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

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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.’

Two months passed. I couldn’t do it. I couldn’t bring myself to take a shift. Every fibre in my body was resisting doing it all again. Could I restrain a child and force medication on them? No. No. I couldn’t. I don’t want in. I really don’t. And then, a lifeline. I was offered a job as a mental health advocate, and I jumped for it. So, I’m Inside the system again, but this time, my fight won’t have to be clandestine.

19 COMMENTS

  1. Wonderful blog, thank you.
    The tragic irony is that people with integrity, empathy and courage like you are precisely who the so-called ‘patients’ need – but the system is methodically contructed to leave little/no space for such qualities.
    I’m sure you will do wonderful work as a mental health advocate – you may find that somewhat frustrating, as you will likely come up agains the system on many occasions – very important work though.
    There are many support lines open to you e.g. through the many people who subscribe to MadintheUk/USA, dropt the disorder, etc etc – If I can be of any help/support at any stage, I would be happy to do so.

  2. Fascinating.

    The moral of the story is never try to change these things from the inside on your own.

    I suspect like many good staff you have left as it is soul destroying to stay.

  3. Fascinating! Would love to hear more but disguise it well!

    Child services really worry me, it seems pretty pro medication and all about selling the bio model to parents who can help enforce the broken brain doctrine.

  4. Guest Blogger 2,

    Your integrity and courage, maintained at grave risk to your professional “acceptability” is palpable.
    Thank you for this brave and moving narrative.

    Science begins with observation.

    You observed, and were compassionate, bravely questioning the institutionalised brutality which we are invited to believe is somehow compatible with the basic tenets of “nursing”.

    In a period of over half a century of studying and practising medicine, I have seen much sacrifice, dedication, total commitment, and inspirational compassion amongst sincerely respected nursing colleagues, at all levels of experience and seniority.

    For a suffering, frightened and distressed human being, empathy in their care professionals is of paramount importance. In a conscious patent, carer-empathy is immediately, and thankfully recognised.

    Captain G.M. Gilbert, Army Psychiatrist at the Nuremburg Trials of Nazis accused of responsibility for The Holocaust observed:

    “In my work with the defendants (at the Nuremberg Trials 1945 – 1949)
    I was searching for the nature of evil, and now I think I have come close to defining it.

    A lack of empathy.
    It’s the one characteristic that connects all the defendants, a genuine incapacity to feel with their fellow men.

    Evil, I think, is the absence of empathy”.

    No wonder your idealism and compassion were incompatible with the dogma and delusion of “mainstream psychiatry” – An area of alleged “medical Practice” where the overwhelming absence of empathy was my own personal – (initially astonishing) observation as a senior doctor from an unrelated medical speciality.

    The institutionalised “Absence of Empathy” was beyond belief.

    Sloppy and inaccurate diagnosis remains forever unaudited. Recorded with false authority and further absence of empathy.

    Patients with life-threatening adverse drug reactions, misdiagnosed as “Severe Mental Illness”, were subject to enforced further “medication” with those drugs whose brain, and multi-systems toxicities remained either denied or unrecognised, as a result of prescriber ignorance of psychopharmacology and toxicology.

    I particular, the prescriber’s denial of psychotropic drug induced AKATHISIA – is a cause of iatrogenic, alleged “Severe Mental Illness” leading to incarceration, abuse of human rights, further grievous drug induced injury and iatrogenic, societal rejection.

    Most at risk are those who develop akathisia as a result of inappropriate prescribing of SSRI/SNRIs.

    Misdiagnosis, undeniably widespread in psychiatry, can never be corrected, even after premature death.

    TRM 123. Retired Consultant Physician.

    • A very enlightening comment, if other (real) medical professionals are aware of this travesty, do they have any thoughts on possible course of actions to end this appalling waste of life and liberty. Truth about the damage these drugs do has been in the public domain for years and nothing changes. There needs to be some sort of class legal action in the uk, suing the RCpsych for fraud. We need a crowd source fund.

  5. This is a courageous and though-provoking account of your experiences. I do hope your time in advocacy is easier, but I have met plenty of people working in IMHA roles who swallow the medical line as wholly as many mental health staff. I hope you continue to resist and disrupt damaging approaches wherever you find them.

  6. It is difficult to fit in when there are so many control systems within our institutions. There is little breathing space for individual expression. If you question the Doctor and they don’t agree with you then you may very well be medicalised. If you question a teacher whom doesn’t agree you may be seen as ignorant. If you question a lawyer’s judgement you may be seen as one who misbehaves.

    Somehow the art of argument, mutual respect and the need to be heard seems to have been lost in the ether. This is why open dialogue is so therapeutic, despite the uncontrollable misgivings of a suspicious wider society, it is possible to function respectfully within smaller family units. Democracy on a small scale.

