I want to explore the challenges of telling other people’s stories in the context of psychiatric treatment and mental health services, and the potential difficulties that can arise. And to do this in as dispassionate a manner as possible. I’m thinking primarily of the notes that are written about us when in psychiatric inpatient care. Although it could also apply to any notes written by professionals about us, which are subjective rather than factual or scientific. In psychiatric treatment professionals have the power to diagnose and prescribe treatment, under compulsion if deemed necessary. And mental health acts are in place to ensure that the treatment goes ahead while the safeguards contained within the act are there to protect the rights of people who are under the act.
The compulsory nature of psychiatric treatment and the power of the notes
mean that people prefer not to engage with psychiatry if at all
possible, and would rather discuss their mental health needs with a GP
(general practitioner). Where they can be prescribed anti-depressants or benzodiazepines
for low mood, anxiety, stress and anything other than a psychosis or
nervous breakdown. The latter often requiring admission to a
psychiatric hospital where voluntary can become involuntary, and a fast
track to diagnoses of a disorder. Labels that stick like glue, are
permanent and cannot be removed from medical notes.
I recently had
a conversation with a senior clinical manager in psychiatric services
about a situation that had arisen and which required clarification on my
part. It was an interesting and useful phone conversation, once the
emotion got down to an acceptable level for both of us. The subject of
note-taking in psychiatric wards came up and the manager agreed that
these were not well written by nurses, on the whole. And that many
attempts at training nurses in note-taking had been undertaken but there
were still issues with notes that were more about opinions than
situations, and behaviours rather than factual representations. The
psychiatrists’ notes are usually brief and to the point, with
descriptions of presentations, diagnoses and medication requirements.
psychiatric nurses work to these notes and are compelled to carry out
the instructions to the letter. It’s easier to be clinically detached
if you are not in a close relationship with the person you may have to
medicate under compulsion, or forcibly drug. The psychiatrist who is
scientifically trained has the authority to diagnose and prescribe. And
the diagnosis may be inaccurate or unscientific, because the
psychiatrist doesn’t have all the facts, might not know the patient
well, and has to decide on a course of action quickly so as to avert or
contain further mental distress. For no-one likes to see another person
in distress, if it can be helped.
Therefore when a nurse has to
give compulsory treatment to a patient who is unwilling there is likely
to be all sorts of emotions going on, in both nurse and patient.
Especially when some of us do not want to take the psychiatric drugs and
think this even when in our right minds. It's not necessarily a
matter of anosognosia
(lack of insight) but knowledge of what the drugs can do, their side
effects, how they make you feel, and the difficulties of tapering and
getting off them completely. In my experience, being mentally
distressed didn't make me more conformist or willing to swallow the
pills. It might be different for others who like and feel safe within a
psychiatric setting. Who are happy to have their stories told by
professionals and to abide by the decisions made, and actions taken.
friction arises when there is a difference of opinion between patient
and psychiatrist, a breach or chasm that the nurse has to bridge. And
it takes more than a spoonful of sugar to help the medicine go down.
When mental distress becomes mental illness or mental disorder and a
reason for considering compulsion. A quick fix solution in a busy mixed
gender ward filled with acutely ill patients at various stages of
distress and presenting differently. In the mix there may be
substance misuse issues and criminal (offending) history, victims of
abuse and perpetrators, the depressed and manic, anxious and obsessive.
Each and every patient with notes that have one thing in common - a
list of prescribed psychiatric drugs. And nurses who have the task of
administering them, by pill, potion or injection, and writing it up in
In Scotland there are a number of initiatives ongoing, to bring about cultural change and improvements to patient care. This Case Study demonstrates a collaborative approach taken in a mental health setting - "In Angus Mental Health Services we worked with Releasing Time to Care (RTC) to make the links between Rights, Relationships & Recovery (RRR), Scottish Recovery Indicator (SRI), Patient Safety and Leading Better Care
(LBC).". And feedback from service users "91% of service users asked
state the care we provide is excellent or very good, with 88% feeling
that staff focus on their strengths and hopes when planning towards
their recovery. 85% of service users feel they understand their
medication and its effects. , previously this had only been 51%.".
want to believe that improvement initiatives will not only bring about
positive changes in psychiatric inpatient care but will have an impact
on the writing of notes. So that a person entering the psychiatric
system does not have to fear that their story will become subsumed by a
lifelong label of mental illness, and psychiatric drug prescribing. And
that traumatic life events, common to us all, and displaying as mental
distress, are not automatically pathologised in notes, at the stroke of a
[posted on Mad in America 13 October 2012]