Psychiatry is probably one of the most significant two-way processes in healthcare. You can see such a change and it refreshes and re-energises you as much as the change benefits those you work with. The emotion that can break your heart is sometimes the very one that heals it.
The mental health nurse
If medicine is a book of stories, psychiatry holds the wisest chapters and the ones from which you will learn the most.
Within each patient narrative is an opportunity to understand – not just about the illness, but about wisdom, humour, life and people.
‘How could you enjoy working in a place like that?’ I hear, over and over again. ‘Don’t you feel unsafe?’
In general medicine and general surgery, I have felt unsafe on many occasions. I have been assaulted several times in A&E.
In psychiatry, I only ever felt unsafe once, a few years after my first psychiatry job, when I was working in a different NHS trust, on a high-dependency ward.
Daniel was diagnosed with schizophrenia when he was nineteen. Now forty-seven, the previous twenty-eight years had eaten into who Daniel was and who Daniel might have been, if he hadn’t been forced to live his life alongside a serious illness.
He was a ‘revolving door’ patient, someone who was frequently admitted.
‘Daniel’s back,’ one of the nurses would say, and no one had to ask ‘Daniel who?’
Daniel was on a ‘CTO’, a community treatment order, a (contentious) part of the Mental Health Act that allows patients to be discharged from hospital and remain in the community but only if they adhere to certain conditions – taking their medication, for example, and keeping appointments with their community mental health team. If any of the conditions of the CTO are broken, you are immediately brought back into hospital. Daniel was brought back into hospital on numerous occasions. His daily tablets had been swapped for a monthly injection, in an attempt to simplify things both for him and the people looking after him, but Daniel would disappear whenever the injection was due. He drifted between houses, sleeping on sofas, living in the shadows of other people’s lives until the community team eventually managed to catch up with him.
On this occasion, Daniel had been brought in by the police. He was agitated and aggressive because he hadn’t received any medication for weeks and he was deeply unwell. Afterwards, the two coppers sipped tea in the nurses’ office. One of them showed me how the police restrained people by forcing the thumb back towards the wrist. He called it ‘soft restraint’. It didn’t look very soft to me, and although I could appreciate the occasional need to restrain a person for the safety of others, let alone their own safety, I couldn’t imagine how it must have felt for Daniel. Ill. Afraid. Alone.
In a perfect world, Daniel would have been admitted to a PICU (a psychiatric intensive care unit, designed for people who are acutely unwell and with specific circumstances and needs). In our imperfect world, the only PICU beds available were out of area, which would not only be upsetting for Daniel and anyone who wanted to visit him, but would also be extremely costly for the Trust. And so he was placed with us first (one step up from a general ward, but not as well-equipped as a PICU), just to see if it was workable.
It was not.
Daniel was tall, broad, aggressive and loud, and the other patients were afraid of him. Like many psychiatric units across the country, it was a mixed ward, and its demographic was hugely variable. Middle-aged women with bipolar sat next to young men with OCD. Older patients, fragile and uncertain, and suffering from the psychosis of late stage Parkinson’s disease, shared their space with men like Daniel, who were often unpredictable and violent.
Daniel’s illness made him throw furniture around and pull a door from its hinges. It made him scream at other people and at himself. It made him repeatedly bang his head against the wall in the corridor. Daniel’s illness made it necessary to restrain him multiple times. He was taken to ‘seclusion’ – a safe room from where he was not permitted to leave – and he was injected with medication against his will. I was not part of the team that restrained patients – it involves very specific training and guidelines and is only used in the most extreme and necessary circumstances – but I have witnessed it several times and it’s the most disturbing thing you will see in psychiatry. It’s the most disturbing thing you will see in any specialty. It is not so much the patients who fight the restraint that makes it disturbing, it is the patients who don’t.
Daniel desperately needed a PICU bed and we were in the middle of organising one for him when there was another emergency on the ward, involving a different patient. The specialist team had all rushed to the other side of the unit and I was alone in the office. I finished what I was doing and closed the door behind me. The corridor I walked on to had the locked exit at one end, and in the other direction was the main ward and the patients’ communal area. It was deserted. I turned, locked the office door, and I decided to start walking towards the ward. When I looked up, though, the corridor wasn’t deserted any more, because in front of me stood Daniel.
I weighed up my options as he stared at me. I could turn left and use my swipe card to leave, but it would run the risk of Daniel following me and I knew he’d be gone. Along the corridor, the only other doors between me and Daniel were for the treatment room and the laundry. Both of those doors were locked. I could go back into the office, but that would mean turning away from Daniel and fumbling with my keys, and my gut told me that wasn’t a wise thing to do, and so I walked towards him. I had no choice.
