Who am I? The Identity, Morality and Silence of Mental Health Staff

Note from Mad in the UK. The following piece was submitted to us with the request that it be published anonymously. We hold the relevant details but felt it important to share this powerful and unsanitised account of life as a mental health nurse. Some details have been changed to preserve anonymity.

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I felt compelled to write this account of my experiences as a mental health nurse. All identifying details have been changed. However, this is a true account of the conversations I had and the people I met. I believe it needs to be heard.

I want to continue to document what I see and experience, in the hope that it will perhaps help us to understand – and make some sense of – what happens to the people who enforce our mental health system.

It’s been three years since I completed my training to be a mental health nurse. During the course, my time working on hospital wards and within community teams shocked and disturbed me profoundly. I had come to nursing later in life from a background of counselling and support work, and the books and articles I eagerly devoured by Robert Whitaker, Lucy Johnstone, Rai Waddingham, Marius Romme and Sandra Escher fuelled my evolving belief that responses to distress needed to be driven by non-medicalised, psychological reparation and meaning-making.

However, at university, I quickly discovered that – to my surprise – I was in the minority. Two exhausting years of constant debates and disagreements followed. I quickly found I had to play a difficult game with some of the lecturers; challenging their power-point slides, yet also consciously withdrawing and shutting down in order to jump through the necessary hoops in order to pass the course.

Although I met some like-minded students and staff along the way, the alienation I experienced from what I saw on placements – the many, many incidents of brutish, incompetent or inhumane practice I felt compelled to challenge – eventually almost broke me.

For those two years, I clung to the staff members who showed any shred of doubt about what they were doing – those who would catch me in the corridors or while walking home, and whisper the terrible incidents they had seen, the morally dubious decisions they saw being made, the coercive culture they had fallen into and – somewhere along the line – become part of.

Those staff were achingly few. Too many seemed void of critical ability or emotional presence. They were absent somehow, lost in the jargon of diagnosis, seeing the distress in front of them as ‘symptoms’, as ‘kicking off’ as ‘manipulative’ as ‘attention seeking’. What is a mental health nurse? A jailer? A therapeutic healer? An agent of the state? Should we follow orders or have own opinions? Nobody seemed to know.

Looking back, I think I experienced the staff’s emotional distance from the people they were ‘treating’ as a sort of double trauma. It made me feel wholly disconnected from those around me, as well as from myself. I experienced something like profound disassociation as I watched them with horror and fascination; standing in front of a person in extreme distress, yet seemingly unfazed and unmoved. The weight of my own feelings would pummel into me, and suddenly, I would feel as though I HAD to provoke them into feeling somehow, to provoke them into humanness. Where had it gone? How did they come to be this way? Did the job do this to a person? Though just as quickly, I would question my own reactions and doubt myself and my abilities. At a deeper level, I think I also doubted my truth. Am I right to feel this way? Is my way any better? Is this even really happening?

The dissociation of many people working in mental health continues to astonish me, as does the concern of staff when I show emotion after seeing a service user. Not tears, but simply human emotion that feels highly necessary and real and honest in this job. It was a truly horrible feeling when I sensed their sudden mistrust in me, an abrupt concern over my competence as a practitioner if I shared anything personal, something as simple as expressing sadness for the person we were discussing. What would have been truly restorative, truly helpful, would have been a human reaction back. I imagine that in some ways, this is what it must feel like to be a mental health patient, being treated with suspicion, ‘othered’ and not listened to, not treated as an equal.

I limped out of that course a brittle shell of myself and I have since avoided the Mental Health System, opting to work within various charity settings. Yet, over the last few months, something began to nag at me.

When a client would tell me about a terrible experience they had on a ward, how medication was forced on them, how they weren’t listened to, I found myself feeling increasingly powerless. I am on the outside peering in and unable to speak – like a wallflower – I have no voice and no weight behind me to stop anything happening or to really change anything for the person in front of me. And with this feeling, came a thumping guilt. I had run away, I had thought only about myself. I couldn’t be a force for change while on the outside.

