Mental commented on this post when i wrote it on the 7th July (which was also when i spotted the article on the BBC) and asked if she could steal it for a guest post.

To be honest I’m still a little jet lagged/diet coke (caffeine/aspartame) detox suffering to be [...]]]> [Guest post by Susiebelle]

Mental commented on this post when i wrote it on the 7th July (which was also when i spotted the article on the BBC) and asked if she could steal it for a guest post.

To be honest I’m still a little jet lagged/diet coke (caffeine/aspartame) detox suffering to be bothered if Mental just copied and pasted it it without even asking.  However i can understand that when i eventually come round from this sleepy, migraine, post holiday, general depression and lack of diet coke induced state i may actually care and be rather upset and angry,  so here it is the officially submitted guest post on a subject that i will always have some thing to say on.

In fact i ended up talking to the off duty pilot who was sat next to m on my flight back, explaining the scars (after he had explained his skin graft scar on his wrist) but i think i childhood accident has less stigma attached that my “self inflicted” scars, which was how i tried to describe them to him, fully aware that my Nan was sitting listening on the other side of me.

So to the BBC (ground-breaking) article about a (revolutionary) report on how self harmers are not getting the help they need.

(No?  Really?)

The original post is here by the way

Another news story where i feel like saying:

1. “Have you only just realised this??!!”
2. “So what’s new?”
3. “Does this mean you will do something about it now?” (to which the reply is probably “no”)

A quote from Lord John Alderdice, a Consultant psychiatrist is one that reminds me how lucky i am to have my GP

“This situation is unacceptable by any reasonable standard. Lives may be at stake”

When i my life has been at stake, i have turned to those closest to home & those i trust first, my GP & the surgery down the road. The have been the ones to call the ambulances and get me to hospital. I don’t know whether it does make a difference, or whether again i have just been very lucky, but when i have then arrived at A&E i have never heard or been on the recieving end of any bad treatment.

Another quote from the recent article from the BBC says that,

“The survey also suggests accident and emergency departments fare worse.”

In my opinion the staff at my GP surgery have got to know me, many of them since about 2000, and they have seen me at times other than when i have needed patching up or shipping off to A&E when they couldn’t deal with my injuries. They have got to know me personally, where as staff at A&E i have generally just seen the once, all they see if the harm and the distress, they don’t get to see the person behind that. In my area i believe the same to be true about the Walk in Centre where as at my smaller Minor Injuries Unit (run by 3 staff and 1 receptionist) i have got to know them over the years, as the main senior nurses there haven’t changed (unlike the conveyor belt of staff that is a busy shift work hospital ward).

So the recommendations of the report?

• NHS services, particular in A&E, should be managed in a way which ensures people who have self-harmed or attempted suicide have proper access to care and treatment by fully-trained clinical staff

• A change to the culture of NHS services, so that staff who encounter people who self-harm are trained and supported

• A proper public health strategy to cover self-harm, and for the suicide prevention strategy to remain a priority in all nations of the UK

• More funding of research on self-harm, which has been neglected and overlooked.

And is the final comment (below) really true?

“Rates are down in young people and we are looking carefully at ways to improve mental health care in frontline NHS services.”

Are they down? or are young people put off by their own bad experiences & horror stories that they have read on support forums, blogs and from people they know?

Firstly, my personal motto: I’m not anti-psychiatry, I’m anti-bullshit.

So whether you’re talking about so-called laissez-faire economics, the madness of Chavez, or the corrective utility of Seroquel, to me it makes no difference. Bullshit is bullshit, no matter the shape, size and texture, no matter what arsehole [...]]]> [Guest post by Rasselas, Prince of Dysthymia]

Firstly, my personal motto: I’m not anti-psychiatry, I’m anti-bullshit.

So whether you’re talking about so-called laissez-faire economics, the madness of Chavez, or the corrective utility of Seroquel, to me it makes no difference. Bullshit is bullshit, no matter the shape, size and texture, no matter what arsehole it’s extruded from. All bullshit stinks.

I have a question. I’m hoping some of you will be willing to give it serious consideration.

In the subcultures of criminalised psychoactive drug taking there are many wisdoms. One of them is that you will get the best deals from trusted, established, peer-reviewed dealers who, by and large, will be users themselves. Coleridge knew this, and so did de Quincey, Baudellaire, Burrows and Self. It’s a wisdom that’s passed down through the ages.

