I would be the first to agree that my brother’s problems are largely of his own making but I also think that he drinks for a reason and those are the usual ones of low self esteem and low mood. He drinks to escape. He has always used alcohol as a coping mechanism starting when he was a teenager and in the army and is now arguably paying the price fore this. However depression runs in my family, my mother was hospitalised twice after attempting suicide when I was a teenager, I have suffered bouts of depression as an adult as has my sister, my maternal grand father was saved from alcoholism by his wife and my brother is currently prescribed antidepressants by his GP for depression so I guess you could say there is a family history of depression as well.
I think it fair to say therefore that my brother has a dual diagnosis. Others have already described the appalling attitude displayed to cases like my brother [1] but just how bad was rammed home with brutal efficiency after I arrived at his house four weeks ago to find him stumbling about the garden having drunk a bottle of port and threatening to hang himself if his children did not intercede on his behalf with their mother not to have him thrown out of the house. His children, ably assisted by some of their friends, had already taken two ropes off him and cable tied the shed door shut to stop him from getting another and had locked the front door to stop him escaping but were clearly bewildered and frightened by what was happening to them and to their father. Luckily I was on hand to take control of the situation although as I am moving out of the area shortly my ability to drop everything and come to my brother’s rescue at the drop of a hat in the future is likely to be limited.
Luckily I was able to get an appointment with my brothers GP that afternoon in one of the 5 min slots he reserves for emergency cases at the end of the day (just the sort of case any GP wants walking through his consulting room door at 5:15 on a Tuesday afternoon). Now this is where it gets interesting because I am a psychiatric nurse and I work for the same trust, Happy Valley NHS trust, now Happy Valley foundation NHS trust which covers the town where I work and live as well as the town where my brother lives. So while I am not personally acquainted with the MH teams in my brother’s location, I work for the same organisation and am familiar with how the system works. Now I am not saying that I deliberately over egged the pudding when presenting my brother’s case to the GP but I think it fair to say that I used my knowledge to present his case in a way that would gain his maximum support in getting my brother admitted to the local psych ward which is where for his and his families sake I thought he needed to be. I don’t know if my input influenced the GP in any way, he knows how the system works as well as I do and how difficult it is to get anyone admitted to a psych ward with an alcohol problem but I like to think that there was an understanding between us although the situation was frankly bad enough without that. Any way he agreed to speak to the duty psych at the hospital and a few minutes later we were on our way to the A&E dept.
Now this is where I have a further admission to make because in addition to being a psychiatric nurse I am specifically the A&E MH Psychiatric liaison nurse at the hospital where I work (not the one I was now headed for with my brother) and I know for a fact that people like my brother are NEVER admitted through A&E for an alcohol detox. NEVER. Alcohol detox has to be referred to the alcohol team who have to assess the individual and if the commitment and the resolve is there, then and only then will they even consider admission by which time of course the person referred to them has either sorted their own problem out, emigrated, or quite literally lost the will to live. It’s the old “you can take a horse to water” argument. The corollary of that policy however is that if the horse is never taken to water it never gets the opportunity to drink until it is all rather too late. If I had my way anyone requesting an inpatient detox would be granted one. If 90% of those admitted in this manner discharged themselves the next day and only 10% of those that completed the course remained abstinent the 1% that gave up the daemon booze ahead of time would still represent a considerable saving on the current situation where you only get a crack at an inpatient detox when your liver is about ready to explode and its all too late anyway.
Anyway I digress
So bearing this in mind I am not ashamed to say that I intensively coached my brother in what to say and how to say it during the 10 minute drive to the hospital where we were duly seen (luckily) by the duty psych who had spoken to the GP earlier. I say fortunately because contrary to popular belief my colleagues and I are far less likely to play safe and recommend admitting an apparently suicidal patient with alcohol related problems. I am not saying I agree with the policy as I said if I had my way any one wanting an inpatient detox should be offered one but that isn’t the way it works Had we been seen and assessed by my opposite number at Anytown A&E dept without the benefit of a GP referral I am sure we would have been sent home with an urgent referral to the Drug and alcohol team because between you and me my brothers suicide attempt was more a cry for help than a determined attempt on his life. As it was we were seen by the duty psych, the GP had obviously pulled all the stops out because the duty psych appeared to have already decided to admit my brother. I remained silent through most of the duty psych’s assessment except to explain to the doctor who was from Lithuania who the “Grim Reaper” was. (My brother had apparently seen the Grim Reaper stood by the end of his bed complete with scythe on waking one morning). Anyway so far so good, my brother had given a bravura performance (had me fooled) GP had done his bit and against all the odds my brother was to be admitted informally to an acute psychiatric ward for a full psychiatric evaluation of his mental state, medical review and an inpatient alcohol detox. Success, job done!
Unfortunately that was when things all started (predictably) going pear shaped.
