Curved Graphic

Coercion and Compliance -
Mental Health Officer Training, 2000/2001



I gave a version of this talk to the Milan Committee that is looking into the Mental Health Act at the moment and will give you a report on the views of HUG on the Mental Health Act and how it might change for the better.

Before I start I should say that I think that the use of sectioning is part of the mythology of our society we don't exactly scare our children with the threat of its use but it is a worry - the idea of "them" coming to take you away!

The very first time I was admitted to hospital I assumed that because there were no bars on the windows and no strait jackets and no screaming people that the use of compulsion must be a bit of folklore too. I was just there being assessed I think, but I can clearly remember one night saying that I thought I would like to leave, and being told that if that was the case that I would have to wait to see a doctor and that it was possible that I would be sectioned. I remember the pit of my stomach becoming hollow at the thought. Until then I had felt looked after and safe and this haven had suddenly turned into a place of fear, a place to be threatened in and a place that I wanted to leave and which I did by mutual agreement soon after.

There was a time some years ago that I look on as when I did my big 'crack up'. From the moment in the G.P's surgery when after my confession of spirits and lights and the need to die accompanied by strange gestures of my arms, I found that my life was taken over. I was told that I would stay in the consulting room and that I would go to the hospital in my wife's car as soon as an emergency appointment had been made and at no point was there any room for disagreement.

When I was finally being interviewed for admission by the psychiatrist at the hospital he was called to the phone and I ended up escaping from the interview because I believed that I was poisoning the person on the other end of the phone line who the doctor was speaking to. I hid in a corner of the courtyard of the hospital and was finally found by a nurse who made me come back to see the doctor before I was admitted to the ward.

In the ward a group of staff surrounded my bed under which I was hidden and spent a long time telling me to take some medicine because it would be good for me. I did not know whether it would be good for me or not I was frightened about where I was, about my experiences, about the staff and the other people around. It felt like I was being exposed to a process of attrition and that when I was finally worn out I would have to take the medication anyway.

I did take it and it turned out to be Haloperidol - a liquid which I grew to hate as I slowed down and my thoughts felt like they were going through cotton wool and yet I grew to expect it whenever I was doing something odd.

When I got wise to the fact that I couldn't leave the ward to go to the trees where I would spill the blood that I thought was full of the evil spirits that were damaging me and those around me, I exercised choice and worked out how to leave with no one seeing. Shortly after one lunch time I ended up perched in the branches of a tree in the hospital grounds with a razor blade in my hands looking at the ugly cut in my wrist and debating "Can I not please cut through that horrid vein".

I exercised choice again and threw the blade away and jumped out of the tree and walked back to the ward thinking to myself if only I could cut myself properly, if only I could finish all this mess and misery and do the bidding of the evil spirits and the next moment I was wishing that I wasn't bleeding at all and that I could be safe and peaceful somewhere.

In the ward I was stitched up and had the burns that I had made on my hands all that morning treated, and in that place on the ward where I was shouting and telling people to stop touching me because I might kill them, I lost my choice again.

My possessions were taken from me. I was searched and anything with which I might hurt myself with was taken from me and a nurse was positioned besides me who stayed there in shifts for the next couple of weeks. At first when I asked for a cigarette and then a light I was easily able to turn around and after a couple of puffs stub it out on my hands.

Whenever I tried to leave the ward by the door nurses would gather around me and tell me that I couldn't and eventually I would end up wandering up and down the corridors again. I had to be accompanied to my bath, leave the door ajar in the toilet, get permission to shave, be accompanied anywhere that I went off of the ward, and at no time was I under a section and for all of this time and most of time in the hospital, I believed that I had to do as I was told and did so.

Eventually I stopped trying to harm myself and both my various nurses and myself grew bored and annoyed at being escorted everywhere. I was then free to be on the ward but not to leave it. The doors became a symbol of liberation to me. I yearned for the day when I could walk up to the door and walk through it to somewhere pointless and aimless but my place where no one would look at me, no one check on me where I could do what I wanted.

Being compulsorily treated as I was or feeling forced to do things against your will when there is no legal sanction for it is not that rare. In fact most people would agree that the concept of choice is always a little limited when in hospital even if there is no overt "you will do this", there is a very familiar feeling of expectation to conform to the rules of treatment and a hospital environment.

This is not to say that it is automatically wrong. When I was being treated against my will I did not feel wronged, but I do distinctly remember certain incidents. I remember fleeing the doctors interview and feeling wounded to the core by his expression of exasperation as he tried to deal with psychotic me and his suicidal phone call at the same time, and yet some minutes later I remember the warmth in the nurses voice who coaxed me away from my corner of the yard in the hospital.

I remember the concern I got from the nurse to whom I showed my cut wrist when I returned to the ward and the anger in the doctor's voice as he stitched me up. I also remember boredom, frustration, fear, tiredness, anger, sympathy, kindness, interest and care from the nurses who were specialling me. Each of these different emotions gives me different perspectives.

I have felt they took away my freedom, they didn't see me as human and they did not reach out to me. I should have had rights and I should have had things explained to me. I should have had justice. And yet nowadays I wonder what I would have done and I feel that my life was saved by the nurse and doctors and hospital and that there were moments of tact and warmth which took away all the infringements that I felt that I saw.