Now, many years ago I was offered Abilify. Whoever conceived of that neologism was a crafty wordsmith; it’s like the noun ‘ability’ (the quality of being able to perform or facilitate achievement or accomplishment) has been blurred breakneck through the Large Hadron Collider smack bang into the verb ‘stultify’ (cripple, deprive of strength or efficiency; make useless or worthless) – nice.

Now back then, as still today, the Myth-worm had squatted on the pusher’s tongues and they were lauding Abilify as the new wonderdrug, the mighty third in the trinity of frontline neuroleptics for the amelioration of schizophrenia. Virtually no side effects, they said. They lied. Considerably less dyskinesias, they said. They lied. No akathisia at all, they said. They lied, they lied, they lied!

I took it. A few days in and I experienced intense akathisia. It’s not akathisia, they said. Have you ever experienced akathisia? I asked. It isn’t akathesia, they said, it must be something else because this drug doesn’t cause akathisia. They lied. Simultaneously I suffered random, situationally incongruous rages. I had never had such rages before in my entire life. I became acquainted with the red mist. I stopped taking them. It was overwhelming, frightening. The day I decided to stop them I’d rang them on my mobile. I was pacing down a high street, confused, and fighting against myself from lashing out. I’d never before or since experienced such unwarranted rage. They said: it must be something else. Has something happened? The Abilify doesn’t do this. They shut off their ears and covered over their eyes. They’d succumbed to the myth-worm squatting on their tongues. They didn’t know yet it was another of the lies.

Actually, now I’ve written that I have two questions. I hope you can indulge me.

First question, which I’m sure has been put to you on at least one other occasion (I’m specifically addressing here those that are qualified and experienced with working on the frontlines): why don’t you take the drugs yourselves, for at least a month, like any good dealer, before you start pushing them onto others? Remember the druggie wisdom: a good dealer is also a user. And when a good dealer gets a bad batch, they move it on, saving their loyal clients from unnecessary disappointment and misery.

And my second question, which is an open one: given that it has long been established that so-called anti-psychotics can induce violent rage in a person, why is it that, to my mind (and I’ve read a good number of Inquiries since David Bennett) the possibility that the neuroleptics were the causal factor in a violent event is never acknowledged by mental health professionals?

Thank you for your time. If this gets through I hope to join the debate.

In this article, we’ll have a look at the public system and how it is funded. Then, I’ll examine the parallel, private system. After that, we’ll [...]]]> The Irish health system is rather complicated, containing both a comprehensive and entirely public network of hospitals and clinics, and an equally wide-ranging system of private non-profit establishments.

In this article, we’ll have a look at the public system and how it is funded. Then, I’ll examine the parallel, private system. After that, we’ll see how the two intersect in the GP system. Finally, I’ll lay out some of the main problems the system is facing.

The Public Health Service

The top level body of the Irish health service is the Health Service Executive (HSE), which answers to the Department of Health. Under the HSE are three separate organisations which are responsible for the day-to-day running of affairs in their catchment areas, the Eastern, Western and Southern Health Boards. These, as you might imagine, serve the East, West and South of the country and function like NHS trusts.

Ireland is a country of approx 4.5 million people, of whom 1.5 million live in the greater Dublin area. This is probably fewer people than Birmingham. This is why 3 health boards are sufficient.

The public hospitals, clinics and outpatient departments are funded entirely by the state. Consultants in each speciality are allocated to geographical catchment areas as in the NHS. If you want to see a public specialist as an outpatient, a GP’s referral is required.  You will be referred to the consultant who is assigned to the area you live in. Outpatient treatment is entirely free of charge.

Other hospital services are not free. If you are admitted as an inpatient you are charged a co-payment of something like 50 euro a day up to a maximum of 450 euro. A visit to A&E costs 100 euro unless you have been referred by a GP. In addition, if your consultant writes you any prescriptions, you will have to pay for them – this means pay the full market price of the medication, not a flat prescription charge as under the NHS.

In mental health, most county towns have a general hospital which includes an acute psychiatric unit. Also, located somewhere miles away, there will be a decrepit Victorian building which houses longer-term patients and the elderly and demented. Dublin is the exception (although not on the decrepit building front), having a number of specialist hospitals that deal with acute cases as well as several acute units.
The Medical Card

The charges mentioned above are all waived if you are in possession of a Medical Card. This is a means-tested benefit card which allows you to avail of all public health services free of charge and your prescriptions are also free. Approximately 30% of the population qualifies for a Medical Card. This is not uniform across the country. For example, 57% of inhabitants of Donegal have a Medical Card, compared to 17% of Dubliners. The over 70s all have Medical Cards, regardless of income.

