The first thing to remember about acute psychiatric wards is that they are very boring places to be (unless you are floridly psychotic of course then things can get a bit more interesting). The ward where my brother was confined, (and I use the word confined advisedly because for the first four days he was “asked” to remain on the ward or risk being discharged) was no different in this regard. There was nothing to do, no occupational therapy or therapy of any kind other than what came out of a pill bottle. He saw the consultant and the Registrar once in the first week and by the end of day three he was climbing the walls. The only exercise he was able to get was to walk from one end of the ward to the other. Other than that he could watch TV, listen to music or lie on his bed.
The acute psych ward at Anytown where my brother was is probably no better or worse that most psych wards which mean that despite being recently refurbished it is a dreary place. On the top floor of the mental health unit it has no direct access to the outside. The rooms are arranged down a central corridor running from one end of the ward to the other, natural light is restricted and the ward feels stuffy and airless. Generally you feel hemmed in and claustrophobic. However the staff are pleasant enough (when approached) and tend to interact (fairly) appropriately with patients and members of the public although they appeared to prefer spending their time in the office doing whatever psych nurses do in ward offices. They do at least have a smoking room on the ward although it is not open 24/7. The worse thing about the place though was the food. Microwave ready meals delivered daily were heated up on the ward; they looked like shit and probably had the nutritional value of damp cardboard.
The next thing that struck me was that an inpatient’s detox which in my day took ten days now takes five so by the weekend my brother was being told that he would be ready for discharge on Monday. I asked when the discharge CPA would be and was met with a blank look.
“CPA? Oh we don’t usually bother with CPA if it is just for alcohol detox”
It was at this point that my brother in law (a social worker) drafted the following letter for my sister to sign and send to all the relevant parties in charge of my brother’s care.
Dr Verity Organpipe
(Consultant Psychiatrist
Any Ward
Mental Health Unit
Any Hospital
Another Road
AnytownDear Dr Organpipe
For your information I am the sister of
.
Since being admitted to your Ward, my brother has been visited by my husband, my brother and myself. We have discussed with Ward Staff his progress and I was informed yesterday that his detox treatment is now complete and he may be discharged on Monday. This is different to the information we received following your Ward Round, when we were told that there would be a meeting on Thursday to discuss his progress which I had planned to attend.
When discussing matters with Ward Staff, they told us you were not completing a Section 47 Assessment, 1991 Community Care Assessment under the Care Program Approach procedures. I therefore formally request that a Care Program Approach Assessment is undertaken to fully consider my brother’s many needs and to formulate a pro-active care and support plan.
The reason for my request is as follows:
• My brother has had drink related difficulties for a long period of time and for the past few years has been fully dependant on alcohol to help him cope with day to day living.
• He now starts drinking alcohol as soon as he gets up in the morning.
• I am aware that when he was admitted to your ward, he was over four times the limit.
• He is regularly stealing alcohol from shops to fulfil his daily need of alcohol.
• He is also using his weekly benefits to buy alcohol, as well as running up credit card debts.
• He is not financially contributing to household expenses and has stolen money.
• He has recently been attending alcohol related support groups, but has not derived any benefit and more often then not has gone drinking at the pub after attending Alcohol Anonymous Meetings.
• He informed yesterday, that he intends to resume drinking alcohol when discharged from hospital, as that is all he has to live for.
• He has other physical health related difficulties, liver problems, depression and sight difficulties due to Graves Disease, for which he has had two operations.
• At times his standards of personal hygiene and self-care are very poor.
• He is currently subject to a Probation Order for assault and domestic violence issues. There have been incidents of domestic violence since 1999 and the Police have been called to the family home on a number of occasions.
• His older son has had to physically restrain him from physically harming their Mother, which is a very sad state of affairs.
• His wife and children have not visited him whilst he has been in hospital.
• His behaviour and actions in front of his children are having serious effects on their physical and emotional well-being, such as the incident last Tuesday in front of his 12 year old daughter, when he was attempting to physically harm himself by hanging with a rope.
• He is almost completely estranged from his wife and four children, who can no longer cope with his lifestyle and the detrimental emotional affect he is having on the family.
• His wife is currently applying to the Courts to have him permanently removed from the family home.
• This will then make a vulnerable person homeless.Family members are fully supportive of my brother and his family and wish to be fully consulted and involved in the CPA Assessment and Care Plan. I am also sending this letter to the CPA Administrator and look forward to hearing favourably from you.