Tags: alcohol
14 comments
June 20, 2008 at 8:39 pm
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June 13, 2008 at 3:59 pm
elliecat
I am also an alcoholic, although I have drunk had any alcohol for over 3 and half years now. I suffered bouts of depression and I self harmed quite seriously. I was given the “borderline” label and all seemed gloomy. Until I was admitted (as kept happening) to a psych ward, where I met a young man who was detoxing. He told me about AA. I went to my first meeting one week after being discharged from hospital and have not had a drink (or a psych ward admission) since that day, 21st November 2004).
I still get low sometimes and I still think about self harm, but these things do not lead my life any more. I am able to deal with the bad thoughts and feelings and, the more time that passes, the easier life gets. I was recently promoted to Head of Department at the school where I teach whereas, before AA, I was struggling to make it to work.
AA is hard work. You hear a lot of things it is hard to digest and people can be bloody annoying, but they do understand and it works where nothing else could. I think the main thing is to want to be well. If you really, truly want to stop drinking and can acknowledge that a lot of the crap that happens is because of the drinking, you can stop. Your brother can get well if he wants to.
Most of the other people I know in AA have had at least one admission to a psych ward and most have had some kind of mental illness diagnosis other than alcoholism.
elliecat
June 13, 2008 at 5:42 pm
DeeDee Ramona
First, E, that’s rotten for your brother. You, he, and his family, have my sympathies.
I’m an alcoholic, I’ve been one since I was 17. I stopped drinking on the first of January 1997. I was lucky: I found something that I cared about enough to stop. No, not me, I didn’t give a toss about me, but my degree. This isn’t an indication of superior reasoning skills or whatever, it’s just that at the time I measured my personal worth entirely by whether or not I passed my exams, so in a weird way, that lack of self-esteem was positive in that it actually got me to stop drinking.
So yes, the cliches are true: the alcoholic has to find something they care about more than the booze. I wouldn’t be so harsh as to say that if he can’t give up, it’s because he doesn’t want to though: look at smokers.
Some people can give up on their own, because that’s the type of person they are and how they motivate themselves . Others find AA incredibly helpful. Still others really need the kind of support an inpatient detox can provide.
The hospital I had a number of stays in in Dublin “back in the day” had quite a big 12-step-based inpatient alcohol and susbtance abuse program. Irish insurance will pay for you to do rehab, of the Amy Winehouse variety, once every 7 years, which I think is very enlightened.
The tricky part I found wasn’t to stay off it in the short to medium term, but long term. 11 years later, I still now and then wish I could have just the one pint. This is where I find AA-type visualisation, “first drink, not worth your life”, very helpful. That particular quote sounds glib but it’s very clever imho in getting you to think through the consequences. I also try to imagine feeling nauseous at the thought of booze. It’s working so far anyway.
And yeah at the time I was a boozer I was nuts.
June 13, 2008 at 6:42 pm
DeeDee Ramona
BTW just to point out: my hospital stays in Dublin were not for booze, but manic depression.
June 14, 2008 at 12:08 am
Posey
Please let us know how he gets on. Your post is brilliant.
I hope that everything goes well for him and the family
June 14, 2008 at 7:20 am
Mr Ian
This is an intriguing dichotomy to the other posts on ‘coercive psych’ - where your brother requires professional coaching, a pinch of BS and some serious issues in order to get admitted voluntarily.
I’m sure there’s a second post to come - but one issue I’ve deliberated of late is the void in the service that does not provide for ’social issues’ (if I dare call alcoholism that - avoiding the behaviour/disease debate for now).
It is patently clear that there are those who suffer through personal crisis and it’s not an acute mental illness. What service provisions are there for emergency support?
I have considered that Social Services (or the local equivalent) ought to provide such service - something like emergency temporary sheltered housing/hostel but with caring paid staff. “Admission” is voluntary and lasts no longer than 3 days in which time supportive “discharge” is arranged. This may include AMHU or DEtox unit.
Please enlighten me of any such services - but I don’t think the welfare service does much real-time welfare care anymore, do they?
June 14, 2008 at 11:05 am
E
Yes it is ironic isn’t it? It is perverse the lengths you have to go to get help for some one who needs help and wants help but who does not fill whatever arbitrary admission criteria is being used to screen people out of services.
Like Mental health services, social services do little or no real time hands on welfare care these days. What there is has been outsourced to the voluntary sector and to charities that on the whole provide a reasonable service, at least they do when it comes to drug and alcohol services.
I make no bones about doing all could to get my brother admitted. I know it’s not fair, not everyone has a knowledgeable advocate who knows the system working for them but when its family the rules are different.
Thanks to all who have expressed concern I will pass your comments on to my brother. I am intending to follow the post up with one about what happened post admission.
