Ethics and mental health – especially related to hospital wards
Trainee mental health officers Edinburgh University.
10 01 2024
Hello everyone,
When I was asked me to speak on this subject I felt quite excited and then confused because if I am honest I am not entirely sure what ethics mean, instead I have chosen to think it is all about doing what we hope is the right thing in an often bemusing and frightening environment.
Before I go any further I better introduce myself, my name is Graham Morgan; I work for the Mental Welfare Commission as an engagement officer but the views I express here are not necessarily those of the Commission, more a mix of personal experience and the experiences of people I have met over the last 35 years of working in the mental health field.
My personal experience? I have had a diagnosis of schizophrenia since I was 28 and before that had a diagnosis of borderline personality disorder. I have been in hospital a fair few times but not for the last twelve years. In that time I have been treated under a compulsory community treatment order. I would imagine the professionals around me and most of my friends would say that this order with its need to take medication is what keeps me out of hospital and I would probably agree. I have vivid memories of one of my CPN’s showing me my hospital notes and pointing out the correlation between not taking medication and shortly after that being in hospital but I also have the knowledge that my partner Wendy and her children and Dash the dog and the rabbits also seem to keep me out of hospital, their love, friendship, energy and general amazingness give me a life I once thought was impossible. I feel very guilty that I am alive but am glad that despite that I take pleasure nowadays in living. Once I didn’t and to me that is important.
My first dilemma is pretty fundamental. It is really all about our shared understanding of what I want to happen and what people like you think should happen when we meet. Sometimes I think this is grossly misaligned. When I am admitted to hospital it is almost always under a section. I will have stopped sleeping and stopped taking my medication. I will have fallen out of many of my basic routines and thoughts that live under the surface will be dominating my mind. I will be sure I am possessed by evil spirits and that I am beaming terrible harm to people around me. I will again realise I am part of the ending of the world and that the fires and wars and famines are all something I am playing a part in making happen. I will usually be seeking my destruction or my transformation into something better and less horrid. Often I think by never sleeping or by burning myself alive I will transform into a pure spirit of love and for me, hospital as a solution to that, is maybe different to what you would hope it would be. First of all, it will be frightening, and secondly I will not even have the privacy to go to the toilet alone because I will be being closely watched. I will be determined to harm myself and will have probably taken razor blades onto the ward or keep on tipping kettles of boiling water over my hands and all the time I will be looking for the moment when I can escape and get rid of my blood or electrocute myself or whatever. My obsession will be about dying and not at all about treatment in any form.
And this is where ethics gets tricky because I imagine you might say that because of illness and impairment I am not my authentic self and that my decision making is impaired and that because if do not agree that I am ill then I need to be protected and treated and kept safe again until I can face the world again and look after myself and part of me agrees. At such times I am exhausted and stinking and very, very, frightened. When I harm myself it usually hurts, when I manage to escape I am exhilarated because I can help stop the world ending by my death but utterly horrified because the thought of what I intend to do to myself is inexpressibly awful.
To date, although I have harmed myself when on the ward, I am generally kept safe and after some weeks I stop my hunger strikes and begin to get some sleep and maybe some months later I return to work and my family and life begins again. My family and friends will be relieved that I am in such a place and hope that I soon recover but I do wonder about this.
First of all, it is now over thirty years of my life in which I have been convinced I am evil and destroying the world. I still, even when I am well, think one day someone will have me put down when they realise this is not illness after all. I still think that as the world gets worse and worse mobs of people will seek me out to carry out retribution for what people like me have done. So after thirty years how do we decide what my authentic self is? What my will and preference actually is? I love my family with all my heart and am so glad that I have the wonderful life I do, but my beliefs remain pretty constant.
Maybe, in context, the intervention is still justified but imagine that instead of being psychotic I had spent the last thirty years deeply depressed and even when I wasn’t in hospital, continued to think life is not worth living; maybe my dismay at the utter barrenness of existence would justify my wish to die and maybe some people might believe the wish to die, despite also having an illness is an authentic demonstration of my will. Maybe treatment has not worked and as happens in some other countries maybe I should be allowed a dignified exit. In the UK I hear of people with an extreme eating disorder who have never responded well to any intervention. I often come across cases on twitter where, despite the knowledge that a persons decision making is almost certainly impaired due to starvation, people are put on palliative care pathways while still relatively young.
