Just Another Poxy Shift (Mental Health Short Story)

City Nurse Project - 1 -

© 2005 Geoff Brennan All material, including front cover image, remain the copyright of the author. Permission is given for reproduced in any format of any and all materials, provided no change is made to the original.


Acute inpatient psychiatry has been getting lots of criticism for what now seems like a long time. Report after report criticises wards for poor teamwork, ineffective leadership, office-bound staff, and chaotic, disorganised routines. Wards, we are told, are unclean ill-equipped environments, dependent on the employment of uncommitted temporary staff, dangerous places where staff and patients can get hurt, and about which ‘something’ has to be done. In short, acute inpatient psychiatry gets a bad press. That has consequences. Fewer professional staff want to be there and develop their expertise, and the grass on the community side of the fence always looks greener. There are traces of a vicious cycle to be seen here.

And yet wards can be fantastic places to work. Some of the most formative moments of my career occurred on wards. The people I met there, both staff and patients, have been hugely memorable and have had a permanent impact on me, both as a psychiatric nurse and as a person. Somebody was clearly needed to tell it like it really is, to find a new way of communicating the value of acute ward psychiatric nursing. That person was Geoff Brennan. I made the suggestion. All the rest was down to him. Here it is. And yes, it is recognisable. This is acute psychiatry. Len Bowers Professor of Psychiatric Nursing After completing the obligatory academic research papers on acute inpatient wards, the City Nurse Project team (see the epilogue for more information) considered how to be more forceful in telling people how valuable ward work is. Chris Flood wanted us to dress up as superheroes and storm the Houses of Parliament, but this had been done already. Len Bowers wanted to infiltrate the e-mail of every psychiatric nurse in the country with subliminal messages such as “ Wards are great” and “Gee, I wish I was back on shifts”, but this is illegal. So it was left to me to come up with something. Geoff Brennan City Nurse/Researcher


Mary asked so I went. Her best friend, Judy, was marrying a socialist environmental worker (no, I don’t know what that means either), and as Judy came from a Middle English, plum in the mouth family, I figured it would be good for a laugh. Officially, though, in the context of relationship politics “ Mary asked, so I went”. We went to the Isle of Man, a marquee, champagne, jazz band, running kids and flustered parents who can’t swear properly (“Is Jade with you? No? Oh poo where has she got to now?”). Mary, the partner I am always amazed doesn’t realise she could do better, was lovely, charming, erudite; there was a free beer tent and a short service with the little personal touches lost on most of us that make up the private-public marriage celebration. In fact it was all going swimmingly - until the tables. You’re having a great time. The beer is flowing and people are chatting or laughing while they torture the bride and groom with photography. Then you are called into the marquee where a big board sets out your fate for the next three and a bit hour. The tables. God, how I hate the tables. They were round, as ever, and we all had place names in ornate copperplate, as ever, and we were all mixed up, as


ever, so we had that process, you know the one, the small talk, getting to know each other that some people (like charming erudite Mary) are so good at and I’m not. It quickly became apparent, however, that we had a face saving Joker on our table. He was young, well spoken, and girlfriended, knew one other couple, knocked over a glass, got talking, didn’t stop. I relaxed and began to enjoy myself. This could be fun after all. But it wasn’t to last. “So what do you do?” This is possibly the most horrible question in the world. Apparently it is only western societies that torment each other in this way. Other, more sensible cultures make inquiries like “How many cows do you have?” or “Have you still got all your teeth?” But the Joker asked that horrible, western question and I felt a familiar sick sensation in my stomach. He asked the older gentleman across from him first. He was wearing a purple beret and had an amazing moustache, so there were other, more obvious questions he could have asked, but the man seemed to take it in his stride. It transpired that he was Polish. When asked the question, Polish lifted a proud head and proclaimed to all that he was a lawyer in some firm that obviously meant loads of money and royal garden parties or something, because


there were some appreciative murmurs and at least one “gosh”. I could sense Mary looking at me, but I wouldn’t do eye contact. In situations like this I had been known, under the influence, to proclaim that I worked “on the bins” and that “you can tell a lot about a person from their rubbish”. It wasn’t meant to annoy. It was meant to deflect the questioner, but it did annoy Mary. The conversation had moved on and I kept my head down, but I had to look up at some point, so I looked up to see if Mary was still looking my way. She was. So was Joker. He was looking straight at me. His lips were moving. “…And did I hear Judy say you were a psychiatrist or something?” Mary’s eyes grew as if a crocodile had just got hold of her leg. I think she began to sweat, but I couldn’t be certain. I looked over at Joker and said “No. I’m a psychiatric nurse. I work on inpatient wards in London”. I don’t know if it is true, but I felt that everyone on the table was looking at me now. Leave it there, I thought, just leave it there. But of course he didn’t. They never do. “Really? I do admire you. I could never do anything like that!” It was at exactly this point that a small voice, which had been quietly, but persistently clearing its throat in the back of my mind, finally stepped forward,


and said, “ Yes, it is an uncanny resemblance, isn’t it?” Joker looked exactly like Tom. It was an amazing match. As a psychiatric nurse and aware of the dire consequences of admitting to voices in the back of one’s head, I think I should leave it up to you if you think that was a figure of speech or not. But if this was a film instead of a story the next thing that would happen is the wobbly screen effect, like you’re drunk or God is giving the world a really good shake, at the end of which you have all your hair back, lose three stones and ten years. In this case I am starting a shift on Bundle Ward, which was named after a doctor in the 1800’s who was superintendent of a Victorian Asylum and died of syphilis in his own institution. This fact causes general merriment among the patient population who have renamed the ward “Poxy”. I glance through windows that do not show the rolling well-tended grounds with rhododendrons and orchards so many people associate with old Asylum buildings. The retained name belies the fact that the institution has now yuppied uptown and this particular unit, which is Bundle Ward mark three, is overlooking a busy London thoroughfare, so I can see red buses, small eateries serving overpriced guacamole and bacon sandwiches and the back entrance to a large department store complete with smoking shop assistants. Tom will come on screen


