitis which the doctors suspected. If that was my predicament, far better a speedy relatively painless death than having a bunch of medics prodding needles into my spine and turning me into a paraplegic only for me to die a slow protracted more painful death, completely at their mercy.

The doctor tries to persuade me that his proposal is the best course of action but, the more he tries to persuade me, the stronger my opposition becomes.

After a few minutes of this, he turns away and moves to the side.

I remember thinking, let him move away for a few minutes, then I can get up from the chair, quietly leave the ward, descend some stairs and leave the hospital by a side exit. Then I can walk up to the top of the hill and leave the hospital ground by one of the exits used by staff in the mornings. I feel very strongly that all I need is some time to rest and hopefully everything will resolve itself. If not, so be it.

Suddenly, two doctors grab me from behind and my last memory is of a needle being shoved into by righthand upper arm.

Image result for lumbar puncture needle

Lumbar puncture needle. This is inserted in between two vertebra until it punctures the membrane which retains the cerebrospinal fluid. 

Next morning

The next morning, I regain consciousness. I am lying in a hospital bed. The lower half of my back feels numb and I am unable to move to any great extent. My mouth is dry and I feel thirsty.

Eventually, a nurse appears and helps me drink some water. Although I haven’t had anything to eat for 12 hours, I don’t feel like any food.

At some point in the morning, a junior doctor comes and explains that the sample of cerebrospinal fluid collected during the lumbar puncture will be sent off for analysis and that they are trying to schedule an MRI scan in order to check for an inflammation of the membrane enclosing my brain.

Later the same morning, a psychiatrist pays me a visit. She is an elderly doctor in her sixties and she exudes calm and competence. She has a kindly manner and gently takes me through the previous evening’s events. At the end of the interview, she says that further tests will be carried out but that she fully expects them to show everything is normal. She also indicates that there has been nothing that she has heard, either from me or from her colleagues, that indicates that my thinking was delusional or that my capacity was impaired the previous evening. She leaves me her card and indicates that she would be happy to see me again in a few weeks times once everything has returned to normal.

After the psychiatrist leaves, I hear a young doctor talking on the telephone in a loud American accent. She is making the call from an office but the door is wide open and her voice carries over the entire ward. She is trying to arrange an MRI scan at another facility and, at one point, she exclaims loudly: “Yes, he is completely demented and we need to urgently get him scanned.”

In the afternoon, an ambulance takes me across town to the MRI facility. After signing consent forms, I lie down on the patient bed and am carried into the bore of the MRI magnet. During the scan, the loud clicking sounds made by the gradient coils surrounding my head make me feel claustrophobic and it is reassuring to feel the nurse’s hand holding my ankle which protrudes out of the end of the magnet.

Later that evening, I am discharged from the hospital. I still remember the inane expression on the Registrar’s face as he proudly announces that he can give me a clean bill of health, as if expecting my gratitude. I leave the hospital in a wheelchair.

 

MH Act 1983

Repercussions

My experiences at the Accident & Emergency Department would have long-lasting consequences.

I am very clear that what happened to me that evening constituted physical assault. Furthermore, the doctors made no real attempt to seek my consent. The treatment that I was given against my expressed wishes was invasive and carried risks that were unacceptable to me. I also believe that their behaviour was unlawful because they failed to demonstrate that there was any significant impairment in my capacity, as confirmed by the psychiatrist the following day. In fact, the assessment that was made was conducted by doctors with insufficient training or competence to make that assessment.

My treatment by the medical staff has left me very suspicious of the medical professions in general. When I meet a new doctor for the first time, I do not take their competence on trust but look for evidence that their judgement is sound and and that their heart is in the right place.

About 12 months after the event, I experienced very similar symptoms of confusion and disorientation and mild paranoia one evening in November 1997. On this occasion, I retired to bed early, took the next day off work, and was back to my normal self within a few days. My wife and I discussed what to do but decided that any contact with the medical professions was unlikely to be helpful.

For several years after, I blamed my wife and my mother for agreeing to the doctor’s prescription, as I thought it impossible under UK law for doctors to give treatment against someone’s wishes without the consent of their nearest relatives. Eventually, after researching the relevant law, I realised that the doctors could legally treat me against my wishes and without my family’s consent provided they argued that I had diminished capacity. I had to accept what my wife and mother had been telling me, that they had in fact not given their consent. This certainly damaged my relationship with my wife for several years, during a period when we were raising our first child, although we were ultimately able to resolve our differences.

But the most significant repercussion from that evening was my altered social status. Before that evening, my experiences of depression were hardly unusual and could be dismissed as adjustments to adolescent pressures. But, that evening, I had been placed under a Section of the Mental Health Act. This marked by transformation from an Engineering Professional with a solid standing in the community to a mental health patient of unsound mind. It now became possible for any doctor to question my mental capacity and to decide what was in my best interests with only cursory reference to my wishes.

 

On one evening in 1996, I went to a hospital with mild confusion seeking help from trusted medical professionals. That evening, I was physically assaulted, given invasive treatment against my expressed wishes and sent away in a wheelchair. That evening, based on a flawed assessment made by a trainee GP, I was sectioned and given a label which would be in my medical notes for the rest of my life.

The first depression is always the worst

The cloud cover cracks open and lets a shaft of light through to the ground below, lighting up a patch of hillside. The light startles a rabbit which rears up and freezes as it scans the slope to its left.

The dew covers the grass in a coarse hoar. A dank mist languishes in the folds of the fields, enveloping the marshy fringes. The air is laden with condensation which collects on exposed surfaces.

The same condensation forms a damp patch on my forehead pressed against the window pane as I observe the scenery. There is something ethereal about that shaft of light breaking through the cloud to illuminate the rabbit on the hillside.

In an instant, the clouds close shut. The mist, which momentarily was hovering, sinks to the ground. The light is flat, then diffuse; now it’s gone.

Suddenly, the rabbit unfreezes and scatters off to the right.

The clouds fuse and coalesce and homogenize, until the sky is filled with a thick grey covering which sinks to the ground, merging with the mist. The air trapped between ground and sky has nowhere to go and is compressed. The landscape flattens as the pressure bears down, squeezing it sideways.

The cold patch on my forehead is now numb. A dull headache has returned and my limbs are heavy. An icy mist has enveloped my mind and a feeling of dread that has no tangible cause yet is no less real has invaded my thoughts. My mood matches the oppressive scene seen through the window.

The glass in the window pane is old and grainy. There is no double glazing, just a single pane of glass held in the wooden frame by a bead of putty. The glass separates my forehead from the cold dank air outside, but the condensation feels just as damp. The glass is held only loosely by the putty and is free to flex. As it flexes, I can hear it creak.

The pressure increases in the air, tension builds up in my skull, how much further will the glass flex before it shatters into shards.

 

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The first depression is always the worst. For what logical reason can there be for believing that it will ever lift?

For me, it was when I was 13 years old. I was doing OK at school but then I got mumps. It felt like I had had the stuffing kicked out of me.

Then sleep ceased to be possible. Lying awake each night, 8 hours on the trot, night after endless night.

Nights merge into days merge into nights. My entire existence becomes flat and featureless. The oppression does not lift, there is reason to think it ever will.  Lessons are attended, food is eaten, television is watched.

And all the time, an endless tension is maintained over the mind, with no release valve and no tangible cause.

At school, there is a 5-storey tower which stands over a concrete area covered with gravel. In physics, we calculated how fast it is necessary to leap horizontally in order to avoid scraping one’s skin against the side of the building.