He seemed to fill the corridor. I tried left, right, left, but he blocked me each time.
Instinctively, I reached for the alarm on my belt that would alert other staff to a problem. It wasn’t there. The ward didn’t have enough to go around and it was decided – understandably – that the doctors were not at risk as much as the nurses were. My pulse hammered in my throat, but it was important to stay calm.
‘Could I get past you, Daniel?’ I said, trying to keep my voice as level as possible.
He leaned forward. I could feel his breath on my face.
‘No,’ he whispered in my ear.
His body blocked my view of the corridor, but I tried to listen for footsteps, or voices, in the hope that someone might be nearby. In the distance, I could hear the rest of the staff dealing with the other emergency. There was no one. Daniel had picked his moment beautifully.
He stepped back.
‘I’ve got something for you,’ he said, and he raised his right hand.
In that moment, I wondered how much damage he was going to do. Would he knock me out? Would he be able to fracture my skull? Would he hit once or would he keep striking me? Once I fell, would he start kicking me? How long would it be before someone realised? My legs weakened. I took a deep breath, hoping it might help me deal with whatever was going to happen next.
His hand came towards me with such force and speed, and I shut my eyes against the impact. But there was none. He stopped, just short of my temple and instead of hitting me, he ran his fingertips down the side of my face.
‘I’ve got something for you,’ he said.
I heard movement somewhere behind him and when I opened my eyes and looked beyond Daniel’s shoulder, there were three more patients standing in the corridor. A little old lady, whose diagnosis changed with each visit to hospital, a young woman who had spent her entire life living with bipolar, and an elderly man who was admitted with depression after his wife died. With one sweep of his hand, Daniel could have knocked them all flying like skittles.
The little old lady took a step forward and jabbed her finger into Daniel’s back.
‘YOU LEAVE DR JO ALONE!’ she shouted. All five feet of her.
He lifted his hand from my face. He turned around and stared at the little old lady, and after one brief moment of hesitation, he did exactly as he was told.
I think he was so shocked that he went back to his room like a naughty schoolboy.
The little old lady turned to me. ‘Are you okay, love? Do you want me to make you a cup of tea?’
The kindness of patients is everywhere. Studies show that an act of kindness not only benefits those who receive it, and provides a sense of well-being to those who give it, but even those who watch from the sidelines feel better just by witnessing it.
It is a true saying that those who have the least give the most. I have seen patients share their very few possessions and clothes with someone who has been admitted with nothing. There are some people who never have visitors or anyone to care about them, and during visiting hours, I have witnessed one patient invite another to join their family instead of sitting with no one. I have seen those who have been on the wards a long time make a cup of tea for someone who has just been admitted, afraid and alone. When you are world-weary, or ward-weary, when you have had your fill of unkindness and cruelty and suffering, to witness small and quiet acts of compassion restores your faith in the world like nothing else.
A PICU bed was found for Daniel and he spent two months there. Once his treatment began to work and his symptoms were more under control he came back to us, and the first thing he did when he arrived on the ward was to walk up to me and apologise.
I had never experienced physical intimidation before Daniel, but I had been verbally abused many times by mental health patients who were unwell, because when you are ill and afraid, when you feel trapped and helpless, you will take any weapon you can to defend yourself. In every single case, without exception, when the patient recovered they apologised to me – although none of them, including Daniel, had anything to apologise for. Their words and behaviour were the symptoms of an illness, in the same way that any physical illness gives us symptoms that are beyond our control.
As a society, we disregard the symptoms of mental illness and we view them as the person and not the disease. The language we use further dilutes them, until they become lost in the mundane and the everyday. OCD is not going back to check that a door is locked: OCD is walking along the middle of a dual carriageway picking up litter, because its presence brings an anxiety you are unable to bear. OCD is not being particular about the way your cupboard is arranged: OCD is urinating in your front room, because the rituals and counting exercises you are forced to complete before you are allowed to walk to the bathroom are so complex and so time-consuming that they do not allow you to get there in time. Schizophrenia is not a ‘split personality’: schizophrenia is sprinkling flour on the treads of your staircase because the voices you hear are so real that you want to catch the person who must be hiding in your house. Depressed is not a reaction to your football team losing: depressed is being consumed by a despair and a self-loathing that is so overwhelming you would rather end your life than continue to carry it with you for a moment longer.
To remain standing under the weight of these illnesses is a sign of the most enormous courage. To retain your humanity and kindness to others under that weight is nothing less than a miracle.