later, but at this moment I am in handover listening to the Vary Capable Angela giving a run down of the current patients. Very Capable Angela is one of our better staff nurses who trained at a top London teaching hospital in the 1980’s. You can tell because she wears the uniform of t-shirt, jeans, and Dr Martens, all black, denoting the true feminist. This is completed with a bright smear of blood red lipstick. I think this particular hospital must have manufactured its own shade called Essence of Vampire or something as I don’t believe I have ever seen it in the general population. Very Capable Angela was not christened as such, you may be surprised to hear, but in my head is and always will be Very Capable Angela. On shift with me today is Still Learning the Ropes Bill, a newly qualified staff nurse who has been recently recruited and is a bit of an unknown. He asks lots of very good questions and Very Capable Angela answers them very capably. Over in the corner is Honest as the Day is Long Mohammed, a nursing assistant who has been on Poxy for a year. Mohammed is an intelligent, caring man who was a teacher in his home country before fleeing and finding a job with us. His English was dreadful to begin with, but he can now swear with the panache of a true Londoner. Mohammed retains enough dignity never to do this in front of patients, carers, women or anyone he perceives as socially superior


to him. I, being none of these, get the full brunt of beautifully constructed diatribes against many people and situations that leave me breathless with admiration. Mohammed is also able to interpret for the area’s biggest ethnic minority, which he does with skill and diligence. He once helped me overcome a misunderstanding in my own language: Ethnic patient (waving at me) – “Dick, Dick?” Me (slowly) – “ My name is not Dick, its Archie.” Ethnic patient to me (slowly) – something I can’t understand Me to Mohammed – “Help me out here, can you tell him my name is not Dick.” Mohammed and Ethnic patient have a good-natured conversation with a few small, intimate laughs. Mohammed to me (matter of fact, no trace of a smile)- “Mr X has informed me that he wasn’t calling your name, which he knows, but using “Dick” as a general term of abuse.” Me- “Oh, right.”


Mohammed had a son who had a learning disability, something that he had just let me know about, and only because he had to take time off when his son received treatment in another London unit. He had told me to get my advice before asking the ward manager for leave. I gave my advice and he shook my hand as an equal, formal and dignified. It was good to have him back. So me, Still Bill and Honest Mohammed were the male wedge of the shift. On the female end of the scale were two polar opposites as different as black and white. One was black and one was white. The black side of the equation was a true colossus, in every sense of the ward. She was called The Duchess. She was called this because she was an aristocrat. Her real name was, in fact, Mrs Duke. If she had not been called that we would have changed her name by deed poll. Describing The Duchess is difficult as she was one of those people who occupy a space much bigger than any allotted to her. It was not so much that she looked at her job description, role and position, status and influence and set about inverting it as that she just decided she knew best about how to be on the ward and proceeded to act in accordance with her own view, rather than any other. I know this does not make sense, but nothing applied to


The Duchess in the terms of rules, regulations, policies or behaviour made sense. But she was never wrong in how she approached things with the most fractured people and you could never, ever copy it because it would not work for you or anyone else. I feel an example is called for. A young man is admitted who has not washed for some days as he has a paranoid fear of water. This fear is not rational to anyone else but himself. We are trying to assess, with him, what this is all about; he has met with the doctor to look at why he believes this, and why his fears are so extreme. From this there is a multi-disciplinary discussion. Actually, this means his doctor and Very Capable Angela have a chat, but multi-disciplinary sounds better and, as one person is a doctor and one a nurse it’s not totally inaccurate, if you ignore this chat happened in the staff room (a cupboard with a Royal College of Nursing poster six years out of date and one broken chair) as Angela is putting on her coat (black leather with synthetic black fur hood with one button badge, black with the word “Bitch” in red) to leave. From this we decide to gently prompt but monitor mood and behaviour over the next few days – psychobabble for “wait”. We, however, do not include The Duchess. So she comes on shift, hears the plan in handover, from which she walks out, fills a bath with water


and a concoction of salts which just happened to be in the witch’s sack she calls a hand bag (need a card for any occasion, button repair kit, globe of garlic, mouse trap? Look no further), and spends the next two hours with the young man, bathing him, washing and drying his clothes and all the time humming “I will survive”, for whatever reason. At the end of this he makes her a huge mug of tea and sits quietly trimming his excessive nails while she watches Eastenders. In all this there is no apology, no rationale and no mistake. I can hear eminent psychologists and psycho-social/ behaviourists sharpening pencils to outline the destructive maternalism inherent in this act and blatant use of the young man to meet one’s own needs, but, and this is very important, they would be wrong. The Duchess would not do this for everyone who presented with these particular problems. She would also not be able to tell you why she had now. The word instinct and intuition are too weak to describe her innate, inexplicable ability to judge a situation correctly and her bull stubbornness in ignoring all other opinion in the carrying out of her desired task. However, and before we begin to ask for some guidance from the Vatican on the checklist for sainthood, The Duchess did have one major flaw. I could dress it up in all sorts of language, but, at it’s crudest was a simple and complete mistrust of


anyone who took drugs (the street variety) and anyone who hurt themselves without meaning to die. For those unfamiliar with the true nature of acute inpatient psychiatric wards, these bland facts may move the Duchess from a position of veneration to a position of disapprobation (look it up), but these blind spots are actually quite common on wards, and not just among the staff. It was this flaw (black and white intolerance) that once led to the Duchess and I having verbal blows over the care of a particular young woman admitted to the ward. The Duchess was finding it hard to fathom why anyone would wilfully harm herself: “I just don’t understand it. Look at her, pretty young girl like that, cutting herself and making her arm look a mess, making the other patients run around feeling sorry for her – It’s not good for them, you know, some of them are really ill, not like her. You know she can stop it, don’t you? You know she does this for people to run around saying “oh, poor you”. I know you Archie; you’re a soft touch for these time wasters. Get her out, I say, show her the door and I’ll give her the bus fare” “Oh come on Duchess, you know that she is damaged as well.”


