Living Under Section – Coercion, Powerlessness and Aggravated Distress

0
549

In this post, I am going to discuss my experiences of being detained long term (and repeatedly) under a section 3 (‘section for treatment’) in an adult eating disorder unit. In particular, I will focus on the ways in which being sectioned and living within restrictive conditions escalated the extent of my distress.

My experiences were not overtly or obviously degrading or violent. I was not abused or bullied. Staff involved in my treatment were never intentionally unkind. Sure, some were less warm/thoughtful than others, but even the strictest, most patronising and least empathetic staff cared (and some were exceptionally caring). Not everyone who is treated as an inpatient is this ‘lucky’, but being sectioned for the long term was corrosive all the same. Having one’s rights and freedoms removed is inherently degrading, no matter how nicely or correctly the procedures for enforcing and managing those removals are implemented. When one’s ability to act autonomously and in personally meaningful ways is significantly undermined for an extended period of time, it is soul destroying, and for me, it certainly contributed to my escalating mental distress.

There are two main levels on which the lived reality of being sectioned play out. Firstly, there is the broad fact of others being in control of your life. This means being in an institution that you cannot leave and having no choice but to receive treatment. For me, this involved being coerced into ‘receiving nutrition’ and gaining weight, either by eating or by being sedated, pinned down and having a tube forced up my nose. Secondly, there are the more subtle, micro-level interactions in which the broader power relations in which you exist are manifest, and in which you deeply feel and embody all of those broader tensions.

I’ll give some examples:

You wake up in the morning and immediately remember that there is a member of staff close by, watching. You feel suffocated. Said member of staff says ‘good morning’ cheerfully. You don’t even bother to try to be polite back, because you cannot muster the strength. You know it makes you seem rude and obnoxious, but they already think that about you anyway.

You want to go for a cigarette so you find a member of staff and ask them to take you. They ask how many you have had that day so far. They tell you they will take you out in half an hour. You wait. The staff member gets delayed. You feel bored, frustrated, and you are craving nicotine. You go to find another member of staff and ask them instead. They point out that X has already said they will take you and you will have to be patient, they are attending to more important duties. You feel stupid and cross. You are sick of the sound of your own voice constantly asking for things. Three hours later you get to go out. By this time you are so pissed off you can’t even bear to talk to the staff member escorting you, despite her being perfectly nice. You know they will record this in your notes.

You’re on bed rest and need the loo. You stand up to get off your bed, and the second you do the staff member who is ‘at arm’s length’ turns to look at you. (Piss off, you think). You ask, ‘can you take me to the toilet please?’ The staff member reminds you to sit in the wheelchair. You do. They push you up the corridor. Other people walk past. You are physically lower than the member of staff, who is in control of your transportation. It is painfully, symbolically apt.

These seem like small events. Cumulatively, they feel like hell. What I found particularly difficult was the inability to act immediately on my own environment. I could not simply make a decision and then act on it. There was always at least one more additional step in the process. This might have been getting permission in ward round, waiting for someone to sign section leave papers or asking for help or permission from a member of staff. This seriously undermines one’s agency which, as it turns out, is absolutely key to having a sense of dignity and self-worth.

It is difficult to find the words to express how hard it was having others make decisions about me, constantly asking for permission and having to justify myself, being restricted and repeatedly being told ‘no’, and (at times) not even being able to do something as simple as stand in front of the wardrobe to choose what I’d wear that day. Receiving forced treatment meant that I was repeatedly positioned in a child-like role, and I found this humiliating. I was also so utterly pathologised that, in most situations, being cast as ‘eating disordered’ and ‘difficult’ was completely unavoidable, no matter how much I may have worked to try to escape it (which I often didn’t). Being sectioned further affirmed my pathology because, not only was I eating disordered, but I also lacked the insight required to adhere to the programme voluntarily. I tussled with staff as I struggled to attain some sense of autonomy and personal power. But like a Chinese finger trap, the more I tussled, the more stuck I became. I found myself in the role of irrational, impulsive, manipulative patient and as the sense of frustration, anger and despair intensified, I increasingly acted in ways that further cemented that role. It was asphyxiating and disabling. I was ‘irrational’. I was rude and got cross. I self-injured, overdosed, went AWOL, hid food, argued, exercised in secret, cried, and repeatedly lost my shit. I was desperate. A psychologist report at the end of my fourth admission states, ‘Reacting impulsively to the imagined bleak prospect of repeat psychiatric hospitalisation under Section, Lauren managed her feelings of fear and despair through suicidality’.

Perhaps being sectioned drove me crazy? I would never suggest that being detained was the sole reason for my distress, but it did contribute. However, being sectioned probably saved my life. On two out of the three occasions of being sectioned I was already in the unit but my heart was failing and I wouldn’t eat, and I was sectioned so that they could force nutrition in me and prevent me from dying. But just because being detained – or any other procedure that is followed in the context of inpatient treatment – might be perfectly rational with a clear benefit, doesn’t mean that it isn’t degrading and traumatic. We need to pay attention to the subtle, insidious and accumulative effects of being dehumanised by coercive practices (even if that coercion might be believed to be ultimately achieving some greater good).

Enforcing life-saving treatment on individuals diagnosed with anorexia against their will raises significant ethical dilemmas (see for example this blog which addresses some of the nuances of these dilemmas). However, assuming for now that saving life is the ultimate ‘bottom line’ of treatment and thus justifies the use of (minimal) coercion, it is vital that this is balanced as far as possible with more humanising day-to-day practices.

Within this, I would suggest that it is vital that ‘patients’ have as much autonomy in their treatment as possible. This is both in the sense of having significant input in treatment decisions, goals and ‘care plans’ as a matter of course, and also in terms of daily life on the ward and the immediate conditions and relations one is living in. As an example, I would have felt a lot less frustrated if I had not had to follow arbitrary, general rules (regarding for example which therapeutic groups I had to attend and what I was and was not allowed to do while on bedrest) simply because the rules were there, and not because they were specifically helpful to me.

There were times during treatment when I was provided with opportunities to give input into the support that I needed. Unfortunately, I often felt so frustrated, stuck and hopeless, that I was unable to use this constructively; indeed, I felt that nothing and no one in the system could help or understand me. Further, I spent most of my admissions pre-occupied with how I was seen by staff, the impression I was giving and consequences this might have for me. The treatment situation itself created a ‘layer’ of dynamics that the treatment then attended to, rather than it getting to the core of what was really going on for me and therefore truly helping. In the middle of all the running away, arguing, tricky questioning in ward rounds and second-guessing, I needed someone to see beyond all of this and ask – ‘what is really going on for you? What is it that you need to say?’. I also needed an environment that would have allowed me to meaningfully respond to these questions. I needed to be recognised as a real, struggling human being, and not as someone that was ravaged by some entity called ‘anorexia’.