To Robin – who helped me survive the terror
Christmas is a particularly difficult time for me… It was during and after Christmas 2008 that my severe depression and suicidality reached a critical point…so that I was sectioned soon after, i.e. on 28th January 2009, for 3 months (until the end of April 2009)…Christmas has therefore come to represent an anniversary of deep trauma and loss for me…on the other hand, I am immensely grateful for the fact that on 25th December 2012, 4 years down the line, I am well and able to enjoy my freedom and intellectual creativity away from conditions of deprivation of liberty…
The Other Side by Alfred Kubin (www. monsterbrains.blogspot.co.uk/2011/04/alfred-kubin.html)
Back in 2009 I was compulsorily detained under the Mental Health Act 1983/2007 in an acute psychiatric ward in North Manchester NHS Hospital. I absconded twice within a week in my first month there – fairly soon after my admission – even though I was allegedly on close 1:1 observation, especially at night. This was because I was acutely suicidal when I was first admitted and that was the reason for my sectioning.
Do you remember that terrible morning, Robin, the morning of 28th January back in 2009? We were at my home kitchen and I was saying that I wanted to get a knife and kill myself…and you and my mum were struggling to prevent me from reaching the kitchen drawers with the knives…and you called for an ambulance and the paramedics and eight policemen came…and I was taken to an Assessment Unit in one of the hospitals in central Manchester where I was eventually sectioned before I was transferred to North Manchester Hospital the day after…and for some time on 28th January I fought fiercely with the nurses who were restraining me in an attempt to prevent me from leaving the Assessment Unit…do you remember how desperately I fought? Do you remember that I was just wearing my pyjamas and a grey coat on top? I had not been allowed to even get dressed before I was taken to the Assessment Unit in the ambulance…do you remember?
Thinking back on the experience of 1:1 observation at night whilst detained on the acute ward, I remember a quite imposing big woman sitting outside my single room for the entire night. She was constantly flicking through a magazine and her job was merely to prevent me from leaving my room; she would not engage with me in any other way. I guess I experienced the woman as a prison officer or a security guard. I did not experience any care or concern whatsoever for me and my distress in her act of watching me. Nobody introduced the woman to me or explained her role. Being watched by a complete stranger at such a close proximity to my (bed)room (supposedly a private space) for the entire night felt quite exposing, threatening, intrusive and oppressive. This was bound to exacerbate my already heightened vulnerability and acute lack of internal security that my suicidality had left me with.
Oppression by Alfred Kubin (www. monsterbrains.blogspot.co.uk/2011/04/alfred-kubin.html)
Reflecting on my experience of being observed on the acute ward, I can relate to the idea of observation as ‘a custodial ritual’ rather than meaningful and ‘purposeful engagement’. I was encountering a formal observation system established as a measure to enhance ‘physical/environmental (i.e. external) security’ on the ward, which– paradoxically – operated at the expense of my internal security. I imagine the woman observing me must have been an unqualified nursing assistant at best, or somebody ‘off the street’ at worst-in either case badly paid to do night shifts in the mad house.
Very early on during my detention I sensed the complete lack of therapeutic care on the ward. Ward staff rarely (if at all) engaged meaningfully and therapeutically with the patients; staff’s interactions with the patients occurred mainly during the administration of medication and the odd bingo night! I remember staff mainly sitting in the nurses’ office and talking, eating and drinking coffee or looking at a computer when they were not administering medication.
From my case records it appears that I was very agitated, acutely distressed and constantly knocking on the nurses’ office door to tell staff that I wanted to go home or that I wanted to go to the vending machine outside the ward. Staff apparently perceived me as ‘intrusive’- it seemed that my acute agitation and distress was construed as a kind of childlike ‘intrusion’, an irritation, by those very people supposedly responsible for alleviating and containing my distress. As a result, I was sent to my room (to have ‘a time out’) or, in a few instances, I was physically restrained. I now wonder whether the absence of staff’s meaningful engagement with the patients was – partly at least – due to staff’s own inability to tolerate acute mental distress and their ensuing need to defensively detach themselves from it.
Nobody had explained to me what ‘sectioning’ meant and how long my sections were likely to last. I just figured out by trial and error that I could not even go to the hospital grounds without permission. I felt disorientated, powerless, unsafe and terrified to the extent that I became incontinent. It was that kind of environment that I was desperate to abscond from.
I never accepted the hospital, Robin, you are right…I actually hated the place with a vengeance…but there was nothing there to accept, my friend…
Terror by Alfred Kubin (www. monsterbrains.blogspot.co.uk/2011/04/alfred-kubin.html)
And I still managed to abscond from the acute ward even though I was on close observation, heavily medicated to the extent of ‘zombification’, very distressed and so disorientated that I did not really know where the hospital was in relation to familiar areas of Manchester. The hospital was in north Manchester and I lived in south Manchester at the time – almost 2 hours from the hospital on public transport. The first time I absconded (which I don’t remember) I apparently managed to get the bus from the hospital and go to Manchester Piccadilly station and then go home! The second time it was night time and I remember it; I got into a taxi, paid £10 and went home quite late. Once the hospital staff realised I was missing and phoned my home asking after my whereabouts, a police car was sent to take me back to hospital. It still both saddens and infuriates me when I picture myself taken back to hospital in the middle of the night in ‘police custody’ like a criminal.
