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Behavioural Therapy from Hell by Adam James

Debbie Holden was 16 when she first started to slip into the lonely, nightmare world of anorexia. She won a competition with school friends over who could lose the most weight. And it was from this ominous beginning that the eight stone teenager became trapped in a cycle of binging, vomiting and laxative abuse. Over the months and years her weight dropped steadily. So that by the time she was 20 Holden weighed just five-and-a-half stone, and doctors feared she was so frail she would die. So they sectioned her and admitted her to North Manchester General Hospital. This should have marked a turning point in Holden’s life, when the staff of Ward G3 would support Holden in overcoming her eating disorder. Instead Holden describes it as when “her period of hell” began. She was heavily sedated, fitted with a nasal drip and confined to one room. Psychiatrists then initiated a ‘behavioural therapy’ programme, based on the principle that if anorexic patients are ‘rewarded’ after gaining weight they would be more willing to eat voluntarily. Holden remembers with horror: “Fifteen nurses entered my room. Without speaking to me they removed every possession I had, including Get Well cards, clothes, and cigarettes. “They just marched off with everything. My doctor then came in and asked me what I wanted. I said I wanted to be out of the room and with my mum.” Allowed just a nightie to wear Holden was told that as her weight increased she would be granted ‘privileges’, including use of a telephone and television, clothes, baths, make-up, visitors and access to the ward’s toilet. She was prohibited from leaving the room she came to call her “glass cage”, and was denied reading or writing materials until weight was gained. “I remember one day screaming and begging my dad who came to visit not to leave me,” recalls Holden who objected to being force fed and saw the treatment as a ruthless system of deprivation and punishment. “I kept pulling out the drip because sedatives were being put through it into my stomach. Yards and yards of the plastic tubing used to come out. I was so heavily medicated I could open my mouth but could not speak. I was a vegetable.” While doctors assured confused Holden the treatment was for her own good, they warned that if she continued to rip out the drip another would be inserted into a vein in her neck. Holden saw this treatment which went on for five weeks as psychological torture. And as the liquid food dripped into Holden’s stomach her weight ballooned by three stone. “I felt I was raped because the whole shape of my body was changed so crudely without my permission,” says Holden. Holden was treated in 1983. But force-feeding and isolating anorexics while employing behavioural techniques is still practised today. “It is often the under resourced busy hospitals which tend to use this stricter form of behavioural therapy,” says Dr Jill Welbourn, who headed a Bristol eating disorder team for 25 years. “It may be used in the kind of hospital where there are perhaps just three nurses for 26 patients. Although strict behavioural therapy is less popular now it can depend on the luck of the draw as to where you live. There are whole areas in the country which are total deserts in term of more contemporary less confrontational approaches to anorexia.” Holden believes the humiliation she suffered damaged her so much it compounded her anorexia and distress. Even now she fears confined spaces. “I was put in that hospital room not for five weeks but for 10 years. I think it was unnecessarily cruel,” asserts Holden from her terraced home in Middleton, Manchester. “You can not expect anyone to go through something like that and for it to have no effect. If it was about saving my life then surely I should feel happy about it.” It was only in 1993 after becoming pregnant that Holden found the inner resolve to beat her eating problems. Against medical advice she came off all her medication as she believed it would damage the baby she was carrying. “I knew that I had to get well for my daughter. I had a responsibility towards another life and could not afford to be ill. Whereas previously I would vomit after eating, I learnt to force myself to swallow the food which I had vomited up in to my mouth.” By 1995, after Holden had returned to a healthy weight of nine stone, she sought legal redress for her “glass cage torment”. Holden was encouraged when granted legal aid to pursue a case of medical negligence against North Manchester Health Authority. As part of the preliminaries, Holden’s medical notes were sent to the distinguished Dr Arthur Crisp, author of Anorexia Nervosa – Let me be. He supported Holden’s version of events, writing that her therapy “contained an unacceptable punitive element which may have led to specific abuse on some occasions… Ms Holden’s treatment is more likely than not to have caused her damage.” In addition a psychotherapist concluded the humiliation Holden experienced in the hands of the hospital should be understood “as though it were a Post-Traumatic Stress Disorder.” But despite such condemnations, Holden learnt earlier this year that she would probably lose a medical negligence claim. Her legal counsel concluded the authority would be able to demonstrate “with some ease” that other doctors would endorse Holden’s treatment. It also believed the authority would be able to trace doctors who at the time followed similar regimes on anorexia patients. In effect this judgement put into doubt whether anorexic patients have legal come back against experiencing trauma as a result of compulsory treatment. Terry Simpson, of mental health user group The UK Advocacy Network says: “I think this represents a sad indictment of the mental health service. Research into anorexia has never looked at how compulsory treatment effects patients. “Compulsory treatment often leads to further problems. It can be very humiliating and stigmatising for a patient and can take many years to work out how such treatment has damaged you.” While Dr Welbourn agrees that many anorexia patients feel aggrieved after compulsory treatment, she believes desperate measures are necessary to save lives. She says she has known more anorexia patients starve to death than to complain afterwards. “Compare it with someone who suffers a cardiac arrest,” she argues. “A doctor might shove their hand into a person’s chest and squeeze the heart to get it going because the patient is about to die. Now that could be an assault.” “Sectioning does save lives and some of my patients have been grateful for being saved. But for others compulsory treatment has become their recurring nightmare. One does not know at the beginning how it is going to go.” Dr Ross Connan of the eating disorder unit at The Bethlem Royal and Maudsley Hospital believes most professionals recognise the distress caused by compulsory feeding. She says the pros and cons of such practice have to be weighed up before going ahead with it. “You can spend the whole day arguing with a patient on what they should eat. But there comes a point when a patient needs to be fed.” she concedes. “And often feeding works best when external control is enforced. Many severely ill patients find making the choice to feed themselves very frightening.” Finally she acknowledges gloomily: “Patients have and will continue to feel they have barbaric experiences. “No body likes to be treated against their will, and inevitably it will leave people feeling trapped and helpless.” Meanwhile Holden, now 37 and with no outward sign of her anorexia years, believes her turbulent family relationships lay at the root of her eating problems and that doctors failed to talk these issues through with her. “Is there really a doctor out there who would stand up in court and support the hideous treatment I went through. Doctors without a proper understanding of anorexia should learn that they can make it worst.” A North Manchester General Hospital psychiatrist who knew Holden’s case chose not to comment.