Yours faithfully
Sister
The day after receiving the above communication, my sister received a phone call, from Dr Organpipe’s registrar who sounded somewhat rattled by the letter his consultant had received and demanded to know where she had got her information from. Like the provision of the 1990 community care act and the CPA procedures are some sort of secret [1] [2] known only to the initiated few. I don’t know if the two are connected but around the time of my sisters contact with Dr Organpipe’s registrar I heard on the grape vine from a reliable source that Dr Organpipe her self had approached the acute in patient service manager for Anytown MH Unit (my bosses boss) to express her “concern” that I may have brought undue pressure to bear on the duty psychiatrist to get my brother admitted the previous week. No formal complaint was being made you understand she was merely expressing her concern.
However despite the intimidation, a CPA meeting had been arranged (at very short notice) for the following Thursday which my sister was able to attend. The minutes from the CPA read.
The CPA meeting was held to make arrangements for ’s discharge from hospital following his alcohol detoxification
During his admission was assessed and there was no sign of mental illness or depression evident. Prior to his admission he had been attending Anytown alcohol support services for help with his alcohol problem and he had been attending groups, which among other things provide strategies for building confidence and self esteem, and having 1:1 sessions with the psychotherapist there, Dr Friendly McNice. She reported that ’s drinking had in fact escalated since he started attending groups and he had pushed the boundaries by encouraging other group members to go for a drink after attending the groups. She advised that although ’s commitment to abstaining from drinking alcohol is not firm he would be able to attend relapse prevention groups provided he could abide by the boundaries.
Dr Organpipe advised that the alcohol detoxification had been completed without any problems and it was now down to to try to remain abstinent. She suggested that he may not believe his problem is too serious in comparison to others and that he may not have hit ‘rock bottom’ but that he needed to take control and aim for complete abstinence. advised that he was scared by this prospect as he has nothing else meaningful in his life and finds it hard to deal with his cravings. It was agreed that he needs to find things to do to fill his time. Anytown alcohol support staff have referred him to Getback2Work in the past and he has been offered appointments to help him look at opportunities to return to work. ’s sister, voiced the concerns of his family that he would find it difficult to cope with a full time job and described the problems he has had in the past in holding down a job for an extended period. Voluntary work was suggested as an alternative, less stressful option. He also described having relationship problems with his wife and was advised that his wife could seek support from Anytown alcohol support group if she wanted it and that with his permission a copy of the minutes of this meeting would be sent to her, which he agreed to. ’s sister advised that she and her husband were keeping in touch with his wife to try to keep her involved in ’s care.
’s sister also advised that there was a history of depression in the family and she thought that was very depressed. She asked about the possibillity of counselling but was advised that had already received 1:1 sessions with the psychotherapist at Anytown alcohol support services, but had not taken advantage of this opportunity in the past, although it would be made available again. He was encouraged to attend Anytown alcohol support groups regularly and invited to attend the group this afternoon. After initially saying he would not be able to get there, he agreed to attend if his sister could give him a lift. ’s sister also offered to have to stay with her for the weekend and he was encouraged to take up this offer.
Dr Organpipe confirmed that would be discharged from hospital and mental health services today. He was encouraged to take advantage of all the support services offered by Anytown alcohol support services. They will make a referral to the Community Drug and Alcohol Team to consider prescribing Acamprosate or Antabuse if appropriate to help with cravings and to remain abstinent.
confirmed that he was happy for his family to receive a copy of his risk assessment and the minutes of the CPA meeting.
So there you are no evidence of mental illness (despite Dr Organpipe’s diagnosis of “Mental and behavioural disorder due to alcohol misuse; F10) and straight back to Anytown alcohol support services where he was before. They could not even be bothered to refer him to the Drug and alcohol services themselves.
Post script. Some three weeks after being discharged my brother received a letter from the Drug and Alcohol Team informing him that he had failed to respond to an invitation for assessment and was being discharged from their service. The letter had been wrongly addressed and had been re directed twice before finding my brother. Since discharge my brother has already relapsed and is drinking heavily again.
E, I have nothing useful or helpful to add to this but I really just wanted you to know that it had been read and that I was very moved by it while simultaneously feeling very angry and dispirited on your family’s behalf.
Thank you pog. I don’t want to blame the system entirely for what is essentially a self inflicted injury but on a purely cost benefit analysis a little bit of effort made now could save a lot of time, effort and expense later.
I hear far too many of my fellow nurses refer to people as “just a detox”, when anyone admitted to the mental health unit rather than for a medical detox elsewhere must have been assessed as having comorbid mental health problems.
I have been very frustrated that our one “planned” alcohol detox bed has been closed, so now detoxes only occur for people in extreme crisis, like your brother.
I wish you and your brother well, E.
I’ve only just found your two posts about your brother, linked from ‘random acts of reality’… I’ve only just lost my dad two months ago with scarily similar circumstances… he was an alcoholic with depression for the last 6 years or so, only he wouldn’t go to hospital unless under the most extreme of situations… basically he was a very private person and did not like very public institutions (the hospital waiting room and wards). I find it interesting and somewhat sad for him that he could have lived had he been able to give himself a chance by actually going to hospital. Sorry that the comment is not based around your post, but I wanted to write something, and this is what came to mind.