 

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After a few sleepless nights, people often feel below par and get a little crabby. A few more sleepless nights and people start to make mistakes. Their judgement becomes impaired. After a couple of weeks, you lose your sense of perspective. Days and nights are no longer delineated. The days all merge into one, your memory is affected, your cognitive faculties degraded.

A few more weeks of sleeplessness and you enter a state where it is difficult to focus on anything or maintain concentration or show emotion. But while that suggests a benign state, there is nothing peaceful about the depressive state. Instead, a sense of impending doom, an all pervasive restlessness and deeply intrusive thoughts that are too compelling to reject.

Animals whose sleeping patterns are severely disrupted have raised concentrations of the stress hormone cortisol. As do depressed people. Animals whose sleep is disrupted for extended periods of time often have shortened life spans.

To describe depression as a disorder of the mind ignores a wide range of physiological changes that are just as physical as the reduction in blood supply that occurs during a heart attacks. The main distinction is that the brain is the organ that plays a central role in depressive episodes while the heart is implicated in an infarction. In either case, measurable physiological effects are associated with impaired biological function and reduced life expectancy.

Hypomanic in Prague, September 1991

Low temperature experiments in Cambridge

That whole summer of 1991 glided by in a whir of sound and sunlight.

Long nights were spent in the lab cooling devices to very low temperature just above absolute zero. In the small hours of the morning, when the town goes to sleep, the noise levels flatline, allowing me to record experimental spectra with clean features and flat baselines. Then, at 5:00 am, we cycle the wrong way around the ring road, with the morning dew condensing on our foreheads.

Dilution fridge

 

 

 

 

 

 

 

 

Dilution fridge used to cool samples down to 5 mK

In June, the lease runs out on our digs and I move my karrimat and sleeping bag into the projector room at the back of a lecture theatre. By getting up at 6:30 am, I can get to the toilets for a quick shave and freshen up before the cleaning ladies arrive for the morning shift.

As the days go by, my energy levels increase and I need less and less sleep. I am planning a trip to the High Tatra in Slovakia and I get into the habit of running 3 miles a day to improve my fitness levels.

From the middle of June, the weather improves. The sun shines brightly from a blue cloudless sky. Colours are vibrant, smells are pungent, sounds resonate.

I clearly remember one sunny afternoon lying down on my back on the playing fields adjacent to Madingley Road. The sky is a deep blue, the grass is green, forming a backdrop in primary colours. Heat shimmers off the fields. The air is redolent of meaning expanding with the heat rising into the ether.

Life is full of possibilities.

 

Vysoka, High Tatra

In August, I fly to Prague and drive across Bohemia and Slovakia in a Skoda hire car, stopping at towns and cities along the way. Brno, Bratislava, Vienna. South through Hungary for a day in Budapest. Across the Romanian plains to Bucharest where people have dark hair and piercing green eyes. Then back to Kosice in Slovakia and up North to the mountains. Cooking on a camping stove and sleeping in my bag under the stars.

High Tatra

The Vysoka group of peaks in the High Tatra

Stocking up with 5 days’ food, I head into the High Tatra and spend the first day walking up to a hut under Vysoka. The next day, I climb up to a col and follow an exposed ridge to the summit of Vysoka. The views are magnificent.

It seems a shame to return the same way I came, so I hatch a plan to descend the 1000 metre west face into a corrie which seems to connect to the path I took the previous day. I have a 25 metre length of 9 mm rope and some nylon slings.

Vysoka

The summit of Vysoka (2547 m) with the west face in sunlight

The ground is steep, making it difficult to see what lies below. The rock is reasonably sound but broken. From a vague memory formed on the way up, I recollect that the left-hand side of the face is easier to descend.

Descending the face, the view down to the corrie is exhilarating. Occasionally, I track sideways in order to observe the ground in profile so to better gauge its steepness. Apart from a couple of short passages where the way forward looks doubtful but eventually relents, the scrambling is straightforward and the skill lies in finding the line of least resistance.

45 minutes after leaving the summit, I find myself at the foot of the face and descend to a loch in the bowl of the corrie. The rock architecture is impressive and the scenery unspoilt. Not unlike the Cairngorms, but at twice the scale.

Corrie under Vysoka

The corrie and loch at the foot of Vysoka

 

Assault

A week later, I return to Prague after the hire car breaks down on two consecutive days. The last leg involves an overnight hitch-hike. I go to the offices of the car rental firm on Opelatova Street, a few hundred yards from Wenceslas Square, in the centre of Prague. Three days of pent up frustration find expression as I talk to the staff.

Recognizing a futile cause, I leave the offices and, as I turn onto the road to go back up to the Square, I give the door a push. As if in slow motion, the door which has a heavy metal frame swings against the frame, shattering the glass in the panes. Oh shit.

I walk back up to Wenceslas Square, thinking that I should go find a policeman so that I can explain what happened. Reaching the Square, I see a man in uniform standing beside some parked cars.

Opelatova Ulice

Wenceslas Square and the junction with Opelatova Street, which is named after Jan Opletal, a student who lost his life during a demonstration against the Nazi occupation at the end of World War II. The assault took place at the junction behind the parking space occupied by the blue VW Beetle.

Going up to him, I try to make him understand in broken Czech that he needs to follow me back down Opelatova Street. He looks at me uncomprehendingly, seeing an unshaven man in tattered clothing who is making no sense at all. Without waiting longer, I pull him after me and start to make my way back to the rental company’s offices.

Suddenly two policemen jump me from behind and are joined by another two. The first man grabs my hands by the wrists and attempts to close them together while his colleague draws his hand-cuffs. The third and fourth policemen have drawn their truncheons and start to hammer my shoulders.

It all happens so quickly and escalates without warning. I react in shock and by instinct. The truncheon blows to my shoulders intensify and merge into a wall of numbed pain.

I have this mad idea that I can somehow escape and run down the street and sort everything out. But time is running out and I must act before the hand-cuffs encircle my wrists.

I am left-handed and I notice that the grip on my right wrist is firmer and that the truncheon blows are harder on that side. The blows push away all conscious thought, leaving me to focus on this single mad idea that I can release my left hand, deliver a punch and free myself of my assailants. But my wrists are being forced together, the hand-cuffs are being readied and time is running out.

The truncheon blows continue to rain down on my shoulders suppressing any vestiges of reason.

Just as they get a hand-cuff over my left wrist, I wrench my left hand free and deliver a punch at the man holding my hands. The hand-cuffs which are hanging from my wrist swing forwards and deliver a glancing blow to the man’s head. But my punch has no momentum and, in any case, I am restrained by hands now grabbing my upper arms. They quickly force me to the ground and fit the hand-cuffs.

Truncheon blows continue to rain down on me for several minutes more, well after I am incapacitated.

A police car screeches to a halt and they drag me across and bundle me into the back, with an officer on either side and two in front.

The car drives down the street and crosses a couple of blocks to a quiet side street off the main drag. It pulls into the side and they manhandle me out of the back, down some steps and into a building. Inside the entrance, they throw me to the floor and start to lay into me with truncheons and boots and fists. One of the men has a pot belly and is particularly vicious.

By now, I have given up all resistance and simply attempt to protect my head and stomach with my arms and feet, by folding my body into the foetal position. There is little pleasure to be had in hitting a person who is not resisting and they soon relent.

They drag me up the staircase to a reception area on the first floor and I am taken to a police cell along a corridor.

 

Prison

After waiting for an interpreter, I am interviewed by an officer. Then I am held in a cell overnight and appear before a Magistrate the following morning. After a three hour session, I am told to sign a 20 page type-written document in Czech. This is my statement. When I protest that I don’t even know what it says, I am told that this is the process. I sign the document under protest after writing down that I don’t understand what I am signing.

