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.

201 thoughts on “Conscientious Objection from Enforcing Treatment

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  1. Hi, This is really good news. How do we communicate on the day, just via our normal emails if that suits?

    Linda ________________________________

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    1. Dear Linda,
      Thanks for clarifying this. We are going to use this website. People may simply ‘reply’ to this blog post and we’ll go from there. We expect quite a number of threads and sub-threads as people ‘reply to replies’, but don’t worry, we will do the job of sorting through all the different ideas to produce some kind of document afterwards for everyone who took part to ‘OK’. Does that make sense?

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  2. Two questions:

    1) Are service users able to become members of this network?

    2) will it be proposed to the relevant unions that nurses ought to be able to conscientiously object to forced treatment?

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    1. Dear Ben,
      Thanks for contacting us.
      1. Actually, we don’t have any kind of membership list or membership procedure. If you (or others) are using this website, reading our posts or contributing, then you are using the Critical Mental Health Nurses’ Network. Our website and occasional events, friendships we have made and our book just out… this is us networking, doing what we set out to do. All are welcome, there is no ‘qualification’ required other than your interest.
      2. Absolutely no idea – that’s why we are having this conversation! First of all we need to establish together whether we think it is reasonable for nurses to raise a conscientious objection to enforced treatment. There are a lot of considerations to that. Only after we have had this conversation can we know if we have any kind of consensus or desire to turn this into a campaign. How we do that, who we would involve, unions or others, would all need to be discussed. Hope that helps – and hope you will take part in our conversation, which kicks off in 6 days time!

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      1. Ben, in answer to your second point: I have circulated the unison nursing sector to encourage participation in this discussion. also, mentioned it in a meeting at which Unite nursing lead was present and that links into RCN. so individual members have every opportunity to take part.
        as for making this union policy: there will be different processes in different unions. in my union, unison, it would have to be a motion presented to national health service group delegate conference, taking place in April. Would probably need some organising before presenting such a motion. Discussions can start in branches and regions and the national nursing sector committee, which I sit on – so plenty of scope for building support.
        this is worth doing and I would certainly be happy to help.

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      2. To get the RCN policy adapted would take a piece of work either through the professional lead supported by the nursing department and then determined by Council, or by a resolution at Congress voted for by the membership. The former would take an indeterminate period of time depending on the workload and other priorities within the field of nursing (not just MH); the latter would be possible probably about 14 months from now if there is some sound policy and evidence base on which to draft a resolution.

        Jonathan, I wonder if we might persuade you to be part of a fringe event in Liverpool next May to discuss this further? I’ll email you separately.

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      3. In reply to Ed-

        ‘To get the RCN policy adapted would take a piece of work either through the professional lead supported by the nursing department and then determined by Council, or by a resolution at Congress voted for by the membership. The former would take an indeterminate period of time depending on the workload and other priorities within the field of nursing (not just MH); the latter would be possible probably about 14 months from now if there is some sound policy and evidence base on which to draft a resolution.’

        My reading of the Code suggests a clear pathway to conscientious objection now (ie we must arrange for a suitably qualified colleague to take over responsibility for that person’s care) around any treatment at all…it’s just that the right to conscientiously object is not protected by statute, nor would it be (of course!) if Congress voted for it…..interestingly, in a previous legal case Royal College of Nursing of the United Kingdom v Department of
        Health and Social Security [1981], RCN sought to limit nurses role in abortions whilst the DHSS seemed happy for nurses to carry out terminations in surgical procedures……I am assuming that the RCN policy at the time would have shaped their stance in that case?

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  3. WELCOME, WELCOME, WELCOME!

    This discussion is for everyone to approach in whatever ways they wish – as long as we are all as respectful as possible towards others.

    If anyone is wondering how to begin, how about this?

    Is this an issue of conscience or an issue of evidence?

    (but equally, feel free to ask questions/discuss thoughts of your own)

    (hit ‘reply’ and off we go!)

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  4. Hi Everyone

    I think it is both – an issue of conscience and an issue of evidence. Psychiatric nurses are expected to implement the requirements of the Mental Health Act ( a framework that is inherently discriminatory) so I’d argue that morality & conscience come into play here. Also, I’m unaware of any evidence to suggest that forced treatment achieves benefits for service users, while there is a huge body of anecdotal evidence from personal accounts of the harm caused by these coercive practices.