I don’t know if this is true or not, but the idea got deep under my skin. So, I applied for a part-time job on a child and adolescent mental health ward. In the interview, I was resolved not to pretend to be anything other than myself, nor to be unclear about how I work. The two nurses interviewing me played Good Cop, Bad Cop. One nodded along as I talked, smiling and saying reassuring things in a gentle voice, the other nurse listened, cocked her head to one side and said ‘I can see you are very empathetic, but it’s also important to know that we have to do quite a bit of forced medication here, as well as a lot of restraint.’ She paused, ‘Do you feel this is something you can do?’

There was silence.

My head was whirring. No No No, I thought, I don’t want to do that, there must be another way…
But, I want the job. I want in.
Don’t I?
‘Erm, I..if it’s the last resort and everything else has been tried, then…yes. Yes, I could.’

The two nurses looked relieved. They offered me the job.

I’m terrified.

As I’m new to this NHS Trust, I need to go through all the induction training. This, I thought, would be a good way of scoping out the kind of people I will be working with, the philosophy of the Trust itself, the way they present themselves, how they show their priorities through what they choose to discuss in the presentations.

Day One goes by without any cause for concern. I hear about fire regulations and first aid initiatives and information governance. It is the second day that unnerves me. Two ‘carers’ are lined up to speak to us new starters. Promising, I think, and I look about the room wondering where the service users are and when we will be hearing from them. There are none. And as the first carer begins speaking, I am grateful for their absence.

‘My son,’ he begins, ‘has been schizophrenic for 40 years. It started when his mum, who was also ill, left the family home when he was 16, and he started to say very strange things. He said that he was hearing things and that the TV was communicating with him, and that was scary. Now, I took him to a doctor, and they put him on chlorpromazine which was good because it really calmed the whole situation down. Then he seemed to get iller, and my younger children were scared of him, and I didn’t want him in the house anymore…you see, this is what schizophrenia is like, they say all these really weird things, like, he started to believe he was this completely different person, with a different name – some strange foreign name (at this point the man made a cuckoo circle at the side of his head) and I said ‘I am NOT calling you that ridiculous name’ and he was upset and said I wasn’t really his father…’

The man continued to list his son’s ‘bizarre’ behaviour as if they were jokes with a punch line, at times, staff in the audience tittered awkwardly. ‘This is what it’s like to live with a schizophrenic’ he kept saying, ‘and then he didn’t want his medication, which was a disaster, and he wanted to come home, but I wouldn’t let him. I didn’t want him there… so then he stopped wanting me to be involved with his care, which was crazy, and the doctors wouldn’t tell me anything because of confidentiality laws – they said – and this was just outrageous, my son is sick, he doesn’t know what he’s saying or doing, you can’t play into or believe his crazy delusions…you can’t believe what he says…’

I felt physically sick. The rest of the room was clapping enthusiastically. Two nurses came up and thanked the man for his ‘bravery’ and ‘honesty’. The woman next to me, an occupational therapist whom I’d struck up a tentative conversation with earlier, was clapping mutely with a blank expression on her face. I breathed out, wanting to scream or cry – I wasn’t sure which. ‘I found that really quite offensive,’ I said to her. She looked at me, clearly unsure what to say. ‘Mm,’ she said, frowning.

The next day I verbally wrestled with a psychiatrist who was teaching a recap on Risk Assessment. I noticed, with a sinking heart, that every slide was about the risk the ‘mentally ill’ person posed either to themselves or to others. I put up my hand, red-faced and agitated. ‘We’re missing the risk from others to the service user, who is likely to be very vulnerable, and they’ve probably experienced some trauma or abuse previously too.’

She looked at me.

‘Well,’ she said, looking ruffled, ‘you can include that in Risk To Self if you like.’ Not really’ I said, feeling my heart beating, ‘if it’s not its own category it’s often forgotten about by practitioners and the person’s story isn’t heard.’ The consultant moved on. Everyone was quiet.

