Impressions from a closed psychiatric ward

“When suffering from a mental illness one no longer has a free will.”

A floor plan of the ward should have been included here, illustrating the conditions in which patients are being forced to ‘live’. However, to ensure I am not legally compromised (trade and corporate secrets etc.), I have been advised against including this. In the hope of enabling some insight here is a brief description:

The ward’s capacity is 30 patients, though this is frequently surpassed. Patient rooms range from approx. 8㎡ to 20㎡, most of them double rooms, each with a toilet and shower. Some rooms can be locked from the inside, most cannot. The total garden space is less than 500㎡, divided into smaller segments, one length no longer than 25m. The total community space is approx. 60㎡, in which patients eat, relax, socialise and watch TV.

[Editor’s note: to ensure anonymity of the patient data as well as the institution, all of the facts and quotes included have been altered, leaving a representative, but in no way replicable account. Further, the author has asked to remain anonymous.]

The words to follow are in no shape or form a direct attack or critique of the individual work I have witnessed. On the contrary, the work was, across the board of professions — from the social workers and junior doctors to the nurses, kitchen staff and consultants — infused with such compassion, empathy and a desire to do the right thing that other areas of the medical profession and beyond would do well to emulate. Instead, it is a depiction and thereafter critique of the mental health normativity that currently serves as the framework for psychiatric care. Further, it is precisely my inexperienced and untrained view, surely considered by many in the profession as an underlying weakness and source for criticism of my account, which can highlight objectionable elements. One surfaces from the outset: the architecture. The caption above should speak for itself.

I
As you pass the video-monitored doors of the security gate, it is the smell which initially welcomes you into the hermetic field of this particular closed psychiatric ward: the stale stench; a fusion of canteen waste and sweat flooding your nostrils. Next, scenes hitherto considered unique to theatrical compositions become human reality: the screaming, the blood, the faeces, the smoking, the walking, the talking, more screaming, more shouting, more blood, the zombie-like movements, and so on. In retrospect, these impressions are hard to recollect, for surprisingly quickly, and easily, such shocking first impressions become a working reality. The surreality of leaving the ward on the first day, for example, reentering the mundane everydayness of contemporary society, cannot be replicated. Sure, aftershocks continue, yet even their combined magnitude is little in comparison to the primary event. It is this process of normalisation which has necessitated this article: a normalisation which stifles critique, however righteous and ethical the individual standpoint may be.

II
Patient: I respect you, but you don’t respect me.
– Nurse: We do respect you.
Patient: If you respected me, you would give me some space and leave me alone.
– Nurse: … But this is our profession, we are in a hospital, we have to help you.

What does this ‘help’ consist of? Two means are commonly employed: restraint and sedation, both of which can be enforced against the explicit will of the patient. In this case both methods are adopted, the patient is removed from the corridor (where she was dancing and praying, in no way a danger to the public, as reported by the police), restrained and sedated. It seems she knew what was coming, for the three security men did not need to help the process along.

Returning to the prior scene:
– Security guard: That’s a shame, I thought it was really going to blow up.

The next day, the patient is walking freely around the ward, her eyes dazed and legs dragging behind her, spit drooling from the corner of her mouth. But she is friendly and cooperative, and can be left to vegetate alone. A week later she is discharged — adeptly tranquillised — with the underlying problem left untouched.

III
Why is the force-feeding being authorised? The patient clearly does not want to live any longer, he is not partaking in therapy, refusing food and medication, and is capable of understanding the consequences of such actions. In a large multi-professional meeting including nurses, doctors, social workers, the legal guardian, a lawyer, a judge and an ethicist, all are in absolute agreement: the wish to die is attributable to illness, which is not to be mistaken for his free will. Further: we owe it to the patient not to fulfil this wish.

Where will this lead? How far will this group of professionals go? How much longer will this individual be controlled, ruled over, his own life lived and mediated by humans other than himself? The irony is: suicide is actually legal, so long as the individual is acting in accordance with their own free will, hence is legally ‘competent’, meaning capable of consenting. Yet can we envision a situation in which an individual who wishes to die, and is not suffering from a terminal somatic illness, is considered competent? In other words: can we envision a situation where an individual who stands in opposition to the mental health normativity is not considered mentally ill? Keep this in mind, it is the first attempt at differentiating between danger to self and danger to others.

IV
How arbitrary the judge’s decisions can be: she’ll stay for 7 days, so until, erm, wait let me check my calendar — oh wait, I’m on holiday then, and the day after is a bank holiday, ok so she’ll stay for 10 days, that’s better for her anyway, she’ll have time to recover.

V
Several weeks ago, the disclosure of suicidal thoughts had led to his involuntary commitment to the ward. Rituals marked his movements; he could be seen talking to himself while walking along the corridors. Now he is sitting across from the doctor, articulating himself very clearly, claiming to no longer be ‘suffering’ from suicidal thoughts and wishing to be discharged. After all, he is reasoning, he is an adult with human rights, he is being locked away against his will, his freedom being impinged upon, and he has had enough.

