The NHS data dictionary describes Multidisciplinary Team Meetings (MDTs) as: “a meeting of the group of professionals from one or more clinical disciplines who together make decisions regarding recommended treatment of individual patients" [1].
I would describe MDTs as: “The wildly unethical and trauma-uninformed practice of a room filled with random strangers discussing and offering opinions on you, your life, your trauma, your pain, your thoughts, your feelings - while you are not present, without your consent, and often without your knowledge - pontificating about why you behave and think in certain ways, psychologising and pathologising the selective words and actions they have chosen to record about you, reinterpreting how you have made sense of yourself to fit their own narratives, so they can ultimately decide - without you - who and what you are, and what course of action they are going to take with your life.”
MDTs are very popular across the whole of the NHS for clinical decision-making, service gate-keeping, and team formulations, and are seemingly considered best practice in terms of patient safety, despite a lack of evidence supporting this [2]. The normalisation of the use of MDTs to make decisions about patient care makes it very difficult for patients to be heard and taken seriously when we raise concerns or express discomfort about being spoken about at one.
When explaining to staff that being discussed at team meetings was harming me, I’ve been met with utterly incredulous attitudes – “we’re just talking, we’re not doing anything to you”. But that is not the truth, because words are not neutral, they hold immense power, and in wielding that power you actively remove me from my own life, strip me of my autonomy and self-authority, and force me to sit and wait while a group of people I have not met, and may never meet, take pieces of me, crush them into a shape which pleases the group and come back to tell me this is how they are going to make me look. This team ‘wisdom’ is subsequently considered more valid, more valuable, and more representative of me than my actual living, breathing body. It is not “just words” when the speaker sits on an entirely different plane of power to the spoken about. It is not “just words” when the words you use strip me of my humanity while bolstering your authority. It is not “just words” when you refuse to allow me to hear the words you’re using, hiding them in places I cannot access. It is not “just words” when those words will decide the course of my life. It is not “just words” when those words rewrite who I am. It is not “just words” when your words are heard, while my words are not.
Within these meetings, my ill-health, my pain, my struggles, my fight, become your property. You sit like greedy colonisers and draw up your territorial boundaries, deciding who owns what, conquering and naming the parts of me you feel entitled to. Of course I cannot be present for this, I am merely the disease host, I do not actually matter in this exchange. You fail to see that my madness is me, and I am my madness, because to you, how I think and feel and experience the world is a cancer to be removed. To you, a normal person exists beneath my skin, all you need to do is cleanse and extract the bad parts, like a surgeon excising a tumour. It is within these meetings you decide what these bad parts are, and how you will go about separating them from me, making me an acceptable human.
Mental health professionals think they have come so far in their treatment of people. They believe they are person-centred; they believe they are forward-thinking; they believe they are practicing strength-based, patient-led, trauma-informed care... but the continued use of team meetings which exclude patients speaks to the contrary. We are still inert lumps of clay to mental health professionals, just waiting for them to decide what form we shall finally take. If I go to hospital with a broken arm and require surgery to pin it, I don’t expect to wake up having had a nose job because the surgeon felt my nose looked better that way. But in mental health services, we present for help and staff unilaterally decide what parts of us are broken and what we need to work on to be a better human, even if we disagree. I asked year after year for support from mental health services to deal with flashbacks and dissociation. What I received however, was a non-stop barrage of demands to change everything about myself; the pathologisation of parts of myself which I have no issues with; the insistence I change behaviours which do no harm to anyone; and the labelling of my personality as abnormal. What I did not receive – help for flashbacks and dissociation.
In mental health services, my opinion about what I need support with, what helps me, how I would prefer to work, and ultimately what I do and don’t want to change about myself and my life, is irrelevant, because staff do not see me as a whole person who has any right to direct my own care. Informed consent plays no role in this space, because on a fundamental level mental health professionals believe that the ways I am broken impede my ability to recognise these broken parts. Staff come from a position of moral superiority and a hidden paternalism they refuse to acknowledge. MDTs which take patients apart and decide on our treatment course, sidestep the Mental Capacity Act and the Mental Health Act, making life-altering decisions without us, which are then imposed upon us for us to passively accept, or face being labelled ‘challenging’, ‘non-compliant’, and as ‘refusing to engage’ if we decline. The threat of these labels is not to be taken lightly, as they come with the very real possibility of receiving retaliatory diagnoses like ‘personality disorder’, having care withheld, being blamed or criminalised for our distress, and facing discriminatory and abusive attitudes from staff. “Agree with us or we will make your life difficult” is not an environment in which someone can truly consent to care, and for some, it doesn’t even reach that, because the option is “this is what is wrong with you, this is the single treatment option, take it or leave it”.
If you sliced mental health services open down the middle, you would see these issues running through all areas of services like the rings of a tree. They are not an MDT-specific problem, but MDTs mark very specific and important points in a person’s journey through mental health services, where the influence of paternalism, diagnostic discrimination, mental health stigma, exclusion of patients from decision-making, unhealthy team dynamics, and clinical superiority is magnified. I have attended MDTs as a medical student. Some very long and intense, discussing individuals at great length, some really rushed and busy, where there weren’t enough seats for all the staff, or we ended up packing ourselves into cupboards or store rooms on wards because all the offices were full. The one stand out memory I have of these meetings was the dehumanising of the people being discussed. They stopped being individuals, and became a set of problems to be solved, or an annoyance to be rid of. Staff go on and on about the merits of team decision-making, and tell us as patients that it is important they work and make decisions together as a team, but what I saw in these meetings was often more a space for staff to express their personal feelings, frustrations, and prejudices, and seek agreement and reassurance from their colleagues that they were in the right. I recognise that MDTs save time by allowing staff to quickly move through a pile of cases, but time-saving is not a good enough excuse for a process which actively removes humanity from those being discussed.
If you are a mental health professional reading this, thinking “it wouldn’t be appropriate for patients to be present at a team meeting about them”, think about why that is. What are you saying at your meetings which you would want to withhold from your patients? It’s certainly much easier to have a meeting about someone without them present because you don’t have to worry about upsetting them, you don’t have to think about choosing language which is not stigmatising or focus on concealing your disbelief/distain/dislike for them. You don’t have to worry about centring the patient or their pain or their needs. You can sit far away, removed from the reality of your patient’s life, and centre your own opinions, feelings, and priorities. But does that even meet the most basic ethical and professional requirements for patient care?
People who have not met me do not know me, and do not have the right or the authority to make clinical decisions, formulate me, or take another person’s account of my thoughts, feelings and behaviour to decide who I am and how I need to be “fixed”. In a service supposedly striving for the reduction of coercive practices and an increase in openness, honesty and collaborative working, there is no place and no excuse for MDTs which exclude patients.
Stop doing stuff to us. This is our care, we have the right to be included in every step of it.
Wren
1. https://www.datadictionary.nhs.uk/nhs_business_definitions/multidisciplinary_team_meeting.html 2. Mannion R, Thompson C. Systematic biases in group decision-making: implications for patient safety. International Journal for Quality in Health Care. 2014;26(6):606-612.