Conscientious Objection from Enforcing Treatment

Welcome to our first online discussion forum on the subject of RMN’s possible conscientious objection to enforced treatment.

Scroll down to take part in the discussion! We focussed on the 15th, 16th and 17th of Oct, but you can read what was written and still contribute if you wish. 

(But perhaps read these paragraphs first, if you haven’t already).

Welcome if you are from the UK, Ireland or further afield. We especially want to welcome our many readers in Australia, New Zealand, The USA and Canada (we know from our website stats that you are out there!) and also from anywhere else (this website is viewed from over 40 countries). Please feel free to contribute about the similarities and differences in your experiences. 

The idea is to have our discussion in as open a way as possible, collecting together everyone’s thoughts and the themes that develop. We hope that the document that emerges will be exciting and something to feel proud of as a rather unusual piece of nursing and social history. Our suggestion is that if you wish to remain anonymous that you create an online username for yourself before contributing. As with anything on the internet this is not a confidential space. This conversation is not limited to nurses. You are welcome to take part whatever your experience is of this issue. All you need to do is to ‘reply’ to this page (from today at 8pm). 

Comments on this website must go through a brief moderation process (one of the editors has to click an ‘accept’ button). Your posts will therefore not appear immediately. This will only be used to ensure that comments are not personal attacks; we will not censor ideas otherwise. You are very welcome to explore reasons why you think that nurses should not have this right. We suggest that you contribute as thoughtfully as you can but in a conversational style rather than with a series of long essays! We also think that critical thinking requires emotional work. Please feel free to share some of that here: what is it like for you to take part in this discussion?

Remember! The aim is not to establish whether forced treatment is finally right or wrong, or whether MHNs should or should not object. Instead, we need to consider whether certain issues and concerns make it reasonable that a mental health nurse could view this as a matter of conscience. 

After this discussion we will have a number of options. It might be that we feel it should go no further. It might be that we want to publish the resulting document in some way other than here on this website. Perhaps we will want to create a video that explains the various ideas that arise. Perhaps we will need to create a list of questions to which at present none of us know the answers. If we do collectively decide that we should campaign for the right to conscientiously object there will be a lot of thinking to do about how to organise that campaign. We would like as many people as possible to continue to be involved and shape what happens next. 

Disclaimer: At the present time, the Critical Mental Health Nurses’ Network does not recommend for any mental health nurse to claim that they have a right to conscientious objection from taking part in enforced treatment. You do not have that right at present.

202 thoughts on “Conscientious Objection from Enforcing Treatment”

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  1. Peter Bull thank you for posting the video on Laing talking about how we treat each other is the therapy.

    I am upset this evening by the way two others treated me today. The first, a complete stranger and a mental health activist who previously had dealings with the Church of Scotland and I assumed could be trusted emailed my epistle to the CoS making the case for much need reform in Scottish mental health services willy-nilly, and consequently, compromised the Church coming to an independent conclusion.

    The other person, who I previously thought liked me, turns out to have a very negative opinion of me. And I think of the schizophrenagenic mother. Her rejection of OD is based on find the notion of the schizophrenagenic mother being beyond the pall. Some would say the concept is “sexist” and was created by white men blaming women for the illness of their children. The mother would say “What about the father? Is he not to blame that our child has turned out this way?” Moving on from the 60s when this notion of the schizophrenagenic mother was popularised today I think the importance of the primary care giver is recognised and the nervous, inconsistent (neurotic) primary care giver will create in the child difficulties coping with the world about.

    Do they teach any of this to the students of are here tonight?

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    1. Peter Bull thank you for posting the video on Laing talking about how we treat each other is the therapy.

      I am upset this evening by the way two others treated me today. The first, a complete stranger and a mental health activist who previously had dealings with the Church of Scotland and I assumed could be trusted emailed my epistle to the CoS making the case for much need reform in Scottish mental health services willy-nilly, and consequently, compromised the Church coming to an independent conclusion.

      The other person, who I previously thought liked me, turns out to have a very negative opinion of me. And I think of the schizophrenagenic mother. Her rejection of OD is based on her finding the notion of the schizophrenagenic mother being beyond the pall. Some would say the concept is “sexist” and was created by white men blaming women for the illness of their children. The mother would say “What about the father? Is he not to blame that our child has turned out this way?” Moving on from the 60s when this notion of the schizophrenagenic mother was popularised, today, I think the importance of the primary care giver is recognised and the nervous, inconsistent (neurotic) primary care giver will create in the child difficulties coping with the world about.

      Do they teach any of this to the students who are here tonight?