“Damaged? How is she damaged? She had everything you know, good home, school, money, looks, friends. In what way she is damaged?” “Well, why else would she be doing what she is doing? You think she enjoys it?” “Archie, you big soft hearted man, let me ask you this, why does she wait until she is admitted and than begin to cut herself, eh? Why does she wait until she is here, with we poor souls who have to look after her, before she starts to take bits out of her arm, eh? She knows we will stop her, she knows the doctors won’t let her out, she knows the patients and soft boys like you will talk to her all whispery “Oh poor you, let me help you” and she will all whispery back “Oh, I’m damaged, only you can help me” and when your back is turned she’ll take another piece out of herself, “Oh, I can’t help it. When you gone off home, I feel so bad”…Bah! If she want pain, let me clean that cut with TCP.” She didn’t. But it was obvious to Sharon, the girl in question, that the Duchess was not amused. It was as equally obvious that her opinion mattered to Sharon. As time went on the Duchess had a point about Sharon getting worse. She did seem to up her self-harm the more sympathy was given. The Duchess’ anger then changed. It was our fault now,


with Sharon being detained against her will and with a nurse observing her at all times. “See what you all have done? What you going to do now, eh? And what about everyone else here, feeling sorry and scared and waiting for the next bit of drama? I tell you now, I get blood on my dress and you get the dry cleaning bill.” Now the Duchess demanded to do as much of the observing as she was allowed and dragged the hapless Sharon from one task to another – laundry, helping to rearrange the games cupboards, the linen cupboard, washing the coffee cups, polishing – all with the booming admonition “not do anything while I’m here or I will make you truly suffer”. As we bumbled through Sharon’s care, and when she eventually came to be discharged some months later, she went out of her way to thank the Duchess, who, after almost suffocating her in her big mamma bosom told her that, if she came back, she would take “a hair brush to your bony backside”. Like I said before, nothing the Duchess did was either explicable or open for duplication. Tom, whose features were resurrected at the wedding table, was, in street reduction parlance, a druggie. He was also the partner of Tracy, who was a patient on Poxy. The Duchess and Tom did not get on, although Tom did not know they did not get


on. The Duchess had decided they did not when she heard Tom used drugs. Before we come to the story of Tom and Tracy, we need to meet the last member of the shift. I called her Anal Anne. Anal and I had, what is fashionably called a personality clash. I would just say we loathed the sight of each other. The parties involved knew this, unlike Tom and the Duchess. Contrary to popular belief, a nursing team is not a group of harmoniously programmed professionals all striving in the one direction like those stylised posters of workers so loved by the old Soviet Union. The process of being around people who are fractured and twisted in their perception of the world is wearing and draining. Now if you thought that the fractured and twisted are all in beds with case notes in the office, you would be wrong. Sometimes the fractured and twisted can be on the off duty and drawing a wage, and some times those being worn and drained can be on a section and worrying about benefits. With regard Anal and me, I suspect she thought I was as fractured and twisted as I thought she was. Why did we have such bad chemistry? It is always difficult to say, when you are one of the elements in the equation. Our ward manager, who was a cross between a Buddhist monk and Clint


Eastwood – soft and gentle on the outside with the ability to kill with a look and a well chosen phrase – said, when I asked in supervision, that we didn’t get on as we were “yin and yang energy that conflicted”. When I asked “can I have that in English please” she said, and I quote, “Archie, you are a disorganised, slobbery mess whom I only tolerate on this ward because the punters here trust you. In you they see a mad person who has managed to keep the lid on the whole thing, but who should, really, be riding with the trick cyclist and eating the pills as well. That fascinates them and gives them a curious sense of hope. A kind of, “if he can do it so can I” feeling. They would follow you anywhere, Archie; it’s true, but mostly with a sense of morbid curiosity. Anne, on the other hand is tolerated, as she is a person who cannot stand mess and will come screaming to me with every small drama that I shouldn’t know about, but occasionally with very important ones I should. Most of the unnecessary stuff you cause, by the way. The punters also trust her, as she will pedantically sort out their mess for them and help them to do things they need to do but don’t want to. You give them hope, Archie, while Anne gives them structure. They need both and they know that, even if you don’t. Get used to it. Anne’s never going to be on your Christmas card list, but she does mine. Get the picture?”


I did, sort of. I had to acknowledge that Anne was a person who not only dotted the “i” but also used a ruler to make sure it was in the right place. Crossing “t”, I suspect would have it’s own, Anne patented tool. This attention, no, obsession to detail would seem in direct contrast to my own relaxed attitude to the bureaucratic nature of our work. For example I did once devise a method of note keeping which would require a simple letter to be entered into the person’s notes for a shift. “A” would mean the person had been “Settled on the ward”, B “Mostly settled on the ward” C “Not that settled” which went up to Z “The word settled could not be applied to this person at any time during the shift”. Other factors could be added to with number addition so the 1 would be “seen by doctor”, 2 “seen by Occupational therapist”. I was going to have 3 “seen by psychologist”, but this never happened, so 3 became “seen by solicitor”, which often did. It did not get many fans. In later years I did come to be one of the great advocates of records. I truly believe that the keeping of notes allow people to access important information about a person’s progress, not least the person themselves. In the days I am relating, however, it was not unusual to hear me rant about not being here to sit and write rubbish or “people work not paper work”.