Should you really have that degree of jurisdiction over life? Either to preserve it or take it away? When everything seems to fail should we be given as easy an exit as possibly instead of leading lives blighted by our own torture and is decision making or trying to give us back our authenticity always what should determine these decisions?
For me personally, and I do not know if this is a sign of moral cowardice or an acknowledgement of the obvious, I could not stand by while someone died and I don’t know why but death due to mental illness seems somehow to be different to an earlier death than would naturally occur due to terminal physical illness.
We will never solve that issue, despite the reviews of mental health legislation that I have played a part in over the last 25 years and there are a thousand different conclusions we can reach with these debates.
But back to hospital again. Why am I there? I have never in all the years I have been in hospital had my treatment explained to me or even seen much obvious treatment. For me it seems to be as blunt as keeping me safe until the meds work, I get some sleep and find small ways of enjoying life again but maybe that is all that we need.
Recently I heard a nurse saying Christmas day is different for nurses and more enjoyable, as they tend to stop doing proper nursing and just engage with patients and yet for us patients that is what we wish they would do every day, what else do they do that is the real nursing we are unaware of?
Maybe the old idea of respite is something that needs acknowledged and respected. Time away from the hideous impossibility of being responsible and coping, time where fresh air and conversations with our peers heals, where painting or music or writing or cooking bring some ease. Maybe that is what we need despite all the theories about our recovery and treatment. Maybe some of us know, in as much detail what it is that helps us as our helpers think they do and if we do how much say should we have in it and what happens to us? If we know we are in danger maybe we should be able to insist on admission? If we know we are not ready to go home, maybe we should be able to countermand the wishes of those who need to free up bed space?
Maybe we approach this all wrong. Maybe instead of the clinical sparse environment of a hospital ward we should be seeking somewhere which feels comfortable and welcoming where we will have things to do if we have the energy and nice food to eat, a home away from the horror that some of our daily lives are: a place of beauty and light and healing. I wonder how that balances against the fact that most people now spend the minimum amount of time possible in hospital, that most are on a section and terribly unwell for most of their stay and are in turn making others unwell.
Our policy makers are in a hurry for us to recover, and keep on telling us home is better for us, but sometimes it isn’t. Home can be where we get hit and where we do not have enough to eat and where we cannot avoid the dealers who offer us escape when we can no longer cope. How does hospital help with that reality?
Is it really no more than an escape to give us the strength to face the unfaceable for a few more months when we have been declared fit to leave and when we go home what is there to support us in the community? Where are the wellbeing hubs and places to go for food and company and comradeship? In some places they do indeed exist but not many. And our mental health teams? It is lovely to say they should come and see us in hospital and provide that precious link to home but until recently my mental health team was functioning on half a CPN and some bank nursing hours. Despite being on a CTO I do not really have a CPN, instead I have a five minute appointment every two weeks to get my jag. Just how do we see this in the context of the possibility of recovery and joy and regaining agency and independence?
Too often I hear of people lost in bedsits leading twilight lives with no money to make it better at all. So here is another issue of ethics – whose needs are we meeting when we hospitalise people like me? Are we giving us safety and peace and a chance to heal and see life and maybe even our illness in new ways or are we just barely patching the cracks in a dysfunctional society?
And with that I will leave these questions and move from the first question of what we are trying to achieve by hospital and is it always good to keep us safe and do we always have similar ideas about what we are trying to achieve and if we do, do we have the resources to achieve them? To a wider question.