Next, I am taken by a car to a prison where I am told to strip down. After removing my underwear, I am told to turn round with my back to the prison guard. I feel vulnerable, not sure what he wants, but then he exclaims loudly about the injury on my right shoulder where the truncheon has left a livid bruise extending down the side of the shoulder blade. I can’t understand what he is saying but it sounds like he is telling me I got what I deserved and warning me to behave. Nevertheless, the tone is not all that harsh and I sense that everything will be OK so long as I do as I am told.

Prison 1

View from the cell in the first prison down onto the exercise yard

I settle into the routine of prison life. During the first week, I am held in a temporary holding facility in a cell with seven other people. New in-mates come and go as they are processed and are taken to other more permanent facilities. The guards are generally firm but friendly and the atmosphere is relaxed. One of my fellow prisoners has a sack full of cheap cigars which he distributes around the cell. Each day, we are taken to a small exercise area for half an hour but the rest of the day is spent locked up.

After the weekend, I am taken to a doctor who examines my shoulder and prescribes rest. There is no danger of me not following her prescription.

After a week, I am taken to another prison where I share a much smaller cell with two other prisoners. There is a toilet in one corner of the cell and we have to sit facing out in order to defecate. The other two will discreetly roll over onto their banks so as to face the other way. The prison food is rather grim and I become severely constipated. After passing no motions for more than a week, I ask to see a doctor and am given some suppositories. These have the desired effect and I spend two hours filling the toilet with turd after turd, shedding several kg’s of weight. Our cell stinks for the rest of the day.

Prison 2

View from the cell in the second prison over the prison walls to a residential suburb

Once a day, we are taken to a large exercise yard fully enclosed on three sides by the four-storey wings of the prison. The fourth side of the yard is formed by a 30 foot wall topped with barbed wire. We spend 30 minutes walking around the perimeter of the yard and our wing divides into loose-knit groups each walking at their own pace. The yard is overlooked by some internal windows from the third and fourth floors and prisoners sometimes shout down to us. Somehow, word gets out that I am from England and one of the prisoners from the floor above throws down a bundle. I unfold a type-written sheet addressed to the UN Human Rights Commission with claims about human rights abuses suffered by political prisoners in the Czech Republic. I promise to send the letter to Amnesty International when I get back to the UK.

After another week, I am given some official court papers with details of legal charges being brought against me. These documents are written in Czech and I use a dictionary to to decipher the contents. It seems that I am accused of violently assaulting the police and one of the policemen is seeking reparations for injuries sustained. One afternoon, I am taken to a visiting room where a physics lecturer from King Charles University is waiting with a bag of apples and some physics books. I visited him on my way through Prague before travelling to the mountains. During the next few weeks, I study the Kubo formalism of electrical transport and Landau and Lifshitz’s classic text on the Classical Theory of Fields. The apples help with the constipation.

Court doc 1

court-doc-2.png

Court documents with details of charges brought by prosecution

After a couple of weeks, my father arrives from the UK and appoints a lawyer. The British Embassy have also been contacted.

After about a month in prison, I am interviewed by a Forensic Psychiatrist. She is an elderly lady in her sixties and is probably someone’s grandmother. She is mild-mannered and appears kindly, although I remind myself that this is someone who has served in a repressive system. A few years ago, she would have been part of a system that repressed dissent and incarcerated political prisoners.

An interpreter is present to translate. The interview gets off to a bad start when I offer to shake the Psychiatrist’s hand and she looks at me with suspicion. She conducts a psychiatric assessment which delves into my childhood experiences. At one point, she asks who are my favourite artists and I make the mistake of naming Salvador Dali and Paul Gaughin. Reubens and Constable would have been safer choices. She spends relatively little time on the events in Prague and I get the impression that she will accept the police statements at face value, without questioning their veracity. At the end of the interview, she breaks with the official narrative and looks at me meaningfully, saying that she will do what she can to help me in a difficult situation.

Several more weeks pass. A group of us decide to go on hunger strike, more out of boredom than any conviction. On the third day without food, the prison officer responsible for our corridor has me brought into his office and offers me a coffee. The coffee is tempting but I resist. He says that the hunger strike is pointless and will achieve nothing. I agree that this is probably true, but I say it is important to show solidarity. He shakes his head in disbelief and I am returned to my cell. I last another day, holding out longer than the others, then break my fast. My constipation is now cured and I start to enjoy the food.

Then, one morning six weeks into my detention, I am told to gather up my belongings, I am taken down to a reception area on the ground floor where a representative from the British Embassy is waiting for me, some forms are signed, and I am released into their custody. No explanation is given, nothing about the legal charges or my future legal status.

That evening, the Embassy staff drive me to the airport and I am put on a flight back to London.

 

Return to Cambridge

Back in Cambridge, I struggle to get back into a routine. I am supposed to be writing a thesis but I am unable to focus on the task.

Autumn turns to winter and the daylight hours get shorter and the nights longer. The sun retreats behind a permanent bank of finely dispersed cloud and mist merges to rain. Leaves fall from the trees leaving branches denuded of foliage.

As the nights get longer, my sleeping pattern is disrupted. I struggle to fall off to sleep and then I find myself waking in the early hours of the morning. My sleeping interval shrinks from both ends until I am only sleeping 3 or 4 hours a night.

I have moved into some new digs on King Street behind Christ’s College. Each morning, I head to one of the university libraries in an old building near the centre of Cambridge. I get completely bogged down in a survey of the literature and lose sight of the end point.

Depression is sometimes described as a mental experience that affects the mind and moods. But the experience of depression is just as physical as the experience of ‘flu. The mouth dries up and food tastes just as stale as the foul smelling breath. Colours lose their intensity, sounds are muted. The limbs increase in mass as if leaden weights have been attached. Movement becomes laboured and coordination is lost.

One by one, the processing centres in the brain responsible for motivation, drive and pleasure shut down. Mental processes slow down and simple tasks are insurmountable. Patterns break apart into chaos. The higher level processing centres close down, leaving the reptilian brain bent on survival.

Eating becomes a chore. Walking demands great effort. Water feels alien and washing is repellent.

Taking a shower just becomes too much and my hair turns greasy and matted. I try to get up before midday and head over to my college where they serve freshly brewed coffee after lunch. If I time it right, I avoid bumping into people I know. Then I bury my head in a newspaper and pretend to read the news. My concentration only lasts for three sentences, limiting my comprehension, but reading helps to block the unwanted thoughts and impressions which crowd out rational thought.

In the afternoon, I walk up Grange Road, turning left after Robinson College, and continue out to the Cavendish Laboratory. Some days, I continue along the cycle path without turning into the science campus and head out into the open fields towards Coton and Madingley. On other days, I make it to the lab in time for afternoon tea.

Winter sets in and a dank mist settles on the town. There is nothing more desolate than the Fens in November.

Therapy

For many years, I asked myself searching questions about the events on Opelatova Street, Prague. What induced me to punch a policeman? Did I really want to do harm to another person?

Failing to find answers, I searched for help and contacted a psychotherapist who dealt with trauma victims. We had a brief chat and I described the assault. When I described delivering the punch, the therapist instinctively flinched. She wasn’t the right person to help me.

I attended a local centre set up by a trauma specialist. At the time, I was descending into another mild depression and I remember the bilateral processing sessions helping to ground my feelings. On one occasion, I fell asleep. But when it came to discussing the events in Prague, the therapist from South Africa simply commented that I had been incredibly unlucky and left it at that.

