Saturday, 13 August 2011

How I saw it in 2003...a psychiatric unit.

This is as good an opportunity as any, to re-visit a piece a wrote in 2003. It will help put my 2011 views into context. 

I haven't changed anything in the piece. Eight years and hundreds of clients later,  I still stand by my observations. 

Featured in the Human Givens Journal Vol 10 No 1 , 2003

Not a Tissue in Sight
I read with great interest and enthusiasm the article in the last issue called “The urgent need for a human givens teaching hospital” (vol 9, no 4). I couldn’t agree more that we are crying out for such a facility. Over a period of five years, I worked on an acute psychiatric unit – private but with NHS beds – and, while it had many of the assets that Ivan Tyrrell described as desirable, (a beautiful setting, architecturally pleasing and with grounds and outbuildings of its own), what was lacking was effective help for its troubled occupants.
I became involved with mental health work by accident when, as a nursery nurse working for a local agency, I was asked to go to the unit to support a mother with postnatal depression. On my second day, the staff nurse asked if I would like to become a member of a bank of nursing assistants on whom they called when they were short-staffed. I thought the work would be extremely interesting, so I agreed. Little did I realise then that what I would see and learn would propel me into a totally new career as an effective therapist.
The unit catered for the whole range of acute psychiatric disorders – eating disorders, addiction, depression, schizophrenia, paranoia, bipolar disorder and so forth. I worked there fairly regularly, on both day and night duty, filling in when staff were off sick or on holiday leave. I enjoyed the hospital atmosphere. We all wore ‘civvies’; patients were called ‘clients’ and there was no institutional feel at all: the furnishings were attractive, the grounds cultivated and colourful, the walls hung with paintings and the rooms filled with plants. Almost all the bedrooms were single occupancy, with private shower and toilet.
I suppose my first surprise was that nursing assistants who worked ‘on the bank’ received little training, no supervision and were not included on the nvq programme. The only training was an initial induction including health and safety topics such as how to lift a patient, but not how to talk or relate to them. While nurses and assistants on the staff were participating in the supervisory support groups that were denied us, just a couple of us would be left to run the ward. Besides helping serve meals and ensuring people took their medication, my main duty was to act as a support to clients and my main ‘intervention’, as it was called, was to offer a shoulder for them to cry on. I might be asked to talk with someone for half an hour, accompany them on a walk to the shops or round the grounds or just sit with them. often I took my turn at close observation of a client ‘at risk’ of killing themselves or running away. Some clients had to have their whereabouts checked every 15 or 30 minutes. All nursing assistants took their turn at observation duty, which sometimes entailed just sitting in a corridor, ensuring that people thought to be at risk didn’t get out. I was never supervised once, either formally or informally. Even on my first day, I was left with an extremely challenging client and given no guidance; the staff just assumed I would cope.
On the whole, I found the work absorbing, although, with no training, sometimes I wondered about my effectiveness. Slowly, however, I became increasingly concerned by what I observed. There was a worrying reliance on the medication trolley and the longer I worked there, the more I realised how long patients tended to stay on the unit too. Often they remained for months on end and seemed to deteriorate, rather than improve, with some clients becoming nurse and/or doctor dependent. Clearly, there were long term clients who knew how to manipulate the staff. They would push at boundaries (for instance reneging on a contract not to drink alcohol or not keeping to an agreed eating regime) and be allowed to get away with it. With my nursery nurse training, this instantly struck me as wrong. One of the first things we learn when we set boundaries for children, is to be consistent.
I also became more and more struck by the fact that people tended to spend a great deal of their time being miserable, not helped by the emphasis on past events rather than looking for solutions. Clients either huddled away to cry on their own, sat in the communal areas or came in a distressed state to ask a staff member to be with them. We were just expected to listen while they cried, and murmur “There, there”, “It’s not as bad as all that” or suchlike. One woman would cry so protractedly, going over and over and over something in her past, that staff tried to avoid her. Even now, years later, if I should meet her in the street, I notice tears will come into her eyes as we speak.
When I did corridor duty, ensuring that no one who was at risk went out of doors, I would see clients go to what was called the ‘end of day’ group, where they would talk with a member of staff about what had not gone right for them that day. It was a time to unload (as if they needed any more unloading). I would watch them when they emerged and couldn’t help likening them to a line of monks in their habits – except, in this case, what they were shrouded in was misery or anger. Tears flowed easily (I was never present at such a group but I gathered that someone would say something woeful and it would set everyone else off). Some went straight to their rooms to self harm.
There was a TV room where people could smoke, and there many would sit, smoking, watching TV and looking miserable for most of the day. Sometimes a nursing assistant would engage someone in a game of scrabble or start a jigsaw, but, for the most part, people were left on their own. There were occupational therapy and psychotherapy sessions, music and art therapy or relaxation classes, but these were often cancelled because the person due to lead them was sick, on holiday or had gone to a meeting. Clients found this very frustrating. My abiding image is of people drifting – shuffling along the corridor between the smoking room and their own rooms. There were many hours of unproductively filled time. Clients saw their psychiatrist once or twice a week and were supposed to see a named nurse every day, but not many seemed to improve. While I privately questioned what I saw, I thought it must be due to my lack of relevant academic knowledge.
