Psychiatry and Mental Health Tribunals: My experience of coercion and of a kangaroo court

The opinions expressed in this article are those of the author and not necessarily of Mental Health Today.

Written by Dr Ben Gray, Former Service User Expert, Rethink Mental Illness

The lived experience perspective

People with mental health problems, like me, can find life daunting, isolating, disturbing, confusing, and even threatening. People can feel excluded and left behind in general life, education, employment and by health and social care research. I have high anxiety in new situations and sometimes panic attacks. I have problems reading people’s non-verbal behaviour and talking with more than one person because I hear voices. The antipsychotic medication I am on can make me feel very tired, lethargic, passive, and even zombie-like. Bullying at school, in particular, made me feel different, stigmatised and socially excluded. I have also heard voices with a hellish and demonic quality, saying: “You’re going down there!!” and “On the bonfire with him!”. Too often, people can withdraw into themselves and be cut off from others and society, living life on the margins and being stigmatised. People can become passive, docile, a shell, almost zombie-like, and feel that they do not matter and are not valued. My experiences, and the experiences of other people with mental health problems, make a very strong case for involving people in all aspects of life, education, employment and in research. This paper describes the lived experience of mental illness, coercive treatment by psychiatry and the problematic case and bias of Mental Health Tribunals. It then makes recommendations for improving mental health services and people’s experiences of them.

Hearing voices and coercive treatment: A personal story.

Certainly, my negative conception of traditional psychiatry and compulsory treatment is coloured by the 12 months that I spent in a psychiatric acute unit. Kept under Section 3 of the Mental Health Act (which allows mental health services to detain people with psychiatric conditions for up to six months), I was both obliged to stay in hospital and forced to take antipsychotic medication against my wishes through physical force was never used against me.

My strange religious beliefs were perhaps quite rightly classified as delusions and discounted by my psychiatrist, nurses, and also my family, but this left me with the impression that my experiences, however negative and painful, were also being discounted and that I was not being listened to in order to be more deeply and humanely understood. The famous line of the psychiatrist Thomas Szasz often came to my mind:

“If you talk to God, you are praying; If God talks to you, you have schizophrenia.”

Among the people, I met during my time in hospital was Rosemary. She was an unassuming, quietly spoken woman, unremarkable apart from an air of sadness. Rosemary had told me and many of the nurses that she would be better off dead than hearing any more of the terrible voices that kept her from sleeping. The nurses called a meeting in the communal lounge a few weeks after her hospital discharge. Rosemary had died of suicide. The girl next to me at the meeting broke into tears.

Night after sleepless night and through the long, seemingly endless days on the ward, where smoking and television stood in place of any attempt of therapy, my fellow patients and I experienced similar feelings to those of Rosemary: feelings of loss, isolation, pain, sorrow, self-pity, confusion, and helplessness.

“You’re alone,” an insidious voice whispered to me. “You’re going to get what’s coming to you.” “You’re going down there!” it shouted. “You wait until you see what I’m going to do to you!”

When I heard my voices, which would often shout at me, no one around me moved or looked startled. It was just me hearing the voices. I tried not to answer them. Better to ignore the voices, repress them, and soldier on, I thought. I had seen others screaming back at their voices, and it had left me with mixed feelings of consternation, pity, and fear. I did not want to look mad like them. Any symptoms of hearing voices would go on medical case notes, be raised as proof of insanity at my case reviews by my psychiatrist and the nursing team, and keep me locked up in the hell of the ward away from family, friends, and what seemed like a long-distant normal life.

I learned several important lessons, too: never admit that you hear voices; certainly, never answer them; do exactly as you are told by staff or concerned family, or you will be seen as ill; never question your diagnosis or disagree with your psychiatrist, and be compliant and admit your mental illness or you will never be discharged, and your medication will be increased. If you refuse medication, as I did initially, you will most likely be given a depot injection of an antipsychotic drug. In my opinion, depot injections are used punitively to coerce compliance with oral medication (or making people take their tablets), despite these depot injections having very bad, humiliating and painful side effects (such as muscle stiffness and the inability to sit still), in my personal experience. The side effects of depot injections are so severe that you soon learn to comply with oral medication and take your prescribed antipsychotic tablets.

All the time, the voices got worse. “Hot fire in your eyes!” shouted a voice to me in the hell of the ward. “That’s where you’re going. In the fire of the sun!”

More worryingly, when in hospital, violence is sometimes used as a tool for getting noncompliant patients to take their medication, usually via a depot injection. This violence is often conceived of as right, as just, and in the patient’s best interest. Certainly, many nurses I have spoken to have not only said that they do not like administering forcible injections but also said that they have a duty of care. Violence as care is an oxymoron and hides the institutionalised abuse of people with schizophrenia and mental health problems. I have witnessed 8 occasions where patients have had to be very violently restrained by staff and only 2 assaults by mental health patients on nurses. This is in line with evidence that people with mental health problems are more likely to experience violence on their person rather than pose a risk of attacking other people.