Everyone else is encouraged to take out insurance which will cover these co-payments. If you are an EU citizen travelling in Ireland and have an EHIC card (descendant of the E-111 form) you will not have to pay anything either. An NHS medical card will also do.

Occasionally, if your ailment cannot be adequately treated by anyone in the public system but there is a private specialist who can, the Dept of Health will send you to the relevant private hospital, or even to the UK. The sister of a friend of mine spent a year in the Royal Marsden in London (a specialist cancer hospital) as she was suffering from a rare form of childhood cancer (yes, she recovered and got married recently). In this case the health board bears all the costs.

Private Hospitals and Clinics
Ireland has a very large number of private hospitals and clinics which in the past were run by religious orders who specialised in nursing. These days they are almost all non-profit trusts run by lay people as there are very few nuns remaining (although you will see the odd one around occasionally). Private hospitals are only available to the 40% of the population who have insurance (unless you’re rather rich). They cover the full range of medical specialities.

Since a large proportion of the population has access to private care, the network is very comprehensive, unlike the UK. Every county town has its public hospital and its private equivalent down the road. The exceptions are mental health and childrens’ facilities. There are only two private psychiatric hospitals in the country and both are in Dublin – St John of Gods in Stilorgan and St Patrick’s in St. James’s Gate. (The facilities at the general private hospitals are not suitable for those suffering from mental illness). Childrens’ medical or surgical wards are limited to the big cities in the private sector as there is less demand for them.

The care in Ireland’s private hospitals is generally of a high quality.

Insurance
There are strict rules governing the sale of medical insurance in Ireland. For example, providers must charge everyone the same for a given level of cover, regardless of age or state of health. Insurers are required to cover all conditions, unlike the UK where insurers do not cover any condition deemed “chronic”. As long as you first took out the insurance before your ailment showed up, you are covered for 6 months of every year as an inpatient and for all outpatient services, for as long as you continue to pay the premium. They are not allowed to increase your individual premium because of this or deny you cover for certain ailments. It’s common for middle class families to insure their children from birth, so everything is covered.

There is only one company offering health insurance in Ireland, it is a semi-state body called the VHI (Voluntary Health Insurance). They offer 5 plans, from the basic, ‘A’ plan up to the more luxury ‘E’ plan. Some private hospitals will accept you will level ‘A’ cover, while others, such as both mental hospitals, require level ‘C’ or higher. My family has level ‘C’. The cheapest VHI plan costs around 650 euro a year per person. Children and students cost less as additions to your plan.

BUPA used to be in the market but pulled out because these rules made it hard for them to make money hand over fist while kicking all the severely ill people back to the taxpayer as they do in the UK. My experience has been that BUPA went to a lot of trouble to try weaseling out of claims whereas the VHI just paid out.

GPs
GPs are where the public and private systems intersect. If you are, as the expression goes, “on the Medical Card”, you need to register with a particular GP as under the NHS. The usual visit fee of 50 euro is waived and you will not have to pay for any of your prescriptions. The GP will only refer you to the public system if you need to see a consultant or go into hospital.

If you do not have a Medical Card you are not required to register with a GP. You can see any GP in the country, any time you like, and pay up your 50 euro. It’s recommended that you see the same GP regularly obviously, but not required. You will have to pay the 50 euro charge and also pay in full for your prescription at the pharmacy. Venlafaxine could easily set you back 150 euro a month.

If you are taking a medication long-term and can get a doctor’s letter saying so, you can get a prescription card from the Department of Health which absolves you of the prescription charges above 40 euro or so a month for those specific medications. You’ll still have to pay for anything else which is unrelated or a one-off, eg antibiotics for tonsillitis when you also take quetiapine long term. As many people on mental health medications have potential monthly prescription blls of 300+ euro, this scheme comes in handy.

Referrals are a bit more open as well if you are not on the Medical Card. You can choose to be referred within the public system. However, waiting lists tend to be long, so most patients with insurance will opt for a private referral. The GP can refer you to pretty much any private specialist in the country who is willing to take you on as a patient. Generally, you will be referred to someone at the closest private hospital, but otherwise, it’s entirely up to the GP.

For example, I was referred across the country to St Patrick’s in Dublin, by a GP in my parents’ home town, 300 miles away. He chose the hospital because I was living in Dublin at the time, but the choice of psychiatrist was made entirely by my GP – there were about 30 to choose from at the hospital. He just happened to like this one. If you want to be referred to a particular specialist your GP can oblige. A lot of private specialists also have waiting lists, but they are not as long as in the public sector (with some exceptions).

