After returning back home from London I didn’t want to go back to a regular ward just yet. But I wasn’t sure exactly what I wanted to do. I signed on to the hospital register to work as a casual nurse, until I made up my mind about a more permanent role. My first line of work came from the local psychiatric unit.
I had the option of working in a general medical/surgical unit, but I was curious about what it would be like to work in such an unusual area of nursing. At Waverly House I had been a naïve student, and now I was an experienced nurse, but I was still fairly ignorant of things psychiatric, and very curious. My interest was only made greater when other nurses said things like:
‘It’s not just the patients that are mad; the staff aren’t quite right either.’
Or
‘It isn’t safe’ and ‘Watch your back.’
The general consensus was that I was making a big mistake.
As the new casual member on the team, I was technically the most junior, but since I had five years’ nursing practice behind me, I was actually a lot more experienced than a fair number of the nurses on the ward. There were a lot of graduate nurses, straight from training, many of them with less than six months’ experience.
Still, I didn’t mind starting at the bottom. This meant being a spotter. I wasn’t allocated my own patients yet, and so didn’t have to be responsible for anyone. As a spotter, my task was to wander the ward every five, ten or 15 minutes, trying to locate where all the at risk patients were. At risk meant that these people had either harmed themselves, threatened to harm themselves, or were acutely unwell because of their various psychiatric problems. It was a brainless but vital job, and I ended up finding it rather ironic that this often life-saving job was mainly given to all the new, junior staff.
Armed with a clipboard and a list of patients, I would stroll the corridors, hoping like hell that no one on my list went missing. But, of course, occasionally they did. My first missing person was on ten-minute observations and was still absent after 15 minutes. What happens next? Well, you begin by feeling sick to the core of your stomach. You assume the worst. You imagine your patient stiff but not yet cold lying in a pool of blood. You frantically begin searching every corner of the building, the bedrooms, the living rooms, the dining room, the pool room, the toilets, and worst of all the showers. Your heart pounding in your chest as you open the door to the showers, a large, bare space with five closed doors facing you, desperately hoping your missing patient is not hanging around in one of the cubicles. Opening each shower door is like a terrible lottery:
And behind door number three is Mr Smith, freshly hanged and still warm to touch.
I found the patient half an hour later. One of the new graduate nurses had foolishly taken him outside for a breath of fresh air. Not only was he not supposed to be outside, she had not told anyone that she was taking him.
But it can go other ways.
One patient, who I came to know reasonably well during my 18 months in the psychiatric unit, had made eight attempts to kill herself, two of those in the previous 12 months. After eight attempts, you might think she wasn’t quite sincere about wanting to finish her life, but she was, she was just plain unlucky (or lucky, depending on your point of view).
She had tried gassing herself in her garage, using her car. Her neighbours had broken in to find her semiconscious.
She had taken three overdoses, each attempt more potentially lethal than the last. She began with Prozac, then paracetamol and finally tricyclic antidepressants, which have a rather nasty habit of affecting the heart rhythm.
She had cut her wrists a couple of times and been found again by her neighbours. I wouldn’t have been surprised if her neighbours ended up admitting themselves.
She had also hanged herself twice. The last attempt while an inpatient in our unit. She was on the spotter list and she was found to be missing (thankfully, I was not on spotter duty at the time).
It was nine o’clock at night and pitch black outside; everyone just hoped that she was somewhere inside, otherwise there would be no chance of finding her. As we raced around the unit searching, I heard a scream, followed by yells for help coming from the bathroom.
It’s horrifying, but curiously amazing, what people manage to hang themselves on. This patient had managed to hang herself from a door handle, with the use of a shoe lace. The door handle attempt worked and she died. The nurse looking after her that shift was not blamed, but The System was. The System let her down and subsequently more stringent regulations were put into effect, to prevent this happening again, or so I’ve been told.
Someone who has made eight pretty good attempts on their life is eventually going to get it right. She was on a five-minute watch, but if someone can be so inventive in their determination to kill themselves, then no matter what safeguards we put in place they would find a way around them.
Despite the tragedies I was fascinated by mental health. My colleagues back in the medical ward – or real nursing world, as they liked to consider it – continued to think I was mad for doing what I was doing. In some respects I could understand their position.
It wasn’t real work as they knew it. There were no patients to wash, no wounds to dress, no one to rush to theatre. Instead of the physical things I had previously considered to be the biggest part of nursing, I was learning to listen.
‘What’s wrong, Mr Townsend?’ I asked.
Mr Townsend was sitting on his bed with his head in his hands, rocking back and forth.
‘I’m sick of fighting them,’ he said as he pulled his hands away, wiping the moisture from the corner of his eyes.
‘What have they said this time?’ I asked.
