Breaking and Mending Read online

  ‘How could you enjoy working in a place like that?’ I hear, over and over again. ‘Don’t you feel unsafe?’

  In general medicine and general surgery, I have felt unsafe on many occasions. I have been assaulted several times in A&E.

  In psychiatry, I only ever felt unsafe once, a few years after my first psychiatry job, when I was working in a different NHS trust, on a high-dependency ward.

  Daniel was diagnosed with schizophrenia when he was nineteen. Now forty-seven, the previous twenty-eight years had eaten into who Daniel was and who Daniel might have been, if he hadn’t been forced to live his life alongside a serious illness.

  He was a ‘revolving door’ patient, someone who was frequently admitted.

  ‘Daniel’s back,’ one of the nurses would say, and no one had to ask ‘Daniel who?’

  Daniel was on a ‘CTO’, a community treatment order, a (contentious) part of the Mental Health Act that allows patients to be discharged from hospital and remain in the community but only if they adhere to certain conditions – taking their medication, for example, and keeping appointments with their community mental health team. If any of the conditions of the CTO are broken, you are immediately brought back into hospital. Daniel was brought back into hospital on numerous occasions. His daily tablets had been swapped for a monthly injection, in an attempt to simplify things both for him and the people looking after him, but Daniel would disappear whenever the injection was due. He drifted between houses, sleeping on sofas, living in the shadows of other people’s lives until the community team eventually managed to catch up with him.

  On this occasion, Daniel had been brought in by the police. He was agitated and aggressive because he hadn’t received any medication for weeks and he was deeply unwell. Afterwards, the two coppers sipped tea in the nurses’ office. One of them showed me how the police restrained people by forcing the thumb back towards the wrist. He called it ‘soft restraint’. It didn’t look very soft to me, and although I could appreciate the occasional need to restrain a person for the safety of others, let alone their own safety, I couldn’t imagine how it must have felt for Daniel. Ill. Afraid. Alone.

  In a perfect world, Daniel would have been admitted to a PICU (a psychiatric intensive care unit, designed for people who are acutely unwell and with specific circumstances and needs). In our imperfect world, the only PICU beds available were out of area, which would not only be upsetting for Daniel and anyone who wanted to visit him, but would also be extremely costly for the Trust. And so he was placed with us first (one step up from a general ward, but not as well-equipped as a PICU), just to see if it was workable.

  It was not.

  Daniel was tall, broad, aggressive and loud, and the other patients were afraid of him. Like many psychiatric units across the country, it was a mixed ward, and its demographic was hugely variable. Middle-aged women with bipolar sat next to young men with OCD. Older patients, fragile and uncertain, and suffering from the psychosis of late stage Parkinson’s disease, shared their space with men like Daniel, who were often unpredictable and violent.

  Daniel’s illness made him throw furniture around and pull a door from its hinges. It made him scream at other people and at himself. It made him repeatedly bang his head against the wall in the corridor. Daniel’s illness made it necessary to restrain him multiple times. He was taken to ‘seclusion’ – a safe room from where he was not permitted to leave – and he was injected with medication against his will. I was not part of the team that restrained patients – it involves very specific training and guidelines and is only used in the most extreme and necessary circumstances – but I have witnessed it several times and it’s the most disturbing thing you will see in psychiatry. It’s the most disturbing thing you will see in any specialty. It is not so much the patients who fight the restraint that makes it disturbing, it is the patients who don’t.

  Daniel desperately needed a PICU bed and we were in the middle of organising one for him when there was another emergency on the ward, involving a different patient. The specialist team had all rushed to the other side of the unit and I was alone in the office. I finished what I was doing and closed the door behind me. The corridor I walked on to had the locked exit at one end, and in the other direction was the main ward and the patients’ communal area. It was deserted. I turned, locked the office door, and I decided to start walking towards the ward. When I looked up, though, the corridor wasn’t deserted any more, because in front of me stood Daniel.