Very many consultants who work in the public sector also have engagements with private establishments. For example, they can be employed for 2 days a month by the local public hospital, 3 days a week by a private hospital and spend the rest of the time in private consulting rooms that have nothing at all to do with any clinic. Regrettably, it’s rare that you get anyone spending all their time in the public system, or even most of it.

Consultants in the private sector also write their own prescriptions. They will write to the referring GP to let them know, but there is no need for you to drop in and see your GP – you can go straight to the pharmacy. Less care is taken in Ireland than the UK to always prescribe a generic, so if you want a generic where it’s available you need to make sure they write that, and not the brand name, on the script.

Problems
The first problem with the Irish system is that the income threshold to qualify for a medical card is very low. In the late 90s, it was about 100 euro a week for a single person. The Medical Card covers 30% of the population.  40% have VHI. The remaining 30% includes a lot of still very poor people who cannot afford to go to the doctor or to A&E if they are sick.

The second is that the public sector is ridiculously stretched. To give you an example, I had my wisdom teeth extracted under general anaesthetic at 18. If I had gone public, I would have had to wait 2 years because the surgeon only spent 1 day a month at my local hospital. Since my mum used our insurance, we had to drive to Cork to the private clinic where he spent most of his time, but the waiting time was 2 weeks. This kind of disparity is the norm rather than the exception and leads to huge resentment. It is felt that the middle classes don’t care about the state of public waiting lists when they can jump the queue whenever they feel like it.

The third is that the public sector is managed by idiots who prefer politics and looking good to actually getting anything done. If you thought the NHS was bad, you ain’t seen nothing yet. They have POURED money into the HSE over the past decade, but all of it appears to have been spent on paperwork and politics, and very little on doctors and nurses.

In addition, all the best consultants, especially surgeons, are in the private sector, showing up in public hospitals once in a blue moon. This is because the earning opportunities in the private system far outstrip anything the Dept of Health has to offer. Again, this means that people on the Medical Card get the less competent or less experienced specialists.

Finally, there is the treatment dished out to medical card holders by some GPs. GPs do not get reimbursed anything like 50 euro from the health board for seeing a medical card patient, and so a lot of visits can be rushed and perfunctory, with a preference being shown for paying customers. Not all GPs are like this, but some do treat their medical card patients differently from private. It’s not as simple to find another GP in many small towns so people end up stuck with crap primary care.

I had the misfortune in the late 1990s of spending a year in total as an inpatient in a Big Dublin Hospital where many of the staff treated the patients with a mixture of disgust, antipathy and contempt. [...]]]> This is a post about the systematic, institutional abuse of patients by mental health nursing staff.

I had the misfortune in the late 1990s of spending a year in total as an inpatient in a Big Dublin Hospital where many of the staff treated the patients with a mixture of disgust, antipathy and contempt. We were the lowest of the low, like convicted multiple murderers. They felt justified in treating us any way they felt like it, with a let up only if they thought we were trying hard enough to redeem ourselves on a daily basis. Behaviour like self-harm, suicide attempts, anorexia or being sectioned was taken as proof that the patient wasn’t interested in getting well and wasn’t trying hard enough, and was dealt with harshly. (Yep, sectioned patients were badly treated purely because they had been sectioned, and so obviously didn’t want to get better, you read that right).

I’ve posted a rather long screed about this on my blog, here, but edited highlights include:

• Roaring and screaming abuse at me when I made a superficial cut on my wrist to the point that I ended up with flashbacks and nightmares.
• Yelling at a depressed woman who tried to commit suicide on the ward, and denying her therapy or OT as a punishment.
• Giving an anorexic woman who had previously been in another hospital a hard time continually because the other hospital would no longer take her on their ED program as she had done it 4 times. Obviously she didn’t want to get well and didn’t deserve a bed.
• Talking about patients to other patients in a derogatory manner or gossiping about them at the nurses station within earshot of other patients.

I could go on. The medics weren’t as bad, but refused to do anything to help.

I know there are plenty of places in the UK with a similar attitude to their patients. (Yes, I know not all nurses and hospitals are like that, let’s not get defensive, ok?). As long as places like this exist, there will be a large population of mental health patients who hate every nurse and doctor in the country with a passion. If you’re wondering where some of the “psychiatry is evil” attitudes come from, there’s your answer. If I hadn’t encountered my current local hospital, which is very good, I’d never want to go anywhere near a psychiatrist or RMN again, regardless of the consequences.