I frequently come across hospital wards that are full and some that I would hate to spend a moment on. I also come across beacons of good practice but what is our role? And what is your role. I have a horrible feeling that the crisis beds of England where people use reclining chairs to sleep when in desperation and when there are no beds available will start to appear in Scotland. I fear that just as we followed the English example of finding hospital intrinsically wrong, a costly sign of failure. Because of their past history we thought they were morally wrong; we did not invest in them and instead made them harder and harder to get into. I worry that we will blindly follow what we claim is good practice and get wards that are more and more toxic and unpleasant to get admitted to. That we will follow the example of England where distress becomes criminalised and we are sanctioned for the failings our illness makes of us; both in mental health services, society and the welfare state. Where responsibility and independence and resilience are words batted around blind to the reality of despair and that words such as manipulation and attention seeking will still be used to justify the lack of help people want to give us.
Too often, I hear of people saying that at least the police tried to get them help when they took people up to the hospital but that the NHS did the opposite. A wait for an assessment and then out again, trying to find non existent buses home, with no help provided.
This is something that worries me. It worries me in my role where I constantly find out how much of a crisis our services seem to be in now but also in what we accept. The NHS has a duty of candour for when things go wrong for its patients and clients but where is the duty of candour and your own protection when you are under so much pressure you cannot meet your statutory obligations in the way you used to or when you are part of a services where instead of feeling cared for patients are often bored out their mind and bemused as to how services think they are helping them.
This is a key ethical question to me. If like me, you witness services getting worse and more stressed and more selective and more judgmental and yet you are a part of them – whose duty is it to question what is happening to your clients and patients – we have our developing user voice, we have advocacy but when you sit down at the end of the day and say to your partner that work is getting just that little bit too pressured and unsafe to be happy with; what do you do about it? Who do you pass the issues onto? Who do you hold to account when you are a part of a system that could and should be doing so much better.
Now a few random issues because I want us to start a discussion and a debate about whatever interests you most after this talk.
As part of my work at the Commission I visit many hospital wards, mainly acute and secure wards but also rehab. Sometimes I meet people who say that the ward is noisy and violent and that some of the other patients are too ill and too frightening for them to feel safe or to believe that they are in a therapeutic space. Some people say they just accept it; others see it as unacceptable. Who do you protect?
And if you say those aggressive violent patients have a right to treatment because they are ill surely those quiet passive patients who may discharge themselves early or lose faith in mental health services completely also have rights? How do we balance this?
And likewise – I have met so many women in the past who say that even with single rooms they feel unsafe on wards with uninhibited large men, especially those women who know to their personal cost what men like them can do. I have been on wards where groups of women have found the safety to dress in their dressing gowns and go to the quiet room to watch films and eat crisps and things and have witnessed the healing that company can create and I have also witnessed the distress when some men make inappropriate comments about them. Should we have single sex wards – I think for some women that would be good. For me it would be a disaster – I have almost no male friends, like many women I find the company of men to be threatening and worrying. I do not know why but on an all male ward, full of wild emotion and hormones I think I would hide in my room and not participate at all.
There are also some issues which seem not to be complicated – smoking – we have a new government directive about smoking or more clearly about eliminating smoking and it probably has the support of most of the population but in the mental health community or at least some sections of it, is it really welcomed?
What communities do our politicians really represent ? I go to meetings of people with addiction problems with someone I am close to in Easterhouse in Glasgow and it is one of the most healing supportive environments I have ever been to but maybe ninety nine percent of them smoke – doesn’t worry me and why should it? Yes it is terribly damaging but not as awful as heroin and crack and so on and likewise, I see the same on some hospital wards. Some of my colleagues are aghast at the smell of smoke on a ward; personally I think I am closer to the view of a ward manager who said when you have nothing left in the world not even hope or joy or energy why take away the last thing that gives people comfort? I would maybe even go further – for the staff; hospital is a place of treatment but to some of us it is a temporary home.
I am old enough to have been taken to the pub by my nurses in the evening and I am not completely sure that was an awful thing while in contrast I can see that it can be awful to immediately discharge someone who has a drink in town on pass following a wards zero tolerance policy. But then illness drunkenness and emotion in what is meant to be a calm environment are not easy bed partners.