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  3. Hi Everyone! I’m working thorugh reading last night’s stuff… let me see:
    Gary: I really glad that you raised the question of whether the highly related topic of whether the MHA is discriminatory is relevant here. In a sense, I see this as a form of a question about whether we can draw a distinction between the use of force to admisiter drugs and the use of locked doors and other forms of coercion. This is, to me, part of what Geoff Brennan said last night too: what about force to save the life of someone who is acutely anorexic? Or to break up a fight?
    For me there is a difference and for me it centres around the planned nature (not enough on its own, as the anorexia example may show) and the contested nature of pharmaceutical interventions, their perceived benefits and their very clear (and increasingly understood) risks. I would be very interested in others’ views on this. I suppose what I am saying is that from some angles, focusing on forced pharmaceutical interventions might seem like a false separation from all of the other coercive things we do, but from another angle I think it is legitiamtely different. Perhaps this needs further thinking.
    Plus the UN document I have already posted which I read as telling me that the use of force is incompatible with any model of thinking about what people in distress need.
    There is one other factor too, that I am not sure has come up yet, although maybe it is relevant to one of Mick’s excellent comments about trauma. The entry point for me is the justifying story ‘there is no alternative’. What we have learned from all kinds of places in recent years is that there are alternatives, even within what we have often dismissed as ‘acute psychosis’. These alternatives include the knoweldges of the Hearing Voices Movement, Open Dialogue and hey, the small business of the Power Threat Meaning Framework. Now, I don’t especially want to debate the detail of any of those here (I’d actually love to, but it would be a serious side-track), but I have had enough invo’vement for them to make me believe that when we say ‘there is no alternative’ we really mean that we currently provide no alternative. If that is the case, then forced treatment is a product of the service, not of the service-user.

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    2. re: ‘best interest’ and the geoff brennan comments above, I’d be interested to read more on when/where nurses feel forced treatment might be justified, i.e. would it hinge on someone’s capacity (for self-determination, autonomy; treatment refusal?), on principle of harm? thanks

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      2. Hi Tom, I can think of scenarios here that I have been involved in….when a patient is incredibly powerful and they want to hurt themselves or other people and all other options have been exhausted, when they are unable to control themselves or are not seemingly making a choice to hurt themselves or others……capacity would certainly matter ( I remember restraining someone who would not stop head butting a doorframe and was in danger of blinding himself), as would trying to prevent harm……these were not situations in which I felt I wanted to conscientiously object, however…..

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      3. Once this debate begins to involve more people, then these are likely to be the most important, and at the same time contentious, issues. At the very least, having dialogue on these points that brings in multiple perspectives should move us closer to a consideration of the limits of any development of CO as a strategy. I believe this would simultaneously reimagine the limits of the legitimate use of force. That would have to be a good thing.

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    3. Oh, and I forgot to say that one of the biggest ‘untried’ alternatives are any public health approaches to mental health. Like everything implied by Wilkinson and Pickett’s work on the effects of inequality, for example.

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  4. Just for tonight I’m going to keep this brief because I am tired but will be back tomorrow. On the subject of trauma. The impact on someone who has a traumatic background is huge. On a basic humanity level….how would it be helpful to say, pin someone down who is superficially self harming for a functional reason, usually because of traumatic memories, by a PET team consisting of the largest, fittest staff? I don’t really know how to word this so I’ll be blunt. If someone was abused by 1 person and it messes their life up, how is therapeutic or even ethical to have 5,6 people pinning you down and to cap it all, inject you and make you incapable, powerless and unable to defend yourself. For victims of abuse, how do you think that affects your mind? Your feelings about being a victim. Only to be ‘legally’ victimised and debased of power all over again? And were expected to all sit down and have a cup of tea and ‘talk about what happened’ to those same perpetrators? So, on a humane level, that is how that population of patients feel. Patients have developed PTSD because of their experiences at the hands of forced treatment. And I’ll put it right out there, who WOULDN’T conscientiously object to destroying a fellow human like that?

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    1. I’d like to think that I would conscientiously object, at this stage in my career, but I am aware, when I have been younger, less confident, more subject to other pressures, that I may not have felt able to. In mental health nursing, I have sometimes felt subject to a culture of bravado and machismo, of going along with uncomfortable practices, of not being sure enough to stand up and speak. A legal right to conscientious objection codifies the right to act on either side of an ethical divide…..in a traditional, hierarchical culture, this legitimises individual action in a way that no other piece of legislation can. It might give newer nurses the ground, the safe place, to not destroy a fellow human like that…….