 


Trains, Voices, Possible Narcoplexy Onset, I the Not Necessarily Divine, A New Theory Buds? By Matilda Melbert

There we were on a train, my son and I. Second row in, on the left. I was in the window seat. Behind my son, a man. In front of me, a lady in a pink coat, with pink nail varnish, on a pink mobile. Opposite us sat a man by the window. Behind him, on the first row, by the window, another man. I was aware of two ladies further up on our side and one lady further up at the end of the carriage, on the right. Well I do have SAS blood in me, ipso factso! Ridiculous, but a safety habit. Oh Bruce, where is the conveyor belt!

We needed the fifth stop. At the second, my son asked me, “Is this our stop?” I replied, “No.” Then a female voice boomed out in the carriage, “Where are you going to?”

I looked at my son to see if he’d heard it too. But he sat there, motionless, expressionless, staring ahead. I was comfortably devastated as I felt the prickles and sweat of anxiety begin. I thought, “Why now, and how will this pan out?”

Suddenly my son said in a really booming voice, “Walsall!”

I turned to him and said, “No, we are not. We are going to Perry Barr.”

He looked at me and I just knew, by his face, his concern about the voice. His expression reflected my feelings of curious and amazed concern as to what would happen next. I started to giggle. I asked if he’d heard it too. He nodded, staring me out with bulging eyes. I whispered, “Who do you think it was?” He shrugged his shoulders. Then the female voice again boomed out throughout the carriage: “We are not there yet!”

Michael widened his eyes at me. I thought, “My god, our first group session type thing, or what!!!!”

I started to laugh and couldn’t stop. I became hysterical. Michael kept widening his eyes at me and told me to shush. I asked, “Where did it come from?”