I have witnessed people with mental health problems being very violently restrained, spread-eagled and pinned to the floor before being given a tranquillising injection and thought: “This could happen to me”. There is terror and despair in mental illness.

Nurses sometimes jump in violently to restrain people rather than using de-escalation techniques, such as talking and listening to the patient to calm them down. More controversially, there is sometimes bullying of patients by nurses, although this is infrequent in my experience. On one occasion, after an argument with staff, three nurses cornered me, and one nurse punched his fist into the palm of his other hand and said: ‘I wish we could’. On another occasion, following a heated argument, my psychiatrist put me on suicide watch, although I had not mentioned suicide. I believe it was punishment for calling him and the nurses “fascists”, which was a horrible thing to say, but which could have been handled less personally and more professionally.

To be fair, nurses are under a lot of stress and pressure, have to deal with time pressures and have many patients who are sometimes aggressive or violent, so the veneer of professionalism may sometimes drop.

Psychiatry has taken a biomedical approach with the prescription of powerful antipsychotic medication, including drugs such as olanzapine, risperidone, and clozapine, all of which I have been prescribed. These powerful antipsychotics have serious and debilitating side effects, are toxic, and have also been suggested to be harmful to those taking them in the long term. These antipsychotic medications have often been described as a “chemical cosh,” leaving people like me who take them passive, docile, debilitated, and zombie-like. This could be suggested to lead to the tranquillisation of people’s personal beliefs, however irrational, and their thoughts, subjectivity, and feelings. Such an approach could certainly be argued to crush diversity and discount the diversity of people’s experience of life and the world in the name of normalisation and keeping a stable social and medical order.

Put very crudely, popping a pill is far less of a burden on a health service that has limited resources, a lack of money, severe pressures on time, resources, in-patient beds, understaffing, which often depends on family carers who lack the knowledge and expertise of dealing with people with mental health problems who may be in distress and where care in the community is limited in scope and often means no care in the community, leaving people with mental health problems with the feeling that they are alone, forgotten, invisible, and ostracised. This lack and shortcoming of services mean there is less time for quality care and therapeutic one-to-one conversations to get to know the individual and facilitate recovery.

All this means that there is little study of what schizophrenics’ voices say to them, which would make people’s experiences more valid and meaningful and also lend itself to a more human account of mental illness. People’s experiences of hearing voices are silenced, which can only augment ignorance and fear, both in society and in the mental healthcare system. Little attention has been given to what people with mental health problems think and feel and what treatments they would prefer. In my opinion, psychiatry over-relies on antipsychotic medications, and there are long waiting lists for less invasive treatments such as counselling and cognitive behavioural therapy (CBT).

To complicate and make matters worse, it is almost impossible to talk with other people and relate the pain that voices inflict when they are raging inside you and shouting you down. It is even harder to face the voices and achieve what psychiatrists and mental health professionals call “insight.” My voices, in particular, often sounded telepathic, as though people were speaking to me through their minds and would often be racist or abusive about mental health staff and other patients. It is perhaps not surprising that voices like these if dismissed as bizarre delusions and not discussed as at least phenomenologically or subjectively “real,” may sometimes lead to violent behaviour toward staff and other patients or—as I have witnessed—the smashing of hospital furniture, equipment, and the television from which the voices emanated.

The main point to reiterate is that these voices are silenced and dismissed as delusions and that they are managed mostly by medical treatment and thus not addressed in human, compassionate and sympathetic terms that might begin to tackle the root cause of the problem, which in turn might help people cope more profoundly and insightfully with their voices.

Certainly, the overreliance on medication is perhaps not surprising, given that people who hear voices can be perceived as aggressive, irrational, and violent. My voices often took on a demonic or hellish quality: “You think you’ve been exploited and abused?!” a demonic voice often shouted at me. “You wait until you see what I’m going to do to you! You wait until you see what I look like!”

Mental Health Tribunals: Are they a kangaroo court?

The final straw of my negative experience of traditional psychiatry was my appeal to be set free from Section 3 and released from hospital against my psychiatrist’s advice by a Mental Health Tribunal. I thought this Tribunal would listen to me, but I found the whole process of the Tribunal a kangaroo court, biased and loaded against me. There are three members on the Tribunal’s panel, two of whom are professionals (one legal, usually a solicitor or barrister and one medical, usually a psychiatrist) and only one lay member, a person who is not medically or legally trained but with some mental health experience. I thought that the odds were against me and that the whole process was biased by elites and those in the upper echelons of society. More controversially, I thought that these elites (including my psychiatrist and mental health nurses) took a perverse pleasure in wielding power and keeping me under Section, taking away my freedom and my voice (although this negative perspective could no doubt be summarily dismissed as merely being a ‘paranoid delusion’).