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      1. Excellent points Peter. I think you are opening up discussion of what counts as legitimate, what is ordinarily seen as just and fair, moral or immoral etc. in other contexts, the public are thought to approve of (or legitimate) the use of state force (eg by police) if so-called procedural justice ideals are lived up to. put simply, if the level of force is commensurate with the perceived need for force (not over the top) and the forcible act is seen as reasonable in the circumstances.

        it would be useful to reflect upon different mental health service examples through such a lens.

        also in play is wider public (rather than professional) attitudes, ideals and prejudice. Arguably, the public, perhaps in interaction with state approved representations/narratives of risk and danger, are prepared to countenance fairly high levels of legitimate violence against mental health patients.

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  5. yes, I think that the relative dearth of decent alternatives, available at scale for everyone to access, is a key problem. I think there are many people within services who are fairly cooperative, even when detained, but who wish to refuse medication. we should have the wit and means to work therapeutically with such people without forcing medical treatment on them. Modelling such alternatives should then open up possibilities for better help for a wider range of people, including the most disturbed and distressed. We then might begin to be able to imagine services that people actually wish to come into, where acute distress is tolerated and attended to relationally, without quick recourse to meds (though there may be room for judicious use) and a range of other things are on offer.

    We have been doing a historical project based upon asylum archives. interestingly, despite all of the anomalies and abuses of the asylum system, there were some alternatives that involved fresh air, farming, recreation/sports, music, amongst other things. That said, the history of the asylums is also the history of the present …. very soon from the outset, the containment of people/risk became entwined with the containment of costs.

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  6. There have been some really interesting comments already, so I’ll keep it brief.

    For me (and I’m not naive, having worked on acute wards for 10 years) it comes down to the point that I cannot possibly have a therapeutic relationship or co-produce anything with the threat of coercive force hanging over the other person.

    Force and coercion is the backdrop to our entire mode of life – peel back all the rhetoric and the bailiff is there waiting to break your door down.

    MH Nursing cannot move on until we can honestly acknowledge this coercive bedrock.

    CO would be a start (although it is maybe too individualistic? What would collective refusal look like) and as others have noted it may have the effect of shifting the psychiatric impasse.

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    1. Nicely put Ed. I think your writing on anarchist inspired activism and related social movements gives us some hints at collective solutions & how more situated, small-scale alternatives may show us the way forward – prefigurative politics, no less

      The case for truth and reconciliation processes at a grass roots level may also contribute

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  7. One interesting theme from last night was whether CO should be about a general identity – ‘I am a conscientious objector, I declare it now’ or whether the right to CO would be excercised on a case-by-case basis. I spoke last week to an legal expert about CO and she argues persuasivly that it needs to be case-by-case.

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    1. Yes, there does seem to be a persuasive argument for case by case judgements. Would have to be careful about how best to navigate the perhaps self-deceptive power of ‘last resort’ narratives.
      And, perhaps a legalistic view of ‘case’ would suit lawyers and retributive, rather than reparative, models of justice and communication.
      If the idea of CO has legs, we should try and avoids a collapse into the courtroom at all costs.
      Activist who seek rights and entitlements often see the law and legal forums as a failure of more collective, setting based activism; wishing to remain, and hopefully win, on the ‘street’ rather than the courthouse.

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  8. After a long day I feel I am scratching the surface of some of the complex issues here but .. I do think the comments Ed and Peter made about the culture and practice of nursing are important.
    I guess they play more of a part a lot further along this work, I would hope as Mick has said that the discussion of CO to forced treatment would add to the debates about its existence and attempts to move to less restriction. But, the pressures to “conform” to a dominant culture and accepted practice are so significant in nursing (certainly not confined to newly qualified nurses but felt more by them) I wonder whether people would feel they could use the right. I guess the unions and education could support this.
    I would be interested to know what the evidence (in the broadest sense) has said about use of other CO in Nursing, and maybe that could help thinking at a later stage.

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    1. Anne, great points (including the observation of tiredness at end of long days!).
      I do know something about unions, so will chip something in on this. first, I think unions tap into the desire for a collective solution. Yet, we ant guarantee that unions, constituted to protect workers’ rights, will occupy progressive standpoints on this territory. And I say this as a really big fan of unions and a long-time activist. Hence, unions often espouse a contradictory mix of policies, concerned on the one hand with quality of care and defending services from resource cuts, and arguably idiotic policies such as zero tolerance of violence (on the part of patients and the public). These policies are often voted for after impassioned pleas on the part of staff who have been seriously injured, beaten or assaulted by patients or members of the public. Though this is understandable, and often the testimony is very heartfelt and moving, the implicit and explicit violence of psychiatry is neglected or ignored.