I’m posting this here as I’m interested to hear if any other readers of this site have had similar experiences.

Nicotine improves brain function in schizophrenics, from Cosmos magazine:

Researchers led by Ruth Barr, a psychiatrist at Queen’s University in Belfast, Northern Ireland, set out to find if the nicotine in cigarettes was helping patients to overcome their difficulties [...]]]> Come across this in a few places. None of which link to the original research.

Nicotine improves brain function in schizophrenics, from Cosmos magazine:

Researchers led by Ruth Barr, a psychiatrist at Queen’s University in Belfast, Northern Ireland, set out to find if the nicotine in cigarettes was helping patients to overcome their difficulties with cognitive function, such as planning and memory in social and work settings.

They found:

The participants showed improvement in brain function, including less impulsive behaviour and better levels of attention, which are both unrelated to nicotine withdrawal, said Barr.

Ruth got a grant to study this kind of thing last year. Looks like the article can be found here. Earlier research by someone else can be found here.

What would you do if you knew that tomorrow when you go to work, all of your patients would have very high IQs, all much higher than your own?

Okay, I really do want an answer to that question, but of course I am also trying to make a point.

I’m kind of on a quest. In trying to figure out how to make mental health care better, I’ve tried to figure out what has gone wrong. What happens to turn people who went into this profession with the genuine intention of helping people into people who harm their patients [...]]]> (Guest post by jessa)

I’m kind of on a quest. In trying to figure out how to make mental health care better, I’ve tried to figure out what has gone wrong. What happens to turn people who went into this profession with the genuine intention of helping people into people who harm their patients egregiously without noticing or caring? I haven’t really figured this out.

I don’t think that most professionals intend to harm their patients, though I am certain that there are some who do. I have posited a few possibilities. In my undergraduate thesis I proposed that part of the problem might be “goal displacement.” That would mean that in the process of trying to achieve a goal, such as better mental health for patients, there are lower level goals that are implemented as a matter of policy, such as doing cognitive behavioral therapy. When the original goal is displaced by the lower level goal, meaning that it is the lower level goal that gets all the attention and energy, things can go awry. If my focus is on implementing cognitive behavioral therapy without keeping in mind the original goal of increasing good mental health, I cannot adjust my lower level goal if/when it starts to subvert my original goal. I won’t stop implementing cognitive behavioral therapy with jessa when it seems to be worsening her mental health because I probably won’t notice because I am not evaluating the sucess of the lower level goal by how much it helps to accomplish the original goal. If cognitive behavioral therapy is the goal, I have succeeded; if improving jessa’s mental health is the goal, I have failed. So I think I am helping jessa when I am actually harming her.

I have also posited that some of this problem might be a result of not allowing for enough ambiguity in life and in the education of professionals. If professionals are taught that each diagnosis has very clear causes and that they are the same for every patient, they will try to fit their patients into those molds rather than considering the plethora of alternative causes, treatments, outcomes, and other possibilities.

I’m not settled on either of these answers. I suspect that there are a lot of things contributing to this problem. What do you think some of them might be?

With additional material provided by a friend who wished to remain anonymous. Please note that as I’ve also been asked to write a version for distribution in the USA, a lot of the language is targetted in that direction.

Introduction Here’s a little guide I wrote to how [...]]]> (Guest post by DeeDee Ramona)

With additional material provided by a friend who wished to remain anonymous. Please note that as I’ve also been asked to write a version for distribution in the USA, a lot of the language is targetted in that direction.

Introduction
Here’s a little guide I wrote to how to stay out of trouble during your stay on a a general adult acute psychiatric ward in the UK. Despite what you might think from the TV, such places are, in general, not particularly dangerous. There are factors that can, however, make your stay more difficult if you’re not careful how you approach the situation.

The problem is that you are, effectively, shut into a set of rooms smaller than the Big Brother house, with twice as many people, none of whom really want to be there and with whom you have nothing in common except mental illness. All of you have had your social skills drastically compromised by illness.  Some of the other patients may live a very rough existence, due to past and present social exclusion and you will need to get on with them too.

Here are 10 tips to help you have a trouble-free admission.

1. Secure Your Possessions
You should not bring anything into a psychiatric ward that you would mind losing. Everything, including your socks, can and does get stolen. The staff will probably give you a key to a locked drawer in your bedspace in which you should place any valuables such as cellphone, money or cigarettes. Carry the key on your person. You will need clothing with secure pockets to keep this key safe.  If no such drawer is provided, then you need to leave your high-value items with staff, or keep them on your person at all times.