More than a decade after the events in Prague, a work colleague died in an industrial accident in America when he inhaled excessive volumes of nitrogen while cooling down a twenty tonne magnet. Nitrogen inhalation causes the brain to shut down and the victim slowly loses consciousness, never to wake again. This tragic event triggered a hypomanic episode in me and, for the first time, a doctor observed me during an episode and made an accurate diagnosis.

I was referred to a Psychiatrist at the Littlemore Hospital on the edge of Oxford and, during the course of two appointments, he conducted a psychiatric assessment. I described various periods in my life when I had experienced highs and lows and I gave a brief description of the events in Prague and how I had been violently assaulted by four policemen. In his notes and formal assessment, the Psychiatrist is careful to record my narrative as my version of the events without accepting its veracity. After I had been detained in Prague, my mother received a telephone call from the authorities requesting information about my earlier psychiatric history in the UK and she contacted an adolescent psychiatric unit where I had been an out-patient as a teenager. In her telephone call to the psychiatric unit, my mother repeated what she had been told by the authorities, that I had assaulted a policeman in Prague. Farcically, in my clinical notes, my psychiatrist gives equal weight to my mother’s garbled statement based on second hand information received from lawyers seeking to bring a prosecution against me. This contrasts with my account which is first hand: I was there and I was a participant in the events.

The way that my psychiatrist has recorded the information in my file is potentially very damaging to my reputation. I have attempted unsuccessfully to have statements removed from my file, as I believe that they are defamatory and could cause me problems in the future. I believe that the fact that a British Psychiatrist would rather believe second hand accounts provided by the authorities in a repressive state which routinely prosecuted political dissidents and other social misfits than the first hand account of his own patient says a lot about the current state of psychiatry in the UK.

As time passes, the events in Prague become distant memories. But, during the cold winter months, my right shoulder seizes up and the dull aching pain reminds me of the imprint left by a wooden truncheon wielded by a Czech policeman.

One citizen’s riposte to the 2018 Wessely review of the Mental Health Act

Abstract

The Wessely review of the Mental Health Act was conducted in the context of a gradual erosion of civil liberties over the last 35 years which contravenes international human rights legislation. The final report published at the end of last year (Wessely 2018) argues for additional safeguards for mental health patients and advocates a more patient-centred culture that respects the preferences of individual patients and family members. But it leaves in place an authoritarian structure which has resulted in widespread abuse within UK Mental Health Trusts and the system’s integrity would continue to depend on the benevolence and professionalism of psychiatrists. The Wessely review fails to address long-standing problems with under-funding, which have caused serious problems in the current system and is out of step with the reasonable expectations of service users.

Introduction

Locking up a fellow human being should only ever be done for very good reason and after careful consideration of all possible alternatives.  Forcing medical treatment on another person amounts to physical assault and should only ever be a last resort reserved for extreme circumstances.  It is to the great shame of British society that detention and forced medical treatment have become normalised for one vulnerable minority whose basic human rights are being routinely abused within NHS mental health facilities.  Last year’s review of the MHA therefore represented a once-in-a-generation opportunity to reform mental health legislation and to bring it in line with modern human rights law.

Historical development of UK mental health legislation since 1945

Lunatics, or people of ‘unsound mind’, started to be given special legal status several centuries ago in Acts of Parliament intended to legitimize the detention of people in mental asylums.  Psychiatrists specializing in the treatment of the insane were given unique powers to detain these people and treat them, often against their will, in large institutional facilities called asylums.

After the second world war, many of the problems associated with long-term institutional care were recognized and this led to the first modern piece of legislation, the Mental Health Act of 1959, which removed the distinction between hospital and asylum (Turner at al., 2015).  The legal concept of mental disorder was developed and greater emphasis was placed on voluntary treatment under less coercive conditions. The 1960s and early 1970s also saw the birth of charities such as MIND, the National Schizophrenia Fellowship (later renamed Rethink Mental Health) and the Manic Depression Fellowship (later renamed Bipolar UK) which campaigned for the rights of people with mental disorders.

In the late 1970s, there were moves for a major reform of the MHA. Unfortunately, the British media sensationally highlighted a number of incidents when bystanders were attacked and killed by patients released from asylums with a diagnosis of paranoid schizophrenia and the Thatcher government decided to selectively adopt the recommendations of an expert committee aligned with its authoritarian agenda, while rejecting key safeguards.  The Mental Health Act of 1983 defined the circumstances in which a person could be detained and given forced treatment. An order to detain someone had to be signed off by a doctor, normally a psychiatrist, and a person detained under the Act had a right to have the detention reviewed by an independent tribunal at a later date.

In 1998, the UK enacted the 1998 European Human Rights Act and it became clear that the earlier MHA would need to be reformed in order to bring it in line with international law. An expert committee led by Prof Genevra Richardson was tasked with proposing changes.  A discussion paper (Richardson, 1999) introduced many concepts that underline modern discussions of mental health practice. Since the 1960s, there had been a long-term aspiration in the UK to reduce the number of people treated in hospital for mental disorders by integrating them back into the community.  The Mental Health Act Amendment of 2007 introduced Community Treatment Orders which allow people with mental disorders to be treated against their will in their own homes while being resettled in the community. It is clear from the green paper prepared by the Department of Health that the key priority of the Blair government was to keep the general population safe and that the rights of patients were of secondary importance (Milburn & Michael, 1999):

‘..too often, patients treated in hospital – both formally and informally – fail to follow their treatment plans on discharge and need to be re-admitted to hospital because their condition deteriorates following loss of contact with care services. It is totally unacceptable that a group of patients who are known to pose a risk either to themselves or to others when they fail to comply with treatment, should so easily drop out of care in this way – sometimes with tragic results’

Yet again, many recommendations and safeguards proposed by the expert committee were rejected by the Blair government. Yet again, reforms to mental health legislation were dictated by an authoritarian agenda based on exaggerated concerns about the risk posed by patients with little basis in fact.

In 2008, the world experienced a global financial crisis caused by lax regulation of financial services coupled with irresponsible lending by banks and other financial organisations. In the UK, the Cameron-Clegg Coalition government embarked on a decade of austerity and made substantial cuts to the health and social welfare budgets.

Actual risk posed by mental health patients

The current legislation regulating the use of detention and forced treatment on mental health patients is predicated on the assumption that a small minority of people with enduring mental health problems have violent tendencies and pose a serious risk to the safety of other ‘normal’ people.

While the general population guided by sensational journalism may think that people with enduring mental health problems pose a serious risk to others, most specialists who have researched the incidence of violence recognize that the absolute level of risk is very low – much lower than the risk attached to other common activities. In his report (Wessley 2018), Wessely misleadingly indicates that people with enduring mental health problems are slightly more likely to commit violent acts than people from the general population. In fact, the data show (Mental Health Foundation 2016) that those violent acts are much more likely to be committed by people with a history of substance mis-use or childhood abuse and the reason that people with mental health problems are (slightly) more likely to commit violence is that they are much more likely to have substance abuse problems or to have suffered childhood abuse.

What available data also show (Mental Health Foundation 2016, University of Manchester 2013, Van Dorn et al. 2012) is that people with severe mental health problems are much more likely to harm themselves than they are to harm others. In 2013, 1,876 suicides were recorded among mental health inpatients in the UK, compared to 51 homicides. The rate of violence over a four-year period among those with severe mental health problems was 2.88%, compared to 0.83% in the general population. Rather than mental illness causing violence, the two were found to be connected mainly through the accumulation of other risk factors, such as substance abuse and childhood abuse/neglect. Lumping all people with mental health problems into a single category and then searching for correlations with social problems leads to misleading generalizations and, as an epidemiologist, Wessely should know better than to perpetuate statistical data which are likely to mislead the casual reader.