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    1. Hi Everyone! This is great!
      Can you ellaborate a little Alec?
      I’m going to use ‘CO’ for concientious objection because everytime I have to type it I have to correct it!
      Who else is on line at the moment?

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    2. And arguably forced treatment is not good for the workforce either, contributing at the very least to alienation from ideals of self (as helper) and undermining professional values of cooperation. To be in conflict is unhealthy for all parties to these relationships and encounters,

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  5. there could a good audience for this better than the hosts for I emailed the editor of Nursing Times to let him know of the existence of the critical mental health nurses’ network along with reasons why NHS Scotland might go the way to Open Dialogue….

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  6. I’ve been thinking about this issue quite a bit recently.
    I’m grateful to you, Gary, in digging out the NMC link: https://www.nmc.org.uk/standards/code/conscientious-objection-by-nurses-and-midwives/
    I’m wondering what people think of our current provision for CO? Are we asking for an extention of this? I find the business with “They must arrange for a suitably qualified colleague to take over responsibility for that person’s care” (see link) very questionable. I certainly want to discuss that further.

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    1. I’m also not sure that the current provision answers a question I have about all this. Supposing enforcing interventions is a matter of conscience, like taking part in abortion. Should CO be a once-and-for-all decision (part of my identity: ‘I am a CO’) or is it an occurance by occurance decision?

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    2. I agree, Jonathan – the finding a ‘suitably qualified colleague to take over responsibility’ doesn’t sound like a viable long term option. But if we choose to pursue the CO route, and thereby resort to existing regulations, there might not be an alternative. At the very least such actions would, I imagine, attract a lot of attention/publicity which might be advantageous in encouraging a wider range of stakeholders to start to talk about the injustices within the Mental Health Act.

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      1. Yes… and I guess that leads to something else that we must talk about…. the attention would mostly come down on the individual in some very unwelcome ways. Probably this is something for later on in the discussion, but I guess we need to talk about a number of ways in which this could very seriously backfire on individuals.

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      2. Yes – good point, Ed. But then agian, some will feel that causing inconvenience is not a downside. If you truely believe that using force in a particualr situation is wrong, then you aren’t worried about it smoothly going ahead with other staff members.

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    3. I think that arranging for a suitably qualified colleague could work well in some cultures, appallingly in others.My own experiences of whistleblowing on a colleague who began (in my opinion) unnecessary restraints remind me of the difficulties of being a lone or minority voice. What if you are short staffed and no one appropriate is available? What if you have to poach staff from other wards and breed resentment and division as a consequence? If a culture sanctions and supports the significance of individual beliefs, if a culture allows responsibility without blame, if a culture nurtures difference, then why shouldn’t it work well? 🙂

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  7. A bit of law: Section 2 of the Mental Health Act allows for an individual to be deprived of liberty in a secure mental hospital for up to 28 days for the purpose of “assessment” of the individual’s mental state. There is also a provision in Section 2 of the MHA that allows mental health professionals to administer drugs to the detained individual, and the logic that lies behind this additional power is: if an individual is “sectioned” for a fourth time then the mental health professionals know already what is wrong with the individual, assuming there has not been a misdiagnosis, and there is no need to wait for the 28 days before Section 3 of the Mental Health Act can come into play, with the increased power that medical health professionals can mandate that the individual take drugs. The assumption of the Mental Health Act is that the professionals know the difference in the extent of their powers of each Section, and accordingly, will exercise their legal powers and duties in line with the will of Parliament.

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  8. I had a lecture on the MHA and in that same lecture our teacher told us about a time she had CO’d in relation to supporting someone have an abortion due to her religion. And I wondered if one day we would be able to CO to enforced treatment, coming from a human rights perspective. So I’m very excited to come across this discussion, and to not feel alone in wondering whether this could ever be a possibility. It seems so overwhelming though.

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    1. It just seems incredible to me that given the highly contested field we work in, that abortion could be the only thing MHNs can CO to! Surely it is obvious that we could have a CO to a number of other controversial and contested parts of the MHN role.