He shook his head and, indicating further up the carriage, said, “I think up there.” I asked, “Was it the pink lady in front?” He shushed me again saying, “No.”

I was crying with laughter. I’d lost it. He told me they would think I was rude. “Who,” I asked, “who??!!” He shrugged his shoulders and laughed too, but with control.

We arrived at our stop. I was bent double and staggering. Michael was cool but laughing in a normal manner. People were staring at me. I felt drunk, and was mortifyingly aware that I looked it.

Michael said, “I think it was the lady opposite.” I said, “No, a man sat opposite.” He said, “No, a lady, mom. Do you think she fancied me and it was her who spoke?” Well, I screamed with laughter all the more. Poor Michael. “It was a man.” We debated rights, lefts, opposites etc. Apart from the odd outburst, I regained control.

Then we were sitting in a warm lecture theatre at a university whilst a lively, deeply committed lecturer bored us both stupid. I began to feel afraid. I felt I was going to sleep and had no control. I lent forward and put my fingers over my eyelids so as to hold them up. It didn’t work. My head was swimming. Michael said, “You’ve gone, Mom.” I needed to giggle but hadn’t the energy.

Well, he hadn’t even applied for the course, and it was a year too early. But it was all an experience. On the tour we were split into parents and prospective students. I couldn’t contain myself. Everything was so exciting to the guide but was truly excruciatingly dull to me. I kept snorting and giggling. I couldn’t stop it. I felt so rude, and kept apologising. Then I saw Michael and called out with a wave. He seemed to ignore me. It seemed he never even saw me.

On the train going home Michael sat opposite me laughing and talking to the window (to his reflection, maybe). Next to me sat a smart, abnormally immaculate man straight out of the 1970s, bouffant and all. At eye level, and at arm’s length in front of him, he held a book. It was entitled ‘How To Deal With Difficult People’. Well, that started me off again. I was snorting to myself.

Then I sneezed, and a voice boomed from behind me way, way back: “Bless you!” Now did someone say that or was it a sprite of a voice? Because if I was on a packed train and a little old lady sneezed next to me, and although I’m not ordained, I may say quietly, “Bless you, dear.” But I would not respond to a sneeze by someone half way up the blooming carriage. Who knows the answer? NOT ME!!!!!!!

I watched a television programme about children in the Gaza strip. How their lives have been obliterated, their innocence destroyed, their hatred fired and their hopes shot by adults! I cried tears of anger and sadness. Then it came to me again that I should correct this evil by taking my life. This thought had such a powerful impact. So I clenched my fists and said: “Think about it, Ange. You are NOT DIVINE. And it never worked for Jesus, anyway, who claimed he was.”

But then I thought: “What is divine anyway? Maybe I am divine. Maybe this is how it is, yet I don’t feel superior or invincible.” Then I thought: “Martyrdom hasn’t solved anything and I’d only destroy the lives of my own children, even if it was a beautiful peaceful world afterwards.”

So here I am.

Strangely enough, the other morning, at 6 a.m., I heard a young girl call out “Hello!” in a desperate way. And guess what – so did my daughter. The voice came from downstairs. My daughter called out to me, “Who the hell was that, Mom?”

Now we both hear voices. But this sharing malarkey gets you thinking, doesn’t it?


This is a sample article from Asylum 19.1.  To access the latest issue in full,  SUBSCRIBE HERE.


Challenging Psychiatric Coercion by Bob Sapey

During the 1980s I was an Approved Social Worker, and I cannot quite understand how so much power was invested in me. I now understand how little I knew and how little I needed to know in order to satisfy the authorities that appointed me.

Over the years since I have heard and read several firsthand accounts of the experience of ‘being sectioned’ and these have reinforced my concerns about coercion. But it was listening to Jacqui Dillon and Peter Bullimore a few years ago that convinced me that it was not only wrong to invest the authority to detain in social workers, but that it was also wrong to invest it in psychiatry.

Jacqui’s and Peter’s explanations of their experiences, along with so many stories from others in the Hearing Voices Network, simply made much more sense than the ideas constructed by pharmacological psychiatry. So in this article I want to question the professional legitimacy of social workers being involved in the detention and compulsory treatment of people struggling to recover from trauma.