  I weighed up my options as he stared at me. I could turn left and use my swipe card to leave, but it would run the risk of Daniel following me and I knew he’d be gone. Along the corridor, the only other doors between me and Daniel were for the treatment room and the laundry. Both of those doors were locked. I could go back into the office, but that would mean turning away from Daniel and fumbling with my keys, and my gut told me that wasn’t a wise thing to do, and so I walked towards him. I had no choice.

  He seemed to fill the corridor. I tried left, right, left, but he blocked me each time.

  Instinctively, I reached for the alarm on my belt that would alert other staff to a problem. It wasn’t there. The ward didn’t have enough to go around and it was decided – understandably – that the doctors were not at risk as much as the nurses were. My pulse hammered in my throat, but it was important to stay calm.

  ‘Could I get past you, Daniel?’ I said, trying to keep my voice as level as possible.

  He leaned forward. I could feel his breath on my face.

  ‘No,’ he whispered in my ear.

  His body blocked my view of the corridor, but I tried to listen for footsteps, or voices, in the hope that someone might be nearby. In the distance, I could hear the rest of the staff dealing with the other emergency. There was no one. Daniel had picked his moment beautifully.

  He stepped back.

  ‘I’ve got something for you,’ he said, and he raised his right hand.

  In that moment, I wondered how much damage he was going to do. Would he knock me out? Would he be able to fracture my skull? Would he hit once or would he keep striking me? Once I fell, would he start kicking me? How long would it be before someone realised? My legs weakened. I took a deep breath, hoping it might help me deal with whatever was going to happen next.

  His hand came towards me with such force and speed, and I shut my eyes against the impact. But there was none. He stopped, just short of my temple and instead of hitting me, he ran his fingertips down the side of my face.

  ‘I’ve got something for you,’ he said.

  I heard movement somewhere behind him and when I opened my eyes and looked beyond Daniel’s shoulder, there were three more patients standing in the corridor. A little old lady, whose diagnosis changed with each visit to hospital, a young woman who had spent her entire life living with bipolar, and an elderly man who was admitted with depression after his wife died. With one sweep of his hand, Daniel could have knocked them all flying like skittles.

  The little old lady took a step forward and jabbed her finger into Daniel’s back.

  ‘YOU LEAVE DR JO ALONE!’ she shouted. All five feet of her.

  He lifted his hand from my face. He turned around and stared at the little old lady, and after one brief moment of hesitation, he did exactly as he was told.

  I think he was so shocked that he went back to his room like a naughty schoolboy.

  The little old lady turned to me. ‘Are you okay, love? Do you want me to make you a cup of tea?’

  The kindness of patients is everywhere. Studies show that an act of kindness not only benefits those who receive it, and provides a sense of well-being to those who give it, but even those who watch from the sidelines feel better just by witnessing it.

  It is a true saying that those who have the least give the most. I have seen patients share their very few possessions and clothes with someone who has been admitted with nothing. There are some people who never have visitors or anyone to care about them, and
during visiting hours, I have witnessed one patient invite another to join their family instead of sitting with no one. I have seen those who have been on the wards a long time make a cup of tea for someone who has just been admitted, afraid and alone. When you are world-weary, or ward-weary, when you have had your fill of unkindness and cruelty and suffering, to witness small and quiet acts of compassion restores your faith in the world like nothing else.

  A PICU bed was found for Daniel and he spent two months there. Once his treatment began to work and his symptoms were more under control he came back to us, and the first thing he did when he arrived on the ward was to walk up to me and apologise.

  I had never experienced physical intimidation before Daniel, but I had been verbally abused many times by mental health patients who were unwell, because when you are ill and afraid, when you feel trapped and helpless, you will take any weapon you can to defend yourself. In every single case, without exception, when the patient recovered they apologised to me – although none of them, including Daniel, had anything to apologise for. Their words and behaviour were the symptoms of an illness, in the same way that any physical illness gives us symptoms that are beyond our control.