      I do, however, remain optimistic that unions can be on the side of the angels in this debate. And the route to this is union democracy, and working to improve union democracy. Along with a quest for honest dialogue with service user and survivor social movements. The idea of truth and reconciliation, and CO, could be the basis for establishing such dialogue on a firmer footing ….

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  9. In some ways I have wanted to leave practical questions aside, because I wanted to get a feeling for whether people see a way through things at a more conceptual level. However, there are a lot of practical questions that worry me.
    For example, supposing there are some members of a team who tend to conscientiously object from forcing treatment. I feel sure that this will lead to very strained relationships with other members of the nursing team, not to mention what might be reasonably predicted to be outrage from members of the medical team. These things will be distressing and need planning for… but I can justify them to myself because I perceive a grave need to open up these very difficult conversations between people.
    But what about what might occur within relationships between the whole nursing team and the service-users on the ward? Once one or more nurses are known to CO, then what does that make the other nurses in the eyes of the service-users? Now, some might say again that this is exactly the kind of provokation that is required and why shouldn’t the willingness of some nurses to use force be openly questioned? But I can’t help feeling it has the potential for some highly traumatic experiences. What do people think about that?

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    1. What if we could envisage different ways of organising how our very work is managed and led; how decisions are taken about how the work is organised? What if we truly had workplace democracy? Some of the alternative forms of therapeutic approach offer versions of such democracy. If we had more democratic systems – workplace democracy – some of the turbulence of team relations in the context of minimising force and assertion of CO may look different, and be able to be worked out differently. Just a thought. Maybe, as well as thinking about CO as an aspiration, we need to aspire to more democratic systems of the labour process of healthcare work?

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      1. thanks jonathan and mick – well up for democratising care and have had some very encouraging experiences in teams that openly discuss/debate a range of perspectives. not platforming but have found values-based models really helpful for this https://valuesbasedpractice.org/

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      2. Yes Tom, thanks for that. I think CO definitely compatible with a values led approach. This also figures in debates about authentic coproduction. Some good stuff generated by ESRC seminar series convened by Pamela Fisher. The website is replete with good material including short videos. https://coproductionblog.wordpress.com/tag/seminar-3/page/2/

        One implication is that truly authentic coproduction transforms not just practice but professional identity – what we do & who we think we are.

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  10. Mick McKeown comment “I have heard that in reality the Norwegian legislation isn’t always enforced.” echoes the UK. I was surprised that no-one remarked after I posted yesterday that Section 2 of the MHA has the safeguard of a wait of 28 days before an individual can be mandatory medicated is never observed in the locked ward environment.

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    1. And safeguards such as independent advocacy are poorly understood and inadequately resourced.

      Interestingly, advocates could be important mediators in team discussion regarding the limits of forced treatment.

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      1. I would prefer finite resources to be spent of OD family therapists than creating a raft of advocates who, certainly in London, are graduates who left Uni and failed to land a job in the area they specialised in, and take a stop-gap role in “advocacy” before moving on to greener pastures.

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      2. Liamtkirk, cant we have both? do think we need more therapy, and OD is one of the potential alternatives that make creative use of democracy.
        My experience of advocates and advocacy is really positive. if we didn’t have a notion of independent advocacy, in a coercive system it would have to be invented.

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  11. To everyone who has so far participated in this discussion:
    A very many thanks! We have scheduled another evening for this, tomorrow. We know that this thread is becoming quite a long read and it is difficult to dot backwards and forwards to keep up (some amazing posts, though, we hope you agree!). However, we really want to encourage as many as possible to come back tomorrow evening and we will turn our focus to what we want to do about all this. Please have a think tomorrow (and another read-through if you have time) and start to think about next steps. It is clear that this discussion shows an appetite for the idea of conscientious objection and even some hopes. For tomorrow then: what comes next?

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  12. … and to those others who have been reading but not taking part – you are very welcome too. Special greetings to those from other parts of the world, too (Australia and US mostly, these last couple of days).

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  13. Dear Everyone,
    Welcome to the third and final evening of discussion – a discussion that aims to gather views and ideas about the possibility for mental health nurses to have the right to conscientiously object from what we often know as ‘forced treatment’.
    There have been many strands to this conversation. In fact, it is not over – this page will remain open for reading and comments after today.
    This evening we also want to ask for thoughts about what to do about all this. How can we bring these ideas together? Should we take them further? Who should we share them with and in what format? What questions remain unanswered for you and how could we begin to think about those? Once again, please feel free to comment on what it has been like for you to take part in this discussion (or be a witness to it if you have chosen just to be a reader so far).
    Thank you very much.