  7. Bravo on this article.

    All interesting and very real. I thought your discussion of risk especially interesting. Risks that the organisation described seem to posed as the risks posed by the service user. In fact what the organisation is really interested in is the risk posed to the institution. In part these risks relate to the ‘patient’ but over recent years the staff themselves are seen as risks to the organisation. This is the catch 22 because much of the poor behaviour you describe is most likely the result of a risk culture.

    As a worker what you do is judged based on the risk it poses to the organisation. When you were interviewed the questioners are trying to elicit what risks you might pose to the organisation given that you might act one way or another. Emotion, critique, questioning, allowing a patient to smoke, refusing to have a flu jab all pose a risk to the organisation. This risk culture is shaping many of the problems and making problems that might otherwise be practically addressed into much bigger issues.

    Well done, and this article will keep me thinking for some time

  8. Thankyou for an excellent and thought-provoking article. I share a lot of your concerns. I work in mental health services and over recent years have done my bit to try and provoke debate and change within the services, at times with a vehemence that has impacted negatively on my own mental health. I’ve realised that I need to approach the issue with balance and to accept that I cannot be ethically pure at all times. Compromise and frankly, a degree of hypocrisy, is necessary to remain working in the system, but ultimately I feel it is better to have people working in the system who have read the works of Robert Whitaker et al. If we all leave, the bio-medical lot will have an open goal. I found Lucy Johnstone’s article ‘Challenge, Compromise, Avoid?’ published in Asylum Magazine in spring 2016 very helpful in maintaining balance.

    • Author response: I completely agree with everything you have said, and having more people stay in the system who challenge, question and offer alternative approaches is the most powerful way to directly influence service user care, that’s why I wanted to go back. I’m so grateful for people like yourself who can stay inside and make a huge difference.
      And thank you for the recommendation of Lucy’s article.

  9. Thank you so much for your well written blog. I relate to what you say so much. I am an occupational therapist who worked in the system for over 20 years both in the UK and NZ, I now work as a peer support worker/advocate. I can relate to everything in your blog. I also was othered because I have a label of bipolar. One time when I got so angry at colleagues I lost my temper and said what I really thought. I was sent home because they thought I was “unwell” and had to get a medical to return to work. The psychiatrist I saw for my medical was shocked at how “together” I was.

    • Author response: Thank you for your comment. I am angered and upset to hear you were treated that way, but sadly not surprised. As well as what I experienced, I saw this happen many times to peer support workers, who constantly risked being seen as ‘unwell’ or ‘unable to manage the work’ if they questioned staff practices.

  10. Dear blogger,
    This is a terrific blog, thank you. I hope you don’t mind me linking to it from the Critical Mental Health Nurses Network blog.
    The feeling of alienation you describe is at every level of mental health nursing. When I became a mental health nursing lecturer I discovered that, just like my experience on the wards, just like my experiences in the community, you could have lots of critical conversation in the office (well, you could sometimes) and then those same colleagues would go out and carry on the status quo. I have a number of critically-minded nursing-tutor colleagues, and yet the course in general is full of the received culture of coercive services and crap science. We mark essays against a marking scheme that prizes critical thinking and yet we allow student nurses to write as if nothing they do is contested, that diagnostic labels are valid… it is shocking. Sometimes I have to mark essays that are, in all honestly, unmarkable because they contain the form of scholarship that I know other tutors are marking highly but appear to contain no critical ideas whatsoever. Then I am left wondering if failing the essay is merely punishing the student for the terrible course. For me, my brave decision is that I will never be very popular amongst most of my colleagues, although I have allies too. I am determined that every student that leaves our course has heard the key critiques of mental health nursing, services, psychiatry and the MHA to the very best of my ability. I get about 5 hours on the three year course to do it. I also invest heavily in my personal students. It is, of course, completely awful for them! They come in to mental health nursing full of hopes to help people and then they have they heads blown apart with the controversial nature of it all. Better than ignorance, but only just!
    There are about four nurses in each cohort that I teach that really seem to engage with a proper critique of mental health services. Those nurses, like you, tell me they feel like imposters, like ‘frauds’ and alienated from their colleagues. We talk about the emotions involved and I try to show them that emotions are the inevitable and right response to the intellectual labour they are undertaking and their experiences of the mental health service. However, it seems to me that in our course students are not really encouraged to see emotions as anything other than as something in the way of the job they have to do – exactly the same way we treat the emotions of service-users, really.
    Well done for making career choices that match your principles. You are not the first MH student nurse to decide to become an advocate and it is also a hard road. Please keep in touch via the CMHNN website, if you wish. I can put you in touch with other like-minded people if you want that. Thanks again.

    • Author response: ‘Thank you so much for sharing your thoughts so honestly, and please do link to it from the CMHNN or anywhere that feels useful. I always really appreciate meeting like-minded people as it is easy to feel very isolated as a critical mental health nurse. You are doing something so important on your course and your students are very lucky to have you.’