Later that day, I went to my occupational health appointment. The nurse was friendly and jovial as she checked my records. ‘Well, we’d like to give you a flu jab…’ she said, ‘as the people you will be looking after may catch things off you easily as they’re frail, and what would be only a cold for you may turn into a full blown flu for them.’ She paused. ‘Where will you be working, actually?’ ‘A mental health ward.’ ‘Oh! Well… in that case, you’ll be working with lots of people who will give you all sorts of things, so you definitely want a jab as they could have all sorts.’

I swallowed hard and left the room.

On Day Three of induction week during a session on de-escalation and restraint, I met a young registrar psychiatrist. Mid-way through a demonstration of how to release your leg from someone gripping hold of it, he smirked at me. ‘It will mostly be the PD patients that we’ll have to do this with, they are the weirdest.’ I felt myself instantly judging him, imagining I will dislike anything he has to say. Then just as quickly, I’m annoyed with myself at having made such a snap decision. So during lunch break, I make an effort to talk to him and I quickly realise how wrong I was.

‘We can effectively do anything we want… it’s scary.’ The young psychiatrist was fiddling with his pen and staring out into the hospital gardens. I felt myself nodding. ‘See,’ he said, ‘this woman on the ward was informal. She wanted a cigarette in the mornings quite soon after the nurses would wake her up, but they wouldn’t let her have one. First, she had to have medication, breakfast, then wait some more, then something else… And she would get more and more agitated. She’d say you wake me up early and then torture me for two hours. The woman wants a cigarette, she needs a cigarette, she’s addicted, I get that, and she should be allowed. Now after some days of this, and her actually having to wait longer and longer, she says I’m off, I can’t handle this. She’s Informal, remember. Now, we assess her and find that she’s not detainable. So, the psychiatrist – my supervisor – just makes something up in order to section her. They just make something up. No one’s going to question it.’

He’s shaking his head now.

‘I’ve seen some things…’ he continues, ‘and I’m beginning to see how these things work, how they happen. Now, when I start on a new ward and the nurses bring me cups of tea with the medication charts, I already know what’s coming… I can feel the pressure. Last time this happened, the Head Nurse wanted me to proscribe haloperidol PRN, she didn’t have a reason, it basically just meant that her shift would be quieter, especially the night shifts. So I said No. I wouldn’t do it. I could feel the tension after that, the other staff weren’t as friendly anymore and I wasn’t invited to things. Then my consultant had ‘a talk’ with me about how I was almost a registrar and that I needed to not be so resistant to staff members’ requests. The atmosphere changed, with my consultant as well. He made out that I wasn’t being professional by questioning medication requests.’

I shared some of my own experiences, and his face grew red as he listened. I felt something like comradery.

‘Another ward I was on,’ he continued, his speech having gathered pace, ‘it was late in the evening and I was standing by this nurse, a patient comes up to him and says that he’s had cocoa, he’s watched some TV, he’s read all the papers and he’s still not tired enough. Then he asks him politely if there’s a book he can read to help him off to sleep. No, the nurse said to him abruptly, but I can give you some lorazepam. He then turns to me and asks me to prescribe it. I refused, of course, and he was really annoyed with me…Maybe this is what happens, you get ground down, I don’t know. Not just psych’s – everyone I mean. It’s that…you really feel the difference when you prescribe what other staff want, or do what your team tell you too. It’s a nice-ness, a friendliness, at least that’s what I’ve noticed. And it’s the same with more senior psychiatrists if I question them or have a different opinion to them they say I’m too new to this, that they’ve been doing it for X amount of years this way and its always worked this way, and that I don’t understand. But you just can’t think like that! I mean homosexuality was in the DSM as a mental disorder until the ’70s! You have to question most things within psychiatry – constantly.’

He turned to me, ‘To tell you the truth, I’m not a big fan of medication actually, and I’m really not a fan of how it’s used on wards.’

We said our goodbyes and wished each other well in our new jobs. I told him I was gutted that he wasn’t working on my ward. He smiled.

‘Good luck,’ he said, ‘it might not be too bad.’