Furthermore, people with mental health problems are more likely to be victims of violence than those without mental health problems. A 2013 British survey among persons with severe mental health problems found that (University of Manchester 2013):

– 45% had been victims of crime in the previous year

– One in five had experienced a violent assault

– People with mental health problems were five times more likely to be a victim of assault and any crime than those without

– Women with severe mental health problems were 10 times more likely to experience assault than those without

– People with mental health problems were more likely to report that the police had been unfair compared to the general population

The reality is that people with enduring mental health problems pose a minuscule risk to other people. There is no good reason to forcibly detain large numbers of mental health patients.

National statistics on compulsory detentions

The number of people forcibly detained under the provisions of the Mental Health Act has risen every year since the legislation was introduced. More than twice the number of people were detained in 2017 as were detained in 1990. During the same period, the UK population has only increased by about 20% and the incidence of serious mental disorders has been flat.

Since the enactment of the 1983 MHA, the number of consultant psychiatrists has risen threefold from 2116 in 1990 to 6365 in 2017. Even during the last decade of austerity, when the budget allocated to mental healthcare was reduced, the number of consultant psychiatrists employed by the NHS has increased.

1980 1990 2000 2010 2017
No consultant psychiatrists 1607 2116 3057 4850 6365
No mental health nurses 36,100 37,000 44,600 49,000 42,000
No of compulsory detentions 19,800 23,100 31,800 45,864

Contesting the medical model of mental ill-health

The Wessely report (Wessely 2018) takes the medical model of mental illness for granted as if a consensus exists amongst professional and within wider society on the root causes of mental disorders and the best treatments. In fact, the medical understanding of mental ill-health is contested and other professions responsible for the clinical care of mentally ill patients propose alternative understandings of mental disorders. Some clinical psychologists (Johnstone et al. 2018) question whether mental disorders should be classified as medical illnesses at all and suggest that some syndromes such as borderline personality disorder should be thought of and treated as normal adaptations to trauma and childhood abuse.

The medical concept of a ‘mental disorder’ is problematic and permeated with social and cultural constructs. Psychiatric diagnoses have been evolving over time since the publication of the first Diagnostic & Statistical Manual in 1952 and some categories of mental illness fall in and out of fashion according to the cultural prejudices of the time. Many of the criteria used to assess mental disorders reflect prevailing attitudes. The assessment of whether an idea or behaviour is ‘normal’ or ‘healthy’ or ‘insightful’ depends on the prejudices of the dominant culture. It is hardly surprising that people from other cultures and traditions are over-represented in mental health wards as they are more likely to hold beliefs considered ‘unusual’ by a white psychiatrist brought up within the Christian tradition.

Many patients and survivors highlight serious conceptual problems with the medical model of mental disorder. Psychiatrists are supposed to assess the level of ‘insight’ but this is a highly subjective process which puts the patient at a disadvantage. Often, the medical concept of ‘insight’ as assessed in a psychiatric interview is treated as equivalent to the legal concept of ‘mental capacity’ used to decide the patient’s decision-making capacity. Such medical practices place psychiatrists in positions of power over the patients in their care. They also have the effect of undermining and devaluing patient perspectives.

Composition of the Wessely Committee

The Wessely Committee does not properly represent all professions responsible for mental healthcare in the UK, neither does it represent patients or service users most affected by its proposals. As someone who has been affected by the MHA, I do not feel represented by the people who took part in the exercise and I refute claims that service users have been adequately represented.

The Chair of the Committee is held by Wessely a psychiatrist and past President of the Royal College of Psychiatrists. The three other chair people are Baroness Neuberger, a rabbi with strong establishment connections, Sir Mark Hedley, a retired high court judge also with impeccable establishment credentials, and Steve Gilbert, a service user who has made a career out of advising local authorities on mental health policies. This is the sort of establishment committee which tells its political masters what they want to hear.

Other committee members include three psychiatrists from academic backgrounds and the usual collection of senior executives from charitable organisations working in the mental health field. There is not a single clinical psychologist or practising social worker on the committee. Not a single practising mental health nurse. Not even a psychiatrist with a strong background in clinical work who would have practical experience of applying mental health legislation. Wessely has a background treating soldiers with traumatic conditions such as Gulf war syndrome in the authoritarian culture of the Army where people on active service have lesser rights than in mainstream society.

The claim has been made that service users have been fully integrated into the work of the committee. Gilbert assembled a sub-committee made up of service users and then organised a series of workshops around the country to which service users were invited to attend. I considered attending one of these workshops, but for me this would have meant travelling to London and staying overnight in order to make the early morning start. It also meant giving up a day’s work at a time when I was struggling financially. Others have pointed out how the early morning start would have effectively excluded a large number of service users who are not well enough to travel across London during the early morning rush hour. The National Service User Network which represents a large number of service users from across the country was excluded from the review.

Although charitable organisations like MIND and Rethink Mental Health do a lot of good work, I do not consider that they represent service users. The senior executives of these charities are generally not service users and their experience of mental ill-health is most often second hand. During the last few decades, these national organisations have become more professional in the way that they are organised and managed and nowadays they are led by executives who have made a career in the charitable sector. More recently, some of these organisations have started to bid for government contracts to provide care services and they are no longer independent of government influences.

For too long, so-called service users have been expected to passively accept treatment in a paternalistic culture of doctors and benevolent charity workers. However well meaning Wessely and his colleagues may be, it is wrong to sideline service users. It is time that our voice was listened to with greater respect.

Wessely assessment of the status quo

In a refreshing change from past pronouncements by the psychiatric establishment, Wessely acknowledges some of the serious problems that are endemic in the British mental health system (Wessely 2018). He accepts that many patients experience a level and quality of care that are unacceptable. He realizes that the quality of care as perceived by patients is significantly worse than perceived by professionals. For the first time to my knowledge, a senior psychiatrist has acknowledged the serious abuse suffered by some patients in British mental health facilities.

However, while it is refreshing to see a senior psychiatrist publicly acknowledge serious failings in the system, it is difficult to know what to make of the bewildered tone with which these acknowledgements are made. Wessely was the President of the Royal College of Psychiatrists when many of these abuses were being committed or tolerated by his fellow professionals. The Royal College of Psychiatrists is supposed to uphold professional standards within mental health facilities. Psychiatrists are not only doctors practising medicine, they are leaders of multi-disciplinary teams and are responsible for what goes on within those facilities. They are responsible not only for their own actions and shortcomings but also the actions of all team members. Wessely cannot possibly claim ignorance of the abuses committed within NHS mental health facilities as these have been well documented for many decades.

When Sir Wessely adopts a bewildered tone acknowledging the institutional abuse and low quality of clinical care suffered by patients treated in NHS mental health facilities, my reaction is:

Where the fuck were you during this time, simple Simon?

Changes to MHA proposed by Wessely Committee

Wessely makes a number of recommendations designed to provide stronger safeguards. Although these are long overdue, they are no less welcome. He suggests that a new Mental Health Act is drafted with an emphasis on four core principles. In fact, this follows closely the recommendations of the Richardson report and one wonders how many abuses could have been avoided if only those recommendations had been followed during the drafting of the 1983 MHA. In addition, Wessely proposes a number of additional safeguards designed to enhance the rights of people being detained under the Act. Advance directives are to be given extra legal weight although, regrettably, it would continue to be possible for an advanced directive to be ignored under certain circumstances, at the discretion of a psychiatrist. Finally, Wessely proposes that treatment plans should be discussed explicitly with patients and should take into account the wishes expressed by patients and their family or trusted advocates.