Anything else – expect it to walk. Have a friend come in and collect your dirty laundry. If the hospital has a laundromat, make sure you keep your belongings in line of sight throughout the wash and dry cycle. If you can’t do this, or there isn’t a member of staff overseeing matters, don’t use it.

2. Smoking Area Drama
The vast majority of psychiatric patients smoke. I don’t know why (I don’t), but they do. You will find the corridors of the ward completely empty during the day as the 30 or so patients squeeze into one tiny balcony area or ventilated room to get on with the essential business of getting through 40 Marlboro Lights a day.

Stay out of the smoking area.

With everyone crammed in there, you get endless drama. A thinks B is looking at him funny, because A is paranoid. B gets really aggressive about this because he isn’t able to control his emotions well due to illness. C starts shouting at them both to can it, because he can’t hear the TV (there is no TV). D and E get stressed out by the noise and start screaming at everyone… (Seaneen Molloy refers to the above as the game of “Mentally Ill Dominoes”). Or there will be schoolboy and schoolgirl bitchery, as one patient decides he or she wants a clique, and passes comment on everyone else….

The smoking area is the source of 90% of all ward drama. If you have a falling out with someone in there, you have to cope with being in the presence of that person constantly, perhaps for a number of weeks, until you are discharged. They may decide to make their distaste at your existence abundantly clear on a daily basis, shouting at you whenever they see you so you find it impossible to go sit in any of the common areas without being yelled at.  Avoiding the smoking room cuts the probability of having this happen to you right down.

If you don’t smoke and another patient invites you in, state that you can’t, because the large number of people in a small area makes you feel “anxious”. If you must smoke, go in there, stay really quiet, and if anyone says anything, mutter, “I’m not feeling well today, the walls are closing in on me” and then leave when you have finished your cigarette, citing that you feel paranoid. No-one will question this, regardless of diagnosis.

3. General Drama
Remember that no-one has any social skills due to illness. This means that a normal conversation, where you discuss a mildly controversial topic in a civil manner, can result in an adult woman in her 50s – who would never behave like this when well – screaming blue murder at you because she doesn’t agree with what you have to say, or alternatively bursting into floods of tears and complaining that you are being mean.

Therefore, be very careful about what you bring up in discussions with other patients and steer well clear of anything that could lead to disagreement or friction. The weather and your dog are good topics. The government and the state of your local football team are not. Avoiding talking about your children or asking others about theirs as many patients feel tremendously guilty that their illness takes them away from their families.

4. The “250mg of Chlorpromazine Walk”  and “Can’t Sit Still” Excuse
If for any reason you are in one of the common areas and someone you don’t want to be near comes in, or drama starts, or someone looks like they are about to start some, wait about 15 seconds and then say something like, “dammit, I can’t sit still today, bloody medication”, get up and leave. No-one will question you.

You then wander off doing what I call “the 250mg of chlorpromazine walk”. This is where you imagine you’re full of anti-psychotics, and shuffle along slowly with a blank, slightly-confused expression on your face. You sort of blend in as part of the furniture and people tend not to notice you. I’m serious, it works a treat.  It’s the ultimate get out of jail free as regards getting away from troublesome patient-related situations.

5. The Violent or Threatening Because of Illness (VTI)
There will always be at least one other patient who is threatening, violent towards staff or overtly lecherous towards other patients because they are ill. The lecherous while manic thing is so common that many wards have a women-only section as otherwise the ladies would have to hide in the dorms all day from one hypersexual male after another.

Avoid this person. Yes, you may feel sorry for them, but they are NOT your problem. The staff are there to assist them with their recovery. You, look after yourself. If they come and sit down beside you, do the ‘can’t sit still’ excuse followed by the 250mg of chlorpromazine walk (see above). It is not judgemental or narrow-minded of you to prioritise your personal safety and recovery in this way. If you see the VTI behaving erratically or in a threatening manner, tell the nursing staff and let them handle it. Just stay well away from them and concentrate on your own recovery.

6. The Nasty Piece of Work (NPW)
There is always one. This is someone who is, outside the hospital, a social predator who spends their time scaring and intimidating others, getting involved in low-level crime, or frankly they are a violent offender who also have a severe mental illness. They tend not to control their condition very well and so end up spending quite a lot of time in hospital. They are used to the environment and have lots of practice. Therefore, they are in a position to exploit people they see as vulnerable and will go after anyone they see as a threat to their position as king/queen of the ward.