As the involuntary commitment is not solely the responsibility of the doctor, a judge and the patient’s lawyer are called. They sit down with the doctor, discuss the case, and come to the conclusion that the patient must stay for a while longer, before either the judge or the lawyer go and see the patient. He is summoned to them, afterwards, on the pretence that the decision is open and that they would like to talk to him regarding further treatment. I am reminded of a show trial in a puppet show: so many individuals, so many ‘professionals’, giving meaning to their own lives by ruling over the lives of others, backed by society’s moral high ground as well as financial endowments: they know, oh yes, collectively they know what is best for the patient. There is simply no room for authenticity in this herd-like thinking.

The legitimisation given by reflected individuals working in the profession for this type of decision making is the experience of patients being grateful, with hindsight at a later date, for being ‘helped’ and treated, thus prevented from harming themselves. This is taken as the mental health normativity which serves thereafter as a point of reference. In this sense, individualism is quickly engulfed by this normative standard and taken for granted as applicable to all. Yet can this really be the case? What about the ‘here and now’ — the wish actually voiced in the present? What about the notion of personal suffering — a widely accepted prerequisite for any mental illness?

In light of severe limitations in our collective understanding of the world, the nature of human mortality and human free will, how can we be so sure? Hence if we cannot be sure, how can we be so arrogant to assume our viewpoint is correct, and thereafter strive for its implementation as a universal law, from which there is no escaping? Nor we do stop here but go further still: we actually force people into confinement; we sedate them, tie them up, lock them away, merely for refusing to adhere to this arbitrary universal law. At this point, for clarity, let me return to the aforementioned notion of danger to self and danger to others: the patient in question was involuntarily committed on the basis of suicidal thoughts, hence danger to himself, and in no shape or form danger to others. This is an important distinction.

In reply to this call for society to endure and tolerate greater diversions from the mental health normativity, including suicide, many react angrily to such ‘absurd’ claims. We cannot, they argue, allow such individuals to run around freely outside, behaving like zoo animals and ruining their lives in the process; we simply must treat them.

Let us return to the patient’s fate. Locked away for another four weeks, he is becoming increasingly aggressive, culminating in an act of violence. The doctors attribute this to a change in his medication, citing other patients as proof for a correlation between certain antipsychotic drugs and aggressive behaviour. Such evidence clearly exists, but what else might have happened? The patient’s aggression surmounted over the past weeks, and has not simply burst out arbitrarily. Looking at it holistically, perhaps it was a reaction to a nurse telling him, in a confrontational discussion and with a hue of professional condescension, that he cannot go home; that his freedom will continue to be restricted. His aggression could therefore be interpreted as a vent of his growing sense of frustration and impotence.

Unsurprisingly in this context, the patient’s act of violence has been reported to the police, with particular emphasis on the premeditated, non-psychotic aspect of the act. This is very interesting: the suicidal thoughts are considered psychotic, hence irrational, hence not borne out of the patient’s competent free will. The violent act, however, is not to be considered psychotic, hence rational, hence is borne out of the patient’s competent free will. Now: is this hypocrisy on the side of the professionals? Or was it an act of lucidity on the side of the patient?

VI
Medically speaking (according to the doctor) the recommendation for the length of involuntary commitment to this ward for this patient is ten days, as the diagnosis is not yet known and it is difficult to foresee what will happen. Clearly, the judge is not at all pleased with this recommendation: she wants the patient to be locked away for four weeks, otherwise we will all be in the same situation again ten days from now. So: in light of these circumstances, what is your medical recommendation? Yes, well, erm, medically speaking, the recommendation for the length of involuntary commitment to this ward for this patient is four weeks.

Again it is the same story, the same show trial. This meeting takes place without the patient, the decision negotiated, objections voiced, and then the patient is summoned. To conclude the proceedings, the judge claims to have to carefully consider the treating doctors’ expertise, and as they are recommending four weeks involuntary commitment she feels obliged to agree.

VII
In all fairness, and to paint the whole, objective picture: there are many, many moments of terror. Terrorising the ward: a horribly fitting description for the feeling imposed by some patients at certain times. There is no therapeutic concept. There is never enough time. These things can be all too easily criticised, but the question remains: what could the therapeutic concept be?

*

As aforementioned, this account is a critique of the mental health normativity that currently serves as the framework for psychiatric care. To be clear: I do not believe, and have thus not attempted to argue, that the restriction of individual freedom is always, and per se, unjust. I have seen, and trust both the empirical and personal experience of certain clinicians who support these measures, that for some patients this is the most humane of several bad options available under difficult circumstances, and thus given time, they will be extremely thankful for the imposition into their lives. However, as I have tried to argue, this cannot simply be applied indiscriminately. Consequentially, it must be a professional and societal responsibility to ensure that autonomy and authenticity are not stifled by the herd, instead finding a way for both to coexist in harmony.

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