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  9. The 4 principles are spectrum for autonomy, beneficence, non-maleficence and justice. Also, what are your thoughts around how an individual feels for instance in a case of enforced treatment where the professional administers a depot or rapid tranquillisation against consent and the patient subsequently dies?

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    1. Thanks, Fi.
      The scenario you describe sounds horrendous, have you experienced that?

      OK. Those 4 principles! Well, that is exactly the point – for me, at least. All four seem to be seriously violated during the use of force. I know that many nurses would argue that beneficence is a complex one and they say that they acting in the ‘best interests’ and that the person will be grateful in the future. They may also say there is no alternative. I personally doubt all of those things.

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      1. Is there any comeback on professionals where a “best interest” action is undertaking which the patient, post “recovery”, finds the intervention was not to their benefit? For example, gestational diabetes caused by antipsychotics in a pregnant woman. I’ve never seen it happen, but wonder how the patient/SU would even begin to approach this.

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  10. I’ve witnessed enforced hands on treatment of others and ‘subtle’ enforced treatment on myself recently. Years ago I was subjected to horrendous enforced treatment which almost cost me my life but owing to being ‘detained’ someone else had the power over my decisions. Even though I was ‘fairly’ rational.

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  11. In the the preface of Sanity, Madness and the Family R .D. Laing wrote: “We do not accept ‘schizophrenia’ as being a biochemical, neurophysiological, psychological fact, and we regard it as palpable error, in the present state of the evidence, to take it as fact. Nor do we assume its existence. Nor do we adopt it as a hypothesis. We propose no model of it.”

    Powerful stuff and this belief is the basis of the Open Dialogue Approach. If Laing was taught then a nurse when knew the medical grounds for CO

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  12. Love Laing 😊 I’m very interested in the aspect of re-traumatising people by the coercive practices employed by services. After all, the majority of people in hospitals have experienced trauma which necessitated their subsequent in patient stay.

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  13. Hi. Just my penny’s worth as a student nurse.

    1) Conscience or evidence?
    I think there is some evidence that enforced treatment can reduce length of treatment time, but also evidence that it can cause harm (to both staff and patient). To be honest, I don’t think it should matter whether or not there is an evidence base for it; cutting someone’s hand off might stop them from stealing but it doesn’t mean we should do it. For me, it’s a question of conscience, especially when it comes to the use of medication. Psychiatric medication is heavy stuff with some pretty awful side effects; I don’t feel comfortable forcing someone to take it if they haven’t given consent to do so.
    However…

    2) I think CO should be on a case by case basis. I can imagine situations where there are real dangers and the use of enforced treatment might be necessary.

    3) At times I have felt that enforced treatment is part of the job and if I can’t stomach it then I’m in the wrong job. However, I feel if I can’t maintain my ethical and moral principles at work then I’m sure I’ll burn out pretty quickly.

    4) For me, CO feels like questioning and objecting to the medical model and therefore the psychiatrists. I’m from a lower socio-economic status compared to a lot of the oxbridge educated psychiatrists I come across and I’ve internalised a sense of inferiority which makes challenging them very difficult. However, I think if I had the right to CO I might feel more empowered to take a stand.

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    1. Nice points. Nice to meet you Lauren.
      As for point 1 – I think I agree with that. As for 2 – I also agree. But I know there are a lot of questions to ask about how on earth that could happen in practice. At what point can someone just say, ‘ok, now I have a conscientious objection’. When the person is already being restrained?! It seems something needs serious thought there.
      As for 3 – now, that is where I don’t agree. My thoughts around CO come from my best understadnings of my professional duty, all the reading I have tried to do, and from my personal values. These are not things that make me a bad nurse, but a good one. And are we saying that force is so core to being a nurse that there is no point being one if you object to force?
      4 – Agree!

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  14. If we were, as a network, to argue that MHNs had the right to CO for enforcing interventions, I think there are several things that we might have to argue. Firstly, I think that there is an important issue to explore or explain: that this is not merely about whether the ‘evidence says’ it is right or wrong. Personally I feel we’ll get nowhere by just saying that psychiatric medications, or forced treatment, are unevidenced. That’s just an unwinnable argument. I think what we could argue is that they are significantly controversial – and that in 2018 this is enough to bring an intollerable issue of conscience to an idividual. I would probably want to demonstrate an awareness of the big important authors and ideas who show that the drugs are problematic (I’m thinking Moncrieff, Whitaker, Gotszche etc) but I don’t want to have to argue that they are right – only that they give me an intollerable problem. Does that make sense?
    I guess that partl of my answer to the question of whether this is about evidence or concience.