Although many of the recommendations are welcome and attempt to make best practice more widespread, nevertheless they fall short of the expectations of many patients and survivors of the British mental healthcare system. The Wessely report also ignores a major controversy which questions the validity of the medical model of mental healthcare provision. Two chair members of the English Hearing Voices Network Akiko Hart and Rai Waddingham have co-written an Alternative Review of the Mental Health Act (Hart & Waddingham 2018, Hart 2018). The race equality campaigner Suman Fernando has dismissed Wessely’s review as a ‘psychiatrist’s report’ (Fernando 2018).

Detention, coercion, loss of autonomy

To someone newly diagnosed with a serious mental disorder, the NHS presents a hostile environment where high quality healthcare is unlikely to be provided and where the risk of detention is real.  The system of care has been designed with an emphasis on staff safety often at the expense of patient care.  Patient preferences are often not taken into account and there is an over reliance on pharmaceutical treatments resulting in sub-optimal outcomes.

Over the last 35 years under the 1983 Mental Health Act, the number of forced detentions has risen dramatically while it is generally recognized that the prevalence of serious mental disorders has remained flat.  This suggests that people with mild forms of mental disorder who do not present any risk are being detained in record numbers without having committed any crimes. The majority of these patients present no risk of violence either to themselves or to others.

There is a very general principle in law which is the principle of proportionality. Any sanction or punishment should be in proportion to the harm or damage caused. It is quite clear that any law that allows the forced detention of innocent people who present negligible risk to themselves or others fails the principle of proportionality. According to most legal norms, the way that the MHA is being used to detain large numbers of innocent people is unlawful because the sanction is grossly disproportionate relative to the alleged risk.

Forced treatment

Many patients detained in mental health facilities are treated with various forms of physical treatment with or without their consent. In some cases, there is little evidence that the treatment will benefit the patient. Even when there is evidence that the treatment could be beneficial if given at therapeutic doses, powerful pharmaceutical treatments are routinely given to patients at such high doses that any therapeutic benefit is likely to be minimal. The widely discredited practice of poly-pharmacy, in which a cocktail of powerful drugs is administered because the psychiatrist has been unable or unwilling to identify the correct drug based on an accurate diagnosis, is too common. Many survivors believe that the primary purpose of using powerful antipsychotic medication at high doses is to make patients compliant and easier to manage. Most patients are not given the opportunity of a second opinion, despite this being official NHS policy, and remain trapped in a system of health care which is not tailored to their needs and is of limited therapeutic value. Many patients leave mental health units with traumatic complications that are more enduring than the mental conditions they were experiencing before admission.

According to the 1998 European Human Rights Act, it is illegal to force treatment on a patient that is of no therapeutic benefit. Forced treatment is only allowed if it will benefit the patient and forced treatment whose only purpose is to control the patient is unlawful. Under human rights law, there is also a clear obligation on doctors to provide effective treatment where this is available and it is clear from many accounts of survivors who have been denied appropriate treatment that many psychiatrists have been failing in this legal obligation. Because of these many systemic failures, any new system should not rely on the benevolence of psychiatrists as experience shows that this cannot be assumed.

Forced treatment in the community

Although some of the original intentions behind the introduction of Community Treatment Orders were humane, the reality has been very different under a regime of austerity which has resulted in mental healthcare being grotesquely under-funded. I think most ordinary people would be uncomfortable with the idea of forcing people to take powerful medication in their own homes. This represents an unprecedented escalation in the powers of the state and a serious infringement of civil liberties. There is no other example of a similar infringement of civil liberties. People with mental health problems based in the UK effectively live in a medico-police state in which their freedoms are significantly curtailed.

Institutional abuse and neglect

Once someone has been detained inside a British mental health unit, they face an environment which is often unsafe and where they are at risk of physical and sexual abuse. While prison authorities have a duty of care over their prisoners and deaths are investigated, the NHS does not properly assume responsibility for the safety of patients detained in mental health facilities. There are regular reports of physical and sexual assault in mental health facilities. In some locations, dangerous face-down restraint is routinely used to restrain and humiliate patients. Complaints about physical and sexual abuse are routinely ignored. Some independent professionals talk about a system of ‘institutional abuse’.

Many patients and survivors describe a toxic culture within NHS mental health units. One weekend last year, an offensive message was posted on Twitter which had been placed on the Mental Health Nursing Group Facebook page by a mental health nurse. The Facebook post showed photographs of haloperidol vials arranged as decorations on a Christmas tree and made disparaging remarks about patients. The post had been ‘liked’ by a large number of members of the Mental Health Nursing Facebook Group. The reaction on Twitter was polarised between patients with experience of NHS mental healthcare and nurses and doctors who are part of the system. Very few medical professionals were prepared to publicly condemn the post, with some explaining the behaviour in terms of black humour. Some of us also contacted the Royal College of Nursing and other professional bodies but none of these were interested in taking this further. When the nurse who posted the original material became aware of the furore on Twitter, she would not give an apology for the offense cause. While the founder and administrator of the Mental Health Nursing Facebook Group page publicly condemned the post, in secret he threatened to ban any members of the Facebook group who made any other material public.

The reaction from survivors of the NHS mental health system was strong and unanimous. Many gave testimony that the message posted on Facebook reflected accurately the culture that they had experienced themselves in NHS mental health units.

Apart from a toxic culture, the way that whistleblowers are treated and scapegoated by the NHS is another indication of a deficit of integrity at the top of the medical profession. Time and again, the General Medical Council has shown that they consider the reputation of the profession to be more important than the safety of patients. Valid complaints are rarely handled without bias. Recently, Dr Clare Gerada, past President of the Royal College of General Practitioners aggressively raised concerns that complaints from patients were causing doctors to commit suicide. Such views should have no place in a patient-centred service.

Institutional racism

Much could be said about the institutional racism found in the NHS. As this is an issue receiving much coverage elsewhere and as this problem has been acknowledged by the Wessely committee, no more will be said here.

Mental healthcare in austerity Britain

After highlighting the dramatic rise in the number of forced detentions under the MHA, particularly in the last decade, the Wessely committee attempts to identify the root causes (Wessely 2018). Some of the possible causes suggested are societal causes, legal changes which mean that someone who is not objecting to detention but lacks the capacity to give consent must be treated as if they did not give consent and a more risk-averse culture. But Wessely ignores the elephant in the room which is the effect of austerity during the last decade. Following the 2008 financial crisis, the Cameron-Clegg coalition government chose to embark on a programme of austerity which has decimated mental healthcare services. At the same time, the welfare system has been reformed with the introduction of Universal Credits, causing great harm and hardship to many vulnerable people.

Mental healthcare has long been under-funded in the UK. The mental healthcare service is often described as a Cinderella service. Since the creation of the NHS in the early 1950s, the leaders of NHS Trusts around the country have chosen to systematically under-fund mental healthcare. For any other patient group, this would be called discrimination.

Second class citizens

During the last 50 years, successive reforms of mental health legislation were intended to modernize mental healthcare and to safeguard the rights of people with mental health conditions. In reality, these reforms have created a hostile environment in which people with mental health conditions are treated like second class citizens with diminished human rights. Anyone with a mental health condition can expect to face severe stigma in wider society. But in the UK, such stigma finds its clearest expression in a legal and medical system which attaches more importance to minimizing phantom risks of violence than to the human rights of vulnerable people.