I had been instructed that this was the wrong thing to say. Delving into people’s delusions only reinforces them, but sometimes you need to understand what you’re dealing with. Personally I think it’s a balancing act; you need to know enough about what’s troubling them to help them, yet at the same time not to dig too deep, or too often.
At 55, Mr Townsend had spent over 30 years wrestling with the voices in his head.
‘They want me to put a fork in the electrical socket . . . I don’t want to do it. I just want them to stop,’ he pleaded.
I’ve seen people survive electrical shocks, but not always and it certainly has to be one of the more unpleasant ways to die. I imagined Mr Townsend with a piece of cutlery in the plug hole, his body convulsing as the current surged through him, his hand turning black and smoke rising from his flesh.
‘Do you want some more meds?’ I asked.
‘Please,’ he begged.
I went and got him something to relax him. The treatment never got rid of the voices, just moved them into the background a bit, where he was able to ignore them for a while. If it wasn’t the electrical socket, it was some other way for Mr Townsend to hurt or kill himself.
Mr Townsend seemed to spend as much time in hospital as out. He was a familiar face in the ward, and his delusions usually had the same theme. They generally involved voices telling him to hurt himself in one way or another. As far I’m aware, his voices never told him to hurt anyone else, although you can never be sure.
Once, when Mr Townsend had been reasonably lucid, he had explained that he knew he shouldn’t do the things the voices said, but sometimes he got confused as to what was real and what was not. Mr Townsend said that by talking to the nurses, it helped distract him from the voices in his head.
Out of all the madness and chaos that became an everyday part of the job, there was one patient who stood out from the rest. Dan was 16, the youngest patient in the ward, and also one of the saddest cases I had ever seen. Dan lived somewhere else, and it took me four months to get a glimpse of that world.
Dan spent much of his day walking up and down the length of the corridor, on autopilot, smiling to himself. His was almost a caricature of an insane smile, devoid of warmth or humour. Sometimes he would even laugh for a brief second, then quickly stifle it if he realised that he had been heard.
For my first few months in the ward, Dan wouldn’t speak to me. When I’d say hello, he would just walk on as if he hadn’t heard a thing. There were a couple of times when his eyes would lock on to mine, but I didn’t like it when he stared at me. His pupils were always so big, as if struggling to cope with all that they were seeing. When I looked into his eyes, it was sometimes hard to see anything human in there; other times, all I could see was a suffering kid. Even when he stared, he didn’t really seem to see me; he was distracted, frightened and alone.
All I knew about Dan’s family history was that he was the youngest of nine children, from the poorest part of our town. He had done what a lot of pre-adolescent children did in that neighbourhood, and began smoking marijuana when he was 12. The doctors believed Dan may have begun to hear voices from as young as 14, although he wasn’t officially diagnosed with schizophrenia until he was 15. At the start he only heard voices when he smoked a joint. Then as his use increased, so did the frequency and severity of his symptoms. To me, it didn’t take a scientific genius to see the link between Dan’s smoking and his illness.
It took Dan a long time to work up the courage to talk to me; he must have been pretty suspicious of me, as I was a new face and probably a threat to him, at least in his mind. Our first conversation came about in a rather unexpected way.
‘What the fuck are you looking at?’
Okay, it may not sound like much of a conversation, but it was genuinely the first time he had spoken to me. The ice had been broken and things rapidly warmed between us. Subsequent conversations extended to, ‘Hello’ and ‘Goodbye.’
I soon realised I would never be able to have an even remotely normal conversation with Dan. He was constantly trying to cope with at least two conversations at once. His mind would wander from one topic to the next, unable to focus for too long on anything I said. The only thing he could focus on were the demons in his head and those sitting beside me.
As Dan gradually became more comfortable with my presence, he began to trust me. One day he decided to open up completely with me. It was as if a switch had been flicked inside his head – I was no longer an outsider, no longer someone to be feared, instead I had become a small part of his world, like a piece of furniture that he was now comfortable using.
‘There’s a black demon sitting next to you,’ he told me. ‘He’s got red eyes. He says you’re a fucking cunt.’
I glanced briefly over my left then right shoulder, knowing I’d see nothing, but unable to help myself. Despite our instructions not to question people about their delusions, I couldn’t help myself asking what this demon was saying about me.
‘Kiss my arse, fuck-head; you’re going to burn in hell. He wants me to punch you in the head.’
I had to remind myself that Dan was just repeating what the demon had said to him. Dan was smiling that humourless smile.
I felt vulnerable, sitting there facing a truly psychotic patient. I had goosebumps on my arms. I had an awful thought, imagining that what Dan could see was real, and it was I who was unable to see what was really there. But such thoughts are too scary to contemplate; at this rate I would be admitting myself as a patient.
