I still recall that very first day, when I walked across a locked door of a mental health ward. It was an ugly big double door that made a loud, horrible sound as you were allowed in. I cannot speak for others operating within mental health services – but what I do know is that, as I crossed the threshold, there was a distinct feeling that I was ‘locked-in.’ On that day, I did not have ample time to consume my feeling because, if you have ever been on a psychiatric hospital ward, you will know that there is a lot of movement and it’s busy. Yet, I still remember looking back at that door with a dreadful feeling. I was locked in. No matter how passionate I was about my chosen area of work and study, I also could not forget my silent sadness and dissent.
Controlled justification
Even now, we see contemporary mental health units staying permanently locked. The justification commonly offered for the wards being locked is that the individuals within them require to be held safe – safe from causing harm to themselves or from committing harm to others. In 2016, a group of researchers analysed longitudinal data from 21 German psychiatric inpatient clinics over 15 years; they employed complicated statistical models and compared hospitals with locked wards and unlocked wards with regard to ‘completed suicides’ and ‘suicide attempts.’ The study concluded that locked doors in acute psychiatric care may not be enough to safeguard patients from suicide attempts and suicide.
In mental health services, the open-door policy remains an issue, the strategies used and reported in the Lancet are (Note, that the words and phrases used below are those of the authors of the paper):
- Admitting all ‘difficult-to-manage patients’ to a single locked ward and keep the others open
- Distributing ‘difficult patients’ across wards and keep wards open temporarily whenever possible
- Providing locked sub-units for difficult patients on open wards
- Keeping all wards permanently open without exception
Thomas Pollmächer and Tilman Steinert suggest that the fourth approach is definitely possible – and report an example, whereby psychiatric wards are open for legal reasons in Austria. Some also argues that the literature is largely from expert judgement that asserts ‘safety is paramount’, however, its assertions are based on unpersuasive evidence that locking people up truly improves safety.
This sadly signifies that there remains unease and conflict between both locked wards and involuntary admissions in the ‘lives’ of those that are locked up because of severe mental illness.
Relinquishing control
A couple of years in and I had gained some experience of ward work; I moved from one locked ward to another. I was a fixture among others working as a team, admitting individuals brought in under a section of the Mental Health Act 1983, as per the role, reducing risk. My experience of working in mental health services ranged across inpatient elderly and adult wards and, finally, community services. I was by then entrenched in mental health services, like all the individuals on the wards; comparably, I too was now used to the culture, its environment, the professionals often operating in silos with their own sets of notes according to their discipline, boundaries, routines, and regulations.
I did not wear a uniform, but in mental health services – I wore my alarm and keys like an additional burden – extra to my feeling of being locked-in. I had not forgotten my feeling of being locked-in, though by now I was also familiar with the use of medicine, the seclusion ‘soft’ rooms that were operational at that time (they were a distinct room and not proposed for patients to remain in them for lengthy periods; they were used to prevent patients from harming themselves when suffering from an ‘epileptic or psychotic episode’.
‘Suicidal and violent’ patients were also put within them). I recall the day that I was the earliest person on the ward accepting a 6-feet tall young individual brought in by the police. Due to staff shortages, doctors not answering bleeps, time of night, no administrative staff, I might have found myself a bit stuck. I think it was termed management at the time – so, I borrowed staff from other wards and had the medication written up. The World Health Organization definition of rational use of medicines, formulated in 1985, emphasises that patients need to ‘receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.’ The young individual arrived, very abusive and violent. That night I left the locked ward, apprehensive, only to return incredibly early the next morning so that the individual would wake up to the same person (my way of instilling continuity in care). I knocked, took a deep breath and entered the room. As I entered, I wondered if the individual would remember me from the night before. I introduced myself again and started to talk as if it was the most natural interaction.
Like many others operating in mental health services, I could not completely decide if resources rather than law had determined the rate of involuntary admissions, although this does not account for all the ills experienced by individuals using the services.
Recently, Professor Sir Simon Wessely and his vice-chairs, Sir Mark Hedley, Baroness Julia Neuberger, and Steve Gilbert OBE have led the recent ‘landmark’ independent review of the Mental Health Act 1983 in the UK to improve legislation. They made recommendations from this review on themes such as choice and autonomy – ensuring service users’ views and choices are respected; least restriction – ensuring the Act’s powers are used in the least restrictive way; therapeutic benefit – ensuring patients are supported to get better, so they can be discharged from the act; the person as an individual – ensuring patients are viewed and treated as individuals. Interestingly, having earned experience of working on the mental health wards, having done research projects over several years and by talking to individuals who have also had experiences in mental health care, the above ideas do ideally sound fitting on the surface.