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    1. good evening, I’d like to get clearer on how CO might be distinguished from ordinary ‘least restrictive’ rationales for care, i.e. where a nurse might recommend an alternative to restrictive assessment/intervention/treatment etc. Would these sorts of examples count as CO or would the conditions for CO need to be more specific? thanks

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      1. Hi Tom, I think this is an important question. It came up a bit last night. For me, I felt that part of the conversation led me to feel that there is something distinctive about the coercion invovled with enforcing pharmacy.

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    2. I wonder if a future step is to retry the experiments of the past and find a way to develop a pilot service somewhere that is purely about co-production and does not accept coercion. Is that just mindlessly naive optimism? Just going to repeat the failures of the past? Do we reset back to Tuke’s moral treatment but with iPads?

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      1. this may be difficult to achieve in short term, but we could do some thought experiments over what such an alternative service might look like & as you say, there have been examples of a sort over the years

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  14. Here are some grounds for a nurse to take a position of CO (taken from Schizophrenia – the meanings of madness by A R K Mitchell 1972):

    The difficulty of finding an agreed operant definition of what is exactly is meant by ‘schizophrenia’ has hampered basic research into its causations, and accounts for some of the confusion and wildly differing views held at the present time. Thomas Szasz, an American psychiatrist, has pointed out that there are dangerous words called panchrestons which are utilised in philosophical argument.
    A panchreston is a word which appears to have a precise meaning when it does not, but it is used as if it did, to further a logical argument. The fallacy is to accredit the word a meaning for the sake of argument, but to forget this has been done and to go on supposing that the word does represent concrete reality.
    Szasz suggests that schizophrenia is just such a panchreston. It was a useful concept invented to aid our thinking about certain types of behaviour, but we have fallen into the error of thinking that beyond this it has a concrete reality. Like our Sorcerer’s Apprentice, we have become the victims of our thinking.

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  16. In terms of moving forward, and keeping in mind the expressed desire from some quarters for a collective approach, I propose getting trade unions involved in promoting, supporting and opening up the debate to a wider constituency of the workforce. We should also seek more broadly based alliances with service user/survivor/refusers and carers.

    on the union front: I intend to take up within unison’s internal democracy, and have already alerted activists to this discussion. The formal thing to do would be to move a motion at next year’s delegate conference. To do so would require a drafted motion to be in the system, moved by a branch or other constituent group, by late this year …. which doesn’t give much time,

    We may feel that this needs more building for, rather than to pitch it to an unreceptive audience and have it fail to be adopted as a policy resolution. An alternate strategy would be to organise the conversation in union circles, with a view to passing a resolution the following year. There are pros and cons to both approaches.

    if we went down the more gradualist route we could pitch for a fringe meeting on this debate at this years conference – this would allow for longer/deeper debate and the chance to develop the idea before putting to the vote

    ideally, a number of us would be making the case within a number of unions which we belong to, and taking the idea to allied groups

    hope makes sense

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    1. Agree. And why not have students or teams of nurses write a collective response that is then posted on this thread?

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  18. I’ve been reading the discussion with great interest. I think the way forward from here would be to take what has been discussed and develop a working document. A sort of position statement. It would flesh out what we mean by CO in this context – what the already identified issues and ramifications are and what it might entail for nursing practice. Beyond that I’m guessing further discussions around the document online, and then perhaps with the various nursing unison and the registrant body would be wise to flesh up what it could look like practically.

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    1. I like this idea. We could use the discussion threads to begin to frame such a document.
      If we do this right, we should have a readable text that speaks clearly to all perspectives/stakeholders and covers the complexity of the issues

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  19. maybe also write something for different outlets that will reach the people we need to talk to.

    we could persuade the editors of nursing journals to take an editorial about CO

    we could write something for asylum magazine

    and the UNITE mental health nursing magazine, unison activist magazine etc

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  20. I think that’s a great idea Mick. ‘The Conversation’ might be a good place. Mad in the UK. I’d also suggest we write for the press too at some stage – e.g. the guardian..

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  21. I think I’m with anadilectic in the first instance. This discussion seems to need to become a document, and a position statement feels right for that. I would want it to be subject to further commenting upon, feedback and alteration in an open way. But a position statement could be helpful because of the tendency for all of us to start dreaming about all kinds of other reform – I admit it, I’m one of those… but if we are not precise abut what we are asking for, I doubt we will get far.
    Would it be easier to write articles for journals, trades unions and Asylum etc., after we have completed a piece of work like that?

