Tuesday, February 16, 2010

On the ward and out of my mind- Therapeutic or Babysitting?

Continuing on from here, here and here

One cannot expect to go into a mental health ward (at least in the public system) and experience any real therapy. There are several reasons. The focus on providing treatment in the least restrictive environment (and lets face it, also the lack of financial resources to have enough bed space) mean that all but the most severe cases of psychosis or the forensic cases are discharged in quite a short amount of time. In my experience, most people are there between 2-14 days at most. The emphasis is quite heavily on containment whilst the worst of psychotic symptoms/ suicidal ideations pass and medication adjustments.

I was first admitted to Ward B in 2006. My first admission was quite a lengthy one, in part due to the additional medical issues I experienced as a result of my overdose. I was in hospital for about 2 and a half months. Over the next two years, I was admitted on four other occasions, for periods ranging from 5 days to two weeks. Whilst in hospital there were a number of people I could theoretically talk to, in order to process what I was going through and experiencing.

Consultant Psychiatrist
Generally, I saw this guy maybe once a week at most. Usually it would be him, a Student, my assigned nurse for the shift and I. Occasionally members from my medical team were invited to participate. Not quite like the horrible ward rounds that you guys in the UK have described. But still somewhat intimidating. The focus of these meetings was primarily to establish where I was at, mental health wise and to adjust medications. They usually only lasted five minutes or so, and there was generally no suggestion on how I might deal with some of the symptoms I was experiencing, other than to suggest I ask my nurse for a prn when needed. The consultant changed over the two years that I was in and out, but the one thing that did remain the same was that he was male, usually quite authoritarian and foriegn. I found myself getting quite upset when having to go through my history with these guys, as a) I wasn't really comfortable with men b) several things on Doctor said to me about my family made me feel quite judged (I think it was due to significant cultural differences in the ideas surrounding parents and respect) and finally, as English was not their first language, it was near impossible to talk in the idioms and metaphors, we would generally engage to soften the impact of telling a trauma. They simply did not understand. Language had to be clear cut and brutally to the point. Raw and stark. Being the passive personality I am, I usually just accepted it, but one occasion it got too much for me and I got up and stormed out of the treatment room. Unfortunately, anyone who has ever needed a walking stick before can tell you it is near on impossible to "storm off" and I ended up going arse up in front of the nurses station and all the patients. I then promptly burst into tears, which the nurses responded to quite quickly, as I am known to be a non-crier. Bundled off to my room, the nurse could do little more than pat my shoulder as I howled for the next 15 minutes. That's why I don't cry. Once I do, I can't stop. Anyways....
As I mentioned, you got an assigned Nurse at the beginning of each shift, who was supposed to check in with you for that shift, and if you had any additional problems you were to find them. The one thing all the nurses had in common was that they were OVERWORKED. The bulk of their time by necessity had to be spent caring for the geriatric patients. They weren't normally sitting in the office ignoring us (it was a cramped, uncomfortable space anyway), they were working hard. That's where the similarities ended. Some nurses were so burnt out from the demands of "general nursing" on the ward that they had no energy left for mental health nursing. A brief "How are you today?" was sufficient to their requirements and if you did approach them with an issue, they would try to listen but you could see that harried look in their eye of someone who knows they have 1001 things to do before their shift ends. Some were burnt out by the demands, but made the effort anyway. Spent the time developing rapport with the patients. Back in the days before somking restrictions came into full force, they may sit in the courtyard and have a smoke with a group of patients, always observing, in a non-confrontational way that is so much better than "How are you today?". They may be too busy to deal with you straight away but they will tell you when they can see you, and they will keep their promise. They had the skills to turn subjects that we had in common into ways of exploring the patients issues. For instance one nurse, who was also a professional photographer, would always want to see what was new in my portfolio, and we would discuss how it was representative of the way I saw the world..... and finally there was the last kind of nurse....relatively rare, thankfully. The ones who hated mental health patients, thought we were all just lazy sods who were bunging it on for attention. Mind you, the community had its share of acopic personalities that made their way to Ward B, but no excuse for the nastiness these women exuded. If its not a field you want to work in, that interests you...then why the hell work there!  I met some wonderful nurses in Ward B. As a gimpy, little long term patient, who wasn't violent or particularly demanding, I was out of the ordinary for them. Most patients were gone too quickly for them to develop rapport and the ones that remained (in Ward B at least) were pretty far gone to dementia. So, I guess in a way I became their little mascot. But for those majority of nurses who did the best they could in an under-resourced area, there were 3 or 4 nurses, whose callous actions or words remain with me today
Case Manager
I didn't get introduced to my first Case Manager until I was about a week away from discharge. Their focus is generally Ccmmunity Care. My first Case Manager (Y) was fantastic. She found away to relate to her clients, she made sure to make the meeting spaces somewhere comfortable, whether it be a park or a coffeespot, and she firmly believed in talking and doing.. in other words, by all means talk about what was going on, but at the same time go for a walk as part of my PT or go and check out a second hand book store. Anyways she was my Case Manager for most of the time I was in that area... and whilst I was in hospital she did check-in on me, she would drive me to and from my private psychiatrist appointments, when I had permission to leave the hospital. She was less of presence than out in the 'real world', I guess because she knew while I was in there I was relatively safe and contained.
Anyone who has spent time in a mental health facility will know that it is the patients that you spend the most time talking to. And often the ones you turn to, for advice or comfort. There are some inherent difficulties in this. You have to be concious of the fact that a) some of them will not be entirely truthful with you, and b) some of them will have issues that may end up impacting on your own mental health. This is particularly important to keep in mind if you decide to keep in contact outside of the ward. But the benefits are they are usually extremely judgmental, and even though no person has exactly the same experiences as you they do have a greater understanding than the average person. The other thing they bring to the table is some comraderie and humor in a dark time in your life. There is a suprising amount of laughter in a Mental Health Ward. The downside to this, is many of the 'acopic' patients, went from this comraderie and support back to their isolated and lonely existences, felt the void, and so would make a suicidal gesture just to be re-admitted for a few days to a world where they felt accepted.
Other hospital staff
Being a longer term patient, the housekeeping staff got to know me quite well, and would often stop for a quick chat. It was all very light, but it was always nice for them to compliment me on how well my walking was coming along, or as one old duck said to me "Some meat on your skin and those dark circles away from your eyes, you're starting to look quite bonny" :) In addition, (S) my physiotherapist was a fantastic support. She worked really hard to keep me goal focussed on the future, to give me hope, but on the few occasions I did fall apart, she was lovely too. I guess she didn't have to adhere to boundaries as strongly as the MH professionals do, and in those times when I was wondering if I was ever going to walk, read and talk properly again, she would take my hand and let me cry. She also provided me ample opportunites to get out the pent up anger inside me and direct it into my rehab sessions, knowing when to push my buttons to get me to push myself just that little bit further out of anger. She was a big reason why I recovered physically as well as I did, but I also believe she was a big reason why I made the steps forward with my mental health too.
Private Psychiatrist
By this stage I had been seeing Dr B for a little over a year. As soon as I was allowed out on leave, I began to go to my appointments with her twice a week, first on escorted leave with either my mum or Case Manager, and then by myself. I found it quite surreal that I was signing out of a psychiatric hospital to get psychiatric help, but the reality was, in order to get the containment I needed to go outside of the Public System.