    Then there are other things. But maybe I’ll come onto those in a bit.

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    1. perhaps we could also throw in to the mix consideration of the persuasive evidence that trauma is the most evidenced determinant of mental distress. then we can consider the traumatising and retraumatising impact of forced treatment, with a view to refusing this …

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    2. I know I’m always banging on about the Mental Health Act, but (if we pursue the CO option) should one important part of our strategy be to draw attention to the discriminatory nature of mental health laws? If we still had laws that explicitly discriminated against ethnic minority groups, or on the basis of gender, there’d (rightly) be a huge outcry. Yet as far as the legalised prejudice against those labelled as ‘mentally disordered’, there seems to be a deafening silence, a mass collusion with this institutional unfairness.

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    3. This matters from a legal standpoint, too- the right to conscientiously object is tied up with moral and spiritual conviction. In the courts (which is where the matter could be determined) nurses would need to demonstrate the grounds for that conviction. It strikes me immediately that the grounds that have been established concern treatment leading directly and expediently towards life and death. We cannot say the same for any mental health treatment: any connection between treatment and life or death is more nebulous….

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  15. The only reason my own health allows me to write this evening is as a consequence of being part of a research study known as RADAR (Research into Antipsychotic Discontinuation and Reduction) otherwise, my miserable fate would be as an exploited individual stupefied beyond meaningful action, living my life out as a spaced-out zombie devoid of a sense of humour and with no purpose, with no critical monitoring of my progress outside of being injected fortnightly with what used to be called a major tranquillizer.

    Yes, the evidence would show I got out of hospital quicker, but in what human state? As a student nurse you are probably not taught what’s going on in Finland with Open Dialogue. But please don’t take this as a reason to debate OD let’s stick with CO.

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  16. I am interested in both the material/practical and symbolic consequences of CO. There is a strong possibility that the call for CO and campaigning for it would bring practitioners and service users/survivors into closer, politicised dialogue, and extend this to wider numbers of people than currently engaged in critical discussions. This would be a democratising turn in and of itself. Engagement in such discussions would also open up potential then for more broadly based political alliances, and the chance to work out a new politics of mental health – something the left has substantially failed to do up to now.

    The basis for solidarity would have to be worked through carefully, but could include elements referred to in the recent critical mental health nursing book – for example, starting with apologies for hurts and harms.

    finding solidarity over a refusal to be involved in further harms (at least some) may be a foundation for greater political trust, mutuality and reciprocation.

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  17. I think it does come down to conscience because really there’s a lot of theories and assumptions about mental health. Its not something we can physically test for. So I think, its society’s perception about people’s normality when some people happily live with and manage their own reality . An individual can and quite often does live in happiness until the authorities come along and decide your thinking is wrong. And cart you off and medicate you so you are so messed up you conform to society’s ideals. That’s probably a bigger discussion but it worries me greatly. And a lot of nurses are pretty individual themselves. So where does it end? Have alternative ideas and you’ll be medicated or ‘coerced to conform’.

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  18. For those interested in the political struggle for much needed reforms that will see Open Dialogue truly embedded in the National Health Service, your focus, should be on the Scottish Parliament. Read about in The Church Times. Below is the end paragraph of an epistle (dated 15 October 2018) to the Church and Society Council of The Church of Scotland.

    “I would encourage the Church of Scotland to show leadership on this and try to shape practices that the Church would like to see, and give serious consideration to a reformation of Scottish mental health services, and take a long hard look at what the public health systems of other European countries are achieving by applying values based solutions to those individuals suffering from emotional distress, and hopefully the Church will come to the view that there should be cross-party support in the Scottish Parliament for turning Scotland into the first English speaking nation in the world to have Open Dialogue at the heart of its public health system for the care of those suffering from emotional distress.”

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  19. in a practical sense – we could argue for a system whereby some sort of collective learning or debriefing must follow any act of CO. Allowing for opportunities for all concerned to have dialogue about what could have been done differently, what led up to the ‘need’ for forced treatment, could a different appraisal have been made, what were the (missed) opportunities for more consensual alternatives.