Coercion and compliance - they are at extremes and yet go hand in hand. In order for someone to coerce me successfully, I have to be passive and comply to an extent otherwise everyone under a section would be under constant restraint, but whether they are always wrong or can be stopped I am unsure. I am devoutly grateful that I was coerced and extremely glad that I accepted it.

However sometimes I wonder to myself whether it was all necessary. Sometimes when I look back I can see myself acting out a horrible game. From the moment I threw away my razor blade I think I knew that I couldn't damage myself to the extent that I really wanted to. Sometimes I think the cocoon of protection, which I fought against, created a whole set of rules for me to fight against in relative safety. It gave me a framework that allowed me permission to stop harming myself.

Sometimes it all became very hard work. I have a very clear memory of someone telling me about a teenager who eventually committed suicide saying that it was sometimes totally exhausting staying psychotic. I have talked about this with other people many of who have agreed that sometimes there is an element of just thinking 'lets stop this and be normal for at least a little bit'.

I think there are elements here which make me think about how much we conform to expectations and how much risk people should be allowed to experience if they wish it. But what is it that we wish for? My story so far is of wishes that contradict themselves.

It is more than this. We will have all heard of the story of people being escorted into a ward by the police taking huge precautions for safety and then the supposedly violent person being put in the charge of a physically weak nurse. Our perceptions of being forced to do something and our reaction to it can be highly influenced by our stereotype of the person concerned.

In mental health, especially in hospital, the possibility of coercion, being put into place with the force of the law behind it, is ever present and can lead to anything being interpreted as an infringement of a person's autonomy or freedom and on occasion it is.

When we are voluntary patients we are (if we choose and if we have the wrong staff), always at risk of being put into the wrong places in our minds where our illness can escalate and our response to treatment change because of our fear of what may happen. Everything can go out of control because our minds are vulnerable and we are frightened and dependent in ways we have not felt before, and where we meet the wrong people or environment this situation can escalate into one where rightly or wrongly, we are put under the threat of force and of being sectioned.

In the HUG response to the review of the Mental Health Act we talk about a number of things that touch on this subject.

For many people there is a 'them and us' atmosphere in hospital and treatment connected to different cultures, classes, status, ages and environments and so on. It means that it is possible that two people, one who is ill and wants to get better, and one who has a training that could assist in this, can find themselves so entangled in the reality of their respective institutions, that they remain forever suspicious of each other, and forever open to accusations of passivity or control.

Both can be saying to themselves "let us stop mistrusting each other" and yet neither is able to do so. How do you make a connection between a young psychotic person who is homeless and has a drug problem, with a well paid well settled professional?

Sometimes you do, but often the use of power intervenes to stop any useful connection that can lead to cooperation. We don't want this atmosphere and neither do professionals. To change it I can think of a number of things:

Presumably if you are a voluntary patient and are being forced to do something against your will you have a lot of rights to challenge this already. It is important that people realise this and have assistance in getting them.

Stereotypes and stigma of people and services need to be challenged to remove the knee jerk defensive reactions we can all exhibit, whether they be against people with a mental illness or workers in mental health.

Power is frightening but can be useful. The exercise of authority can make someone safe and can make someone agree to treatment that they couldn't admit the need for before.

Equally the perception that a hospital environment can be place that just gives rules for someone to rebel against can be treated as a positive thing, or something to be removed to allow people to take the risks we all take with life.

Where government and society needs scapegoats for anything that goes wrong it is very difficult to take risks by passing over control to a user if the failure of that gesture and mark of respect exposes you to pillory from the wider community.

With information we will generally make informed decisions and act reasonably. We will have difficulty in acting reasonably if information is withheld from us.

If society could accept we are all prone to illness and that we have a common goal to help people to a healthy lifestyle in an environment, which encourages diversity, then the misuse or use of power over another could decrease.

If hospitalisation did not often mark a fall from grace, we might be treated and act better partly because we would react better too.

If my friends and wife were consulted more about what I needed when was ill then there would be more appropriate treatment.

If, as is likely, we are to have power exercised over us when we are too ill or cannot easily express our views, then we should have access to advocacy.

Advance Directives
The use of these may sanction powers that people are reluctant to take when it is clear that we cannot give very clear consent to what is happening.

Where we can join in as we get better and know that we have a clear say in what is happening to us, and even have some optimism about the prospect of getting better, the concepts of compliance and coercion begin to dissolve.

The use of the Mental Health Act will always have an influence but it is important that voluntary patients have access to rights and representation and that the training, education and cultural issues outlined here, are acted on to minimize the bluntness that compulsion conveys.

There are a whole range of issues that we can talk about here. Attitude is often the key. Nothing can stop a section, whether right or not, acting as an infringement of a person's liberty, but where it is carried out with love and respect for that person, then its impact becomes less.

A section can both save lives, protect families, bring hope to people who were fast losing it and do all the opposites. Its use whether justified or not can ruin a persons life and relationships whether with their workers or others. So to end on a preaching note, handle the issues with care and as I am sure you know, remember that the closer treatment is to a persons wishes and experiences, the more productive it can be, and the less is the need for the sort of use of power that damages people.



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HUG Talks - Coercion & Compliance