  As a society, we disregard the symptoms of mental illness and we view them as the person and not the disease. The language we use further dilutes them, until they become lost in the mundane and the everyday. OCD is not going back to check that a door is locked: OCD is walking along the middle of a dual carriageway picking up litter, because its presence brings an anxiety you are unable to bear. OCD is not being particular about the way your cupboard is arranged: OCD is urinating in your front room, because the rituals and counting exercises you are forced to complete before you are allowed to walk to the bathroom are so complex and so time-consuming that they do not allow you to get there in time. Schizophrenia is not a ‘split personality’: schizophrenia is sprinkling flour on the treads of your staircase because the voices you hear are so real that you want to catch the person who must be hiding in your house. Depressed is not a reaction to your football team losing: depressed is being consumed by a despair and a self-loathing that is so overwhelming you would rather end your life than continue to carry it with you for a moment longer.

  To remain standing under the weight of these illnesses is a sign of the most enormous courage. To retain your humanity and kindness to others under that weight is nothing less than a miracle.

  Peripheries

  Visiting time on the medical and surgical wards is always chaotic.

  There are never enough plastic chairs. Families crowd around beds, despite the rules. Relatives (understandably) hunt down doctors for information. There is no point trying to do anything for a patient during visiting hours, because you would often have to wade through a vast sea of people in order to do it.

  Visiting time on a mental health ward sometimes passes unnoticed. There are, of course, patients with incredibly supportive friends and families – support that plays a huge part in helping recovery – but for many people, visitors are few, and often completely absent. Occasionally, someone wants to keep their admission a secret, because the stigma attached to a psychiatric admission, sadly, has many and long-lasting repercussions. Usually, though, this happens because the patient has spent a lifetime alone. Families have broken apart, friends have drifted away. Here, often, are people who live on the periphery, people who are never included and rarely acknowledged. In every town, in every village, even on your own street, there will be someone who is isolated and ignored. Chances are, they are also suffering from a mental illness.

  It’s difficult to imagine how that exclusion might feel, but if you work in psychiatry, you will occasionally see a glimpse of it.

  A few years after my first experience of psychiatry, I was working on a different ward for a different NHS trust. I had only been there a couple of days and, in the confusion of a new routine, I left my swipe card and lanyard at home. Because the unit I was working in was locked, it meant, for that day, I had to rely on other staff members to let me on and off the ward. It was a nuisance. So much of a nuisance, I knew I wouldn’t forget my swipe card again.

  I had just left the ward to collect some patient notes from one of the secretaries when I found myself a short distance behind a social worker in one of the long corridors. I knew her from a different job, many months ago. We’d only met once, but she had very distinctive red hair, and I recognised her straight away. She also happened to look after one of my favourite patients. We were the only people in the corridor.

  ‘Hello!’ I said. ‘How is Leo doing?’

  She was only a couple of steps in front and she turned. There was no reply, she just glanced at me, up and down, and then she turned back and carried on walking.

  I was puzzled. She definitely heard me. She even looked at me. ‘You take care of Leo, don’t you? I just wondered if he was okay?’

  She kept walking, quickened her step. I quickened my step too.

  We turned into another empty corridor.

  ‘Excuse me,’ I said a little louder. ‘How is Leo?’

  Still I was ignored. If anything, she walked faster, an occasional trot in between the steps.

  It was baffling. I came to a halt. Gave up.

  ‘It’s Doctor Cannon!’ I shouted, in a last-ditch attempt.

  Finally, she stopped. She turned around and walked towards me.

  ‘I am so sorry.’ She gestured to her neck, where my lanyard would normally sit. ‘I thought you were a patient.’