    Ultimately, the need for a range of alternative forms of support is tied up with the context in which a need for CO arises. it is difficult to conceive about how some forms of help/support might be forced, and the dominance of those that can be forced works to squeeze out imagination regarding alternatives ….

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    1. You are right. Many progressives end up deserting the ‘sharp end’ places where forced treatment is most likely to be enacted, or get jobs in universities. An important part of these discussions ought to be how to support staff in inpatient environments to offer more consensual care and treatment options and object to forced treatment. it is easier to speak of these things in the abstract – but abstract discussions are necessary to drive ideas forward.

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  20. If you are on the wrong side of the hypodermic then you need said stuff the left our only hope for salvation lies with the libertarian wing of the Conservative Party. Consequently I am never comfortable when someone puts left over right and vice vesa, preferring to seek an all-party consenus.

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    1. for what it is worth, I think the best hope for a more progressive mental health polity and services is with the left of the political spectrum. this isn’t the same as saying the left have the answers, rather I believe they are likely to be more persuadable. There is also the obvious arguments that can be made about neoliberalism and mental health – and most lefties want to be positioned against neoliberalism 🙂

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  21. If you are on the wrong side of the hypodermic then you might well say stuff the left! Our only hope for salvation lies with the libertarian wing of the Conservative Party. Consequently, I am never comfortable when someone puts left over right and vice vesa, preferring to seek an all-party consenus.

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  22. I worked on a project once where I asked staff and patients about physical restraint. The question I ask was do you remember the first time you restrained someone? Staff answered yes and actually went into detail about the traumatising aspect for both themselves and the patient. I asked about subsequent restraints and it was like after the first time they became almost ‘immune’. Miserably muttering about it being ‘part of the job’ and just coming across as an automaton and ‘used to it’ .my next question should have been ‘ so why did you carry on if the first time affected you so much’

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    1. These are such important questions. I think the simplest answer I can give, as a nurse who finds restraint (and, indeed, other aspects of coercion) very traumatising – but I still did them – is that becoming recruited into the stories nurses use to justify force is part of the ‘price of admission’ into the group called mental health nursing. That still leaves a lot of unanswered questions, I know.

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      1. Yes, such stories we tell each other and ourselves are part of wider narratives of legitimation and professionalisation. Equally, psychiatry and mental health nursing are subject to a very real crisis of legitimacy. CO and associated acts may be part of how we begin to escape this loss of faith in the worth of mental health care???

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    2. Hi Fi, we both worked on that project. I would add that one of the most telling observations was the lack of time that ward staff spend in relational encounters with service users. Also, more directly relating to your point, how force could be used, not as a last resort, but as part of a planned administration of medication. in this regard, the rationale for CO would seem to have to take account of objections to medication. The idea of last resort has been criticised as a fictional narrative that helps staff accommodate themselves to unpalatable practices ….

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  23. The patient answers were usually to the tune of ‘I felt like I was being attacked-again!!!’ But conversely, there were some instances of feelings of being ‘comforted’ or ‘held’ which held some therapeutic value.

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  24. “conversely, there were some instances of feelings of being ‘comforted’ or ‘held’ which held some therapeutic value.”

    Patients do lie, as in “Thank you Doctor, I’m so much better thanks to the medication.” and “I’m feeling so much better since the last course of ECT!”

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    1. I think one of the interesting things about this debate is that hurt and harms are distributed unevenly, and, whether one likes it or not, some patients will report that forced or other treatment that many of us object to, perhaps in retrospect, ‘helped’ them. This isn’t necessarily an argument against CO, but it does suggest that our democratic dialogue has to be care-full.

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  25. I was prepared for a tribunal hearing and my solicitor supplied guidance that he called “a simple formula for getting out,” that is: get a haircut as soon as possible, take regular showers, change your clothes frequently, attend as many “therapeutic” activities as you can, and most importantly, during ward rounds agree with your consultant and don’t argue!

