A Peek Behind Mental Health Facility Curtains

No Saturday links this week, instead try this.

On Wednesday I went along to the 53rd Maudsley Debate at the Denmark Hill Campus of King's College London, as trailed here last month. The proposal was vile, but simple.

This house believes that smoking should be banned in psychiatric hospitals

For avoidance of doubt, this isn't about an indoor ban, but an outdoor one, enforced on otherwise free and innocent people who are not allowed to leave the premises to escape it.

Now, I'd customarily give a detailed rundown of what happened, but technology is such these days that I don't have to. Instead you can watch it yourself here if you can set aside 75 minutes of your time.

If you can't, I'll just pick out some salient points from the evening from my perch up in the naughty seats at the back of a packed room.

The arguments presented were as you'd expect. Psychiatrist Simon Wessely and ASH's Deborah Arnott defended what I'd call torture of mental health patients on the basis that it's good for their health. There, there, pat on the head, aren't we great?

Wessely pointed out that it was a good policy because there was no proof that adverse outcomes had materialised where it has been tried before, an assertion which is contested by some.

Since the indoor smoking ban came in, cases of self-harm have rocketed by 56% in the UK. Meanwhile in the USA, where state-run units in 35 of the 50 states now have some form of outdoor ban, patient-on-patient violence has risen by an average of 22% and up to a whopping 390% in Austin, Texas. Furthermore average durations of stay have increased by nearly 90%.

Meanwhile, Arnott began her piece with an anecdote - which 'public health' usually discard as irrelevant (more about that later) - and made some hubristic claims in favour. For example, at one point she said that banning smoking is a wonderful policy because, at the moment, patients have to "experience withdrawal many times a day". Her justification for this is that because they can't smoke indoors the mere act of smoking outdoors is causing harm by making them experience prohibition every time they return inside. It beggars belief that someone who was instrumental in making smoking forbidden indoors at such establishments can possibly use that as an argument, but then I often wonder how these people sleep at night on an issue such as this.

It was also jaw-dropping to hear Arnott saying that ...

"Vaping is banned in many hospitals and I don't know why that is. It's not acceptable."

Do you want to tell her that it's directly down to scaremongery and irrational hysteria whipped up about the mythical danger of passive smoke by Arnott's ASH and their equally noxious chums, or shall I?

Arnott also went so far as to say that "cigarettes are the only outlet" for desperate mental health patients, but that this was "not acceptable". She was very passionate though, I could hear shards of her fast beating heart of stone splintering off as she spoke.

In reply, Chris Snowdon pointed out that, with mental health patients, their physical health isn't the be all and end all, and that bans just lead to "anger, resentment and a breakdown in trust" between patients and staff. Furthermore, that quitting smoking when you're completely prepared for it makes you miserable, but that is amplified by being forced to do so when not prepared and is therefore worse and inhumane.

Fellow opposer of the motion, @Sectioned_ - speaking on condition that she wouldn't be filmed - succinctly summed up her contribution after the debate.

Summary of my view: No argument anyone raises is going to convince me that I'm any less a human being than other people. #MaudsleyDebates

— Mental Health (@Sectioned_) November 11, 2015

The point being made is that the bans being proposed go against the very fabric of doctor/patient relationships in mental health facilities, something that others also noticed. How can one equate care for the desperation being suffered by those in such institutions - and the goal of increasing self-esteem - with coercion and high-handed finger-wagging; and how does a service which claims to treat mental health patients as equals in society square that with treating them differently to everyone else? Why only mental health sufferers when banning smoking outdoors for everyone else, everywhere, would be seen as fascistic?

You cannot be for agency of choice and body (core medical ethic) & then be against patients making that choice themselves #MaudsleyDebates

— Obi-Wan Kenobae (@Alexwintermute) November 11, 2015

Let's encourage smoking cessation support in community MH services. But don't force people in depths of despair to quit. #MaudsleyDebates

— Fi Douglas (@fidouglas) November 11, 2015

In short, outdoor bans in psychiatric hospitals are being applied by tobacco control extremists not because they should - because if that were the case Arnott et al would be advocating them on all of us, everywhere - but instead merely because they can.

This leads me onto my main take-home from the evening. You see, it gave a glimpse into an unsalubrious and quite disturbing ongoing battle within NHS mental health services. Those who have experienced the service, as well as troops on the ground, were eager to get their point across.

A mental health nurse stated that she had encountered some patients refusing to go to hospital simply because they can't smoke. The response from Wessely was that this was anecdotal and "not recorded" so therefore, presumably, didn't happen. Considering his co-debater Arnott rooted her contribution with exactly such an anecdote, it kinda blew away part of their case.

Similarly, one audience member who had been admitted before and after the smoking ban spoke about how the 2007 ban had created division, and that this latest move could only "increase deviancy and friction between patients and staff". The other side was conveyed by a truly odious hospital manager (Arnott directed the Chair to take a comment from her) who spoke of how banning smoking everywhere was a "caring" thing to do because it was "supporting" patients to quit. As vomit-inducing weasel words as I have heard for quite a while, delivered in that soft condescending faux-caring tone which I've heard from many an authoritarian con-artist over the years. "For your own good" expressed not as what it is, an order, but as somehow being your friend while not even remotely respecting your choices.

@Sectioned_ brought a large piece of seaside rock as a prop to convey the idea that "coercion runs through psychiatry like a stick of rock, and it poisons it". The manager's condescending stance simply confirmed that this was likely true.

The debate ended in what was near as dammit a draw, just one vote splitting those for the motion from those against. But this was in a health establishment so to be expected, the fact that it was so close simply showing that the proposal is a quite hideous thing to do to people with mental health problems. The online poll delivered a thumping 72% majority to those opposed, which is probably far nearer the way the public would view the idea.

One last point. I still, days later, cannot believe that - on a night where I counted three smokers in the entire 200+ audience - there were nearly 100 people in that room who voted in favour of restrictions on others when they have no experience or understanding of being in the same situation themselves. It speaks volumes about the horrible, judgemental, self-satisfied and interfering world in which we now live.