As someone with a mental ‘disorder’, I am wary of entering any hospital operated by the NHS. As I enter a hospital, I am very conscious of the fact that I could have my liberty taken away from me at any time. Any junior member of staff could object to my ‘attitude’, blame this on my mental state and assault me. I also know from experience that any complaint I lodge will be ignored and no action will be taken to address my complaint.

A someone with a mental ‘disorder’, I am not regarded as a full member of Homo Sapiens.  Instead, I am relegated to being Homo Sapiens Discordia, intermediate between a full human being and a mountain gorilla. I am granted some human rights but only as determined by Homo Sapiens Normalis. If my behaviour is determined to be abnormal or objectionable or disturbing, then I can be locked away, physically abused and assaulted.

Some proposals of my own

It is clear that many of the failures and shortcomings described in this report are consequences of systemic problems that exist in the NHS and the medical profession. In order to improve the quality of healthcare, these systemic shortcomings need to be addressed. However, it is our contention that the legal framework of the Mental Health Act facilitates these shortcomings while failing to provide sufficient safeguards.

Here are some proposal for reforming the Mental Health Act and the practise of medicine in the UK:

  • Review of Mental Health Act chaired by a leader from the SU movement to propose a radical reform of mental healthcare provision in UK in order to place the interests of patients at the centre of the system
  • Royal Commission to review current status of psychiatric medicine in the UK with a view to reforming the profession. Clear demarcation between the medical and legal enforcement roles of psychiatrists. A psychiatrist treating a patient should have the same doctor-patient role as any other doctor with sole priority to provide the best treatment to the patient. MHA to be enforced separately by forensic psychiatrists with no involvement in the future treatment of patients.
  • Compulsory detentions to be notifiable events that trigger enquiries designed to correct poor practice
  • To counter the upward trend in the number of sections, set targets for reducing the number of compulsory detentions to pre-1983 levels
  • Additional legal safeguards for mental health patients and dedicated fund of legal aid money to support legal prosecutions by patients against NHS mental health trusts. NHS to be legally obliged to release all information to patients seeking to mount a prosecution.
  • 20% increase per year to mental healthcare budget every year in the next 10 years; if the money cannot be found from outside the overall health care budget, then the budget allocated to physical healthcare should be reduced in proportion – this would only require a 2% reduction in the budget spent on physical healthcare

 

Note about the author

I am a Physicist and Chartered Engineer working on the development of medical imaging and clinical diagnostic technologies. I am the father of two children of university age. I have also been in contact on and off with mental healthcare providers for 40 years, since first being referred to an NHS adolescent psychiatric unit at age 13. I have been sectioned once when I was given treatment against my expressed wishes. On another occasion, I was admitted as a voluntary patient after being threatened with a section by the crisis team (‘either you come in voluntarily or we will section you and you will come in involuntarily’). For the last 20 years, I have been in the care of a private psychiatrist, having decided that the ‘care’ available within the NHS would not allow me to work as an engineer, be a Dad or retain my dignity.

 

References

Fernando, S. ‘Review of the Mental Health Act fails to put ‘race’ on its agenda for change, but acknowledges the reality of institutional racism in the mental health system’ ROTA Race On The Agenda (2018). Available at: https://www.rota.org.uk/content/review-mental-health-act-fails-put-%E2%80%98race%E2%80%99-its-agenda-change-acknowledges-reality

Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018). ‘The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis’. Leicester: British Psychological Society.

Hart, A & Waddingham, R, ‘The Mental Health Act – An alternative review’, Hearing Voices Network (2018)

Hart, A, ‘Disabling convention: does the UN CRPD fail to reflect mental health realities?’, Mental Health Today (2018)

Mental Health Foundation, ‘Fundamental facts about mental health 2016’ (2016). Available at: https://www.mentalhealth.org.uk/sites/default/files/fundamental-facts-about-mental-health-2016.pdf

Milburn, A & Michael, A, ‘Reform of the Mental Health Act 1983 Proposals for Consultation’, Green Paper (1999) Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/265574/4480.pdf

National Service User Network (NSUN), ‘Independent review of the Mental Health Act: what next?’ (2018). Available at: https://www.nsun.org.uk/independent-review-of-the-mental-health-act

Peay, J, ‘Reform of the Mental Health Act 1983: Squandering an Opportunity?’, J. Mental Health Law (2000)

Richardson, G, ‘Reform of the Mental Health Act 1983 Report of the Expert Committee, Available at: https://webarchive.nationalarchives.gov.uk/20120503145140/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009576

Turner, J et al., ‘The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research, , Med Hist.; 59(4): 599–624 (2015)

Wessely, S. ‘Review of the Mental Health Act, Final Report (1918)

University of Manchester, ‘National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Annual Report 2015: England, Northern Ireland, Scotland and Wales’, Manchester: University of Manchester  (2015)..

Van Dorn, R, Volavka, J, & Johnson, ‘Mental disorder and violence: Is there a relationship beyond substance use?’, Social Psychiatry and Psychiatric Epidemiology, 47, 487–503 (2012).

Receiving a psychiatric diagnosis: Does it aid the understanding of a mental condition?

I have delayed writing this post because I wanted to mull over my ideas and I was hoping that the ‘battle of the professions’ would die down so that the voices of patients could be heard.  This is not intended to be a comprehensive account of all competing narratives, rather this is my own response to the debate on diagnosis based on my personal experience with mental ‘ill-health’.

I was born in 1967 and experienced my first episode of depression aged 13 years.  This arrived out of the blue one night when sleep ceased to be possible.  Later that year, I was referred to a team of clinical psychologists at an Adolescent Psychiatric Unit in the UK.  Despite being suspended from school later that year, on the rebound from my depression, I wouldn’t be diagnosed with Bipolar Disorder II for another 20 years.

On a practical level, receiving a diagnosis at 33 years of age was undoubtedly helpful.  It meant that my GP took my problem seriously, whereas, in the 1980s, many GPs habitually dismissed depression as ‘something in the mind’ addressed by more healthy thinking.  It allowed me to treat my highs with an anti-manic agent (Olanzapine) which proved very effective.  It meant that my doctors were a little more cautious in prescribing antidepressants, although the psychiatric profession was still questioning the reality of anti-depressant induced mania. To treat a depressive episode, I would be prescribed an SSRI anti-depressant which would reliably trigger a high, which I could then treat with an anti-manic, and this turned out to be a very effective treatment, although my doctors continue to search for alternatives. Eventually, I met a psychiatrist whose judgement I trusted and he persuaded me to go on a mood stabilizer with mixed effects. So, receiving an accurate diagnosis has given me access to services and has allowed my doctors to identify pharmaceutical agents that are more or less effective at treating my mood episodes.

But let’s not pretend that receiving a diagnosis was an entirely positive experience.  My second and last appointment with my first psychiatrist was one of the most disagreeable experiences of my life. He had a habit of completing my sentences for me, often to say the opposite of what I wanted to say.  At the end of a one hour session, he sat back in his chair – which was padded and had arm rests while I was seated on a hard-backed chair – and said: “Right, now that I am your psychiatrist, you are going to do what I say”. That was the end of the session and the end of my relationship with that nasty little man.

In retrospect, I am surprised that no one thought to explain to me the social consequences of a diagnosis and how this might affect my standing in the community.  There is an indication in my medical notes that the clinical psychologist who saw me when I was 13 years old decided not to diagnose me with a serious mental condition because that could be to my disadvantage.

