by Alexis Quinn

The implementation of surveillance systems, such as Oxevision, within inpatient mental health settings raises significant ethical and legal concerns. Long sold as a benign installation that can help support safety, surveillance is known to negatively impact the therapeutic environment. For instance, it alters staffs’ behaviour, reduces opportunities for the observed person’s agency and self-determination, and increases unethical and rights restricting practices. These outcomes can be attributed, at least in part, to the objectification and dehumanisation of those being surveilled. This article will explore these issues from a lived experience perspective and suggest ways staff might re-humanise care despite digital restriction. 

Objectification

Objectification occurs when people are treated as things rather than as fully realised and autonomous subjects. As far back as the 1800’s the German Philosopher Georg Hegel introduced the idea of a dialectical relationship between subject and object. He suggested that our ability to be fully human relies on a self-consciousness person being recognised and responded to by another self-conscious person. As such, mutual, reciprocal and face-to-face encounters which accept a person (including their distressed aspects), are centrally important to therapeutic care. However, when I was in psychiatric inpatient settings, too often staff dismissed my suffering, anxiety, fears, hopes and desires. Instead, they surveilled me, understanding my outward expressions/behaviour as data points – an example of objectification. 

Surveillance meant my unique identity and inner life was overshadowed by numerical assessments of my outward expressions. These were then framed within the language of deficit and disorder, effectively reducing me to a non-person. Whether I sat, showered, excreted, stood, laid down or paced, surveillance separated my body from its inner life, and the complexities of my emotional and psychological distress became quantifiable metrics. 

The numbers were crunched and compiled into charts that I sometimes bore witness to at monthly Multi-Disciplinary Team meetings. The interpretation of my actions was not my own and staff attributed its meaning as they saw fit; too often based on their own subjective understandings. Staffs’ musings carried greater weight and so-called objective truth, owing to their authority. Consequently, I felt Hegel’s dichotomy deeply, as well as a cruel manufactured distinction between the observed and the observer. Control was prioritised over connection and understanding. 

Impact on the therapeutic environment  

The inclusion of cameras on wards and in people’s hospital bedrooms can allow observations to take place, without disturbance, reducing intrusions while people sleep. However, surveillance disproportionality affects both staff and patient behaviour as it increases pre-established power differentials. Staff accessed me whenever they wanted to, via video/sound links, observing my most intimate experiences without genuine informed consent. Meaningful consent for surveillance is unlikely to ever be achieved because staff will naturally use surveillance for purposes not sanctioned by their own policies (e.g., using it to see if a person’s behaviour differs in their bed space to communal areas). Such behaviour breaches privacy, and many staff appeared to be doing so unknowingly and without understanding that this is rights infringing behaviour.

Staff were often critical of my surveillance-observed behaviour more than when they engaged with me during in-person encounters – an observation supported by research. Too often I became an object of scrutiny, rather than a person entitled to privacy, dignity and therapeutic support. Disturbingly, this phenomenon has been associated with alarm fatigue – a term attributed to occurrences where staff do not take warning signs seriously. This can have fatal consequences. 

Staff interactions are more mechanical and detached when surveillance is used, and staff are less likely to respond to a person’s behaviour with nuanced understanding e.g., in ways that promote curiosity when responding to distress. Moreover, the therapeutic use of touch (e.g., a hand on the shoulder for support or a hug to convey compassion) is reduced, despite its beneficial effects. This is because staff fear their compassionate support will be misinterpreted. Perversely, surveillance increases the chance of staff using physical force as they believe CCTV will show the restraint was applied effectively. 

Surveillance has long been thought to regulate the population and maintain social control. Certainly, I felt forced into a being a docile body, owing to the uncertainty I felt:  Was I being watched? Or wasn’t I?  I began to scrutinise myself, adjusting my outward expressions, just in case – becoming a surrogate of their control. Inside, I experienced greater stress, anxiety and fear, especially in relation to behaviour I thought staff might interpret as illness induced. This further reduced opportunities for me to exert my own agency and develop my own authentic self-identity; I feared being caught doing something I might be judged for, and which may extend my detention.  In essence, surveillance prevented the possibility of soothing through co-regulation with staff which, in turn, prevented self-soothing. 

It is not difficult to see how surveillance can be (re)traumatising (for some people) as feelings of helplessness are surfaced in the face of all-powerful staff/surveillance that perpetuate power differences. Psychological restraint overwhelmingly influences patient beliefs as they seek to please staff and gain favour for earlier release/preferential treatment – I certainly admit to doing this. However, such compliance comes at a price – evidence suggests that when patients feel constantly monitored, they may disengage from treatment, fearing judgment and this resulted in a greater loss of agency – a perverse outcome of systems supposedly designed to provide bespoke, person-centred support. 