I don’t want to question this legitimacy from a strictly anti-psychiatry position. As Bentall puts it, the challenge to psychiatry today is utilitarian compared to Szasz’s1 arguments fifty years ago. It is not simply about not doing wrong, but of being in a position to offer alternative social and psychological forms of help.

Bentall2 summarises four powerful arguments against coercion:

• Psychiatry has failed to show an adequate understanding of mental disorder, enough to justify its prescribed treatments.

• Pharmaceutical treatments prescribed for psychosis are not only generally ineffective but they have harmful side-effects.

• Coercion can harm a person’s psychological capacity to recover and is therefore, in relation to mental health, intrinsically wrong.

• Compulsion is unhelpful in establishing a therapeutic relationship that could be helpful in recovery.

However, while the arguments against coercion may be growing, so too is its use. In England in 2009/10 there was a 30% increase in the number of people being compulsorily detained in hospital.3 This was almost 10,000 additional people. This is accounted for mostly by psychiatrists and Approved Mental Health Professionals filling beds that had become vacant due to the introduction of Community Treatment Orders.4

In England, the 1983 Mental Health Act allows psychiatrists and Approved Mental Health Professionals to detain people and to treat them without their consent if they are ‘suffering from a mental disorder’ and if detention and treatment are considered to be in the interests of their health or safety, or so as to protect someone else. Yet, at the same time, Article 5 of the European Convention on Human Rights requires states to respect people’s ‘liberty and security’. However, the Convention does make certain exceptions to the right of liberty, including wherever a person is deemed to be ‘of unsound mind ’.

In its ruling in the case of Winterwerp v The Netherlands, the European Court of Human Rights said that:

The Convention does not state what is to be understood by the words “persons of unsound mind”. This term is not one that can be given a definitive interpretation … it is a term whose meaning is continually evolving as research in psychiatry progresses, an increasing flexibility in treatment is developing and society’s attitude to mental illness changes …5

Whilst psychiatry is empowered to assess people and to detain and treat them if they are ‘of unsound mind ’, what is meant by ‘unsound mind ’ is open to argument and challenge.

Szmukler6 has suggested that the UN Convention on the Rights of Persons with Disabilities challenges detention on the basis of a person having a mental disorder. The argument is that the Mental Health Act is discriminatory since it is aimed at reducing dangerousness, yet it only targets people experiencing mental distress – and in fact this excludes most dangerous people.

Two articles of the UN Convention are particularly important. First, Article 12 says that ‘persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life’. The World Network of Users and Survivors of Psychiatry suggests that Article 12 creates a paradigm-change in the attitude towards mental distress. They argue that it means that all people have the right to decide ‘whether to accept medical treatment or go into a hospital’, and that ‘mental health commitment laws violate this Article’.7 However, Article 12 allows states to place limits on a person’s legal capacity in accordance with Human Rights legislation. In English law this means that the ‘unsound mind’ exceptions of the European Convention on Human Rights take precedence (but of course ‘unsound mind’ is not defined or static).

Similarly, Article 14 of the UN Convention states that countries should ensure ‘that the existence of a disability shall in no case justify a deprivation of liberty’. Szmukler suggests that this appears to challenge the legitimacy of the inclusion of mental disorder as a ground for detention by the 1983 Mental Health Act. However Article 14 does recognise that detention may be lawful if it is in compliance with Human Rights CHALLENGING PSYCHIATRIC COERCION legislation. Hence, the legitimacy of detaining someone of unsound mind is still preserved.

Yet what seems to remain is the possibility of challenging the way in which ‘unsound mind’ is understood and used in psychiatric practice.

One group of people who are regularly detained and treated are those who ‘hear voices’. While bio-medical psychiatry maintains that this experience is a symptom of a disease that should be eradicated, other explanations for this experience are sufficiently developed to challenge the continuing legitimacy and competence of psychiatric diagnoses of schizophrenia, especially when they are also used to legally define someone as ‘of unsound mind’.