Treasure whatever is left of your brothers non-alcoholic character while he’s still here, try hard to save him, but never blame yourself when he doesn’t take the help or is no longer there to receive it.
Nick.
Well, E, it`s a pile of shit but I`m afraid it`s the woolly minded, left wing thinking that predominates through nursing and through mental nurse that`s created it.
Whatever happened to SHO`s assessing and making the call with regards to admission. Sure they made mistakes but they were working hard and they were learning. Where I worked last year we didn`t have any A and E Liaison Nurses. Where I work now we have four ( as often as not there are four on at once – of course they only work 9-5 ). Out of hours Charge Nurses get involved. On top of that there will be a policy and procedure for everything. It all creates the lovely impression that admissions should be faultless. The reality is that no one has a clue, no one knows who they are to defer to, admission decisions take forever, mistakes happen, e-mails start flying ( no one is prepared to sort anything out face to face ) everything is disected ad nauseum, more confusion, less confident practitioners and the admission process becomes even more of a shambolic Chinese parliament. Personally, I`d be quite happy with a SHO using their discretion.
As for the acute wards they need the tools to do the job. I`m not stupid, there are a good number of lazy bastards in acute psyciatry who have yet to grasp the fact that working on an admission ward means you have to admit people. However, I`m sick of management duplicity. The constant pretence that we have admission criteria. We don`t, we take everyone who can`t be dealt with elsewhere. Sure, it`s galling watching the other teams cling to their asdmission criteria but we deal with everything. It makes us better nurses. Let`s celebrate the fact and embrace the challenge rather than moaning and pretending things are otherwise.
Setting aside the laziness and resentment there are other reasons why acute nurses are wary of detoxes. Drunks are at best belligerent and at worst hostile and aggressive. Nowadays, management have to recruit whoever scores highly at interview regardless of glaring deficiencies in the skill or gender mix. Management will hide behind C and R certificates but you need some big, burly, amiable blokes to maintain a bit of order. Likewise you need a smoke room and preferrably a couple of older female nurses with obvious maternal qualities to have a fag with the patients. Suddenly your detoxing patient doesn`t appear anything like the threat they did previously.
As for therapeutic activity and crap meals. That`s no concern of nurses any more, is it ? We`re educated now aren`t we ?. We`ve had our heads turned by the academics. That`s the trouble with wandering off into the territory of medicine and burying your head into the nursing notes, someone else will waltz into your traditional role. I am the only registered nurse on my ward who routinely attends all mealtimes and, I`m afraid, I`m the only nurse on the unit who makes any attempt to look after the communal therapeutic resources. One or two others make some attempt at therapeutic activity but I`m the only one seeking out new ones. It`s the job of the O.T`s and the dietitian, innit ?.
As for the detoxes themselves, it`s time for some tough love. Ted`s head is going to explode but I think there should be a section of the MHA enabling addicts to sign away their human rights and be sent away for detox followed by a spell of hard labour. Not as punishment but as realistic way of keeping costs low. Throwing resources at people doesn`t work. Sending them back into the environment they came from with no real self belief doesn`t work. Not addressing the fact that many of them will be wretched physical specimens with no stamina and no capacity to structure their day doesn`t work. Six months hard labour, therapies in the evening, a small wage most of which is witheld so you have a lump sum on discharge.
The trouble with nursing is that it`s brainwashed with non- judgemental liberal ideology. Change is coming, the forthcoming recession will necessitate change. I just hope nursing recognises its mistakes and helps make the change meaningful.
Whilst I understand you and your families need to get the best care possible for your brother, your post seems to be telling me that the medical and nursing staff don’t like being asked/told to do their job properly and have then responded by this half arsed attempt at “doing the right thing”.
I have seen a similar thing in a medical ward with a nurse being heard saying “who does she think she is, she’s just a student nurse?” When actually, I just wanted the best care possible for my sick relative (I didn’t get it).
Being standoffish and offended when someone is asking for help in a better manner than is offered really is a poor human reaction.
OSB – “drunks are at best belligerent and at worst hostile and aggressive”
Not me mate. It took several detoxes before I finally got sober, I was always grateful for the opportunity and I thank the staff involved for their persistence (as they thanked me for being a nice, compliant and, I quote, “model patient”.)
Do the research – most drunks, like me, have several detoxes before they finally sober up, and as I am now an employed, tax-paying, family type chap, I can honestly say that all of the help I got from services was worthwhile, from both mine and the wider point of view.