Evidence for or against discharge from hospital is sifted and filtered by the Tribunal through the narrow lens of psychiatric knowledge. This attends to people as clusters of symptoms or evidential facts for or against discharge rather than seeing and opening a dialogue with a human being. My experience is that Tribunals corroborate and rubber stamps the psychiatrist’s bias and prior decision to keep and detain me in hospital under the Mental Health Act. In other words, Tribunals may be prejudiced and make people feel that things have been decided beforehand. This means that Tribunals reproduce the coercion, power and inequalities of psychiatry. Tribunals also consider themselves medical and legal experts, which I found quite patronising.

The set-up of the Mental Health Tribunal exemplifies the hierarchical nature of society, medicine and psychiatry, with those at the top involved in decision-making and power over other people’s lives. Those at the bottom, such as people with mental health problems, are coerced, dominated, controlled, ostracised, disempowered, and subjugated.

Many of the people with mental illness whom I have talked with, both as a patient and as a researcher and academic, tell me that they have had to suppress and hide their voices to be considered well, stable, and healthy by Mental Health Tribunals. Not only is this a suppression of symptoms, but it is also a suppression of people’s personhood. Traditional psychiatry, in this gloomy and pessimistic view, could be argued to be little more than an instrument of social control and of oppression and a system of scientific belief that perhaps unintentionally crushes people’s subjectivity, choices, human and legal rights, and free will.

The majority of individuals with schizophrenia and mental illness that I have spoken with, and from my own personal experience in a psychiatric acute unit, I have to agree, find meeting with Mental Health Tribunals threatening because any unusual thoughts or behaviour can be taken out of context and construed as psychotic. Many people with mental health problems are genuinely afraid of meeting the Mental Health Tribunal. I remember a teenage boy on the ward literally shaking and wringing his hands with fear, much to the concern of nurses, the boy’s mother, myself, and the boy’s mental health advocate.

Many people with mental health problems hide their symptoms, their aberrant beliefs, and their voices, but this means that they are ostracised and that there is a lack of dialogue between Mental Health Tribunals and people with mental health problems. This also means that there may be a lack of disclosure and of what is really going on in people’s lives and what voices they may be hearing. Because people with mental health problems fear Mental Health Tribunals and are afraid of punitive intervention or compulsory treatment, professionals are not getting the full picture so as to agree to a consensus on care plans and treatment.

Ironically, the lay member at one of my Tribunals was in favour of releasing me from hospital. However, this was overruled by legal and medical experts. They warned the lay member: “We have to work together”, suggesting a hierarchy and power relationships within the Tribunal itself.

To make a final point: other people cannot hear the schizophrenic’s voice. There needs to be a dialogue so as to treat the voice hearer’s experience as valid and meaningful. A more democratic approach listens to people with mental health problems and is open to their experiences and voices so as not to stigmatise the voice hearer, which in turn may lead to more holistic, democratic, and sensitive packages of mental health care and better systems of due process in mental health law and in Tribunals.

My recommendations for improving services

There are several key recommendations from this admittedly negative and critical article about coercive psychiatry and biased Mental Health Tribunals:

• Psychiatrists and Mental Health Tribunals need to listen more attentively and openly to people with mental health problems. They need to listen to what people are saying and telling them. In my experience, they can be focused on listening for signs of psychosis rather than the person’s lived experience.
• De-escalation techniques (for example, talking calmly with the patient) should be used before physical restraint. In my experience, nurses can sometimes jump in with a violent response.
• Psychiatry should be less bio-medical, with the prescription of powerful antipsychotic drugs that have serious and debilitating side effects. There should be a search for more open and humane perspectives and treatments, such as counselling, cognitive behavioural therapy and the recovery approach.
• There should be better support and dialogue with carers. In my experience, carers are often the workhorses of care and are left to pick up the pieces when things go wrong. Their knowledge and expertise are vital in deciding treatment pathways and advocating for the service user at Mental Health Tribunals. So too, with mental health advocates who require more training on Mental Health Tribunals and processes of mental health law to better equip them in their advocacy.
• Finally, in my experience, Mental Health Tribunals are biased, hierarchical and dominated by elites. There need to be better, more democratic, more open processes of law. People’s human rights need to be valued and set in stone. People need to feel that they are involved in the legal process rather than being its target/ subject. People are entitled to a more democratic approach, better due process, and to feel that they have received justice. More research is needed on how to improve Mental Health Tribunals in this way.