Having said this I am increasingly worried that every new problem on wards seems to lead to a new form being filled out which has little to do with caring for people. Examples of this bureaucratic paper nonsense are not difficult to find. Once, for example, the female toilet on Poxy become blocked and we filled out the Request Works Order form, as per policy, sent it to the manager and the works department, entered the time and date they were due to come in the diary and prepared the budget requisition sheet, made a sign for the blocked toilet and waited the three days for the works to send someone - only to find that The Duchess and Honest Mohammed had unblocked the toilet with some implement The Duchess had in her bag. We then had to send a separate form to verify that the works person had come but had not been required to attend to the job. This was sent to the manager and the works department, as per policy. After about a week the works department again turned up as the job had been logged as outstanding on their database. As it happened the toilet was blocked again due to having a patient who was flushing a whole toilet roll at a time. The works person would not do the job, as it required its own form and database number so as not to be confused with the first job. We sent one off, booked the times in the diary and The Duchess and Mohammed again cleared it


without telling anyone. Life could have gone on in this interesting cycle for some time but the ward manager confiscated the Duchess implement. Anne was the queen of the bureaucratic process, knowing each bulky duplicate book, its function, who needed copies, what all the codes were, at what room temperature they should be stored, what they ate and all that. She also was the one whom the ward manager nominated to audit the paperwork – to check that people were complying with the policy on note keeping. Accordingly, once a month I would find a little note in my pigeonhole outlining in what way I was breaching policy, the nursing code of conduct, common and judicial law in the manner in which I kept records. Anal love letters I called them. In one I was told to not write in red pen, so I changed to green, only to be informed it had to be black. I was then told I could not put just my initials beside an entry, so I took to writing my full title, “Archibald Deaglan Sean McMulish (Junior) RMN, RNLD, BA (Hons)”, which I was informed was excessive, particularly as it was longer than the actual entry into the notes (which had been “Settled and seen by doctor”, although this could have been even shorter, a clear “A –1” in my system). Anne, however, retaliated when the off duty rota was given to her.


The off duty rota is an amazing object and should be the subject of a separate field of science. On the surface it is a simple record of which nurse is on duty and what shift of three they will be covering over the period of a month. Simple, I hear you say, except that there can be up to twenty staff with separate requests and leave due to child care, courses, football matches, weddings, maternity leave and other baggage of life. In addition, each shift has to be a balance of qualified and unqualified nurses, mixture of the genders, balanced in terms of weekends off, balanced in terms of day staff going onto nights, balanced in terms of me and Anne being on the same shift usually meant open warfare. Einstein was apparently becoming familiar with the vagaries of the off duty when he said, “If you can speak of technical things only in technical terms, you do not understand them.” Research has shown that the best people to compile an off duty are those with a mathematics degree who have taken psychology as an option, who do not have a history of alcoholism, drug abuse or depression in their family and who are capable of alienating everyone they work with whilst coping with having the worst shift pattern of all. These are rare beasts that tend not to breed as no one likes them and they are always at work. The off duty usually causes health problems to any normal soul if the proper precautions are not taken, like avoiding doing one.


In Anne’s hands, however, the off duty became the vehicle when Revenge came to visit me with his big brother, “You Had This Coming, Buster”, to hold his coat. Between them I ended up in shift hell, finishing at 9.30 pm to start again at 7am during the week, working late on Friday, with a late on Saturday, day off Sunday early Monday and no hope of overtime. If you don’t know, trust me that every shift-working nurse is now wincing in sympathetic pain. Oh we had our little war, me and Anne, during which the ward manager would appear as the UN peacekeeping forces for a short period, would negotiate ceasefire lines and give us a good telling off, but we would resume hostilities as soon as she went on holiday/to a meeting/into the next room. If it wasn’t for the excellent distraction of nineteen people who happened to be our patients, I think we would have killed each other. Nineteen patients. It has always been a quiet source of amazement to me that some people came into our ward and trusted a disparate bunch of people loosely held together by a veneer of professional identity. I still remember the psychological shock when, as a student, people twice my age would sit and tell me the most intimate and personal of information. The feeling of being some sort of


impostor was hard to shake. I could understand them telling the Duchess, as she was an earth Mother receptacle of the world’s woes, to whom bus stops and the supermarket became places of confession and the dispensation of a variety of Trinidadian sayings and narratives that seemed to ease the pain of whomever had unburdened themselves. But to relate your woes to a scruffy, untidy, disorganised mess like me simply because I had a badge with the word “Nurse” on it was, not to put too fine a point on it, mad. As the photo in the badge made me look like a baby eating, drink addled alien with pointy-head and rictus grin, it could only have been the word that was responsible for this phenomena. Except, I suppose, that I did not work alone. People were not just talking to me, but to one face of a multi-dimensional human object, which, as was then the case on Poxy, was a whole more than the sum of its parts. I did not truly appreciate it at the time, but we were what are colloquially known as a “good team” and the people who trusted us with their personal information trusted us as a whole, even when they felt they were talking to an individual part of that whole. This doesn’t mean we were clones of each other. I defy anyone to find any similarity between Anal Anne, and me. No, we were different in every way,


as the shift in question demonstrates. A Muslim asylum seeker, a Black Trinidadian tank made human, Howard Hughes role model (female type), a walking reminder of chaos theory (Scottish type) and a nurse so new he should have a big red L on his back, were the best that society could muster to look after nineteen of its most vulnerable people in one of the poorest areas in the county. Yet, in many ways, we were the best that society could do. In case you are wondering where are the doctors, the psychologists, the psychoanalysts, the occupational therapists, the social workers, the art therapists, the Music Therapists, the Drama Therapists, the Nurse Consultants, the Practice Development Nurses, the directorate managers, the service managers, the Nursing/Medical Directors, the Chief Executive (whatever their name was) or anyone else were, as most of this story happens after the hours of 5pm, I suspect they were at home, down the pub or in their tai chi classes. After the witching hour of 5, the wards are left to the nurses, patients, carers and a few junior doctors who know better than to get in the way. I like this time because we no longer had to feed the above with information, return their phone calls, show them were anything was, introduce them to the patients or distinguish their gluteus maximus from any other part of the anatomy for them. No, on any real sense, the team I have outlined is the thin