One way of approaching this might be through the Mental Health Act ‘Code of Practice’. This makes provision for consulting with other professionals with a particular expertise when assessing, say, a young person or a person with learning difficulties. This is the recognition that most psychiatrists will not have the relevant expertise. Those involved in the process of ‘sectioning’, particularly the Approved Mental Health Professionals, could seek to apply the same provision to people who ‘hear voices’, since conventional pharmacological psychiatry has failed to prove itself as possessing the appropriate expertise to work with ‘voices’. Instead, they might only be able to claim to work with ‘schizophrenia’. While there are some mental health practitioners with expertise in working with ‘voices’, there are also many experts-by-experience within the Hearing Voices Network who could, and should, be consulted.

Another approach which might be taken would be to challenge coercive treatment through another UN Convention, the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. In 2008, Manfred Nowak, the special rapporteur to the UN Human Rights Committee, reported to the General Assembly of the UN on his Review of the Torture Framework in Relation to Persons With Disabilities. 8 In this he wrote:

 Inside institutions, as well as in the context of forced outpatient treatment, psychiatric medication, including neuroleptics and other mind-altering drugs, may be administered to persons with mental disabilities without their free and informed consent or against their will, under coercion, or as a form of punishment. The administration in detention and psychiatric institutions of drugs, including neuroleptics that cause trembling, shivering and contractions and make the subject apathetic and dull his or her intelligence, has been recognized as a form of torture.

If treating people with neuroleptics without their informed consent is torture, then it is contrary to Article 3 of the European Convention on Human Rights – and also to Section 134 of the UK’s 1988 Criminal Justice Act.

Manfred Nowak was quoting from an earlier report to the Commission on Human Rights (February 1986), handed down from a previous special rapporteur.9 This means that for more than a quarter of a century the UN has considered the use of neuroleptics without informed consent as a form of torture.

I believe that it is by now evident that psychiatrists and other mental health professionals ought to practise without coercion. This would make mental health interventions more effective in helping people and it would not compound the trauma that distressed people may have experienced. Psychiatrists and Approved Mental Health Professionals must be challenged to change the way they interpret the phrase: ‘being of unsound mind’.

The UN Convention on the Rights of Persons with Disabilities, decisions of the European Court of Human Rights, and of the UN, all recognise that compulsory treatment with mind-altering and physically destructive drugs is a form of torture. These decisions can and should be used to combat psychiatric coercion, so as to defend and extend the human rights of people experiencing psychosis.

Bob Sapey is a lecturer at Lancaster University.

Endnotes

1. Szasz, T. (1962) The Myth of Mental Illness, London, Secker & Warburg.

2. Bentall, R. (2009) Doctoring the Mind. Why Psychiatric Treatment Fails, London, Allen Lane.

3. NHS Information Centre (2011) Mental Health Bulletin. Fourth report from Mental Health Minimum Dataset (MHMDS) annual returns, 2010, London, NHS Information Centre. Page 20.

4. NHS Information Centre (2010) In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual Figures, England 2009/10, London, NHS Information Centre. Page 7.

5. Winterwerp v Netherlands 6301/73 (1979) ECHR 4, Paragraph 37

6. Szmukler, G. (2010) How mental health legislation discriminates unfairly against people with mental illness, Gresham College lecture, 15th Nov. 2010, [www.gresham.ac.uk].

7. World Network of Users and Survivors of Psychiatry (February 2008) Implementation Manual for the United Nations Convention on the Rights of Persons with Disabilities [www.wnusp.net]

8. Nowak, M. (2008) Interim report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, New York, United Nations.

9. E-CN_4-1986-15 pdf United Nations office of the High Commissioner for Human Rights.


This is a sample article from Asylum 19.1.  To access the latest issue in full,  SUBSCRIBE HERE.