The NPW will likely immediately try and see if you can be intimidated into handing over cigarettes, or, if you don’t smoke, money. They will either approach you while walking around the ward, or, if they are feeling more aggressive or confident, come directly to your bedspace with their demands.

It is ESSENTIAL that you do not give in, regardless of how much this person may scare you. Otherwise you mark yourself as an easy victim for the duration of your stay and this person will not back off. Just flatly state, sorry, I’m not giving you anything. No matter what kind of tantrum the person throws, or how much they scream in your face, just stand there and keep repeating yourself. They are unlikely to resort to violence as this will get them in hot water with nursing staff. Once they have backed off, report them to staff immediately. With luck the staff will come running anyway if things get in any way loud, and your problem has gone away – the NPW now  knows you are not to be picked on and so they will interest themselves in someone else.

Don’t be tempted to become the “ward police” and report the NPW whenever they step out of line. If you do that, they may see you as a threat to their dominance of the ward and could react violently. Mind your own business if they are not directly affecting you.

7. The Phantom Staff
Regrettably, there are still some acute wards where the staff do not have a presence on the ward at all, preferring to lurk in the nurses’ office, emerging only to administer medication or if a violent incident has occurred.  This is going to be a real problem if you have been targeted by the NPW – they are free to threaten you with violence and you have no backup, and they know this. It’s a situation that is totally untenable and no hospital should inflict it on you – but there are still cases where this does happen, so it needs to be mentioned here.

You may be thinking about smacking them one, hard (the NPW, not the nursing staff). They may richly deserve this, but, remember, your goal is not to teach this person a lesson, it is to get to the nurses’ office and pound on the door. This way, the NPW they realise that the outcome of any threat made to you will be hassle from the staff whose darts game has now been interrupted.

There is an additional problem you need to think about if you do decide to engage in violence to deal with someone like this – that of what goes on your file after the previously non-existent staff erupt from the nurses’ office, find 2 patients “fighting” and give both of you haloperidol jabs to calm you down. The merest mention of “tendency to violent outbursts” in your file could change the tone of your treatment forever from working with you to find the best solution to containing the potentially violent offender at all costs. You don’t want your doctor to be scared of you.

I would suggest you study carefully what Marc MacYoung has to say about bullies and how to deal with them on his excellent site No Nonsense Self Defense. Take a very detailed look at this page, and indeed at the rest of his site, before you decide what you would do in that situation. Mr. MacYoung has a LOT of experience in the field of self-defense in the USA and is highly knowledgeable (Note for Mental Nurse readers: yes I’ve met him and yes he really is that good).

8. Drugs and Alcohol
It is commonplace for “friends” of patients to bring illegal drugs or alcohol in to them. It was so frequent at my local hospital that there are now stern notices at the entrance threatening anyone so doing with immediate arrest.

If you suspect someone has brought in booze or drugs, my advice would be DON’T report them to staff. Mind your own business. Do not become a “snitch” on what is a criminal undertaking or you could be letting yourself in for serious violence. The staff are not stupid, they will find out and handle it themselves – they see this every single day.

Just stay out of the common areas, especially the smoking area, for the rest of the evening, as drink and drugs on top of a major psychosis and heavy medication can turn some otherwise OK patients into violent assholes.

9. Loudly saying “I don’t belong in here”
This goes down about as well as in the Shawshank Redemption. You may feel that you’ve just landed in a ward full of hard-core mentalists who have all been hearing voices since birth and have been fully “in the system” for most of their adult lives whereas you have been depressed for precisely 6 months – and this is possible. If you were on a kidney unit you’d meet all the people who have had dialysis 3 times a week since they were 6 years old even if all you needed was 2 days of treatment. Nonetheless, although these people are sicker than you, you are all mentally ill and that is why you are a patient on that ward.

Patients are very sensitive to any suggestion that someone is “too good” for them or that the severity of their illness makes them a lesser person than you and will interpret anything that remotely suggests this as such. Many have suffered years of discrimination and ill-treatment from their families and communities. So no matter how scary you think everyone else is, do not express this view in conversation with other patients, or to staff where other patients can hear, even if you don’t mean it like that. It will not make you ANY friends and will probably create drama.