Concurrently, the COVID-19 pandemic has driven concern on the impending impact of suicide rates and measures to contain it. Raw figures and their interpretation remain debated, but there is some evidence that the 2018 rate rose by 12% and the 2019 rate, reported in September 2020, showed a 5% rise. Even so, The UK government has issued a white paper in response to the above-mentioned landmark review, which is a major step in changing the law. The focus of this paper is to increase the liberty of citizens, seek to implement reforms that view individuals ‘not as just patients’, but with rights, preferences, and expertise, so being able to rely on a system that supports them and only intervenes proportionally, where their health and well-being will be of central value. All, sounding similar, as they had done in ‘the 1950s and 1960s when a range of influential studies adopted a ‘structural’ approach to mental health inequalities, such as the community studies of the impact of the environment on mental health conducted.’
However, the landmark review has drawn criticism from some survivors of mental health services on social media platforms such as Twitter. It is also not surprising that individuals who have been admitted involuntarily narrate their experiences harshly as is true for them, and many continue to feel ‘unheard’. Hence, researchers accurately capture how the current policy emphasis on ‘voice’ apprehends the discourse of activism colluding ‘in this shift toward individualism, albeit under the guise of participation, collaboration, and co-production.’
This is not an argument against the inclusion of those with lived experience, it is rather a call to problematise how ‘inclusion unfolds for individuals using mental health services when suddenly invited to operationalise systems that have long been sites of systemic discrimination.’ The value of service user involvement in professional education is widely recognised within the literature as contributing to good practice, while also challenging and transforming dominant biomedical ways of knowing and practising.
Helen Lester, along with her colleagues, have shown in their focus-group study, that the experience of serious mental illness was deeply personal, and many individuals recognised the notion of recovery as important and achievable. However, researchers also found potential tensions between health professionals’ perceptions of serious mental illness as a chronic disease and patients’ preferences for optimism in treatment that ‘recognised recovery’ as a ‘possibility.’ Their findings also shed light on the ‘struggle to get legitimate access to care, and the individuals’ many strategies for negotiating and facilitating access – in particular. All individuals in the study were distressed by having to act up their symptoms to get an appointment and their condition would deteriorate further, possibly resulting in an urgent admission.’ (p.5). Most individuals were uncomfortably aware that exaggeration might feed existing negative stereotypes of malingering, yet some felt compelled to use exaggeration as a strategy when access was problematic.
It was also suggested the notion of acting up was mirrored by some health professionals, who discussed the methods they had used to overcome secondary care barriers and admit patients who were unwell, but not yet quite at crisis point; these methods included exaggerating the severity of the presenting symptoms to the admitting psychiatrist. So, malingering is not a mental illness – malingering is the dishonest and intentional production of symptoms. Nevertheless, some suggest these are specific challenges that are not common but run counter to, and can confront, usual clinical practice, relationship building, and may expose professionals to highly testing legal situations. Respectfully, a recent proposed talk on ‘malingering’ was cancelled by the first author mentioned above, due to ire expressed on Twitter, a social media platform. A compassionate statement was issued :
‘I have seen some of the postings on Twitter about the talk, and reflected on the hurt it has caused, particularly for people who have personal experience of not being believed by mental health professionals or services. It is also true that this is very much a minority occurrence, and the vast majority of people are doing their best to manage their mental health with or without the support of professional services. It is also the case that many people have felt ignored, marginalised, and disbelieved when engaging with services.’ – Derek Tracy
The cancellation perhaps was a positive example of ‘empathic listening’ or an ethically ‘sensitive approach’ taken by a psychiatrist. Negotiating a step away from the insecurity for legitimacy – or need to demonstrate the value of intervening in the lives of others. Better still, it was the operationalising, one of the six ‘core competencies’ of medical education. Demonstrating what some suggest, that a medical ethic underpins an ethic of loyalty to the patient, social obligations, compassion, and the characteristics or virtues that should govern a healing relationship.
Previous works also highlighted barriers and challenges to accessing care for those managing severe mental illness, including the effects of the illness itself – a lack of confidence and assertiveness, for example, made access to services harder to negotiate when individuals were depressed, had a diagnosis of schizophrenia and bipolar disorder, also individuals described the need to seem ‘rational’ so as not to appear too ‘together,’ as they would not be believed or seen urgently. Individuals who were anxious or had symptoms of psychosis have reported difficulty negotiating noisy or crowded waiting areas.
Therefore, context around how individuals come to access care, and ‘swift’ access to care with aspects of continuity of care seem reasonable and highly important for patients, because of the sudden onset of some mental health crises and are salient for how ethically sensitive mental health care is enacted in practice.
Trust in the direction of humanisation
Since the landmark review reported its findings, the recommendations have already influenced the main decisions and actions the government is making to improve mental health care. However, the considerable additional investment is mainly to change the mental health ‘estate’ so that ‘inpatients can have the privacy and dignity of their own bedrooms with en-suite bathrooms.’ Furthermore, investing over £400 million is for erasing ‘mental health estate of dormitory provision,’ and as the ‘review advised’ building new mental health hospitals and undertaking the maintenance work needed in the mental health facilities.