My own reaction was to read as much as I could about bipolar disorder in a bid to build some kind of conceptual understanding of what a mental ‘disorder’ is. ‘An unquiet mind’ by Kay Redfield-Jamison. ‘Breakdown’ by Stuart Sutherland. ‘The anti-depressant era’ by David Healy.  ‘Users and abusers of psychiatry’ by Lucy Johnstone. My reading made me aware of a debate about the reality of psychiatric diagnosis. I found a copy of the DSM IV and was amazed by the arbitrary nature of many diagnostic criteria.  I compared the criteria with those listed in the older DSM II and was surprised how these changed, often without reference to any empirical data.  A scientific endeavour this certainly was not.  Completely new diagnoses were created, presumably by psychiatrists only half listening to their patients.  Outmoded diagnoses like homosexuality disappeared without trace, except in the collective memory of abused communities.

About 18 months into an episode of depression, treated unsuccessfully with two different tricyclic antidepressants, and 6 months after my session with the nasty little man, I refused point blank to take another tricyclic antidepressant.  My GP scolded me for not ‘taking my medicine’. As far as I was concerned, the side effects were obnoxious and the benefits non-existent.  By this time, I had taken considerable time off work and the company doctor of my American employer suggested I might benefit from one of their ‘assets’.  This turned out to be a consultation with a private psychiatrist.

The second psychiatrist was a wonderful man.  He covered much of the same terrain as the NHS psychiatrist but his questioning was sensitive and his thinking nuanced. By this time, I was familiar with the DSM (or ICD) criteria and I could see how he was methodically working his way through the relevant check-lists, ticking off the various items. At the same time, the DSM framework was no more than a scaffold on which to hang ideas and store information. Beyond this structure, the information being sampled was finely calibrated as required by the complexity of the underlying ideas. He also asked some very specific questions on the sorts of thoughts and feelings I was experiencing – much more pertinent than the rather blunt questions asked by the first psychiatrist – and he seemed to weigh up all this information before settling on a prescription. He also took his time explaining his diagnosis, where he was confident and where uncertainty remained and how we could remove that uncertainty; finally, what treatment he recommended. There was no element of coercion or compulsion. I came away from the appointment feeling that my own experiences of depression had been acknowledged and validated, instead of feeling belittled and humiliated.

One month later, after starting on a course of an SNRI antidepressant, I was euthymic and back at work full-time. Three months later, I was high and was ‘persuaded’ to attend a local psychiatric hospital by the community mental health team under threat of a section. The next morning, I left the secure unit via the window, having used a knife from the staff kitchen to loosen the screws securing the window. Once I was a safe distance away, I telephoned the hospital to let them know that I had chosen to leave the hospital just as I had agreed to voluntarily attend the day before; I thanked them for their help.

While it is based on some valid arguments, much of the criticism of psychiatric diagnosis ignores how good psychiatrists actually make a diagnosis.  It is as if those criticising the process have never sat in on a diagnosis and observed how real psychiatrists carry out a mental state evaluation.

Since receiving an accurate diagnosis and finding doctors whose judgement I trust, I have enjoyed good health and returned to work (after first being sacked by the American employer for insubordination during the hypomanic episode). But neither the diagnosis nor the medical treatment have helped me attach meaning to my lived experience.  When I am treated for a physical complaint, a good doctor will take time to explain the cause of the problem and the nature of the treatment. Often this allows me to make sensible adjustments and to get better quicker. The trouble with many psychiatric diagnoses is that they do not provide much of a causal description of what is going wrong or how a drug will correct the problem. Vague explanations about ‘chemical imbalances’ are downright misleading. This state of affairs is sometimes explained in terms of the great complexity of the human brain, but similar complexities have not prevented medical researchers from developing mechanistic understandings of other complex organs such as the sympathetic nervous system or the endocrine system.  Another issue is that many people experiencing psychiatric conditions do not interpret their experiences in terms of medical processes. Meanwhile, many doctors do a very bad job of relating underlying physiological disorders to how these are experienced in terms of thoughts and emotions and anyway this is not really part of their training or expertise.

After reading Lucy Johnstone’s book 25 years ago, which seemed to offer important insights, I remember wondering what she had to offer instead. Did she have an alternative to diagnosis? When the Power Threat Meaning Framework was launched at the end of last year, I was hoping to find an alternative explanation which might fill in many of the psychological gaps not addressed by the medical narrative.  It is clear from the enthusiastic response in certain quarters that the ideas presented by the PTMF team resonate with some people and provide a narrative which allows some people to make sense of their experiences. In addition, many professionals have said that the framework will help them intervene more effectively with their patients.  I am pleased for all these people and I am happy to stand back and listen respectfully to their experiences and wish them luck if they find something that helps them. For myself, I can only speak from my own experience and, for me, I have never thought in terms of a great power struggle that poses an existential threat to my wellbeing. Part of the problem is that I am not a social scientist and I don’t see the world through that lens. To me, society is not some kind of oppressive agent bearing down on all us little people, it is just the collective presence of a large group of people. Although my first psychiatrist was in a position of power, I was quite free to turn my back and reject his ‘care’ and that is what I did.

For myself, I am quite comfortable with the idea that my bipolar condition is a medical illness requiring treatment. I am grateful that my doctors have identified pharmaceutical treatments that are more or less effective and allow me to lead a fulfilling life. In the polarised debate about diagnosis and mental conditions, both camps base their arguments on greatly over-simplified descriptions of mental conditions. The mental processes that make up someone’s mind are products of a hugely complex biological system with a multitude of feedback mechanisms operating at different levels. To say that thoughts are the results of electrical impulses controlled by synaptic events in different parts of a network of neural circuits is a grotesque over-simplification. The neurotransmitters which regulate this activity are part of complex biochemical regulatory systems and are implicated in hormonal systems which control mood and emotion. Very similar biochemical pathways are implicated in the autonomic nervous system just as they are in the somatic nervous system. When I take an antidepressant or antipsychotic, it changes both the way that I consciously think and the way that I instinctively react and feel. Biologically, there is no clear demarcation between conscious thought and unconscious feeling; those are simply metaphysical constructs which our minds like to invent.

Much of the discussion of mental conditions completely ignores the complexity of the underlying biology. To say that depression is the result of a chemical imbalance in the brain is not only simplistic it is also potentially demeaning. As a result, people with a scientific bent feel short-changed and look elsewhere for meaning. While other people with a more artistic bent simply dismiss such discussion as containing no meaning at all. But a faithful description of the biological processes responsible for influencing our thoughts and emotions, which incorporates all the scientific knowledge and ideas generated during the last fifty years, would be a rich treasure trove of information which would inspire reverence and wonder. As well as being scientifically accurate, such a description could give meaning to the experiences of people whose minds are wired differently or whose hormonal systems are mal-adjusted. Such a description would emphasize what we all share in common, with any differences situated on a continuous spectrum extending from the most typical to the less common. Mental ‘disorders’ would be thought more accurately and less contentiously as mis-configured neural circuits or maladjusted hormonal systems requiring minor recalibration. Is it too much to ask that such a conceptual realignment would encourage our friends in psychiatry to deploy their pharmaceutical therapies with just a little more skill and finesse, transforming a chemical cosh into a cool elixir of wellbeing?

So those are some of the positive and negative effects of a psychiatric diagnosis as I have experienced them. And that is how a psychiatric diagnosis has given me some limited insight into my bipolar condition, but how a much deeper and richer understanding can only come from more nuanced and sophisticated thinking based on the latest science.

“When you realize nothing is lacking, the whole world belongs to you.” ~Lao Tzunscottish landscape