And similarly with food, I met an Afro Caribbean man recently who said he needed money to buy the food he knew was good for him, he wanted limes and vegetables and salads and likewise a Romanian woman who said it is unheard of to eat vegetables boiled till they are tasteless in her country, she needed fresh veg and spices. Making a ward culturally appropriate means much, much, more than providing an interpreter and if you are trans and your helpers constantly get your pronouns wrong how welcome and cared for will they feel.
Speaking of culture – I am a pretty firm believer in the biopsychosocial model of mental illness and it appears that social work and psychiatry is too – though you wouldn’t believe that if you witness the furious debates on twitter of different professionals determined to provide the meaning and explanation of people like mines experience – I tend to feel angry about their insistence that they can define people like me via their own radical idealism or for that matter reactionary beliefs. But I do know that there are many communities who view mental illness and especially neurodivergence through a very different lens and maybe people who say that psychosis is their own spiritual awakening or who say as is widely accepted nowadays that if you are autistic it is fundamentally wrong to try to make you other than you are, instead that experience or sometimes peoples beliefs about illness need respected and adhered to. How do we cater for and adapt to different communities and cultures view of mental illness when we tend to follow a fairly conventional view of it?
I am going to finish now before we get into a wider discussion and here I will freely admit that I am one of the more reactionary people of my community. I went to a training event recently where one of the trainers went down the familiar line of saying mental health services are too risk averse and do not allow people like us the freedom to make mistakes. Wherever you go with that; remember that when the mistake is made it is us that suffer. If we are denied services or sent out on pass and die as a result that happens to us and if we are locked up for too long and put on obs for too long and feel humiliated and trapped it happens to us and equally if we are set to wander the community and get in trouble with the police through our illness, that also happens to us but because all those things are to date determined by people dedicated to helping us; it is you that have enabled it and of course that is another debate – should anyone have power over us even if sanctioned by the state and invested in with qualifications and powers to detain? When you get excited by this thing of risk assessment and the freedom to let us take risks do remember it is not you taking the risk, it is us, you are just enabling it to happen.
For every one person I meet who says they were treated with too much caution I meet a dozen who lament the lack of help they got when the were suicidal and who are beyond angry that they or their loved ones came to harm or even died when discharged from hospital or community services before they were ready or who didn’t even get as far as assessment and yet still pleaded for help and still died or lost their jobs or their family or their health. Can we individually take the mantle of saying;
“By my actions I will decide what happens to another person and I am comfortable with it.”
That is what each and every one of you are doing and again I hear my cautious self saying – please do so – people like you keep people like me alive and usually we are glad of it even if we tend to hate what has been done to us, but what is that phrase about power corrupting – always keep that in mind and ask yourself how you would feel if it were done to you or would you do this to your child, partner or parent and still feel comfortable with the decisions and the support you have provided?
And a last question for consideration – the human bit!! I takes me ages to trust people especially with these intensely private things and I am always aware of the people who are caring for me; aware and deeply sensitive. I often say that if I am to be sectioned it should be with love; you might prefer compassion. For me compassion sounds a bit too professional. At my most distressed I want kind, warm, calm, people who can sometimes bring a smile to my face. I want to know I am valued and that the person sectioning me is not worrying when they will write their notes up or if they will be late picking the children up from school. I certainly don’t want met with fake kindness disguised as professionalism which masks a coldness and remoteness that humiliates me.
For me; my very existence is in the balance, I am incredibly distressed and incredibly frightened and probably angry. At these times I need so much for some form of connection and humanity. I worry, to be honest, that the need to protect me and yourself and to preserve a professional distance and the fact that for you this is just another event in many that day mitigates against my need for warmth and kindness even when I say I hate you. How do you keep your humanity present even when we are horrible to you and your workload unmanageable?
I wish you luck in the future in your work – it is a brave, difficult and often thankless job but it is a job which can both save lives and enable lives to flourish when that had once seemed impossible. That is pretty special – I have never done something as valuable or as important as that and don’t think I would be capable of it.
Thank you
(photo: my latest CTO suggestion and my walk yesterday at Ardmore- i know what i prefer!!)