(except for the bit that represented the Duchess) multicoloured line that was all that stood between the patients and the truly crazy world of normal society. It was a measure of how good we were that normal society very rarely got in. So we fast-forward, the handover finished and the witching hour past. Now we’re left to our own devises. I am tempted to say that horrible phrase, “the lunatics had taken over the asylum”, but this would presuppose that there was ever a time when the asylum was in the hands of some sane management system. To my mind, this would not be the case. In actual fact, without the pressure to be mad for the procession of professional visitors now gone, the people on the ward could now settle into a much more honest madness, without the pressure to perform. In this space, with the phone only occasionally annoying, the threat of impending management dissipating, the stage was being set for the incidents which prompted this recall in the first place. As I remember, it was not a particularly unusual afternoon moving to evening on Poxy. A few patients had taken the opportunity to go off the ward and family or friends were visiting a few others. We had a young man called Jake on close


observations. This meant that a nurse was with him at all times. The reason for this observation had been his feeling about another patient, Mary. Jake believed Mary had been his guardian angel in the past and had the power to absolve him. Although this account often highlights the absurd and comic nature of the work I do, Jake was truly tormented. He had a bizarre feeling he deserved punishment and Mary was also being bothered, as he wanted forgiveness for his misdemeanours, imagined or otherwise. Mary, being a street person with a long term alcohol problem didn’t seem to mind at first, but had understandably become irritated when Jake took to sitting outside the toilet when she was busy, asking her to lay hands of healing on him through the keyhole. Knowing Mary, it would have been good to check she had washed them first. Our observation was a subtle means of keeping them apart while we tried to both reason with him and let the effects of medication take hold. This meant long periods of time trying to get Jake to relax, give Mary some warning and space if he came within distance and wait for time to effect it’s healing grace. In the meantime, one of us was allocated at hourly intervals to spend time with Jake during which he would pray, sleep, eat and occasionally read aloud from the Bible.


It is always funny looking back as the actual ward appears through a fog brightened by individual events. I can see the shift and the people clearly but gathered around the few hours of this story. I can’t remember the day before or the day after except as a general mash of separate strands, but I can remember Jake being on observation as Bill was with him at the time, and I can see Bill’s anxious face peering round the four bedded dormitory door and hear Jake praying behind him. You’ll see why in a minute. Think of Jake and you come to Mary, for obvious reasons. There are other patients in the bright space in my memory, and I can see West Ham Billy. West Ham Billy did not support the team, in fact he detested football, but had a fixation on the owner as he believed the club was his legacy from his real father. This meant he was generally admitted after causing a disturbance at the ground. I can see Billy, as he was the one who came to the kitchen to warn me there was something wrong with Tracy. I can see Dianne, who was a woman depressed because she had a partner who took to beating her until she didn’t know who she was anymore. I remember Dianne as she was in the kitchen with me and we were making tea for her mum. It was her mum’s birthday and, as she was looking after Dianne’s two kids, Dianne was having a double whammy of guilt – “I am a crap mum” and “I am a crap daughter”. Dianne was, however, a good artist and had made a cracking


card for her mother. Depression robs you of the ability to see yourself in any other than a negative light and she was anxious about her mother not liking the card or not feeling it was enough. Knowing her mother, who was one of those strong women who can hold entire communities together whilst changing a nappy and cooking a meal for twenty, I was confident that, if Dianne could overcome the impulse not to tear it to pieces, it would be well received. We were talking about this when West Ham poked his head round the door. I remember walking out of the door and leaving Billie and Dianne looking at the card. I passed other patients, or there were other patients sitting in the lounge, I can see their shadows, would know their individual stories and have vivid recall of events, groups, meetings or simple conversations if I knew their names and that they were there, but I can’t see them clearly in my memory. Except for Leroy. I can always see Leroy. Leroy was a walking example of Camu’s throwaway line, “Nobody realizes that some people expend tremendous energy merely to be normal.” He had a diagnosis of schizophrenia, and was indeed tormented by voices whose content was abusive and derogatory. He also fit into some of the lovely stereotypes of black Jamaican males in that he had a cap like the cat in the hat full of luxuriant


dreadlocks, would talk longingly of the powerful healing effects of ganja and had an encyclopaedic knowledge of all things Reggae. We used to really enjoy young doctors learning their trade informing us that Leroy had delusions of grandeur after telling them he knew various Jamaican music wunderkind. “And how do you arrive at a the conclusion he is grandiose?” “Oh it’s fascinating. He even said he met Bob Marley’s son. He has a whole delusional system that includes these performers sending him best wishes for his birthday, having photos of their kids, having them to stay in his flat. He talks about having an influence on their music. It’s the most elaborate and fixed set of delusional beliefs I have ever come across. When I said to him “ do you think there is a possibility it is all in your mind?” he laughed and said, “Everything is only in the mind, man. You are one of the things in my mind I could truly do without.” Does he have a history of violence?” “Oh, only to junior doctors, and that is considered fairly normal around here. You intend to present to the consultant in the ward round?”


True sadists would let the buzzing registrar go ahead and present to an incredulous consultant, who had known Leroy for years and was familiar with his inclusion in the London Reggae scene, including the fact that his cousin ran a recording studio in Brixton and that Leroy had been considered a very promising writer and artist before his mental health and possibly his treatment made his performing erratic. If required, a scrapbook kept by his mother could be brought to the ward with birthday telegrams, photos of children, billing posters and write ups for music newsletters compiled by Leroy himself. The consultant would listen with his eyes closed, shaking his head and inform the ward manager that the nurses really should try and guide the enthusiasm of the junior doctors a bit more constructively. Interestingly, when she came to ask us who had prompted the idea of presenting to the ward round no one could remember. Leroy was an old friend. When he was admitted it was always a pleasure to see him, in the human sense, although recently it had been a concern in the professional sense. For five years in a row he had been admitted on the Tuesday following the Notting Hill Carnival, after walking around late at night talking to himself and coming to the attention of the police. These carnival admissions were really a kind of extended hangover, which Leroy


accepted as the price of a good party. As a consequence he would be admitted informally, would stay for a couple of weeks at most and be discharged to the care of a community psychiatric nurse who had known him for some years. His family were supportive and close and there really was little in Leroy’s life that was changing or that he actually wanted to change. Then his father died of cancer, and the bottom fell out of everything. Leroy, as the rest of his family, was distraught. His father had been a stern, proud patriarch who valued worldly success for his children, but had adjusted to his son’s problems with impressive flexibility. Leroy told me that, after his first admission, the discharging consultant had asked his father if Leroy would accept medication. His father had replied, “My son is an honest man. If he says he will, he will. If he says he won’t he won’t. Ask him. He will not lie to you. That’s not how we are.” Cancer had consumed him inch by cruel inch. For Leroy, admissions piled up and extended as his voices changed and he heard his father’s voice, begging him to help him but not saying how he could. When his father finally succumbed he began to battle grief as well as hallucinations and it ate into his considerable strength.


