Tuesday, December 23, 2008

A STRANGE CUSTOM IN ENGLAND - RELIGIOUS UNIFORMS in PSYCHIATRY by Dr Helen Bright

Introduction: When in summer of 1999 Harrow Social Services in Middlesex, England employed a Catholic nun to work as a social worker with mentally ill she was wearing her religious uniform. There were members of Community Mental Health Team who rolled their eyes at this appointment and I wondered why. I asked them how did they know she was a nun and they told me because of the way she was dressed when she came to her interview.
In UK psychiatrists, psychologists, nurses, administrators and social workers working with mentally ill have not been wearing uniforms since at least 1970's. I decided to investigate this issue of uniforms. At first, I did literature search and found that there were already hundreds of papers about the wearing of uniforms in psychiatry. The research found that not wearing e.g. nursing uniforms was associated with better compliance with medication, less violence on psychiatric ward, and less self-harm. It has been thought that medical uniforms act as a barrier to trust between the patients and staff. However, I could not find any scientific publications about the wearing of religious uniforms and mental illness. There were newspaper reports of murders of nuns by a psychotic patient. Therefore, I thought it could be worthwhile to find out what mentally ill patients living in the community thought about religious uniforms. Do they find religious uniforms off-putting or attractive? There were newspaper reports of various nuns being murdered by mentally ill. Method: In order to investigate, I asked a psychologist to review my methodology ( a questionnaire, I designed) and he made very useful suggestions but did not wish to be named in fear of persecution as he was still working in National Health Service (NHS), United Kingdom, Europe. In 21st century he feared persecution and I think he was right to do so as I discovered it for myself too late. General Medical Council, UK made itself busy for more than twelve years persecuting me and destroying my career. They still allow religious fanatics to sit at their fitness to practice panels and judge other doctors. They have been allowed to sit at Council as well and obstruct progressive medical policies. Religious extremists can decide what will be on the agenda and what will not be. Labour government from 1997 - 2010 pushed religion into public forum and GMC followed it. Thousands of doctors were persecuted and mainly ethnic minorities suffered. An Information page about the questionnaire on religious uniforms worn by social worker was given to patients in order to obtain their consent and confidentiality was assured. Research Ethics Committee was informed about the proposed research and permission for research requested from a medical director. An Ethics committee member wrote to say no permission from the whole of Ethics Committee (17 members) was required for such a simple research project. Medical director in the Department of Psychiatry where research took place refused to reply to my requests for permission (four times). Finally, at the public hearing before GMC he gave his reason: as the results of the research could go against his friend, another medical director in a different trust where a nun, social worker was situated and working wearing her religious uniform. Thus "old boy network" came before patient or justice needs. Many years later I discovered this Medical Director was in fact, a religious man, associated with Special Interest Group in Spirituality at The Royal College of Psychiatrists. Contrary to Good Medical Practice he was actually, blocking research because of his own religious views. For research two questionnaires were designed: Questionnaire A and B. In one there was a photograph of a Christian nun dressed in her religious uniform (actress) and a male figure was in casual clothes (actor). Under each of the photographs there was a Linkert scale (line) and patients had to place a line across a horizontal line which at one end said: Most off-putting and at the other: Most attractive. That way they would indicate their preference. The closer the vertical line to one end, it would indicate preference for that dress (photo above the scale). Another questionnaire had the same male actor but this time dressed as a Christian priest dressed in his religious uniform and the same female actress, but this time wearing her casual clothes. Again patients had to score on Linkert scale. Questionnaires were mixed and given randomly to patients attending mental health community center and a couple to hospital in patients. Two patients declined participation. Results: Forty-five mentally ill patients completed the questionnaires. I found that 60% of patients preferred a casually dressed person to the one wearing a religious uniform. Twenty five percent had very strong positive feelings towards a social worker dressed in a religious uniform as well as towards the social worker dressed in casual clothes. In other words, 25% had expressed extreme view of liking either. Fifteen percent had strong negative feelings towards somebody dressed in a religious habit or casually dressed. Some patients wrote uninvited comments on the questionnaire such as having difficulty trusting a religious person e.g. with intimate problems of sexual nature. There were also verbal comments by patients when questionnaires were handed. Some told of