    With my whole life depending on it I followed my solicitor’s advice to the letter, and, as he expected, I was discharged before my tribunal hearing was scheduled to be held. His simple advice turned my psychiatrist’s opinion from one, where Dr Nuala Mullans tried to disingenuously persuade from attending the tribunal hearing on the grounds that my cross-examination from the hospital’s solicitor would be too distressing for me to handle, to one, that I was well enough to go home.

    If I had continued with the logic of Breggin, Laing and Moncrieff in ward rounds, I would, probably, still be in the locked ward environment today. The solicitor no longer works in mental heath and may have moved on to working in an another more profitable area of the law.

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    1. Hi Liam – Well, I think your brilliant and witty point is in some was a sort of a reply to a little of what Mick says about about expressed gratitude – that we don’t run a mental health system in which we can reliably call expressed gratitute a retrospective justification for force! People learn to say what professionals seem to need to hear and they do so because they are not stupid! That solicitor was clearly worth his weight in gold…

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  26. As a pedantic person I’m keen to think what CO would look like, as someone said earlier. I’m against a general CO status as this would create two camps with, I think, undercurrents and I’m not sure which I’d be in to be honest.

    I can see a position of situational CO – in parallel with a review of forced treatments as a nurse specific activity. In other words, should we be looking more at the right, indeed the necessity, of CO where the prescribed practice has been set by a person or persons not present and where the principle of “least restrictive” or “last resort” has not been discussed or satisfied?

    And this is all planned interventuons such as forced meds or feeding in acute anorexia. Fights or impulsive severe self harm – are they another discussion?

    Anyway. Great we are debating

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    1. Brilliant points and I am going to think about these, and other things people have said, and come back tomorrow night. In fact, one of my strongest thoughts is that I’m very very very glad we are not on twitter because I can barely keep up as it is (I want to make sure I haven’t missed replies to replies, for instance). I want to go away and think!

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  27. I knew that was coming Liam 😊 yes you’re right. But I have met many many patients for whom restraint is the only physical contact they’ve had in years. I’m thinking particularly about the forensic population. Or the cases of patients actually kicking off on purpose in order to gain that contact. Its not right. It says something about society that I think. I complied with medication for years to let the doctors know I was being ‘compliant’ . And now I take nothing. And they took 20 years of my life due to antipsychotic medication. So I’m looking forward to those who enforced that treatment being asked by my family why their grandmother and mother died early due to society disagreeing with my thinking and the enforced treatment that shortened her life.

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  28. In Laing’s seminal work Sanity, Madness and the Family Laing wrote that the lifespan of the “schizophrenic” was the same of that of the general population, in stark contrast, today, in 2018, the lifespan of the “schizophrenic” can be thirty years shorter than that of the general population.

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    1. We should be candid about it! NMC Code 5.5 ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively
      and in a way they can understand’ NMC Code 14 ‘Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place.’

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    1. Laing was a complex and contradictory clinician and proselytiser – often not the best advert for his own ideas. yet, made plenty of telling contributions. Peter Sedgwick’s take on Laing and ‘anti-psychiatry’ is worth re-reading, not least for a plea for ‘more and better psychiatry’ and relational alternatives to singular bio-medicine. Sedgwick was dismissive of anti-psychiatry but arguably was fonder of some of Laing’s ideas than others. He did want more attention to the concerns and rights of families as potential allies in a politics of mental health.

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    1. CO to enforced treatment begs the question what is treatment? Do we mean medication specifically or can it also relate to hospital admission or compulsory community care, protection from risks? Also the idea of enforced is complex, what if the service user is happy with the care they have or don’t understand it properly. What if our objection is based on all sorts of idiosyncratic factors – our beliefs, religion, politics, experiences, knowledge about what works, our trust in doctors, or our mistrust of specific persons.

      It is interesting to think about CO to aspects of work that are not enforced or not treatment. What if we think the service user should be afforded more freedom or what if we think they are not getting the dignity or honesty they deserve or that there is a focus on risk. Perhaps the focus needs to be more systemic asking not just whether CO is right or wrong but how the system can be reconfigured so that the dignity of both service users and workers are better respected – a good place to start is to take emphasis off crisis and risk management and treat both nurses and service users with some dignity.