Not that it was all gloom and despondency with Leroy. He was the person who taught me about the Arawak and the Taino Indians and other titbits of Jamaican history. We once agued about the comparative merits of Jimmy Cliff, Marcus Garvey, Bob Marley, and reggae music as compared to the great Scottish institutions of Billy Connolly, Sean Connery and single malt whiskey. “Go one, you long haired, drug addled philistine, sure you were born on the sunny beaches of Peckham Rye common.” “Now, Archie boy, no need to get I-rate just because a comedian and some cleaning fluid you all drink lets you forget that you come to London to get away from the land you say ya love so much. London like Jamaica, man “out of many, one people.” If I could get to Jamaica by walkin down to Euston and jump on a train, you think I stay here? I’d go man, see where me father came from, feel that sun on me back.” It became the goal that sustained Leroy, to see Jamaica again. It became my goal to beat him at chess as I could not beat him in an argument. As mad as he could be, Leroy was brilliant at chess. Over the years I had played him when he was hearing voices almost continually, when he was sedated with medication and once when he was


listening to a compilation tape his cousin had sent to him for approval. He always beat me with an ease that verged on the insulting, especially when he informed me “Your getting better Archie, I almost had to concentrate that time”. On the shift in question I remember Leroy as he was sitting in the lounge beating Mohammed at chess while watching MTV. He must have seen Billy come to get me as he said, simply “She vexed, Archie, go easy” when he saw me. In the corridor leading to the ward office was Tracy, on the patients’ phone, talking to her mum. Leroy was right. She was vexed. Tracy. Bi-polar and in a manic phase, seven months pregnant Tracy. On the phone to her mum and vexed. Now we are in real trouble. In order to allow you to understand the fact that I left the kitchen feeling OK and saw Tracy and felt like I wanted to run away screaming, let me fill in a few gaps. Tracy is a small woman, about five foot two. She is slight and must have been in her mid to late thirties at the time of this story. Tracy first came to the ward about two years previously having moved into the area in a rehousing deal. Tracy had a history and had been admitted to another hospital for some years. Her diagnosis was bi-polar disorder that usually presented in what is


called the manic or elated phase of the condition. I love those words, manic and elated. They are so simple, so crisp, and so easy to say. Tracy wasn’t at all simple or at all easy. The first time she came to the ward she was accompanied by seven police officers and she was in handcuffs. One of the police officers had a blackening eye and one had blood on his tunic and a nose that resembled a plum. The ward manager met them at the door and told them to take the handcuffs off. They looked at each other for a second and then asked us if we were sure. They did remove the handcuff and Tracy walked into the dinning room of the ward and proceeded to smash windows. The ward manager and the Duchess managed to talk her out of breaking all the windows and she cried for about an hour. She then started smashing the windows again. We couldn’t manage her in this state and she had to go to the Psychiatric Intensive Care Unit, which is a permanently locked ward with more staff. There they have unbreakable Perspex instead of glass and she managed to smash three of these and a nurse’s nose before being adequately restrained and sedated. She slept for twenty-four hours, woke up with a nurse observing her, got up, picked up her bed and threw it at the nurse. I know you don’t believe me, but she picked up her bed and threw it at the nurse. She was five foot two and slight. She was a real handful.


That is, when she was manic. When not in a manic phase, Tracy was either one of the nicest people you could meet or she was suicidally depressed. Mostly she was one of the nicest people you could meet. It is of interest to me that mental health problems can have such a different effect on what I call a person’s true personality. For example, when Leroy was under the influence he was always present as Leroy. To understand what Leroy looked like tormented, visualise his hallucinations as those cartoon figures of a devil and an angel on each shoulder arguing. In reality, Leroy’s figures were generally nasty and torturing and not at all funny, but the main point is that you could see Leroy; he was always present, even if he was struggling. When Tracy was under the influence it was different. In one moment she could change from her true personality and you would be faced with a Tasmanian devil in Tracy form, whirring about like a tornado and shouting abuse. The true Tracy would be hidden, consumed within this whirlwind of anger and pain and might not be able to surface for some time. Having said this, when well, Tracy was a raw and sensitive a person with a burning sense of justice and integrity. Watching any feature on the news that focussed on children coming to harm, whether it be by cruelty, poverty or hunger, would reduce her to a quietly burning white-knuckle rage. On the ward she would take people


under her wing when in control, and had tried to help Dianne on many occasions in the past. It was no surprise that in her true personality Tracy was an active member of various community and political groups, and that she had been banned from others for being too outspoken. She was also active in the local user movement, which advocated for mental health patients and was a terror of the hospital management. But unwell, her anger would swamp her, billowing out in a torrent of energy, smashing anyone and anything in its path, irrespective of whether it was deserved or not. But when the tide abated and Tracy was left standing in the middle of destruction and faced with the injustice of some of it, that anger would turn around and savage her. Then she would collapse into that black hole hollowed out by depression and became just as hidden. This time it was under a thick ice sheet of misery, despair and guilt. This could also take a long time to thaw, even with the warming care of her family and us. I often thought that Tracy would have been consumed by these battling elements if it had not been for Tom. In Norse mythology there is the tree of life called Yggdrasil that has it’s roots in the exact junction between the land of all burning fire and the land of all freezing ice. I always felt that, for Tracy, her relationship with Tom had its roots in exactly the same place. It was true that Tom made money