However, the main negative contention with mental health care might or might not be ingrained in the bricks and mortar of these new institutions, but more held in the culture of medicine which will be the real challenge for change in the Mental Health Services and for operationalising the findings from the landmark review. Dehumanisation is endemic in medical practice – one way this happens is when subtle forms of dehumanisation enter hospital life. Haslam explains that dehumanisation can take a ‘mechanistic’ form in which humans are likened to objects or automata and are denied qualities such as ‘warmth, emotion, and individuality.’ Such ‘mechanistic’ dehumanisation is more likely to occur in interpersonal interactions and organisational settings. Haque and Waytz suggested that rather than pointing fingers at individuals, primary causes for these outcomes result from structural and organisational features of hospital life, as well as from functional psychological demands intrinsic to the medical profession. They are the by-products of common and otherwise effective medical practices and institutional situations that facilitate the dehumanisation of patients.
Here is an individual’s narrative on dehumanisation, an example from the social media platform on Twitter:
‘Husband just spent four months in hospital; rehab facility fol a major stroke. The absolute worst part of it for us both was the lack of emotional support; care; the daily microaggressions/dehumanisation. His recovery increased dramatically once he got home which speaks volumes.’
Ivaylo Vassilev and David Pilgrim, in their paper titled have cited Bauman and May when discussing encounters with health professionals. Zygmunt Bauman and Tim May point out ‘such professionalism is not simply about knowledge and competence as approved by professional bodies after extensive training and exams, but concerns trust.’ Vassilev and Pilgrim have also delved into the many ‘shortcomings of trust relations’ in mental health services. They argue that the betrayal of trust is based on both a ‘normal and abnormal’ experience in mental health services and suggest an approach that scrutinises the ‘situated meaning of trust and risk in mental health provision’. The social justice literature indicates that individuals appear to care as much or more about how they are treated in the course of decision-making (procedural justice) as they do about the decision outcome (distributive justice). This conclusion is especially strong once resources remain insufficient and outcomes are ambiguous, as is regularly the situation in healthcare decision-making. Additionally, procedural justice is likely to be notably significant in healthcare environments, where individuals often build emotional connections to professionals and other providers with decision-making power. Lammers and Stapel also found that the experience or possession of power increases dehumanisation. They explain it by the fact that power implies difficult decision-making which may affect and harm other people.
On the face of it, individuals may or may not trust organisations or whole systems, indicating a supra-personal dimension to the concept. Interpersonal relations are continuously rooted in larger societal traditions and systems. Therefore, trust attitudes and trustworthiness at the personal level (e.g., doctor-patient) are always intertwined with expectations about the operations of formal institutions (for example, the NHS) and social systems (such as the health, legal, and political systems). The latter have distinct logics of generating trust and being trustworthy.
Anne Rogers, together with her colleagues, have discussed the changing professional role that psychiatry has sought for itself through the rise and popularity of anti-stigma campaigns which have been viewed as ‘interest’ with a view to softening some of the future workings with individuals. Then perhaps psychiatry is ideally placed to inform the analysis in the mental health field because those operating within mental health services recognise that these ideals are often and routinely unmet; even if the essential ethical ideals of the medical profession involve acting in a patient’s best interests, treating patients as ends in themselves, maximising patient autonomy in informed treatment decisions, and distributing medical benefits fairly.
Challenge for the future
The considerable collective challenge for health professionals and individuals using the services is to define and produce an organisation that is not experienced as coercive or ‘locked-in’ for both, in which individuals with serious mental illness can be seen and feel engaged within the care and with their health professionals without fearing that they will be misinterpreted. And for professionals to not feel work-related stress, feeling as being confined in a ‘prison-like world,’ professional and ethical tensions in the process of keeping patients safe while trying to promote recovery; higher levels of depersonalisation; and burnout. Perhaps related to this, dehumanisation can be seen to work as a coping strategy to mitigate emotional distress and justify tough decisions that are required in mental health care. Moreover, previous works indicate that experience of power ‘decreases perspective-taking, makes people more closed to others, and increases deindividuation – three psychological processes associated with increased dehumanization.’
The importance attached to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge may also encourage health professionals in mental health care to play a greater role in the care of patients with serious mental illness.
James Nazroo and his colleagues have in the past called for identifying the benefits of a pluralist approach to mental healthcare research and practice and with exploring the possibilities of a reconciliation of seemingly opposed but possibly complementary roles of medical and social science perspectives. This may now seem a true possibility as in the New Year, the Royal College of Psychiatry announced that the next college dean will be Professor Subodh Dave. His campaign statement was: ‘Deprivation and its impact on people’s mental and physical health struck me afresh, consolidating my values of social justice, equity, and a humane, person-centred approach in psychiatric practice and training.’
Professor Subodh Dave willingly talk about the understanding of the evidence of the role of social determinants, namely adverse childhood experiences, poverty, and gender/race inequalities on physical and mental health outcomes. This welcomed change in vision by those operating within mental health services may provide and eventually reveal ways of exploring distress within its social context by highlighting the reverence of using and understanding social processes, social theory, and paying attention to the ‘personal narratives’ of individuals with mental health problems.
As I was leaving the ward at the end of that first day, I remember one of the patients smiling at me, I smiled back ‘one human to another.’
Nagina Khan, PhD is a mental health advocate.
