Funder by the Department of Human Services Auspiced by Our Community

THE QUESTION OF 'CHOICE'

Having the option of being centrally involved in selecting our own psychiatrist is a human right, but unfortunately too often that's not possible.


Public psychiatric units

Public psychiatry units are attached to large public hospitals. The movement from stand-alone psychiatric hospitals to units within general hospitals took place predominantly in the early 1990s and was called 'mainstreaming'. The vast majority of these units are locked even though there is a minority of patients within them who are not 'sectioned' (held against our will).

Almost everyone who is admitted to a public psychiatric hospital or uses a public mental health service has no choice about who they see in term of clinicians.

Even if we are a patient of a private psychiatrist, there is usually only minimal contact between them and the clinicians within the public hospital system - usually we are admitted by a different psychiatrist, especially if we are being detained involuntarily. This is because the Victorian Mental Health Act stipulates a maximum time between when the crisis team detains us and when we are formally assessed by a psychiatrist. So whoever's around has to do.

You will not see your allocated consultant frequently during your hospital stay. The longest opportunity you will have to speak with him/her will be the first conversation you have. He/she will ask you to follow them into a small, sparsely furnished examination room. The registrar will accompany you and the consultant might also ask you if you mind if a student can observe.

This first conversation, which the medical staff call 'getting a history', might feel a bit like a forensic cross-examination to you. This first conversation is the time to present your clinical Advance Directive if you have one. Note, though, that there is no guarantee that they will treat it seriously and many clinicians still don't know what it is.

The consultant will then pass 'the case' (you) on to be 'managed' on a day-to-day basis by their registrar. Again, we have no choice in this. If the registrar is someone who is completely rude and intolerable to us, incompetent or lacking confidence and experience, we can complain to the nurse unit manager that we are unhappy with this doctor-who-is-a-student and say that we need another one. This doesn't guarantee action but it might work if the manager is empathetic, confident, has read our Advance Directive, and has the capacity to shuffle his/her team around.

But with the occasional exception, we get who we get. Most psychiatrists working in public mental health services are:

Even if we did have any sort of choice it would be limited to these groups of people.


Area Mental Health Services

The majority of people who are committed to a public psychiatric unit also work from an Area Mental Health Service.

There are several ways that we interact with clinicians once we are registered in an Area Mental Health Service, but basically we have no choice about which clinicians do what in relation to our health.

This is no different from public hospitals and services in the area of physical health except for the fact that as soon as you are declared to be an involuntary patient you not only have no choice about the clinicians you are allocated, but you also have no choice about whether you accept clinicians in your life at all.

This gives extraordinary power to clinicians who may or may not earn it and who may or may not abuse it. In this situation a weight of responsibility falls on the 'management team'. It is their responsibility to make sure we are safe from unnecessarily coercive treatment.


Community Treatment Orders

A Community Treatment Order (CTO) is an order made under the Mental Health Act 1986 (soon to be replaced by the Mental Health Act 2013), which is signed off by the Mental Health Tribunal.

People on such orders have many freedoms taken away even though they are no longer in hospital. Failure to keep the conditions documented in one's CTO results in people being re-sectioned - that is, locked up in hospital again.

Victoria once prided itself on using CTOs to get people out of oppressive regimes in psychiatric hospitals. We led the world but the unfortunate result is that Victoria now has far too many people on CTOs.

Those of us on CTOs have our lives controlled by a team of medically trained 'police' who once were clinicians. What is choice for any of us under such orders? The term that we are being released from hospital 'back into the community' under a CTO is a euphemism.

Unfortunately there is rarely any choice or opportunity to work with clinicians we believe would suit us, have a good reputation with consumers, or whom we seriously believe will do no further harm. It is pot luck (or pot misfortune).

While there's no doubt that there are many excellent clinicians working in the public sector, and sometimes efforts are made to match a client with the clinician they believe will most aid recovery, this is all too rare.

Unfortunately we have also heard of consumers whose complaints about a particular clinician, a complaint that has merit, has been dismissed as further symptoms of their 'illness'. This is so dangerous for consumers on CTOs because they can be whipped back into the lock-up hospital extremely easily.


Patients as 'guinea pigs'

Those of us who use public services are in the view finder for clinical trials of 'new drugs' or double blind trials testing things like people's reactions to Vitamin D supplements (or whatever).

We are also in the line of fire for registrars trialling a new way of doing this or that in preparation for their exams.

Sometimes we are 'bagsed' by clinicians who are undertaking research in an area that is compatible with our diagnosis and life circumstances.

Although research psychiatrists do observe the requirement to obtain informed consent before doing any research or using our files for research purposes, there are many reasons why many of us say 'yes' to this when we mean 'no'.

These issues have a lot to do with power and relatively little to do with wholesome choice (on a purely practical level, learning to please the most powerful is sometimes crucial for survival.

This is not to say that some people using public services are not pleased and excited about being involved in something that may bring better outcomes for them or others. But it's important to note that you do not have to take part.


The effect of money on choice

The public end of psychiatric practice is skint. Poor people who rely on it never get the choices (or arguing power) that people using private psychiatrists do.

It's not just that choice isn't there to start with, it's also that 'getting better' also works to limit your choices - 'getting better' in public services means something quite different from what it means in private psychiatry; wellness on any level often leads to us losing our service. Many of us learn to sabotage the 'therapeutic' relationship in the vain hope of holding on to the services we have.

Those of us confined to public services by our financial circumstances also get less choice in terms of 'treatments'. Psychiatrists working in the public sector sometimes use cheaper and less effective drugs that have worse side-effects, or use us to trial brand new, untested drugs. While we are asked for consent, in truth we have little 'real' choice about this.