No More Psychiatric Labels by Sami Timimi

The new Diagnostic & Statistical Manual (DSM5) is soon due to be published. DSM is the modern ‘bible’ for diagnosis in psychiatry. Yet there is little or no evidence to support the idea that the categories used in DSM are either based on sound science or clinically helpful. So I decided earlier this year that it was time to start a campaign. Read more


One Step Beyond: Alternatives Beyond Psychiatry – Book Review

One Step Beyond: Alternatives beyond Psychiatry
Edited by Peter Stastny and Peter Lehmann
Book Review by Helen Spandler

Alternatives Beyond Psychiatry is grounded in many years of work and activism within and against the mental health system. This provides its validity. Its achievement is in bringing together the shared wisdom and experience of service users, survivors and activists. The book arose out of a co-operation between Peter Lehmann, publisher in Berlin and survivor activist within the international user/survivor movement, and Peter Stastny, Associate Professor of Psychiatry at the Albert Einstein College of Medicine in New York and founding member of the International Network Toward Alternatives and Recovery (INTAR). Both have a long-standing track record of developing alternative services that negate the need for psychiatric intervention and offer autonomous paths towards recovery and self- determination.

As its title suggests, the book does indeed take us beyond a number of limited ideas and practices in mental health. First, it demonstrates how far the survivor movement and radical mental health initiatives have moved beyond ‘anti-psychiatry’. Although the various authors in this book do not completely disregard the insights of the anti-psychiatrists (and some of the authors make due reference to the work of R.D Laing et al.) their work is only informed by these critiques, i.e. they are not framed by them.

The alternatives presented not only move us beyond the potential nihilism of ‘anti-psychiatry’ and various academic critiques of psychiatry. They also take us further than the reformist strategies of the Italian Democratic Psychiatry movement, social psychiatry or community extensions of psychiatric institutions (what Robert Castel has referred to as ‘merely a form of psychiatric expansionism’). Indeed, the authors are careful not to impose any new replacement psychiatric or psychological ‘models’ or ‘techniques’. Rather, Alternatives Beyond Psychiatry prioritises new ways of living with madness and diversity, without recourse to diagnosis, psychiatrisation or undue reliance on medication.

On this count, this book could be construed as ‘anti-medication’. But that would miss the point. The mental health system in the West is heavily reliant on medication as a basis for mental health care. The authors make a compelling case that this isn’t always necessary and that there are viable alternatives. It would be more apt to say that the book is anti-coercion and pro-voluntarism and informed choice.

Alternatives Beyond Psychiatry functions as a powerful indictment of the failings of the mental health system and a rallying cry for more humane and authentic support services. It is driven by anger at a psychiatric system that is seen to invalidate people’s experiences and actually prevent recovery. But, rather than dwelling on negativity, it uses this anger to inspire and develop new forms of support infused with hope. We read of the experiences of Dorothea Buck-Zerchin (a 90 year old woman with seventy years experience of coercion in the mental health system), Kate Millet’s passionate re-instatement of the ‘myth of mental illness’, survivors’ personal accounts of how they survived, about examples of concrete working alternatives (e.g. Soteria House, the Windhorse Project, Hotel Magnus Stenbock, and the Berlin Runaway House) and various practical support tools. From around the world, it offers examples of innovative and creative ways of supporting people through mental health crises, but outside the conventional mental health system.

Yet, this book also goes well beyond ‘self help’ by offering examples of legal, community and political action to secure rights and demand alternatives (e.g. the ‘Evolving Minds’ group in the UK, PsychRights in Alaska, and the international Icarus Project). It also takes us beyond mainstream liberal ideas about ‘recovery’ and ‘social inclusion’ by rooting its ideas in the actual practices of mental health activists, users/survivors and their allies. This means that the chapters do not assume our goals should necessarily be ‘inclusion’ in mainstream society and ‘recovery’ regardless of mental illness (which at its worst translates as: ‘Keep taking your medication, get off benefits and get back to work’).

Lastly, Alternatives Beyond Psychiatry moves beyond tired academic or professionalised debates concerning the latest competing models or theories ‘about mental health’. Packed as it is with stories, information and ideas, it provides an indispensable resource for anyone concerned with improving mental health care and creating a better society.

Alternatives Beyond Psychiatry edited by Peter Stastny and Peter Lehman
Peter Lehmann Publishing, Berlin / Eugene / Shrewsbury 2007 ISBN 978-0-9788399-1-8 (GB), 978-0-9545428-1-8 (US), RRP £ 18.99

For more information: www.peter-lehmann-publishing.com