Dave's Progress. Chapter 32: Power, Control and the Defacto Detention.

The other day at MAGMH we were discussing self or internalised stigma. This is what happens when one's past experience of stigma or, indeed, anticipation of the future experience of it, actually stops those who have experienced mental ill health from doing things which would have been a normal part of their lives, e.g. applying for jobs or attempting to forge new relationships. According to Graham Thornicroft's book, "Shunned", this is a very common trait amongst those with mental ill health and , indeed, one which is not helped by the mental health system itself.
Professor Thornicroft points out that some of the things which would make service users feel better is having some form of control in managing their illnesses, being treated with respect, and finally, not feeling powerless in the face of the seemingly all-knowing psychiatrist. Unfortunately, his book suggests that in all of these areas the system is sadly lacking, with many service users reporting experience of verbal abuse, physical abuse, patronizing attitudes and direct discrimination. Once such negative attitudes are established they seem hard to stop, which leads to self-stigma. Indeed, even as treatment appears to improve symptoms and functioning, the memory of stigma remains and continues to complicate and undermine the lives of service users.
What most disturbs me, though, is the imbalance of power between service user and psychiatrist, and the consequent loss of control one feels as a patient. As it states in "Shunned", "so long as users can be subjected to involuntary interventions in supposedly voluntary services, the power differential is a real and overwhelming obstacle to any real equality in decision making". By "involuntary interventions" the book means the process of sectioning, whereby one can be involuntarily taken into hospital. Indeed, one study showed that although many enter hospital on a voluntary basis, they are aware that they cannot come and go as they please and indeed there is often an implied or explicit threat that if they try to take their discharge against medical advice they will be legally detained. Professor Thornicroft suggests that this blend of care, concern and threat is, at worst, "a dishonest amalgam of both help and control". And it is here, I believe, that my own experience of being detained comes to the fore.
It was, if I remember correctly, in the February of 2004 that I was legally sectioned for the first time. However, when I got into hospital the section was dropped and I was led to believe I was now a voluntary patient. But, in a meeting with my psychiatrist and nursing staff, he then said that if I attempted to leave I would be involuntarily detained once again. Such meetings are intimidating at the best of times, and as the nurses and my psychiatrist all sat in a large circle around me, you could say I felt quite overwhelmed. Mental Health Law was all new to me, but I knew that something was wrong here. So I thought to myself, "am I getting this right? I am here voluntarily. But if I want to go, I can't because I'll be sectioned?". "That's exactly right", came the response. So, what had been, I thought, an informal meeting had turned into a scene from "Catch-22". In that novel, bureaucracy begins to assume such an absurd logic that it becomes inhumane. And, indeed, in a later conversation with a solicitor, she remarked that I had been put under what is known as a defacto detention, whereby officially I was in hospital voluntarily, but ultimately could not leave because I would be sectioned if I attempted to, so was, in fact, an involuntary patient. "It's some catch, that catch-22", as the character Yossarian says. I also found out that defacto detentions are an illegal practice, and so as I angrily marched down the hospital corridor, I saw one of the nurses who had been there in the meeting.
"Erm, you do realise that what's just happened is illegal, don't you? You can't put me under a defacto detention. You do know that, don't you?"
"Yes", she replied, laughed seemingly uncontrollably and walked off.
Needless to say I was somewhat in a state of shock. The law had been broken, and yet no one seemed to give a damn. But, even more fun was yet to be had.
With the legal advice I had, I decided that I did, indeed, want to leave the hospital. I felt that with what I knew I now could not be stopped. However, my psychiatrist had one more trick up his sleeve. I told him that I knew he could not keep me in hospital. He told me that if I did leave, as I had expressed my wish to do, he would no longer treat me and would not supply me with any medication after I left. I got on the phone to my solicitor again and she now said that he really was beginning to be, to use her words, "a little bit naughty". In fact, she said, this was coming close to an "abuse of my human rights" and the case would have to be taken to tribunal. Knowing this, I left the hospital, fully expecting my point to be heard at a later date and to be referred to another psychiatrist. In the event there was no tribunal. In the event I did not see another psychiatrist for another eight months. In the event I was left without any medication for what must have been eighteen months. So, what happened? Well, I just descended, more and more, into a delusional, hallucinatory insanity. I got ever more paranoid and drank relentlessly and probably came close to killing myself. What happened to the psychiatrist? Was he reprimanded? Was he rebuked? Was he punished for his actions in any way, as he had seemingly punished me for, what seems to have been, simply not doing what I was told? The answer is, ladies and gentlemen of the jury, a big, depressing, no. I went on to nearly destroy myself while the one most responsible for it got off scott free.
Which brings me to a somewhat diversionary point. Are there ever, really, any happy endings in real life? It would seem to me that sometimes the good guy loses, the bad guy is rarely punished, and evil, if that's what you want to call it, goes on in all its banal glory, terrifyingly unnoticed.
But let's not go too far here. What my psychiatrist did was certainly an abuse of power, and we all know that "power corrupts", so perhaps it is time that the mental health system sought to redress this balance, and indeed, I believe now it is making some headway in further involving service users in the decision making process. However, this would only seem to happen in periods of good health. It is precisely at the opposite time, when you are too ill or debilitated to stick up for yourself that the seemingly inherent imbalances of power within the system need to be addressed.
Indeed, my own ill-treatment seemed to continue after I had discharged myself from hospital. When I did eventually see another psychiatrist she told me that, despite what I now know was a harrowing psychotic episode, there was "nothing wrong" with me. That if I decided to commit suicide it would be entirely my choice, as there was "nothing wrong" with me. As I was not getting the treatment I so desperately required I continually rang my residential unit for help, only to get a phone call back (also when I was in bed at around eleven o'clock at night) from the police telling me that if I phoned the residential unit again I would be liable to five years in prison for "harassment". Ironically, whereas before I had wanted to leave hospital, it was now the case that I couldn't get in. So, I ended up in private care, where I have to say there was a massive difference in attitudes and standards of care. It took only two weeks to get a diagnosis and to be put on some form of medication to halt my ever burgeoning psychosis.
The closest I ever got to any form of resolution of the issues I had faced came in the form of my psychiatrist admitting that what happened had been "bad practice" and "hadn't always been my fault". Wow, thanks for that. But in the end I had to accept it. So when I talked about anger in a recent blog, you can see why I was once an "angry young man". But as I described there, that anger has now dissipated and even at my residential unit I think I am, almost without exception, liked and respected. If only that could have happened when I was ill and the imbalances in power were not so harshly evident. It could have made all the difference, and until such matters are addressed, it would seem that the effects of such treatment, like self-stigma, will continue to be a problem.
That's all for now from your normal, average paranoid and delusional man.