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    1. Yes I think so Jonathan. Further articles that discuss various aspects of CO could raise attention – stimulate further dialogue and draw attention to the discussion around the position statement. Gain some momentum and enable us to form alliances with service-user/survivor/resistance/activist groups.

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    2. See what you are saying here
      But think we could do both
      as long as we see articles as the start of a conversation, rather than a final word
      articles could point to the position statement once done, or encourage participation in its drafting beforehand

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    2. yes, and the idea of multiple signatories fits with a collective approach, so a few individuals are not isolated and vulnerable to negative reaction

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  23. Tangential idea –
    It is the 100 year anniversary of the first world war
    CO figured strongly, and also intersected with institutional psychiatry – with COs made to work in asylums and psychiatrised

    Maybe we could draw upon this history to aid our arguments, drawing attention to a range of matters of conscience within mental health nursing

    what I like about this is that in terms of historical time, COs were typically vilified in WW1, but with the benefit of hindsight are now broadly seen as a courageous vanguard

    the entwinement with the psychiatric system exposes various conceptual and practical anomalies and shortcomings that can be part of our argument

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    1. Yes. And we should probably learn from history in other senses too. We have been a fairly like-minded bunch here, I feel… hey – everyone needs that from time to time! But the fact is that CO is deeply controversial and people find ways to construct is a plain immoral. We should expect anger.

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      1. Yes, at least from some quarters. A bit of passion and turbulence not necessarily a bad thing. Could be a spark for active debate rather than indifference

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    2. Mick, I think this analogy makes it clearer why the concept of CO is problematic – psychiatric treatment and going to war are completely different things. The concept of CO has a history. I wonder if we are more talking about ‘refusing to participate on ethical grounds rather than CO. CO can be done for religious reasons but the type of refusal I think we are talking about involves nursing staff viewing a treatment as clearly unethical and hence refusing to be involved. The expectation is that the system would protect them if they refuse.

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  27. I would be more worried about either ridicule or polarising those against the position.

    A good excessive for me was thinking how organisations such as 100 families would react. They are a group supporting the families of people killed by people with MH problems. They focus on dangerousness, primarily in psychosis and anti- social personality disorder. They state that services are blind to the realities of dangerousness and should, essentially, be more aggressive in the treatment. http://www.hundredfamilies.org/why-does-it-keep-happening/

    If worried about having too many like minded opinions, it would be a good excessive to imagine defending the position to this group and others of a like mind.

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    1. Yes. Totally. On a more mundane but perhaps even harder to deal with level, I expect many nurses to say that anyone who CO’s is making the job much worse for everyone else, are not someone that can be trusted in a crisis, is not a team player, and ight even be responsible for injuries sustained by colleages and service-users. Someone who CO’s might lead to horrible off-duty problems.

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      1. Women were encourged to give CO men a white feather during WWI as a sign of contempt and cowardice.

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    2. yes, a canny way of thinking about how to formulate best case for the idea.

      in first instance we can say CO to forced treatment can be separated from compulsory detention, we can do the latter (for potentially dangerous people) but this does not necessitate forced treatment

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  31. Well, what a fascinating discussion. I remain, I must admit, neutral, but a position statement would be a great way to move the debate on and clarify the position. Thanks for organising and making me think so damn hard!

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  33. Thank you all once again. It’s been really interesting and we feel very pleased with the level and manner of the comments. Please feel free to continue to think and comment below.

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  34. This is kind of difficult for me to write. I’ve got several incarnations behind me: psychiatric nurse in the 70s and early 80s; CBTherapist from mid-80s to 2009; psychiatric patient mid-late noughties; survivor of the institutional psychiatric system ever since; academic writer/course/module leader/under- and posgraduate lecturer in MH/Nursing and CBT1997-2017; narrative/qualitative researcher and writer 2001-now; critical mental health activist for the last decade. Bottom line for me: the whole of mainstream ‘mental health’ is predicated on a huge series of lies. There are no mental illnesses. Diagnosis is about as scientific as astrology. Acute wards are spaces where damaged people compound the damage of others; where there’s roughly a 1 in 3 chance of inpatients experiencing either physical, psychological (including violence to narrative identity) or sexual abusr. The 1 in 4 story is a quarter of the truth. Collaborative discussions with users about drug treatment are far from the norm. I could go on…And I have – if you’re interested, check out my work in my Research Gate pages. What place for CO in all of this? We need to start again; to re-invent responding to human misery on the basis of its social rather than medical origins. You don’t fix cars that have failed their Lots by giving them a fresh coat of paint.

