All posts by Victoria

'Secret smoking'

No Smoking?
No Smoking?

The Mental Health Foundation has this month published the results of a survey which suggests the ban on smoking in inpatient units has been highly problematic, and has lead to ‘secret smoking’. You can read the full report here on the Mental Health Foundation website.


I began working as a CPN when the ban was introduced – and, certainly initially, I felt very sorry for the colleagues I had left on the PICU of a Regional Secure unit who had to tell patients with very limited access to outside that they were forbidden to smoke. I am not a smoker, however I can imagine that if I smoked and found myself in very distressing circumstances, and in an unfamiliar environment, I would find smoking a source of comfort and reassurance.


Unhappy Staff:

The Mental Health Foundation report suggests that attempts to ban smoking are simply driving the habit underground. They found that only a minority of wards in England have introduced the ban successfully. 85% of 109 respondents to the survey said the ban, which came into effect in July 2008, had not been implemented effectively. The rise of “secret smoking” has lead to safety concerns: the risk of fire, and also the risk that patients who are very unwell may become aggressive to staff when told they may not smoke.


Members of staff are reportedly unhappy to take on an additional policing role, when they are already faced with the problems of holding people against their will and persuading them to take medication. Some staff members said they felt they had no choice but to break the law and ‘turn a blind eye’ to smoking, especially when patients were acutely unwell, and in units which lack an appropriate outdoor space to allow people to smoke. The ban was also felt to be a drain on resources as staff members were needed to escort patients off the unit to smoke.


Unhappy Patients:

There are questions that need to be asked about the effect the ban has had on the wellbeing of patients. Whilst it may be the case that a smoke-free environment is a healthier one in terms of the physical effects of smoke, Vicki Nash, of the mental health charity Mind, said: “Forcing people to stop smoking abruptly on admission to hospital when they are already likely to be distressed is inappropriate and could heighten anxiety”. According to Mind, people with mental health problems are twice as likely to smoke as the general population – which means that this ban is very difficult for a high proportion of patients.


Happy Tsar:

Despite all of this the government’s mental health tsar said he had visited many trusts where a ban had been smoothly implemented. Louis Appleby, the National Director for Mental Health, said other research had shown that although implementing the smoking ban had posed challenges, most trusts believed it had been done successfully. Professor Appleby said: “I have visited many trusts who have implemented the ban with little or no difficulty. Mental health wards are being transformed for the better and going smoke-free is part of this. We believe that mental health staff and patients deserve the same healthier, smoke free environment as the rest of the NHS and there are no plans to change the policy.”


Hospital or Prison?

Prison inmates are allowed to smoke in their cells, as prison is classed as a ‘home’. Does it seems odd that there is greater freedom in prison that in a mental health setting? May be not! Prison inmates also have the right to refuse medication.

On July 28th 2008 there was a nine hour rooftop protest at Ashworth Hospital in response to the smoking ban. The Liverpool Echo reported that an Ashworth source said: “It just went cold turkey on July 1. After that it was no smoking for anyone anywhere on the premises. We’ve got lags coming in who are used to prison life and have that prison mentality, and now they have lighters and cigarettes confiscated when they come through these doors. They don’t like it and you could see trouble had been brewing because they didn’t take kindly to it. We’ve been waiting for something like this to happen.”

I’m not sure I would take kindly to the smoking ban either if I had been admitted to hospital from my own home. Even if I wanted to give up smoking I am not sure that the day of my admission to a psychiatric hospital would be the best time!


What do you think?

Pictures from Flickr (click images to see more from these photographers)

1.  by get down

2.  by Penseri

3. by Mot

Birmingham City University – Recovery forum


We are planning to start a Recovery Forum at Birmingham City University.  In January I contributed a post about the Hearing Voices module that had been running throughout the autumn term.  The course gave students an introduction to the work of Marius Romme and Sandra Escher, whose work has inspired the Hearing Voices Network.  There are now over 170 Hearing Voices groups in the UK. 