selling cannabis and speed to a select band of customers and that he and Tracy partook of his wares. He and Leroy shared a belief about the healing effects of the weed and I suspect that Tom and Tracy believed more in the stabilising effects of the two drugs on her turbulent mental health than the conventional medication. It was this that led to the Duchess’ blanket dismissal of him as anything other than an evil drug baron, while Leroy and Tracy were his hapless victims. But when it came to Tracy, I felt that Tom, or what he meant to her, became her tree of life, the central point around which she survived. They had been trying for children for years, and Tracy had been on and off medication, as she thought it would harm her chances. Until this pregnancy, four emotion-sapping miscarriages were all they had to show for their efforts. They were both desperate for this child and Tracy believed that time was running out for her. Now before you go all dewy eyed, remember that Tracy is in the acute ward of a mental hospital and we still have two months to go. Social services are looking very closely at the whole situation for obvious reasons and we are all walking a path previously uncharted. The possibility of a child has been a mental exercise for all concerned until this point. All, that is, except Tracy who has felt four lives die in her womb. As the reality of the birth


comes nearer, we are all taking each step into the unknown. To date, Tracy has been with us for about three weeks and meeting after meeting has monitored her progress as window dressing to the fact that no one knows what will happen next. Then, for some unknown and possibly unknowable reason, on this shift, at this time, Tracy decides she has had enough. She wants to leave. So, there I am, walking past her, huge and ripe at the telephone. She is still Tracy, but I can hear the Tasmanian devil rearing its ugly head as I walk past. “I said come and get me, mum. Are you deaf? Come and get me out of here. They are all bastards, mum. Don’t give me that. They don’t want me to have this baby; they want to take it off me. Look, I’m not crazy and I’m not fucking staying. Don’t tell me not to swear. You coming to get me or what? Do I have to walk home, ‘cause I will, you know. Right, that’s it; I’m out of here. DON’T SAY I DIDN’T WARN YOU.” Although I am walking away the volume is rising. I get near to the office, but hear the phone being put back on the receiver with a force that will shake the local telephone exchange. Anne is in the office


doing some paperwork and on the phone, multi-tasking as usual. I don’t have time to warn her so I hurriedly and loudly knock on the door. Behind me I can hear the Tasmanian devil moving. I get to the ward’s front door and turn around. As the men’s four-bedded dormitory is next to the front door, I can hear Jake reading aloud from the Bible. “Yea though I walk through the valley of the shadow of death….” Nice one Jake, very apt. There is no choice, there is no one else, and there is not enough time. I stand there in her way and wait for the clash. Behind an enraged Tracy, I see Mohammed and Leroy running up the corridor, I see Bill’s head poking around the dormitory door, Hear Jake intoning “My comfort in my suffering is this: Your promise preserves my life.” I see Dianne and Billy standing at the kitchen, I see Anne coming out of the office, and I see the Duchess running through the lounge shouting, “Tracy. Stop”. It’s so clear in my memory all these years latter, that image, those faces, that moment. Then she hit me. Oh come on, did you really think she wouldn’t? She hit me hard on the upper arm and screamed,


“Get out of my way you balding twat. Get - out - of - my - way -.” The hyphens in the above sentence are representative of punches to my left and right arms. I can’t speak. I bruise easily. It does hurt. I instinctively turn my side to protect myself, and find that Anne is beside me. The barrage stops and I hear Anne say “Tracy, take it easy, now, easy. Think of the baby Tracy.” “But this balding twat is in my way, Anne. I just want off the ward.” “Tracy…” “Get this balding twat out of my way” “Tracy.” Anne’s voice has an edge to it now that I recognise from when people put the duplicate books back in the wrong order. “This balding twat is trying to look after you.” Oh thanks a bundle, thinks I. Leroy is talking now. “ Tracy, slow and gentle now. Archie is on your side girl.”


Tracy is slowing now but the Tasmanian devil looks from her eyes in a subdued rage. He no longer has control over her fists, for which Anne and I are grateful. I see Anne rub her arm and realise she must have taken part of the barrage. It also dawns on me that my arm doesn’t hurt as much as I thought it would. I don’t have time to dwell on this as the Duchess is with us now, persuading Tracy to turn and move back to her room. This is at the other end of the ward. The rage is giving way to tears and Tracy begins to shake. “You balding twat. I want this baby. I need this baby. Don’t you understand that? I can’t take much more of this.” The Duchess has her arm round her and is trying to soothe her. “He may be a baldin whatever, but he was right to stop you. You’re in no fit state to go off in a rage. We can’t let anyone see you like this. Come with me now. Come on.” They move off, but I have an uncomfortable feeling and a nagging question. Am I really going bald? No one has mentioned anything to me before.


As we move past the office, the Duchess asks Anne to support Tracy who is now leaning on her crying. She jinks into the office. What is she doing? This is your forte, for goodness sake, Duchess. Tracy really trusts you. Where are you going? I see her pick up the phone and a cold fear grips me. She’s not calling the team is she? Oh come on Duchess, there’s no need for that. The team is a colloquialism for a shift allocated heavy brigade, one from each ward who will respond to distress calls where a ward needs additional help. The team is a great idea if things are seriously out of hand, but you have to think carefully before having five or six nurses running through your ward looking for someone to guide them to an incident. A useful last resort, but a last resort none the less. For me things were under control, and the team may cause more harm than good. If Tracy felt we were not on her side, the sight of five or six nurses coming to stop her might bring Tasmanian out in force. Also, were we really going to do battle with a seven-month pregnant woman? I tried to catch the Duchess’ eye, but we had moved past. I didn’t want to leave Anne, and Leroy, as Mohammed was going around reassuring other


patients and visitors, so I went with them. Tracy was calming anyway. Except she wasn’t. We get to her room and it is evident that there is another wave building. “Take your fucking hands off me, do you hear. I know your game, you gits. Keep me here until I have the baby and then get the Social to take it away. What are you looking at you balding twat?” The Duchess returns and is able to dispense her magic again, but we can all see Tracy is fighting for control and not winning. After about fifteen minutes the roller coaster of crying and anger are still evident and it is touch and go if the Tasmanian will escape again. “Oh God, it’s no use, I’m never going to have this baby. I don’t deserve this baby. Tom won’t be able to take another dead baby, Duchess, he will leave me. Oh God what am I going to do, what am I going to do.” “It’s not you Duchess, It’s that balding twat over there, thinks he’s fucking God, thinks he knows best all the time.” I am beginning to think that my presence is making things worse, but when I go to leave the room


