Sunday, 14 October 2012

The Power of Notes in Psychiatric Settings

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.

The 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.

The 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 the notes.

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%.".

I 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 pen.

[posted on Mad in America 13 October 2012]


  1. Another really good blog that brings real meaning to the improvement work we are involved in together. Thank you.