Nationally, it appears that services are attempting to contain distress by installing power laden surveillance systems, insisting that patients concede their right to privacy for their own good. Certainly, some patients reportedly like the intrusive nature of cameras in their spaces, and I can only assume that such attitudes are heavily influenced by a system which means patients gain staff favour as they model the ‘ideal patient’ while under the control and command of the institution.

Surveillance can be associated with disciplinary power because of its capacity for criminalisation. For example, I found that staff often disengaged from providing proactive, timely and responsive support when I was distressed. Instead, they preferred to seclude me, and my distressed reaction to social disconnection and physical, chemical and mechanical interventions, was used to criminalise me.  No context, intent or balance were sought in their analysis of the carefully edited segment of footage. Of greater concern was the additional scrutiny found in solitary confinement which led to decreased sexual safety and vulnerability to voyeuristic gazes. Being naked, in an empty room under the watchful eye of more electronic surveillance was dehumanising and humiliating. As the safety of others was not a factor, the use of CCTV (while also being watched through a window by staff) is arguably not legally justifiable – it is not a ‘least restrictive’ use of force. In fact, it felt punishing which is in direct contravention to the Mental Health Act Code of Practice (2015) and human rights law. 

Surveillance as a restrictive practice 

Restrictive practices refer to limiting a person’s freedom. The Human Rights Act (1998) upholds a person’s right to privacy, physical and psychological integrity and autonomy (Article-8). Surveillance fundamentally infringes this right. When applied as a blanket restriction – e.g., all people in the service being subject to Oxevision without accounting for individuals’ risk and needs – it is arguably rights restricting and illegal. 

I personally found surveillance severely compromised my humanity and dignity which should be protected under Article 3 of the Human Rights Act which stipulates the right to freedom from inhumane or degrading treatment. Being observed at any time of the day, sometimes naked and in great distress – a state I would want no-one to observe – left its mark to this day. Article 3 is supposed to be an absolute right, which should never be compromised, yet arguably services routinely ignore this when they treat people as objects, knowingly risking dehumanisation and stripping away patient’s autonomy. 

The national roll-out of surveillance and its blanket application in inpatient settings implies all people with psychiatric conditions require additional scrutiny due to an assumed danger. This reinforces stigma and harmful societal perceptions, constricting people’s right to be free from discrimination (Article 14 of the Human Rights Act). The latter is linked to my earlier earlier point about criminalisation.

Towards humane care and support

Surveillance is a restrictive practice that can grossly infringe people’s human rights owing to its objectifying, invasive and dehumanising potential. Staff must act to mitigate its adverse effects, changing the focus from monitoring to truly understanding and engaging with the human experience. This would acknowledge patients as people with unique inner worlds and experiences which cannot be observed but must be felt and responded to. For instance, people need to feel that staff are interested in them as equals. Open-minded and non-directive curiosity can help build trust, cultivating safety, which is crucial where people feel powerless, objectified and scrutinised. A non-directive approach can foster autonomy and help reclaim the agency that surveillance can strip away. Such mutual recognition would support staff and people to connect in ways that extend beyond blind observation, expanding their storied selves, needs, and emotions. 

References 

Desai, S. (2009). The new stars of CCTV: what is the purpose of monitoring patients in communal areas of psychiatric hospital wards, bedrooms and seclusion rooms? Diversity and Equality in Health and Care, 6(1).

Desai, S. (2021). Surveillance Practices and Mental Health: the impact of CCTV inside mental health wards. Routledge.

Griffiths, J. L., Saunders, K. R., Foye, U., Greenburgh, A., Regan, C., Cooper, R. E., … & Simpson, A. (2024). The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: A systematic review. medRxiv, 2024-04.

For more information on rights and how to reduce surveillance as a restrictive practice see the Restraint Reduction Network Surveillance Resources e.g. Restraint Reduction Network. (2022). Surveillance: A restrictive practice and human rights. https://restraintreductionnetwork.org/resource/restraint-reduction-network-launch-surveillance-resources-to-help-protect-human-rights/

Alexis Quinn is Manager of the Restraint Reduction Network, Human Rights Activist at Rightfullives and author of Unbroken – a memoir about her time in psychiatric inpatient units. Alexis works as a psychotherapist in private practice.