memories of oppressive religious upbringing. Discussion: United Kingdom has policies of religious diversity in public life. When I enrolled to study a political course I was amazed that this was recognized as: " religious diversity at the price of social justice". Clearly, what was new to me was perfectly well known to political academics. There is a long history of religion coming before the interests of the patients in public institutions, apparently. During Labour Government, Department of Health issued guidance on uniforms worn when working with ill people. It lacks clarity as to where religious uniforms are danger to health and safety but it does say that health and safety comes first and not religion. But who is going to interpret it to whom? As far back as 1998 Economic and Social Research Council published: Taking Stock What do we know about violence? The Economic and Social Research Council is the UK's leading research and training agency addressing economic and social concerns. It describes its "aim to provide high quality research on issues of importance to business, the public sector and government. The issues considered include economic competitiveness, the effectiveness of public services and policy and our quality of life". In its publication mentioned above it concludes: "Those who experience discrimination because they are gay or lesbian, have experienced psychiatric treatment, or have mental health problems, are members of disabled, disfigured, racial, religious or 'ethnic minorities', also report high levels of violence. Twelve percent of priests were physically attacked compared to ten percent of police. Seventy one percent of clergy had been verbally abused or threatened with violence in the same two year period according to this mainly government funded research body. On 17th November 1999 I blew the whistle on the wearing of religious uniform by a social worker. It was ineffective in terms of the action taken by Social Services in Harrow. They continued to employ the nun for several years until she left to work for a residential home for the elderly run by Catholic Church where she is a manager now. The Royal College of Psychiatrists, with religious President, decided the issue of religious uniforms, when mentioned at the Public Policy Committee was not part of the College's responsibility to take a view on in 2001 but they eagerly formed Spirituality Special Interest group for themselves previously. My pleading letter was sent to Spirituality Section of the Royal College of Psychiatrists! In 2003 I was found guilty of serious professional misconduct by the General Medical Council (GMC), London for offending the Catholic nun because I invited her to a meeting to discuss the issue of wearing the religious uniform. Of course, this cannot be professional misconduct and even less so serious. However, I mention it to illustrate just how incompetent that Fitness to Practice Panel at General medical Council was. One of the members of the Fitness to Practice Committee that judged me so wrongly was a Secretary of Christian Medical Fellowship who wrote of his belief that demons cause epilepsy and who thinks psychiatry is a specialty down the corridor so he would never practice it. Another member of the same committee knew the person who brought complaints against me to GMC. This is a double bias. I did appeal to High Court, but they tend to rubber stamp GMC decision. There is religious bias/other authority in High Court. Only in December 2006 Department of Health promised guidelines on uniforms following requests for clarification by a Conservative MP in Parliament. I think he was worried about Muslim dress. I wrote continuously to various politicians since 1999 without success. In 2007, eight years after I raised the issue of wearing religious uniforms Department of Health produced the guidance on workwear. It is inadequate and, of course, ignores mentally ill, children and elderly. It puts the wishes of the workplace before the needs of the patients. In 2007 Department of Health NHS guidelines on uniforms and work wear were sent to NHS trusts who were allowed to develop their own policies. None of the policies I have seen so far show any definitive statements about religious uniforms in mental health. Nobody wants to touch the subject, it appears to me. There is a general statement that Health and Safety issues are primary concern. Most professionals would not find time to study this safety issue and old scientific papers are not at all readily available as I found out. The original papers on uniforms in psychiatry are not to be found on the Internet or in most medical libraries. There is also the cost of obtaining them. Who would be so dedicated? Who would pay hundreds of pounds out of their own pocket to find out the results of research on uniforms in mental health? It would appear that this blog is the first publication in the world about the opinion of mentally ill people about the wearing of religious uniforms. It seems to mirror what one would expect from normal population: tendency towards secularism too. Religious uniforms are off putting to patients. This is not a spectacular surprise. My recommendation is that no religious uniforms should be worn in mental health settings ever in keeping with current knowledge and custom that uniforms in general should not be worn when working with mentally ill people. It is also in keeping with European Convention on Human Rights as well as Equality Law 2010. There are many reasons why religious uniforms should not be allowed when working with mentally ill: 1. Equality and fairness for all mental health workers-no uniforms of any sort should be worn; religious or not. 2. Specific reasons e.g. violence prevention. There have been a number of murders of priests and nuns in the world already. Away from this extreme one finds that most of the clergy in UK have experienced at least verbal aggression (at least 70%) 3. Trust between patient and professionals is essential in order to obtain medical history and therefore, further down the line formulate diagnosis and plan treatment. Uniforms act as a barrier to trust. 