I watched Bedlam, a documentary based on the work done in the South London and Maudsley (SLaM) NHS Foundation Trust last week and this week. I was reassured by last weeks’ episode, titled “Anxiety” which followed some people who had obsessive compulsive disorder so I was looking forward to the episode broadcast last night titled “Crisis” which was based in an assessment ward (which they called a Triage ward) where, the programme makers told us, decisions were made about whether to admit over longer periods or discharged home.
The “story” aspect of the programme focussed particularly on four people – two men and two women who had found themselves in situations which had necessitated (or where they had chosen – in the case of informal patients) to be admitted to psychiatric inpatient wards. Fashionable documentary style is very much in the ‘story-telling’ vein. We like stories. We like stories with ‘happy’ endings and as the programme finished, they made sure we had the resolution we required but I was left uncomfortable by a number of aspects and details in the programme. Maybe I was more critical this week because it was an area I had more experience of but I didn’t walk away from the programme thinking it had necessarily reduced stigma and instilled a greater understanding of the mental health system as it is. Of course, that’s not the purpose of TV programmes at 9pm. The purpose was entertainment and perhaps that’s where some of my discomfort lies.
I saw a lot of the positive waves of support for the programme, helpfully tweeted out by NHS Maudsley through the programme. Interesting (but of course, unsurprising) that they didn’t deal with some of the criticisms. I know the issue of capacity to consent to filming has been raised and the programme makers have addressed it.
The producers state
One of the complex questions for filming on the ward was that of patients’ capacity to consent. We’d agreed a rigorous consent protocol with the Trust which included getting an initial steer from a lead consultant in charge of the patients’ care before even approaching an individual. At times we just got a patients’ consent to film them, we had to return to them at a later date to get consent to broadcast the material. We filmed with one lady, M, for a number of days while she was on the ward and then when she was discharged home we met her for lunch and she decided not to be involved further. Central to the filming was a respect for people’s right to privacy and we respected M’s decision.
Clearly they have covered themselves legally but some of the situations presented made me wonder how much thought had been given to the future impact of the broadcast on recovery in the long term and a full understanding of the implications of being filmed at your most unwell “in the public domain” for perpetuity – and the effect on yourself and your family of this. Of course, I’m sure these issues were covered but I was uncomfortable in the same way that I was with the ‘much lauded’ Protecting Our Children series. I’m not sure that seeing people at their most unwell or disturbed is ‘entertainment’ and now ‘educational’ it is. Do we need to ‘see’ crisis? Do we need to see a psychiatrist telling a patient he is going to use section 5 (2) of the Mental Health Act to demand that he remains on the ward when he has asked to leave? Are some things necessary to film and show on the television with real people to understand?
Perhaps I’m too sensitive because I’m thinking that for me, the thought of being filmed if I were to be restrained and forceably medicated by a team of staff is abhorrent personally. And thinking about the shots of someone being ‘persuaded’ to take their medication and forceably injected, I wonder how much it was necessary to see it. It reminded me of Panorama where the abuse at Winterbourne View was shown – not because there was abuse, clearly, but because I wondered at that point too, how much needed to do shown on camera and whether we were indulging voyeurism too much. Of course, legally, the Trust and TV production company had consent tied up but I can’t say it didn’t leave me with unease at the way we view entertainment and couch it in ‘education’ and ‘attention raising’ to make us feel better.
My other discomfort, and I’ve been criticised for raising this, was some of the racial undertones and stereotypes that I felt were perpetuated by the ‘storytelling’. Dominic, the white middle class man who would be someone who could be ‘identified with’ by many at home, was a ‘danger to himself’. Rupert, a black man, was presented as having been a ‘danger to others’. I felt distinctly uncomfortable not with the people telling their own stories in the context of the programme but with the narrative of the documentary makers that ran over it. The sequence with Dominic and Rupert singing together, seemed particularly focused on the viewer ‘empathising’ with Dominic – possibly at Rupert’s expense. Dominic was someone who was ‘like us’ – at least, until he got his ‘new’ diagnosis of having a personality disorder which immediately ‘othered’ him. Rupert was presented differently. Perhaps I am too sensitive to these things but having worked in mental health services in central London, it’s hard not to attune to race as an issue – particularly when we look at compulsory admissions.
Lots happens on admissions ward but in terms of staff, we only saw doctors and nurses. It’s a shame that there was a missed opportunity to see some of the multi-disciplinary work that happens on inpatient wards constantly especially as people move towards discharge but perhaps that’s an unfair criticism, after all, it isn’t an ‘entertaining’ as seeing people in distress. The ‘follow ups’ we got intimated that hospital admissions were successful. If that’s the case (and it isn’t always although obviously, we hope it is), I’d have liked to have seen some of the ‘why’ that we saw last week. Apart from seeing someone medicated, what other ‘tools’ are used to help prepare someone to move out of crisis. In my view, that’s an opportunity that was missed.
Early in the programme, I heard the documentary makers mention that patients who were ‘informal’ needed to see the doctor before they could leave the ward. This, I have to admit made me bristle. I hope it was a misunderstanding on the part of the documentary makers as it is veering dangerously close to ‘de facto detention’ on the part of the Trust. Someone asked me, during the programme to explain this better so I’ll give it a go. An ‘informal’ patient is a patient who chooses, willingly and with capacity understanding the implications of their actions, to admit themselves to a psychiatric ward. They are free to leave whenever they like. They are not under any compulsion to stay. If staff feel they are making a clinical decision that there is a need for someone to remain on the ward, or ‘see a doctor before they leave’ they have to ensure they have the legal authority to do so so as not to breach article 5 of the Human Rights Act – either by a detention under the Mental Health Act (known as ‘sectioning’) or by using immediate short term holding powers under section 5 of the Mental Health Act (5(2) is where a doctor can compel someone to stay on the ward until an assessment is carried out and 5(4) is where a nurse can do so for a much shorter period). Leave cannot by restricted for an informal patient. If they need to stay, or if their leave needs to be restricted there are legal processes which need to kick into place. Detaining someone is a massive infringement of human rights and needs to be considered carefully. It cannot be a flippant comment by a member of staff on a ward about ‘staying to see the doctor’.
So Bedlam this week, definitely not leaving me feeling that it was waving the flag for stigma busting. It’s a shame as the opportunity was there but the need for stories and entertainment were paramount. Personally, it compounded my view that fly-on-the-wall wouldn’t be my personal format of preference for gaining insights into worlds that might not be apparent to others. I am of the view, and I am aware I’m probably in a minority on this, who thinks that created drama without ‘real’ people on camera – at least during their moments of crisis – would be a better way to achieve this. Drama created by people who have understanding and experience, absolutely, but I’m not sure how much seeing the ‘real time’ distress and illness is a help to those who are experiencing it. Is that my inherent paternalist nature creeping out? Perhaps it is. Perhaps I overthink things and should let people get on with it but frankly, after last week, I was disappointed with last nights’ episode – as a rather sad epilogue, I am also thinking, thank goodness the Trust I worked in didn’t agree to TV cameras. Stories are good. Stories are necessary. But do we need every part of a story to understand? Do we need to see the needle being injected, the distress and confusion, do we need to see all that in ‘real time’ to understand? Maybe we do now. I accept I probably don’t hold the majority view on this, judging by the waves of praise for the Trust and the TV production company but it doesn’t shake off my general unease.