As Dan’s trust in me grew, I thought I would put it to good use. Over the past couple of weeks, I had been getting patients to join in activities outside of the building. It was nothing special, just kicking a football around, but it made a welcome break from sitting in the lounge watching television – a television that was probably broadcasting secret messages into everyone’s head – plus the patients seemed to love it.
Dan had not been outside the unit in over three months. He was scared of something.
I got him as far as the door before he had a change of mind.
‘I don’t want to play. Football is a stupid game,’ he said.
‘Why don’t you try standing by the doorway?’ I suggested. If I could get him outside I felt sure I could get him to eventually join in. ‘You don’t have to play, just watch. You can always go back inside if you don’t like it.’
Dan reluctantly followed me out. Many of the staff came out as well, just to see for themselves that Dan had made it outside.
At first Dan stood by the door, watching everyone else kick the ball around, when suddenly he just bolted, straight out into the middle of the field, straight after the football. He wasn’t interested in choosing sides; he just wanted the ball for himself. No matter who had the ball, he went after them. Dan laughed – the first genuine, normal laugh anyone had heard from him. I could see patients and staff alike affected; we were all grinning from ear to ear.
But the next day Dan would not come outside; he wouldn’t even get out of bed. He lay curled up in his blankets, the sheet wrapped around his head with only a tiny gap where I could see two eyes staring out at me. Those eyes showed absolute terror.
‘They’re going to get me,’ Dan said by way of welcome.
‘Who’s going to get you, Dan? What’s going to get you?’
Stupid of me. I’d just strengthened his delusion; I should have said ‘No one is going to get you.’ I needed to think before I spoke. I did get an answer.
‘The dogs are going to get me! I can hear them outside, barking, snarling; waiting for me.’
I tried to persuade him to at least get out of bed.
‘We won’t go outside. We’ll just get out of bed. The dogs are outside, not inside.’
I silently berated myself; I kept saying the wrong thing. I’d just reinforced his belief that the dogs were outside. I meant well but I knew I was causing more harm than good.
‘Fuck no! Are you crazy?’
Dan was almost shouting at me now. He seemed frustrated that I couldn’t seem to understand him.
‘Listen, Dan, let’s just try sitting on the edge of the bed. I’ll sit with you. Nothing is going to happen.’
‘Can’t you see them?’ He had lowered his voice, but the terror was still coming through loud and clear. ‘They’re everywhere, all over the place. Fuck, they’re on me.’ He began to raise his voice again. ‘They’re on me,’ he repeated. ‘Do something.’
I didn’t know what to do. I was as confused as he was. I wanted to help, but I only felt completely useless.
‘The spiders are everywhere,’ he shouted. ‘I can feel them crawling on me. I can feel them biting me.’
His voice was becoming less coherent as he became more excited. I was at a loss at what to do and so I called the doctor.
Dan was given more medicine, and although it didn’t alter his belief in his reality, it did relax him enough that he did manage to get out of bed with a lot of persuasion and a promise that I would stay with him. I also promised him that nothing would happen to him. Another stupid thing to say; all medical people know not to promise anything.
As we began walking along the main corridor Dan suddenly slumped to the left. He couldn’t lift his left arm and his left shoulder was 12 inches lower than the right.
Dan looked at me and said, ‘Why am I walking like this?’
I knew why, this was a side effect from all the medication he had been given. I even knew the name given to these side effects: extrapyramidal. I was still surprised at such a sudden and dramatic onset of symptoms, especially as I had never seen anything so severe as this before.
Extrapyramidal side effects are a common result of taking antipsychotic medication. They can take the form of tremors, restlessness, sudden contractions of a muscle, or even group of muscles. Some can be life threatening. The most common side effects I had seen were rolling of the tongue and tremor in the limbs.
Dan received further medicine, an injection this time, to counter the extrapyramidal side effects and to our immense relief his symptoms disappeared.
It seemed ironic to think that it was drugs that had triggered Dan’s schizophrenia and here we were pumping him full of more drugs. It also seemed strange to think that many people take drugs to achieve the sort of effects that Dan had, but still we gave Dan more. For all the drugs we gave Dan, we didn’t seem to make a positive difference. Instead, we gave him side effects. It was just as well we had drugs to treat the side effects, too.
I am not discounting the value of psychiatric medicine, because it does make a huge difference for some and it does allow many people to lead normal lives, but with Dan nothing seemed to work. Dan was eventually placed in a long-term community house with 24-hour supervision. He would never be able to look after himself and I cannot see a cure in the near future. Dan’s life was and will always be a battle between what is real and what is delusion, although it seemed that battle was already lost for Dan.
As time in the psychiatric unit went by, I truly began to appreciate how powerful the mind is. Here the mind reigned supreme. It was strange to see people without physical problems – no obvious deformity, no missing limbs, no failing body parts – often somehow worse off than those with. To see a young man or woman ruined by the thoughts running through their head is terrifying.