4. Religious dogma against homosexuality, abortion, other religions, and races is not useful to say the least in mental health setting or any other public setting. 5. There are religious beliefs that mentally ill may be possessed by devil, demons and so on. Who needs that to burden and stigmatize them further? 6. Those who have suffered abuse at the hands of clergy and have post traumatic stress disorder are more likely to suffer panic attacks. Those who suffer from panic attacks are more likely to die from heart problems. Recent research has confirmed the latter. People who have mental illness have reduced life expectancy by as much as twenty years. Why stress mentally ill people further in order to please the religious people? 7. Wearing of religious uniforms in National Health Service is like religious institutions getting advertising for free in state funded health settings. We would not accept people wearing e.g. Mc Donalds Restaurant uniforms to come to work in NHS. So why allow religious uniforms? Limitations of the study: This is the first research in the world on the wearing of religious uniforms and bigger and better studies could follow. Substantial discussions on this subject could be easily developed further. There are a number of aspects that have not been addressed at all e.g. fear of religious authority. Perhaps some people would express strong positive answers about the attractiveness of religious uniforms when in fact they do not like it at all. Strict religious upbringing could result in this false answers. Similarly, some people may react in the opposite direction and have intense dislike of religious uniforms based on their bad experiences or views. European Court of Human Rights has already decided that the right to religious expression is not absolute right and when there are already established rules these should be respected. Thus a Sikh was not allowed to wear his turban on his passport photograph in France. This is in sharp contrast to what British High Court decided e.g. Sikh can wear his turban instead of a motorcycle helmet. Perverse, is it not! European Court ruled for Switzerland that Muslim teacher could not wear her scarf to classroom because children are impressionable and could develop wrong impressions what the school stands for. We have established rule in UK that uniforms should not be worn in psychiatry and therefore, a nun or a priest should respect it. Medical institutions such as GMC and the Royal College of Psychiatrists have unfortunately, so far, failed to use their authority constructively and have shown religious bias on this particular issue and the reluctance to even address the arguments. Ethics Committee refuse to think of it from patient perspective. Their obsession is pleasing religious workers. This is contrary to law and custom. The government has been deprived of good professional advice and guidance in the development of its policies because the Royal College of Psychiatrists is dominated by religious lobby and cannot think of putting patients first. So embarrassing for the whole country.
It is thought that cannon lawyer Thomas Doyle blew the whistle on Vatican on that one and watch it here to see him speak about it.
References: 1. Allan C, Heffernan C, Pallent S, Weaver L. Uniforms: a strange custom? Nurs Times. 1992 Sep 2-8;88(36):51 No abstract available PMID: 1528753; UI: 92409406 2. Smith D. Uniforms: worn out. Nurs Times. 1990 Jan 17-23;86(3):32-5. No abstract available. PMID: 2353951; UI: 90138213 3. Lavender a. The effects of nurses changing from uniforms to everyday clothes on a psychiatric rehabilitation ward. Br J Med Psychol. 1987 Jun;60 (Pt 2): 189-99. PMID: 3620396; UI 87299541 4. Trauer T, Moss AV. Psychiatric patients' opinions of nurses ceasing to wear uniform. J Adv Nurs. 1980 Jan;5(1):47-53. PMID: 6898235; UI: 80116392 5. Rinn RC. Effects of nursing apparel upon psychiatric inpatients' behaviour. Percept Mot Skills. 1976 Dec;43(3 pt. 1):939-45. PMID: 1012875; UI: 77101849 6. Klein RH, Pillsbury J, Bushey M, Snell S. Psychiatric staff: uniforms or street clothes? Arch Gen Psychiatry. 1972 Jan;26(1):19-22. No abstract available. PMID: 5009421; UI:72096552 7. Brown JS, Goldstein LS. Nurse-patient interaction before and after the substitution of street clothes for uniforms. Int J Soc Psychiatry. 1967-68 Winter; 14(1):32-43. No abstract available. PMID: 5601658; UI:69015464 8. Stanko EA Taking Stock what do we know about violence? 1998, ESRC Violence Research Programme; Brunel University, Uxbridge. Middlesex UB8 3PH, UK ISBN: 1872166 94 6 UPDATED 14-3-2011

1 comment:

Dr. Liz Miller said...

This is an excellent piece of research answering a practical and relevant question
Thank you.

Your methods and your reasoning are transparent, and your conclusions fair - Well done!!!