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      1. Enforced treatment encompasses default environmental enforcement. I have written extensively on the human rights abuses that this gives rise to, in JP&MHN, NET and MHP articles,  in successive editions of the Barker (ed) then Cambers (edP book Psychiatric and Mental Health Nursing: The craft of caring, and in this year’s Bull et al. Critical Mental Health Nursing…. PCCS text. It has astonished me for years that mental health nurses don’t protest about the (negatively evidence-based) acute ward environment, in which service users have roughly a 1 in 3 chance of abuse – either physical, sexual, emotional, or violence to their narrative identity.

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      2. Smith…. you are right about the significance of the word treatment-in Greater Glasgow Health Board (Appellant) v Doogan and another (Respondents) (2014), the meaning of the word ‘treatment’ was clarified and extrapolated to include multiple aspects of midwifery work in relation to abortion, clarifying what might be covered, to a degree and also, what would not be covered. I wonder which aspects of treatment you could conscientiously object to? Just the restraint and the injection? Drawing up the injection? Calling the doctor to sign the appropriate paperwork, if required?

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      3. Peter, my ‘objection’ relates to the entire ‘reformed’ system – the crisis/risk focused and biomedical system has clearly not been progressive and is creating many problems.

        Enforcement may or not be a good thing it depends of context- speed limits being enforced is an example of what is generally a good rule but it can always be improved. The trouble comes when force is not used ethically – it occurs is ways that are unjustly, unequal, without thought, in an instrumental or isolated way. We will never get a perfect system but what I am saying is that the current system is clearly unethical and not working and will continue to get worsen. I note that other social systems are similarly failing – health care in general, the prisons, education, policing and so on. This is a wicked problem and wicked problems cannot be fixed by instrumental solutions, rather they require clumsy ones and most important is an ethics that goes beyond rules.

        Alec, I agree, nurses don’t protest because they are trapped in the system. Any straying from the program will quickly lead to sanctions and is a very real risk. Most nurses are tying to pay their bills and get by. Older nurses, as Mick has described previously are more recalcitrant but the newer nurses don’t even know that a better system is even possible. They are caught in a ongoing crisis mode that only gets worse over time. For me context is very important.

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      4. “nurses (in 2018) don’t protest because they are trapped in the system. Any straying from the program will quickly lead to sanctions and is a very real risk. Most nurses are tying to pay their bills and get by. Older nurses, as Mick has described previously are more recalcitrant but the newer nurses don’t even know that a better system is even possible. They are caught in a ongoing crisis mode that only gets worse over time.”

        Yes, I hear you. But what the trade union? Do nurses have a trade union? Are they allowed to join a union? Unions are the traditional route to protest.

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      5. There are several unions representing nursing, from the GMB to Unite, Unison, Royal College of Nursing and probably others too.

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      6. In the neoliberal world unions are mostly a spent force, the evidence is that industrial action has vastly decreased over the past 40 years.

        I hope they can be revitalised but I see them as another part of the bureaucracy, mostly staffed by careerists and kept in check by regulations. Most of their focus is on risk mitigation and dampening down a crisis when it gets out of hand. I am familiar with the talk that unions are only strong as its members, we need to remember that unions have become another part of the neoliberal state and to pretend otherwise is wishful thinking.

        I am arguing that the real issue is systemic and goes beyond the mental health system.

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  29. As a background, I am a Charge Nurse on an Adolescent Psychiatric Intensive Care Unit. This area of MH services is typically (I say typically, as I think assumptions are unhelpful) associated with higher rates of enforced treatment. Indeed, all of the patients who are on the ward are compelled to be there, i.e they are detained under the Mental Health Act. Thus, it could be argued that their entire treatment regime (which the courts have defined widely, to include not just medication and therapy, but also nursing care) is enforced.

    For the purposes of this discussion I think it makes sense to focus to define treatment as the enforcement of coercive and restrictive interventions e.g medication, restraint, seclusion. There is a wider debate about involuntary hospitalisation as a whole, but it is important to make a distinction between enforced ‘hospitalisation’ and enforced ‘treatment’ (defined above) as they are both different things and involve very different decision making. It may be felt to be necessary for someone to be compelled to be taken into hospital, but inappropriate and unethical to enforce treatment on them.

