Practice What Your Patient is Thinking

What it feels like to be compulsorily detained for treatment

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3546 (Published 16 August 2017) Cite this as: BMJ 2017;358:j3546
  1. Anonymous
  1. Correspondence: @DrEm_79

Taking a patient’s autonomy is life changing. This account shows the importance of careful handling of the situation both before and after the event

It was a Bic—the biro—that changed my life. I’ve wondered since if the doctor using it knew that many years later his signature that day would still have impact.

I hadn’t seen it coming. I do now; watching for it affects all my interactions in healthcare. But that day, when the doctor arrived in the emergency department, I thought he’d come to discuss my blood tests. Less than 10 minutes later he was sitting at the nurses’ station with the biro, signing the form. And with that, I entered a world of compulsion. The choices I thought I had were gone. First for 72 hours then for 28 days, and then for six months. I didn’t leave the hospital for almost a year.

The hidden harms

Compulsory detention in a psychiatric ward—known as “being sectioned” in the UK—has legal implications that go further than a locked door, and can mean compulsory treatment as well as detention. For me that meant restraint, injected drugs, and forced tube feeding. Ongoing treatment orders sought to control where I lived, how often I attended appointments, and what drugs I had to accept. That the law had a controlling interest in my body weight, whether I had invasive surgery to insert a feeding tube, or my blood levels of a drug, was a profound intrusion. It meant that it wasn’t just my mind that was frightening and unfamiliar when unwell and detained, but my body as well.

One thing that is striking looking back, is how the different clinicians approached what might seem like a standardised process; there are ways to rebuild trust and make the process as dignified and caring as possible.

How to approach compulsory detention

Clinicians who have emerged from a “section” with some trust still intact are those who explained long before a crisis the circumstances under which they’d think that I would need to be detained and the reasons why. It didn’t make it easier at the time, but in retrospect I was able to come to terms with the fact that it had been done from a place of care, concern, and integrity. Sometimes professionals have sought to mislead me—for example, telling me an assessment was for an antibiotic prescription when instead it was for a treatment order application. They said they did this to try to help me—to reduce distress or because they thought being honest with me increased my risk. In reality, as well as losing my autonomy, it meant I didn’t know how much of what else they said was true.

Avoid platitudes about safety. The work of protecting me does not stop with a section. If I cannot leave or cannot refuse a drug, I need you to be extra vigilant for any harm happening to me in that place, whether it be environmental risks or the side effects of drugs. Don’t just assume that I am safe; ask me, and listen to what I tell you.

Too often as soon as papers were signed, the doctor disappeared and I never saw him or her again. Yet that is the point when I was confused, frightened, had my rights taken from me, and felt betrayed. Try to understand the enormity of this, and work to rebuild what the use of compulsory powers can destroy.

I know that your time is limited, pressured, and precious, but taking my autonomy is life changing and I need your time, effort, and humility to counterbalance that power and to fight for the rights I have while detained.

What you need to know

  • Loss of autonomy is a profound and life changing intervention; if you think I need to be detained, be honest about why

  • Not being able to decline treatment can leave a person vulnerable to harm, so you need to be especially vigilant to any risks to me from my environment or medication

  • After detention, part of protecting me is being prepared to work at rebuilding trust so I am not left without healthcare

Education into practice

  • If you have assessed or triggered a routine or emergency assessment of somebody under the Mental Health Act or similar legislation, how did you describe to the patient what was happening to him or her? Are there changes that you might make next time, which might make the process less difficult for patients?

  • • Are there other ways in which you might improve the process of being more dignified and caring as possible?

  • Advanced signposting of the circumstances that might lead to detention may help to maintain the doctor-patient relationship while patients are recovering. For people in your care, are there ways that you might do this better?

  • • For those with reduced autonomy over their care and treatments, are there ways that you can improve monitoring for harms of management?

  • Is there any other way that you reflect on or might alter your practice based on this article?

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following: none.

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