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    1. Alec, I am almost in total agreement but I am a little wary of the car analogy. I think everyone needs to acknowledge that the crisis focused current system has not reformed into what it should have been. That said, I think we need to be careful about proposing too radical reforms because it may create a justification for an even worse system that is even more risk and crisis focused. This is especially the case if radical libertarian philosophies are adopted.

      I realise it is difficult to imagine that the situation could be even worse but I think it really could be if further neoliberal reforms are instituted. Indeed, as bad as the asylums were (though the story is complex) there a plenty of frightening statistics – homelessness, the increasing prison populations, the ability of psychiatry to colonise everyday social life – that relate to the closure. For me the moral of the story is to be very careful about what you wish for.

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      1. Personally, I see these two comments, from you Alec, and from you Smith, as some of the most important of the whole discussion. In fact, they are worthy of expanding into a lengthy discussion in their own right…
        I often believe (but I act in a number of ways that are inconsistant with this belief) that mental health services are incapable of reform… and that the only change we should accept is much more radical. In the name of ‘balance’ we take the best thinking we can manage and mix in the sloppiest nonsense imaginable. I agree with Alec’s astrology analogy and I think it is a very good match for a diagnostic system that has been shown to have ‘failed to self-vindicate’, does not ‘carve nature at the joints’ has been widely rejected by academic institutions and disciplines, the NIMH US, the BPS, etc. All of those points and many more have been made repeatedly, but because such critique does not address the power operations of mental health services we find that we can let all the scientific air out of mental health services’ tyres (another car anology!) and it still goes to work each morning.
        In some ways, I think a Brexit anology helps me, too. One argument for what is going on with Brexit might be like this: Remain, and we might wish for a more collaborative dialogical sense of European identity but we mostly end up coupled with a neoliberal machine that is profoundly antidemocratic, giving massive subsidies to the already rich, allowing de-regulated corporate power to continue to fudge climate change, and trapping the poorer Southern Europeans into more debt they then cannot vote themselves out of. Leave, and we might wish for more self-determination but we then give more control to a profoundly neoliberal government who will make us into a huge tax-haven island of the coast of Europe, continuing to disempower and disposses all but the big corportate giants and their shareholders, relying completely on busted ideologies like ‘big society’ and ‘trickle down’ to try to persuade us that this isn’t just total robbery. So the problem isn’t remain or leave. With certain very important issues notwithstanding, remain or leave is a bit of red herring from this point of view. The problem is massively unregulated capitalism in cohoots with politics, or, as Wilkinson and Pickett have it (and I think this language is in some ways preferable to talking about ‘anti-capitalism’ or ‘neoliberalism’), a severe lack of ‘economic democracy’.
        Likewise, proposed changes to mental health services that tweak issues rather than meeting the failures (and agendas) of mental health services head on are so much fiddling while Rome burns, aren’t they?. Open Dialogue? Trauma Informed Care? Partnerships with survivor movements? Some of them look so promising, but all of them will probably become another vehicle for the pathologising status quo – just like the way the recovery movement of peers became the recovery model of services and then recreated the same sham expertise and pathologisation game all over again, leading to smaller and more coercive services (wrapped in positive double-speak).
        Into this moment, what use could campaigning for the right for MH nurses to consceintiously object from enforcing pharmacy have? Isn’t that just a very niche set of arguments about only one specific issue, that not many nurses will take up anyway?
        I believe it has some absoltuely unique features that make me think it could be genuinely worth going for. I’m going to begin trying to incorporate some of those thoughts into a position statement with accompanying background for this website and I very much hope that we can treat that as a draft that we can refine collaboratively.

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      2. Johnathon almost in complete agreement. I thought the Brexit analogy was quite interesting. For me, the thing about objection is that we tend to object to things which are obvious – forced medication administration for example. It is harder to object to conditions and contexts that surround these issues. In part this relates to the social conditions and contexts that created such issues and critically minded people tend to focus on this – social determinants etc.

        But, I often think that what is often missed is the risk context in which these situations occur. Mental health care is maligned by a risk culture that justifies ethically problematic (and unhelpful) actions and often in doing so this create the very problems that are trying to be addressed. If we think about the ethics of CO we need to think through the risk logics and contexts that are associated with this act.