    I want to illustrate a point from my own work environment. We recently undertook a seclusion audit of our ward, which provided us with an insight into reasons for seclusion, duration of seclusion, as well as the nurse who initiated it. It was striking that some nurses did not seclude patients at all or minimally (1 or 2 instances over a 6 month period), whereas some other nurses appeared to be much more likely to (10 to 15 instances over the same time frame). Although the audit has not taken place, I am sure that the initiation of enforced medication via rapid tranquillisation would tell a similar story This is worth further inquiry. We have worked with the same patient group. We have nursed them at all stages of admission and at during times of varying acuity. No one nurse has dealt with more difficult situation than the other. So why is this happening? Despite some nurses’s attempts to reduce enforced treatment (arguably a form of pragmatic CO), there are still others who are much more likely to use it. Does this defeat the object of CO if there’s always someone else to do “the dirty work”?

    I’d like to quite Peter Bartlett about this particular point: “…the decision regarding….compulsory treatment will depend to an unacceptable degree on the professional staff assessing the individual. This will in turn often depend on who is on duty when the individual is apprehended: detention, enforced treatment and human rights become a lottery.”

    I wonder if CO does not necessarily achieve the necessary goal, and an individual decision not to enforce treatment does not stop someone else from doing so. Thus, violence remains central to our profession. Perhaps we need to talk about a collective decision to stop enforcing treatment all together…

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    1. Wow, Owen. Such a meaty contribution! Thanks. Loads to think about.
      I think a part of this question for me is about disruption.
      Conscientious Objection may in some ways be problematically indivudal, when new sets of team discussions might be better.
      CO may also be problemtatically focused, when coercion is so widespread and takes so many forms.
      However, for me, not only am I attracted to CO because I genuinely think I do suffer an intollerable issue of conscience, and I get there for good nursing and personal reasons, but because it is disruptive. I suspect that no kind of reform or new team protocol has the power to disrupt the otherwise smoothly flowing powers that can lead to the logic and use of force that many service-users experience.

      I’ve just read a new post here by Fi Jones and I feel convicted all over again.

      I would also like to put in a very strong additional statement about the distress of mental health nursing students as they become aware of this side of the role. It is clearly not why most come into the pofession and many fear (I think rightly) that they will be damaged by it.

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    2. Hi Owen, your audit sounds very interesting indeed! Have you considered publishing it in some form? As you say, it poses the interesting question ‘Why do some nurses restrain and some don’t?’….my first thought was as someone who used to use services, ‘I bet some of them enjoy it more than others’, but then I remembered my own experiences restraining in a MSU in East London. I restrained more than others, I think because I was male, taller, stronger, had lower professional status…perhaps there are lots of factors to consider? If you say ‘it’s a dirty job, but someone has got to do it’, there is an acceptance of a job to be done….alternatively, if no-one will carry out the task, surely there is no job to be done?

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      1. I’ll have a look into that.

        I think the “acceptance of a job to be done” hits on something really pertinent – for great swathes of mental health nurses, the idea of conscientiously objecting to enforcing treatment is just not on their radar. ‘Enforced treatment’ is part of their day to day job. For some MHNs, the idea that someone could think that it was “wrong” let alone object is ludicrous. Even if they aren’t quite as explicit, they may be ambivalent, accepting it as a “necessary evil” of the job.

        This is why the idea of CO is important. It as much a personal and individual statement as a rallying call to other nurses to open their eyes to the issues at hand. Maybe division is good. Maybe, as Jonathan suggested, disruption is the only way that we get people to start asking questions.

        I think, unfortunately, that a lot of enforced treatment comes from staff ambivalence, poor critical thinking, and laziness. When you understand that these things result in patients being subject to abuse and violence, it is terrifying. I think along with CO, there is a duty to address the culture of coercion in general, to train staff in human rights issues, and to have clear safeguards and procedures in place to stop staff abusing their power.

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  30. I have never experienced compulsion as a service user, but in my 25 years as an ASW (now AMHP) I often ‘commissioned’ others, usually police, to compel people who I had assessed under the MHAct. Additionally, in Child protection work, I would sometimes take children from their parents, occasionally by force. I always found these actions painful and traumatic (though obviously I suffered far less than those against whom the force was being employed).
    I imagine that MH nurses may have used the same rationale that I did, that what I was doing was, in the long run, in the person’s ‘best interests’.

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