Some nurses, in conversation, might casually question the benefit of it all, but mostly they put up with it. Not one of them showed any interest in a flyer advertising a MindFields seminar, entitled “How to be an effective counsellor”, posted up on the staff room notice board. By that time, sometime in 1998, I was frustrated enough to be willing to spend my own money to go along, in the hope of learning something I could put to positive use. That seminar changed my life. I continued attending MindFields seminars and workshops, and quickly learned swift, reliable ways to help people overcome distress. I took the Human Givens Diploma course and now work in private practice as a human givens therapist. But, at the beginning, I was tentative in applying my new growing knowledge in the psychiatric unit where I still worked.
We used to have clients knocking at the staff room door, begging for medication when they felt they needed a top-up. Nurses tried not to give it before time, so people could be left in a extremely agitated state, not knowing how to get through the next half hour or 40 minutes until they came and pleaded again. I asked permission to try calming them with relaxation, and clients found it enormously helpful.
There was a man in the unit who had been a soldier involved in a conflict abroad and suffered severely from post-traumatic stress syndrome. I offered relaxation but he was wary at first. I soon found out why. At one of the group relaxation sessions, the nurse inducing relaxation, had instructed individuals to imagine a lovely, green field. The man panicked and ran out of the room in complete terror. It turned out that it was in a lovely, green field that he had very nearly been blown up by an exploding mine. I persuaded him to let me try to help him and, of course, invited him to visualise a peaceful place of his own choice (which turned out to be his bedroom at home). I also talked to him about the effects of emotional arousal and helped him reduce it by encouraging 7/11 breathing – breathing in to the count of seven and out to the count of 11. It was simple and effective, and he was pleased with both interventions. But I always made sure I received permission from the staff before trying any such thing, however minor.
One woman – I’ll call her Maria – was severely manic depressive. One day she started crawling over the furniture in the communal area, shouting and jabbering non-stop. The staff just left her to it. It was early days for me in my ‘therapy career’ but I knew about entering individuals’ reality as a technique for getting through to people who are psychotic. So I started nodding as she jabbered, as if she were talking sense. She was already clearly in her own trance state, so I decided to try a hypnotic suggestion. I said, “AS you carry on crawling over the furniture, you’ll notice that you start feeling more relaxed and sleepy.” Her movements slowed and she stopped on the sofa. I added, “You will go to sleep, waking up when you want to, feeling calm and relaxed.” She fell asleep almost immediately and, half an hour later, opened her eyes and went calmly back to her room.
I was highly encouraged by this small success. On another occasion, Maria had trashed her bedroom and bathroom. She was wandering the corridors, ranting that she had to get ready; people were coming to see her and she had to get the flat sorted out. Taking her at her word, I said, “Well, we’d better get your flat sorted out, then,” and walked with her to her room. It was in an appalling state – everything all over the place and talcum powder everywhere. But she set to, and cleaned the room in preparation for ‘the people’. I wasn’t confident in my new skills, at that time, so I didn’t make much of anything I managed to achieve. I did mention to staff that Maria had cleaned her room but no one was particularly interested. I was just a nursing assistant with no nursing or academic qualifications. Who was I to suggest something that might work?
A major restructuring programme took place and the one unit became two units with their own specialisms, because the mix of conditions hadn’t always been helpful to the clients. But, overall, the effectiveness of treatment appeared to change little. As I furthered my training outside of the unit, I knew I couldn’t work on the units anymore, without saying what I thought. So I wrote to the two psychiatrists, one psychologist, two staff nurses and four management staff, saying I had enjoyed my time at the unit but now felt something important was missing from the care. I said I thought every nurse and doctor should be trained in how to lower emotional arousal and in the use of therapeutic trance states. I donated a set of the organising ideas monographs to each unit but, although some thanked me, I do wonder if they have been read.
From what I know now, the negative aspects of the care that was offered in the hospital are probably common to the majority of such units to which people are routinely admitted (although staff to patient ratio is likely to be lower). Medication cocktails are administered that induce highly questionable side effects; emotional arousal is encouraged (in our case, boxes of tissues tended to be everywhere – bedrooms, dayrooms, the consultants’ rooms and corridor tables); and there is not enough to occupy people, so damaging introspection can hardly be avoided.
As a result of taking other observations into account too, in my own consulting rooms the walls are not white; the chairs are not institutional or placed towards the light; there is no large clock ticking loudly, at which the therapist keeps looking; and there is not a tissue in sight!
Good luck with the proposed human givens hospital.
Rita Leaman


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