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  36. thanks again for the organising & discussion.
    re defending the position, I suppose a slight worry I have at this stage is getting clarity on what CO might be able to to the current means nurses have of reporting & registering their professional concern, or indeed ‘objection’. so asking at the naive level: if a nurse felt a rationale for care was poor, or unjust, inhumane or abhorrent – what are the current means they’d have of responding? and maybe secondly, what is it about these means that’s inadequate to the point where something like CO should be available. thanks

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    1. Hi Tom,
      I just can’t imagine saying to the multi-disciplinary team, or in writing to my line manager:
      ‘I believe the rationale for using psychiatric drugs within a treatment model is highly unevidenced and the arguments are circular and poor. As such, I would like to argue that they cannot be seen as ‘treatment’ but only as a form of drugging, possibly a helpful one at times, but something that can often be very harmful in the short and long term. I therefore feel we need to make such substances a personal choice only and develop a number of other options for people, even while they are detained in hospital’. I might also want to add in other arguments about the damage caused to my relationship with that person, or between that person and services. Or I might want to say that I believe that the existance of alternative perspectives like those of the Hearing Voices Movement make it impossible to say that we are acting in the last resort. Or I might want to say that I believe that there is a profound connection between outer and inner violence and we should model non-violent approaches to the self.
      Do you feel that the existing mechanisms we have as nurses are adequate for the level of controversy we are dealing with here?

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      1. thanks jonathan.

        my answer is: I’m not sure.

        I think the ^concerns are vital, and the responses seem – to me, compatible with current nursing practice.

        as I understand it, mh nursing (UK) ordinarily includes delivering care based on sound evidence; reducing/combating the harmful effects of treatment; speaking out against oppressive practice, fostering dependable relationships, consent, choice and alternatives to force or restrictive intervention.

        it’s clear from the discussion though that these things don’t eliminate harms, oppressions, alienations … and this is painful for nurses trying to work in good faith.
        but – whether CO could resolve these problems more adequately? maybe nurses could feel less alienated, but in terms of reducing harm? I’m less convinced.

        thinking fast, I have a worry that CO might even render patients more vulnerable if one part of the workforce removes its voice & values from an intervention – particularly if it’s one that champions the more relational aspects of care drawn out above …

        I’m down for the cause (combating oppressive practice), but I suppose I need more convincing as yet re nurses & CO.

        thanks again

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  38. Posted on Twitter so now found where the discussion is Late 2 the discussion Q Does CMHNN members endorse NICE NG10 evidence based Aggression & Violence guidelines & patient’s right to NHS Constitution reference 2 NICE Advanced statement on how to be treated in event of relapse promotes shared decision making & Person centred care

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    1. Dear Francesco,
      Thanks so much for your contribution. You have used a sort of key word… ‘endorse’. We don’t really do that. A critical network probably struggles to endorse anything! There are some fine words in the documents you have mentioned. A link is below for others who may be interested.
      One phrase that may be found there is ‘least restrictive’ and that has a great bearing on this conversation. A number of participants to this conversation would probably suggest that ‘least restrictive’ is a loophole that leads to the justification of lots of problematic behaviour. It may be that service-users are given the least restrictive option available… but that the range of options that are available is poor.

      https://www.nice.org.uk/guidance/ng10/chapter/1-Recommendations#principles-for-managing-violence-and-aggression

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  39. Jonathan (Gatsby), I want to say a personal thank you to you for having the energy and imagination for radical change to facilitate this historic blog. It would be great to see this, in an expanded form, as eg a book. I’m thinking maybe a new one for the PCCS ‘Our Encounters with….’ series (Conscientious Objectors). As you say, there’s lots of important material in here. This book would function as: social history; a further call to arms; a conscience text; a consciousness raising text; an addition to the crit MH corpus; an ethics text for students….

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  43. Pingback: What’s going on right now? – Critical Mental Health Nurses' Network

  44. Hat off to you Jonathon – an excellent debate, and very timely. I wonder if a sense of conscience is not far away from a number of nurses, yet invasive practices still persist even with this conscience, suggesting the drivers for such ‘treatment’ goes beyond any mental health setting. I would imagine discussing CO in the public domain, might require a debate on ethics, and what it is to be a mental health nurse. Importantly what is our role, duty, and who do we actually serve? I would question also that in practical terms to object might not be determined by the need of the service user, hence there is a question to what is objectional and what is not, and importantly who decides. My personal view is until there is an outright ban on physical restraint and seclusion, we might not think of alternatives.

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  45. I had an additional thought, many times mental nurses are put in a situations where they have little or no opportunity to object. They are in an urgent crisis situation, where they have few options and resources. CO commonly refers to a situation where one is an outsider to the action and one can decide whether or not to participate – such as going to a war. In mental health nursing, sometimes, but not always one is inside the crisis and so one has little opportunity to object.

    I think – in these more urgent situations – what is needed is a retrospective systems approach that looks at what led up to the action and what created it rather than a blame culture that holds individuals responsible and morally responsible. This would be I think quite productive and should be especially done by people outside the organisation but who try to understand what is happening.

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