Robin, do you remember the second time I absconded from the hospital? When I got home in the middle of the night, I got hold of a blanket (I still have this blanket), I put it in a plastic bag and I announced to you and my mum that I would rather sleep rough than go back to the hospital…do you remember?
Both times I absconded anything could have happened to me – I could have been run over by a car or I could have killed myself. But nobody on the ward asked me – as far as I can remember – about my suicidality in a meaningful and therapeutic way: why I had wanted to take my life, what exactly I was feeling and thinking. I guess I was just asked whether I wanted to harm myself and a box was ticked. I wouldn’t call this competent and meaningful risk assessment.
In reflecting on all this I have found the distinction between ‘environmental/physical security’ and ‘relational security’ on psychiatric wards really helpful. Measures currently used to enhance environmental/physical security in mental health wards include constructional features (e.g. fenced garden areas), alarm systems, formal observation systems (e.g CCTV monitoring; scheduled staff observations), swipe card systems for controlled access to wards, or making wards ‘locked’ wards. Using the threat of compulsory detention for voluntary patients if they attempt to leave the hospital or withholding patients’ leave are also measures used to allegedly ‘keep patients safe’.
However, genuine safety and security in mental health wards cannot be achieved merely through interventions targeting the dimension of physical/environmental security. An essential dimension of safety/security in mental health wards concerns relational security which can create a sense of attachment and connection for staff and patients alike. Relational security is thought to be enhanced through high staff-to-patient ratios, increased face-to-face meaningful contact between staff and patients, achieving the right ‘balance between intrusiveness and openness’ and establishing clear relational boundaries on staff’s part, as well as promoting understanding, trust, respect and therapeutic rapport between patients and staff. It is also thought to be improved by staff being appropriately trained and aware of individual patients’ histories and areas of vulnerability and risk, as well as involving patients in planning their own care.
As my story shows, I felt that this kind of relational security was totally absent from the ward I was detained in. This I think explains my profound experience of a lack of genuine safety and security on that ward, as well as my ensuing absconding. Evidently, physical/environmental security provisions cannot substitute for relational security.
The Pursued One by Alfred Kubin (http://www.flickr.com/photos/mutantskeleton/5578562175)
Following a Supreme Court ruling back in February 2012, the NHS now has a positive duty to protect all psychiatric patients (both detained and voluntary) against the risk of suicide under Article 2 of the European Convention on Human Rights which stipulates that ‘Everyone’s right to life shall be protected by law’ (i.e. a duty to protect all patients’ right to life). This is undoubtedly an important development in the arena of human rights legislation. However, unless the ruling in question is combined with a recognition of people’s ‘positive right’ to truly therapeutic environments when in crisis, it may only result in more surveillance and policing in NHS psychiatric wards – particularly in the current socio-political and economic climate in the UK.
As we face increasing funding cuts to UK public services with the ensuing job losses, drastic restructuring of services, as well as uncertain and disheartening employment conditions for staff in the mental health sector, rulings such as the one by the Supreme Court, whilst well-meaning and progressive in principle, may actually result in even more coercion than that already existing within NHS psychiatric services. It is extremely worrying -for example- that according to official figures, the number of people detained under the Mental Health Act in England has currently hit its highest level. Evidently, 48,600 people in England were detained under the Mental Health Act in 2011-12, an increase of 5% from 2010-11. The number of detentions is now at its highest level since monitoring of the Mental Health Act 2007 was introduced in 2007-08. Furthermore, a particular concern is that the number of people discharged from hospital under community treatment orders (CTOs) rose to 4,200 in 2011-12, an increase of 10% on the previous year. CTOs place people on compulsory supervised community treatment with strict conditions.
Note: this is a shortened and modified version of an article which appeared first in Asylum 19:2 (2012)
 McClean, R. J. (2010) ‘Assessing the security needs of patients in medium secure psychiatric care in Northern Ireland’, The Psychiatrist, 34, 432-436
 Kennedy, H. G. (2002) ‘Therapeutic uses of security: mapping forensic mental health services by stratifying risk’, Advances in Psychiatric Treatment, vol. 8, pp. 433-443
 Burns,T. L., Gargan, L., Walker, S. et al. (1998) ‘Not Just Bricks and Mortar : Report of the Royal College of Psychiatrists Working Party on the Size, Staffing, Structure, Siting and Security of New Acute Adult Psychiatric In-Patient Units’, Psychiatric Bulletin, 22:465-466