There were some differences and some similarities at Big City Hospital.
Consultant Psychiatrist
Usually there was just you, him and  the junior doc. Not quite as confronting as at Ward B, but also it meant that there was no nurse to explain things to you when you left. I often found it hard to absorb what was being said. The consultations were the same length, about 5 minutes, but seemed to be more regular than on Ward B. Every 2-3 days. He is also the guy who heads the team the Junior Doctor and Case Manager assigned to me in community care are apart of. This means he is kept more regulalry apprised of what is going on with me, and is generally consulted in CM thinks I might need an admission. So there is a lot less repeating myself. And quite often they will do a direct admit rather than make you endure a horrible A&E admit.
Now this is one that I do get quite cranky about. I understand that we live in a world of paperwork, back-up paper work and back up, backup paperwork, but the amount of time the nurses spent even out of the office, let alone actually engaged with patients was abysmal. They did not have the same geriatric workload as Ward B nurses. WHAT ARE THEY DOING?? I believe a small part of it can be attributed to the system of medication hand outs. In Ward B, three times a day you lined up outside a window for your medication, this took two nurses about an hour to do. Of course, they had to track down the odd non-compliant patient, but it worked pretty well. Assigned nurses gave out any prns or the odd medication that fell outside these times. In BCH, each assigned nurse, prepares the meds for each of their patients and then runs around the ward like a headless chook with a dixie cup of pills and another of water, trying to find their patient. As there is a bunch of nurse all trying to do this at the same time, the tiny meds room gets quite jammed up, which slows the process further. I've watched an individual nurse take two hours to get through all her meds. It seems to be a waste of time that could be better spent with patients. In BCH, I quite often went an entire shift without talking to my assigned nurse, or even knowing who is was until they came to give me meds. A common phrase was "Ive been measning to come and see you. Just let me finish these meds". And then you never see them again... I am not a squeaky wheel in hospital, so I am easy to overlook. Additionally, I have had a nurse tell my private psychologist who rang, that I was doing very well, and that she has spoken with me that morning....and she had not even seen me! Most of them are good nurses I think, but there is a culture of inefficiency and a tendency to migrate to the nurses station where its comfy. The nurses station in addition, is nowhere near the middle of the ward, so they had no idea what was actually going on (i.e patients smoking dope in the corner (I witnessed this!), there was gossip about patients getting it on in the laundry (not sure if that's true) If you did need to see your nurse, it would take a lot of banging on the door just to get anybody to respond. Massive Fails in my opinion.
Case Manager
Unlike in Ward B, my Case Manager in BCH was housed in a separate location from the hospital. I think she only came to the hospital once, when I was first admitted to introduce herself. However she does always make sure to let them know if I am coming etc and checks on me when I am discharged.
Other staff
Consumer Advocate (K) came and saw me twice during my last incarceration   admit. She also arranged for her counterpart to check in on me on my birthday, which was sweet.
Similar to Ward B, but have had a few bad experiences this time round. One of the girls I befriended in there ended up taking me on a bit of a roller coaster ride outside of the hospital. But I will always be grateful for the few months of friendship we did have. And I truly hope she manages to work through her issues. Unfortunately, I had to distance myself to preserve my own mental health.
Private Psychologist
I began seeing (D) about two months before I landed in BCH the first time, over the next 6 months I had two subsequent admissions. I cannot emphasize how much of a support she has been when i have been hospitalised, and I really need to remember that at times like now, when I am pissed off at her. I was really reluctant to go in my first admission. I had stayed out of hospital for nearly two years, I didn't want to go back to that. I didn't want to admit to how far things had gotten out of control. She did not push hospital, in fact she is in many ways anti-hospital, but eventually we both had to admit we were out of options. The first admit, she sat in the ER with me for hours, waiting for admittance. She also did a lot of the talking (background history stuff) that I was unable to do. I don't think I would have stayed and waited if she hadn't have been there. She also rang me pretty much everyday to check how I was going. At the end of the admission, the Consultant Psych told me, that if I was admitted again, (which I think he suspected I would be, with D-day anniversary coming up) that I was to go to my bi-weekly session with her, for continuity. So on the subsequent stays, I was faced with the surreal prospect of leaving a mental health ward on leave, to go and get mental health help. Seems ludicrous! But it helped.

