Mental Health Act- Evil necessity?

[RNewbie15]

Hey everyone, I was hoping I could start a discussion around mental health nursing and the use of MHA or what ever variation there is in your country. I would love to know how the mental health system works in different parts of the world.

Part explanation and part rant:

I am a new graduate nurse working in Mental Health. I love Mental health but I hate the Mental Health system. I currently feel very conflicted in my practice and two main points of conflict for me are the mental health act and the use of seclusion/ restraint.

In New Zealand (where I work) people can be placed under the mental health act if they meet two criteria: 1. They have a mental disorder (Axis I diagnosis) and 2. They are at risk for harm to themselves or others (this includes perceived neglect or vulnerability).

While under the act people are not able to refuse medical treatment for their mental illness, this includes medications, procedures (eg. ECT, although if they don't consent a 2nd health professional is required), and interventions. It is the only piece of legislation in my country (besides the crimes act) that allows us to uproot people and force them to stay in a chosen environment and it is the only piece of legislation that forces people to have treatment. I find this challenging because it disempowers, restricts, isolates and stigmatises people, the complete opposite to what I want to achieve with service users.

In addition people under the act are reviewed in court, the responsible clinician, a second health professional (normally nurse but sometimes OT), the person under the act and their lawyer are required to testify to the judge as to weather they should remain under the act. When I testify I feel like the trust and therapeutic relationship I have developed with the individual under the act is completely destroyed and it's so difficult (impossible) to get back. There is a real sense of betrayal and my relationship moves from being the nurse who wants/ tries/ does help to the mean nurse who is conspiring and forcing them to stay in an unpleasant ward.

In addition to the MHA acute inpatient wards are locked, and restraint and seclusion are still used in an inpatient setting. Holy hell I am so so so uncomfortable with this. We get trained how to restrain people, and in situations where people become violent I understand the need but I have seen it used to force an IMI. I feel it was incredibly traumatic for the person who was restrained by four people and had her trousers pulled down. Yes she was unwell, yes she was under the act and so can't refuse treatment, yes she was disturbing others on the ward with intimidating behaviour (slamming doors shouting at staff). But there is no way forcibly restraining her and injecting her was the best option. Was it?

I can see why in this individualistic, risk-adverse society that there is a need for a MHA but I guess I would just like to hear others opinions and suggestions for a conflicted new practitioner.

TL;DR

Mental Health Act and forcing people to have treatment doesn't sit right with me. What happens in your country, and do you have any suggestions to help me deal with this internal conflict.

Thanks

[angeloublue22, BSN, RN]

I've worked in mental health for 7 years including in jails and prisons. I too was uncomfortable about forcing patients to get treatment but unfortunately that is the only way to get them well sometimes. It's either they are forced into treatment or they end up in jail where they get almost no treatment. I was really surprised to find out that even an inmate who is banging his head against wall can refuse treatment. Prisoners have more rights than mental health clients. But that is not a good thing because there I got to see what these people turned into without forced treatment. If there is no other way, forced treatment is your last ditch effort. Some are so out of touch with reality and once that treatment happens and happens consistently they become a different person and you see why it is an option. It may not work for all clients and you are right in saying that sometimes it makes them worse but the world is still trying to find the perfect way to deal with mental health clients.

Don't think of it an has testifying against them, think of it as testifying on their behalf to get them help. It is a double edged sword in that way, the clients may see you as the reason they have to be there. Unfortunately, that's the nature of the job. If you want to make changes, do some research and present it to your administration. You may be able to change how certain situations are handled. Maybe suggest some good de-esculation training. For me, forced meds or restraint is the absolute last resort and only happens if I have used all my tools in my toolbox to de-esculate the situation which has worked since I have only ever had to restrain a client 3 times in my entire career. Good luck and never lose your caring spirit.

[RNewbie15]

Thanks for your perspective, I really like what you said about testifying on their behalf, thats a good way to look at. I know it makes logical sense but I can't help going home some days and feeling like I've failed or that I'm a bad person. I guess I need to shift my perspective a little.

[Zyprexa_Ho]

I may be wrong, but I think in the US involuntary admits can refuse treatment unless it is an emergency. Or maybe that's just the case in my particular state.

[elkpark]

I may be wrong, but I think in the US involuntary admits can refuse treatment unless it is an emergency. Or maybe that's just the case in my particular state.

That has been the case in the five states I've practiced in over my career -- involuntary commitment does not mean an individual has given up the right to refuse medication, and other basic rights enjoyed by voluntary psychiatric clients, outside of an emergency situation in which s/he is acutely dangerous to her/himself or others (in which case, anyone can be medicated against her/his will).

AFAIK, every US state has some kind of legal process for forcing medication on a psychiatric client who is refusing in a non-emergency situation, but it's typically quite a bit more complicated than just being an involuntary admission.

[Kooky Korky, BSN, RN]

I do understand your feelings and views, OP. Not to put you down in any way, but you might start thinking differently if you ever get hurt on the job. Broken jaw for one nurse I worked with, broken glasses and facial cuts for another, stabbed with blade for 2 nurses, a tech, and a patient at the same event involving a patient, choking, punching, I could go on. One doctor was so scared she had to be ordered by her Chief of Psychiatry to go see a patient after a restraint.

Patients throwing heavy objects, flinging feces, spitting, jumping over the 4 foot high Nurses' Station barrier to attack staff, patients secreting razors under wigs so they could cut themselves even while attended by 2 staff at all times - these are some very sick people. I do feel sorry for them but not sorry enough to get hurt.

Either you will make peace in time with your role, or you should probably get out because it's too hard on your emotions. Best wishes in your decision. No shame if you decide to leave Psych Nursing.

BTW, I think it's wrong to make a nurse testify, The nurse is with the pt a whole lot more than doctors are so is much more vulnerable to danger.