The Hearing Voices module encourages participants to begin using Romme and Escher’s Maastricht Interview Schedule with service users.  The Maastricht Interview Schedule is not a quick assessment tool, but rather a way of helping people to talk about voice-hearing.  We also discussed ways that people have found to cope with problematic voice-hearing; and we talked about group work led by voice-hearers themselves, that has been shown to be effective in offering support, hope and meaning to people.   


The underlying premise of this work is that voice-hearing itself is not a problem which needs to be eliminated.  Many voice-hearers consider their voices to be positive, or at least an acceptable part of their experience.  Romme and Escher’s work helps people to talk about their voice-hearing experience, to accept that the voices are real – and may have meaning based on life experiences.  This respect for the experience of the person is at the heart of the recovery movement.


The recovery process according to the Mental Health Foundation 

  • provides a holistic view of mental illness that focuses on the person, not just their symptoms
  • believes recovery from severe mental illness is possible
  • is a journey rather than a destination
  • does not necessarily mean getting back to where you were before
  • happens in ‘fits and starts’ and, like life, has many ups and downs
  • calls for optimism and commitment from all concerned
  • is profoundly influenced by people’s expectations and attitudes
  • requires a well organised system of support from family, friends or professionals
  • requires services to embrace new and innovative ways of working

The recovery movement has been gaining strength within and outside of mental health services.   Many people with the recovery movement are challenging the traditional language and power structures of psychiatry – and the recovery model is as much user-led and influenced by professionals. 


In order to support those who have attended the Hearing Voices module to continue to work collaboratively with voice-hearers, and according to the recovery model we are setting up a Recovery Forum at Birmingham City University.  We anticipate the first session to take place in July 2009.  There will be more details to follow.  Members of university and trust staff with an interest in this area are also warmly invited to attend. 


Listening to Voices

We have just finished teaching the Hearing Voices Module for post registration nurses, which can be taken as part of the ‘top-up’ to a degree qualification, or as a stand-alone course.  We felt privileged to have a very keen cohort of students made up of CPNs, OTs, staff nurses, and support workers, many of whom have considerable experience in working in mental health. 


The course is centred on Romme and Escher’s way of working with people who hear voices, Making Sense of Voices (2000).  In their early work Romme and Escher highlighted the considerable number of people who hear voices who never come into contact with mental health services.  They posited that voice-hearing in itself is not problematic.  In their work with people who are distressed by hearing voices Romme and Escher attempt explore whether there are any links between the personality of the voice and the content of what is heard; and incidents of trauma in the life of the voice-hearer.  They developed the Maastricht Interview Schedule to help voice-hearers to make these sorts of connections. 


The Maastricht Interview Schedule is not an inventory or rating scale, but rather a series of pointers for the helper and the voice-hearer to use together at a pace which suits the voice-hearer.  The questions need to be asked with care and sensitivity as they explore the nature of the experience, the personal history of voice-hearing and the childhood experiences of the voice-hearer.  At first glance it looks like a daunting piece of work to undertake, however we were very pleased to see each of the students begin to use the Maastricht Interview Schedule in their day to day work with clients. 


Students on the course shared how they felt, as they were beginning to work in this way – either with individuals or in setting up voice-hearing groups.  Students gained confidence, and could see how powerful this way of working could be in their own practice.  We heard that service-users said they felt they were being given the opportunity to talk about their experiences in a way that had not been possible before.  The ‘normalising’ of the experience of voice-hearing seemed to be very helpful for many of the clients; and the formulation of a construct to help to explain the origin and meaning of the voices was felt to be very important in redressing the balance of power in the relationship between the voice-hearer and their voices. 


We are hoping that part of our role, which includes an honorary contract with the mental health trust, will be to support those who have attended the course to implement this way of working wherever possible.  I look forward to seeing this way of working used more widely.