Ultimately, I can see that Public Mental Health Facilities are not meant to be therapeutic communities, I can see the arguements for least restrictive environments etc BUT if the patients are going to be in the hospital anyway, you would think that there should be some attempts to provide an environment more conducive to processing whatever emotions etc they are feeling. I don't know exactly what the answer is, but I suspect a big part of it, particularly in BCH is getting the nurses off their arses, out of the nursing station and into the messy melee that is a psych ward. That's what they signed up for after all.

The second thing I have become aware of in retrospect, is how lucky I have been to have other people, (private practitioners, physiotherapist, auxilary staff ect) step into to fill the void left by the lack of involvement of behalf of the nurses.


  1. hi ophelia. found your blog from lola's. have been reading a bit lately - your experience about our MH system is very interesting. hoping to avoid being "forced" in...

  2. Ophelia, I have finally been able to sit down and read your account of hospital and it very much like mine, except for your difficulties with the brain injury. I only ever had short stays but I had many many short stays. I would end up in there every single friday and go home on monday mornings because I could not handle the outside world. This happened for about 2 years, though there would be the occasional weekend they couldn't get me in or I would end up in a place I hadn't intended. I used to go one hospital and the same ward but sometimes this wasn't possible if there were no beds. I'm glad my days of these seem to be relatively over but I sometimes still long for that safety but I always forget about the horrible boredom that I get in hospital. I also don't like the other patients alot of the time as you learn things from them that set you back. Anyway, I really liked readin this :-)