Bruno Rushforth: The jailer

Bruno Rushforth Who’d be a psychiatrist? The emotional burden of caring for patients presenting in real distress; trying to negotiate a way forward when dealing with someone with a skewed sense of reality; potentially life and death risk assessments on a daily basis; general lampooning from medical colleagues… No wonder psychiatry’s not such a popular choice among UK medical graduates.
But it’s something much more fundamental that would stop me from pursuing a career in the shadow of the Victorian asylums: the thought of repeatedly depriving people of their liberty and, more importantly, the impact this has on the doctor-patient relationship.

Sure, like police officers and judges, I know that in certain circumstances all doctors may have to act to detain someone in that person’s (or society’s) best interests – it’s just that I don’t want to be the one doing it. Having worked for six months as first on-call covering acute psychiatric wards as part of my GP training, it seemed rather alarming that by filling in one side of A4 paper I had the power to hold someone, against their will, for up to three days.

Perhaps, more worrying, was a colleague’s comment that this power made him feel rather intoxicated. I was more concerned about how this ‘elephant in the room’ would affect interactions with both voluntarily admitted patients and those already detained under the Mental Health Act.

But it wasn’t all doom and gloom. I loved the fact that for the first time there was a sense of true multidisciplinary working, with doctors, social workers, community psychiatric nurses, psychologists and ward staff all focused on a common goal. And I had to pinch myself when I was told there was one hour allocated for out-patient appointments with new patients. Integration of community and secondary care appeared fairly advanced too, with psychiatrists embedded in community teams while also covering the acute hospital.

And the crisis team staff were – to put it mildly – an inspiration.

These poor sods spent day after day (and night) at the very sharp end of emergency psychiatric care. Yet their compassion and professionalism – not to mention astute judgement – was truly admirable. I learnt much from their sophisticated risk assessment tools and thorough approach in clinical encounters and particularly documentation. And the team spirit and debrief – often informal and with a good dollop of black humour – was a model of team self-care. Then again, they weren’t the ones signing the section papers…

Bruno Rushforth is a GP trainee

  • Mo

    I find this entry curious, bordering on ridiculous.

    I think it takes a special person to take on the “emotional burden of caring for patients presenting in real distress”, to “negotiate a way forward when dealing with someone with a skewed sense of reality” and yet, face the “general lampooning from medical colleagues”. No, this is not for everyone.

    While acknowledging Dr Rushforth’s previous experience of working with homeless people and his degrees in philosophy and healthcare ethics and law, I find his views less than balanced, especially as an author of BMJ blogs.

    Victorian asylums are long gone. Yet, having worked in almost all subspecialties of psychiatry, I truly believe, society provided better care for a significant minority of people in those asylums than they provide now in the community with such money saving schemes called ‘crisis team’. Some of these asylums had workshops, post office, playgrounds. With the closure of day hospitals and activity centres, do you know what that patient of yours with mild learning disability is doing now? He is going to the local 12-store shopping mall, again and again and again – and that is his ‘activity’.

    Are you concerned about free will and all that? Would I let someone die in the corner of the street like a dog in hunger or would I ‘section’ him, feed him, wash him and provide him with cloths? The choice is clear to me, but may not be to you.

    Intoxicated by power? Your colleague needs supervision, pronto! Any psychiatrist worth his salt would think twice before applying Mental Health Act section, and then will think again, twice.

    Yes! I don’t get Christmas cards from my patients, but I didn’t join the speciality to get Christmas card. Those who want that may wish to become GP.

    COI: Career Psychiatry Trainee

  • Adrian

    Oh dear, it seems that the myths of psychiatry are still alive and well. This blog reads like an attempt to troll psychiatrists and get them riled. I feel sorry for the author of the blog if they truly believe what they wrote.
    FYI all hospital RMOs can detain someone inhospital for 72 hours under section 5(2) of the mental health act.
    I have had people thank me for detaining them under the mental health act once they have improved in their mental health, they were aware that they did not have the ability to make those decisions at the time. At least with the mental health act people have rights.

    There is no elephant in the room, the ethics and implications of the mental halth act are debated at length in the profession and detention is a last resort.

    I know I have been dragged into this despite my best intentions but this sort of mis-information is more damaging to the doctor patient relationship than detention.

    COI: Consultant Psychiatrist and member of Amnesty

  • Jamie

    I would agree with Mo here. This is exactly the the kind of misrepresentation and reinforcing of stereotypes that undermines psychiatry’s credibility. Detaining someone can be a therapeutic act but needs to be explained delicately.

    COI RCPsych member

  • Dr John Corish

    So it disturbed you that by filling in one side of a sheet of A4 paper you had the power to detain someone against their will for up to three days? Would it have made you happier if this detention could only be achieved by filling in 25 sheets of A4 paper? Because that’s the way the non-patient seeing bureaucrats who control UK psychiatry would like it to be.

  • Brian Kurrle

    I agree with the respondents to Bruno’s letter. As a GP with 25 years experience,I believe it is not a disservice to a patient to have him or her confined involuntarily for (gasp!) three days. I am always worried about what happens if I do NOT schedule a patient. Murders happen. Suicides happen.

  • Trefor

    As an experienced GP who recently spent 5 days trying to get an admission under the MHA I agree with the above comments. Compulsory admission is necessary in a tiny minority of cases. As it says on the forms you filled in, ‘for their own protection or the protection of others’

  • I would agree with Mo here. This is exactly the the kind of misrepresentation and reinforcing of stereotypes that undermines psychiatry’s credibility. Detaining someone can be a therapeutic act but needs to be explained delicately.

  • Elliott King

    As a medical student considering a career in psychiatry and more specifically the forensic aspects of this, I find the comments made interesting. I view psychiatry today as having moved well beyond the Victorian era and in a state of modern care, especially in purpose built units. Having worked in a secure unit one sees that it is absolutely essential that some people are deprived of their liberty in terms of their own treatment and protection from the public for sometimes very serious disorders. In general psychiatry I have never seen the MHA applied without serious consideration and with consultation with many facets of advice and expertise available to them. I have seen far better doctor-patient relationships in this field than other areas of medicine. Perhaps some people find working at the acute end of psychiatric care both interesting and challenging.