10. Relationship Troubles
This is not the time to start any sort of romantic attachment with another patient. If you really think this person is the one for you, they will still be that 2 months after discharge. It’s best to wait. It’s known to be bad for your recovery, which is why your doctor will not be happy with you about it, plus you risk breaking up on the ward and this will cause further drama.

11. Relax!
It is extremely unlikely that you will be threatened with violent assault while a patient on an acute ward anywhere in the UK. It is more likely that you will have a falling out with another patient that will make your life more unpleasant, or that the behaviour of other, very ill patients might result in drama.

The tips presented here should reduce the likelihood of these problems occurring. I hope you’ve found this guide to be useful. The most likely problem you will encounter is other patients eating your grapes when you’re not looking!

Howard Martin – I hope you don’t mind my nicking your copyright notice as I need one:

Copyright 2009  DeeDee Ramona (Z knows my real name for this purpose).
All rights reserved – for publication only as part of the Mental Nurse website. No editing or copying by whatever means or for whatever purpose without express consent.
ps Why yes, I am up posting to MN at 2am. I’m not manic at all, of course not…

I must apologise for this first introduction as not only are there my normal levels of confusion to deal with, but I have also taken my sleepers, which add all sorts of exciting confusion such as voices and people running around fast etc etc. So this may actually make [...]]]> (Guest post by A Mental)

I must apologise for this first introduction as not only are there my normal levels of confusion to deal with, but I have also taken my sleepers, which add all sorts of exciting confusion such as voices and people running around fast etc etc. So this may actually make no sense at all. And it may well be long. I waffle. Writing in a succinct manner is not a skill I have ever mastered – my A level English Lit teacher told me so.

Anyway, as you may (or may not) have guessed from my name, I am not an RMN (does the term ‘Mental Nurse’ make anyone else chortle by the way? Mental Health Nurse or Psychiatric Nurse I could understand, but Mental Nurse?? I can just imagine 2 nurses talking ‘So what sort of nurse are you?’ (asks RMN) ‘Oh, I am a Children’s Nurse, I work with children. What about you? Our imaginary RMN replies ‘I am a Mental Nurse. I work with mentals. Does anyone see my point regarding the slightly odd terminology there used in the titles? Or is it just the Zolpidem that makes me find it amusing? Anyway, enough chortling, back to the point, the point’………………………………. Ah yes, the point is I am not an RMN, or any other nursy type, or anyone professionally involved in mental health. I am a patient (refuse to be client - seems linked to prostitution) under MH services, and have been since I was 17, and am now 23 (or will be in a week). I swear this had a point, I haven’t a bloody clue what it was anymore though. So anyway, I just registered my name as ‘a mental’ since we have already established RMNs treat mentals, and there is only one of me, hence the lack of s in my name. Wonderful, you have had to endure a blog about my name. It really was about something else, I promise.

Yes, my post. So I am a mental. Seeing the local CMHT. I have problems with depression/anxiety/ED among others but I will go into that at another time. My CCO is an incompetant moron, hereonin to be known as twatman (rhymes with batman – get it? ) At my last session with him 2 or 3 weeks ago I was feeling very low, and I have suicidal thoughts a lot of the time, but can distinguish between when they are just flying around irritating me, and when they are uncontrollable. So yes, I was very low with the irritating suicidal thoughts, so not good really, and twatman said to me ‘Maybe you need to accept that things are never going to change and that this is as good as it gets’ and then asked how I felt about that. I said I would kill myself in a heart beat if I knew that to be true as why on earth would I want to keep on going if this was it – being unable to get out of bed except for appointments, constant thoughts of hurting myself, no confidence, no self esteem, hating myself. You get the picture. a mental is not a happy person, and therefore would not continue to live if she knew nothing was going to change. A mental was also very upset as couldn’t cope with the thought that nothing could change – that is HER thinking but she isn’t used to having it reinforced by the professionals. Following this twatman said well you are your dad’s only child so I want you to sit there as him, pretend to be him and talk to me, as your dad, after you have committed suicide. I refused to do this, so was then told that I was refusing to comply with therapy. I left that appointment very upset, with twatman having given me an appointment for July (and this was at least a couple of weeks ago now), and have been feeling terrible and very suicidal ever since, but that bit is irrelevant with regards to my post. I suppose my main question is, was that session suitable? Should you tell your patient that they need to accept things won’t change and then get them to role play their parent following their death? I genuinely don’t know – I know how it felt, but is this type of, what I find fairly aggressive, therapy helpful to people/suitable/appropriate etc? Any thoughts from all you good nurses would be muchly appreciated, and final apology for the post med rambles!