I do understand your concerns and it must be very frustrating and frightening to feel unable to help your brother and to feel that the services are not helping him. I do feel, however, that he is very lucky to have a family who are not only willing to do anything they can to help him, but are also equipped with a comprehensive knowledge of the system (as limited as it may be). Many people in your brother’s situation are not so lucky. Then again, ironically, the system sometimes seems more willing to extend services to people who do not have a supportive family.
I hope that he is able to find a way through all this and I also hope that, one day, services are made available for people who require help with alcohol/drug problems who are not able/willing to abstain with the help of an organisation like AA.
Elliecat
@ E
Your account reminds me very much of my time working on an adult acute ward. Psychiatry aside, it is not surprising that government run institutions fail so badly so often — if they had some genuine competition things might improve. Imagine how quickly a private hospital would go bankrupt if it treated its clients as you have been treated. As you rightly point out, acute wards are very boring places, and yet still nobody knows what is going on. It doesn’t help that admissions are usually reserved for those without any demonstratable illness (or if they have, they are self-inflicted), but the more general point is that the government will always make a mess of what it is supposed to do. Anyway, I hope things turn out well for you and your family.
@ oldschoolbaby
“Ted`s head is going to explode but I think there should be a section of the MHA enabling addicts to sign away their human rights and be sent away for detox followed by a spell of hard labour.”
Well, there is a pretty good debate within libertarian political theory (and elsewhere) asking whether people can do such things. It is an advantage that people would have the decision in the first place, but generally I wouldn’t accept it as valid. Nor would I expect such legislation to require a home in the MHA.
OSB, on the New Republic blog there’s a few lines that might tickle you, to paraphrase “I asked them [the cmht] to refer me to a supported work scheme…they referred me to a social group instead.”
Jan, I`ve done more than enough “research” dealing with drunks, in one capacity or another for 20 years. I`m not daft enough to suggest that there are no exceptions to the rule but if you`re a nurse on duty and you have a drunk on the ward at the very least they will be gregarious in the extreme, witty as hell and irresistible to the opposite sex. That`s the best case scenario. You want them to go to bed. They won`t want to go. It`s also an invariable truth that once sober they will be delightful and a pleasure to nurse. I`ve got no objection, at all, to repeated detoxes. I`m just curious about alternative, lower cost, potentially more effective options.
Many thanks for you kind thoughts and words everyone they are appreciated.
Sailinghome
Sorry to hear about your father, like him my brother has many fine qualities unfortunately talking responsibility for himself has never been one of them. There is still enough of my brother’s non alcoholic character left (he was always my favourite older brother) for his family to go on caring for him so we certainly havn’t given up hope yet.
OSB,
It was the SHO who assessed and admitted on this occasion (after talking to the GP) it was what happened next that was the problem. I was particularly incensed at Dr Organpipe’s Reg phoning my sister at work (she is a teacher so making phone calls during work time is difficult) and giving her a hard time for formally requesting a CPA meeting, like CPA is some sort of secret. What would have another family, less sure of their ground have made of that? Or Dr Organpipe’s insinuation that I had brought unfair pressure to bear on the admitting Sh? Dr Organpipe obviously hadn’t spoken to her or read the GP’s referral.
I agree totally with your comments regarding skill mix, C&R certificates, management, smoke rooms, amiability and maternal qualities. Alcoholics can and frequently are difficult people to deal with.
“and need to be sent away for detox followed by a spell of hard labour”
sounds like National Service”!
Azulinebloo
Do any of us, if we are honest, like being told to do our jobs?
Jan
I am encouraged to heat that you needed several detoxes before finally sobering up. That is my point exactly, if it takes 6, 7, 8, 9 or 10 tries (and it often does) then so be it, in the end it is worth the effort and is a cost effective alternative to doing nothing. My concern is that having got my brother in under the wire once we are not going to be able to get him readmitted again so easily.
Elliecat,
I hope he finds a way though too, if he does not it won’t be for wan’t of trying on our part.
Ted,
Yes can you imagine what supermarkets would look like if the NHS ran them all, some thing like this I imagine?
http://en.wikipedia.org/wiki/I.....ioning.jpg
Dealing with drunks is like dealing with a opposite of you…. when ever you try to speak to a drunk he/she always opposes what you say…. esp core drunkard’s…. i think it would be better if we find a way like zap and the drinking problem is gone. more or less like a brain wash.. the best low cost option to detox is use the will power… i dont know how to convience a drunk to stop drinking but yes if somehow you do it… i bet you win.
——-
RohanA
http://www.drugalcoholrehab.net/
Depression is a commonplace event in modern times, taking on many different forms, including physical, sexual, emotional, and verbal abuse, occurring in many different contexts.
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TOM
Dual Diagnosis Info: Dual Diagnosis