June 14, 2008 at 10:43 pm
cAsAcambs
E, don’t really know what to say… My brother typically drinks 9 litres of cider a day (I mean 9 litres, not nine pints) and has managed to alienate just about everyone he comes into contact with. The degree of stress it causes me is of a similar magnitude to that caused by seeing my father’s deterioration through dementia. Life, eh?
June 15, 2008 at 12:15 am
Lorna
Much sympathy. I hope he’ll pull through.
Regarding his suicide attempt being a “cry for help”, it is one of my pet hates that inspires fury and swearing that “cries for help” never seem to get answered. That “cry for help” seems to justify not doing anything, rather than giving someone the damn help, if they’re crying that desperately.
And take care yourself. Worrying about someone on the edge SUCKS.
June 15, 2008 at 11:15 am
a and e charge nurse
E - you will know better than most how difficult it is to perform a mental state examination on intoxicated patients in A&E.
My experience with patients who are the worse for wear, after x1 bottle of port say, is that they require a period of observation in A&E (usually for several hours) before any meaningful examination can take place - as you know, such patients often become frustrated and walk out long before they have ever been fully assessed (either physically or psychiatrically).
The main reasons for this seem to be be:
*The psych liaison nurse rarely stays with the patient during this period of observation (in my experience).
*A&E nurses must balance the needs of the intoxicated patient against those of all the other patients in their designated area (some of whom will need admission to the ward, sometimes there is more than one patient with acute mental health needs in the department at any one time, etc, etc).
*Security staff have an obligation to police the entire hospital site, additionally they may be on uncertain grounds when it comes to issues around capacity, restraint and so on.
If a patient is intoxicated then they are unlikely to be acutely withdrawing, but at our place (unlike yours), we do admit patients who exhibit SIGNIFICANT symptoms of withdrawal (but to a medical ward).
I’m sure you know that DTs can be life threatening with the associated risk of seizures, GI bleed, etc, etc, so I’m slightly surprised at the policy to refuse medical admission to ALL patients requiring detox - I have no doubt, that in some cases this must amount to a gross dereliction of duty of care ?
I must admit I’m impressed the psych SHO who examined your brother had ‘direct admission rights’.
At our place once an acute physical agenda has been excluded and a mental state examination has been performed (by the PLN or SHO) then it is the turn of the crises team to undertake their assessment (except when S2/3, etc has been put in motion).
If a patient has seen a GP, then sent to A&E, waited for physical/psychiatric examination (by the PLN or psych SHO in tandem with the casualty officer, who usually checks LFTs, etc) then asked to wait yet again for the crises team you can imagine one or two patients are often not best pleased - a fair few simply walk.
Needless to say these labyrinthine processes result in an accumulative reservoir of frustration (for all concerned) and this must contribute in no small part to those with dual needs who have negative experiences in A&E ?
June 15, 2008 at 2:38 pm
Mr Ian
re the A&E intoxicated patient - Anyone ever had a ‘drunk tank’ at a hospital?
June 15, 2008 at 4:13 pm
E
At our A&E if the individual is acutely withdrawing from alcohol that is treated as a medical emergency and the individual is admitted to a medical ward for detox. Otherwise planned alcohol detox on the psych ward has to be done as an elective admission through the drug and alcohol team. This results in the ridiculous position of A&E discharging a patient who has been drinking 9 litres of strong cider a daily, who has turned up in A&E requesting detox still drunk, because the medical team won’t accept him because he is not actually withdrawing and because psych’s wont take him because when he does start withdrawing the risk of him going into convulsions (even with medication) is too great to manage on a psychiatric ward.
The only advice in these cases I can give is to go home and wait until you are in withdrawal then come back and we be re assessed by the medics. Of course they never do, they go home and carry on drinking.
Our policy on assessing drunk patients is a little different A&E Psych liaison will see drunk patients and assess if an assessment can be made. The duty psych’s used to have a rule that if the breath alcohol was above 50 or 75 or 100, depending on when they were due to go off duty they would not see the patient but since A&E got rid of their alco meter they can’t do that any more.
My brother was x4 over the limit when he got to the ward but was reasonably coherent when he was being assessed in the A&E dept.
June 17, 2008 at 9:24 pm
TonyF
Depression is not a lot of fun. I think that many people do not realise what is happening to the sufferer, and even worse, the sufferer may not know themselves. Alcohol does not help, and is such a difficult trap to escape from.
I wish I had a suitable answer for your brother, but, I fear that there is none. The ’system’ as it is currently, will do little unless it is forced. By then, I suspect it will be way to late.
I have been very lucky, and had support from a friend that thought more of me than I did. He has a sister who thinks the same. If it is any help, my thoughts are with you both.
Tony.
June 18, 2008 at 7:12 pm
E
TonyF,
Thank you, for your comments. The trouble is that alcohol does help, at least in the short run. It sooths, it emboldens, it relaxes, it soothes and if you have enough it brings on oblivion.
“It provokes the desire, but it takes away the performance”
(Shakespeare, Macbeth)