Tracy rises off the bed. I see the Tasmanian snarling in her eyes. “Where are you going you balding twat. Not brave enough to face me, eh, can’t look at me eh? You proud of yourself, you great BALD TWAT.” It is at that moment that the door bursts open and in walks Tom. The Duchess had called him on his mobile and asked him to come to the ward. Said that Tracy needed him, that we needed him. The Duchess rang Tom and asked him to help her. Not a moment too soon. He walks in and straight over to his snarling partner, throwing his arms around her. “Its all right now love. It’s all right. Tell me what’s wrong now. I’ll help you. I’m here. I’ll help you.” Tracy dissolves into the deepest sobs, the sort that come from the pit of your stomach and fight their way out of your body, the sort that are almost too painful to witness. Her breath is ragged as the Tasmanian dissipates in the air around her, leaving her exhausted, frightened, childlike. “Oh Tom, oh Tom. It’s that balding twat over there, he stopped me Tom. He stopped me.”


Tom, who knows me, has talked to me about his own fears, his own hopes, turns to look at me. His eyes are dark rimmed caverns, full of sadness, full of fear, full of his anguish. I get a brief glimpse of the terror he must have felt on his way to the ward. With this look he turns to his frail partner and then utters the immortal words. “Tracy, he might be a bald twat, but he’s only trying to help.” Oh yes, thank you Thomas. Thank you so much. For the rest of my time on Poxy I was nicknamed the BT. The above story went round the other wards in one day so that the ward manager greeted me with a cheery “Hello BT.” on the next day’s early shift. When it was alright to leave Tom and Tracy in peace, I took one of the female patient’s hand mirrors into the staff toilet and, by standing at a funny angle I could see that there was indeed a blooming flower of scalp nested in the middle of my ginger hair. So it was true. The Balding Twat had defeated the Tasmanian devil, with a lot of help from his friends.


So there we are. Now you know whom the Tom is I am remembering at the dreaded wedding table, why looking into the Jokers face as he asked me that question kick-started a train of powerful images. The likeness was uncanny, it’s true, but they were different people. To tidy up the bits, Tracy and Tom had a baby girl, spent some time in a mother and baby unit and got to be a family. It was the making of Tracy, actually, and being a mother seemed to short-circuit the Tasmanian. I saw her, Tom and Kylie at Victoria Station some years latter as I was waiting for a train. I didn’t say hello as sometimes people want to forget their time on Poxy and we become a receptacle of things they would rather forget. I was also enjoying watching a normal family on the concourse with other normal families. Leroy got to Jamaica the year after the time of this story. We got a postcard from a place called Negril, which is apparently very beautiful. It said simply “Thinking of you. I am so sorry. Don’t feel sad. ” For on the last night of his stay, Leroy sat on the beech at Negril, watched the stunning sunset and ended his life by his own hand. We mourned for him; I mourned for him and still think of him when I play chess. I never did beat him.


The Duchess and Mohammed stayed on the ward after the rest of us moved on. The Duchess eventually retired when they eventually found out how old she was. I went to her leaving party, where I was called upon to relate the above story. Being as bald as a chicken’s arse by then took some of the edge off it, I feel. Anne became a Professor of Psychiatric Nursing, believe it or not. I still have the opinion she uses her personality as a means of contraception, but she has done well. I was always grateful for her sharing the firing line with me. We met up years later at a conference and I found I was actually pleased to see her. When she did her presentation she quoted Einstein’s “Not everything that can be counted counts, and not everything that counts can be counted.” And I thought, “I bloody told you that.” How we change as we age. I left the ward to work in the community, but never really liked it in the same way. After some years and considerable training in various things I was invited to return to wards as a practice development nurse. I jumped at it, and have never regretted it, although the wards are as unappreciated as ever by everyone. Every now and then I see another Duchess or Mohammed or Anne. I’ve even come across the odd Archie. I have never come across


another Poxy ward, however, as it was my ward, my team and my time. Now God is doing the wobbly screen thing again and I am back to being the chubby, bald, wedding guest, and with the more socially skilled partner. I am looking at the Joker who looks so much like Tom but isn’t. He is saying. “..I could never do anything like that!” I think of all the memories flying around in my head in the split second it has taken to hear this sentence. There is no way to tell these people what they cannot, in fairness understand. I would only confuse them or, worse, pander to some set stereotype that is wrong. It’s not that they are stupid or uncaring; it’s just that I don’t have the words. I actually want to forget about it all for a while. So I mumble the platitude “Oh, I’m sure you could.” and am just about to deflect the focus by asking him what he does when his up-to-now quiet girlfriend leans across and asks in a hushed whisper. “But aren’t they - the patients - dangerous?”


The rest of its family has joined the crocodile on Mary’s leg. She is definitely sweating and drains all the red wine from the huge glass in front of her in two noisy gulps. I refuse to give her eye contact. Well, you have to put people straight, don’t you?

FINI


The initial impetus and inspiration for this story was generated from the City Nurses project. Since 2002 two City Nurses have been working with acute psychiatric wards in the east end of London. The aim has been to decrease conflict and increase co-operation between patients and staff. Previous research has led to the following model of the processes, which are important in the promotion of harmony and peace on the wards.

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Low containment

Positive impact

Positive attitude

Low conflict

High therapy

PPoossiittiivvee aapppprreecciiaattiioonn

EEmmoottiioonnaall rreegguullaattiioonn

EEffffeeccttiivvee ssttrruuccttuurree

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Positive Appreciation: Seeing the work as positive and patient needs as paramount, being honest and transparent, even when in disagreement. Emotional regulation: Being able to process and control one’s own emotions. Effective structure: Having a structure and set of routines that are there to promote health, wellbeing and honest collaboration. �

The careful reader will discern that this story tackles and illustrates some of the features and challenges of the model.


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Just Another Poxy Shift (Mental Health Short Story)

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Transcript of Just Another Poxy Shift (Mental Health Short Story)