  The many quiet acts of cruelty directed at mental health patients must accumulate. Before I started working in psychiatry, I had spent a brief few months on the wards feeling as though I didn’t belong, and I had the smallest taste of what it means to not fit in. I still had a home and a family, I still belonged somewhere, but even then I wasn’t able to cope. To spend your entire life feeling that way, with no shelter, no respite, is unimaginable.

  A few months after I had chased a red-headed social worker down a corridor, I was standing at the nurses’ station on the ward, talking to some of the other staff. There were quite a few of us – nurses, a pharmacist, support workers. I liked being at the nurses’ station, rather than shut away in an office, because it’s impossible to learn anything if you don’t spend time on the shop floor.

  It was almost break time and we were talking about nonsense – food and holidays and television programmes. One of the patients came over and joined us. Rob had been on the ward many weeks. When he first arrived, he was agitated and paranoid. He was convinced that the ward was filled with cameras and he was being watched. He thought we were all working for the government and a chip had been placed in his ear to monitor all his activities. Each day he would beg me to remove the chip and set him free. With a change in medication and the right support, Rob had slowly improved. There is no greater privilege than to witness the symptoms of an illness fade and to get to know the person who waited beneath them. Rob was a wonderful man. He lived on a canal boat with his dog, and he loved art and poetry. He knew more about nature and the countryside than anyone you will ever meet. He reminded me a little of my dad.

  Rob and the nurses and I were laughing about something we’d all watched on TV the previous evening when the ward clerk came out of the office. She was new, very pleasant and deeply efficient. It was break time and she had decided to make us all a drink, but – being new – she needed to count the teas and the coffees, the milks and the sugars. She systematically went down the line of people standing at the nurses’ station, asking us all what we would like. When she reached Rob she just skipped over him and asked the next person. As if Rob wasn’t there. As if he was completely invisible. I caught the eye of one of the healthcare assistants and we both stared at each other.

  It wasn’t the ward clerk’s fault. She was new. She wasn’t supposed to make tea for the patients. But still.

  In the end, I made Rob a cup of tea myself. It felt like the only thing I could do to make the si
tuation a tiny bit less painful. When I handed it to him, he smiled at me.

  ‘Don’t worry, Dr Jo,’ he said. ‘It happens all the time.’

  Landscapes

  Being a wild card isn’t always easy. You are occasionally mistaken for someone else (are you a social worker?) or for someone with more knowledge (are you the lecturer?) and very often, people think you have far, far more experience than you actually possess (I want Dr Cannon to take my blood – no, no you really don’t).

  Wild cards carry with them uncertainty, doubt, ambiguity. Why are you here now? Where were you before? Why didn’t you arrive at this point sooner? A wild card feels a constant need to explain and justify themselves, and there is a certain comedy value in being the junior doctor on a team where everyone else is a very great deal younger than you are. Sometimes, though, what you did before, and the fact that you didn’t arrive at this point sooner can, strangely, be played to your advantage.

  In my first rotation in psychiatry, in my newly qualified role, I sat in morning ward round waiting to discuss the previous day’s events. I had already spent four months there, and I was the most comfortable I had ever been in my life. Psychiatry was why I had applied to study medicine in the first place. It was all I had ever wanted to do. The thought of sitting in that seat had got me through five years of medical school and the challenges of my previous rotations in medicine and surgery. The team was amazing, the patients were brilliant, and I was welcomed into what immediately felt like a family. Other wards can sometimes seem fragmented and there is a strange disconnection between different departments, but in psychiatry, we were a team and everyone was encouraged to use their individual skills and strengths.

  There were people from many different backgrounds: those who had worked in psychiatry for decades, and those who had been drawn to it recently, often due to personal experience or the experience of friends and family around them; those who had moved from completely different jobs, and those who had always wanted to work in mental health. Each of us was listened to, every opinion was valuable, and it was the first time I was asked what I actually thought about something. It was such a tight jigsaw of people that it felt at times as if we had all been conjured there by fate and good fortune, and it seemed to me as though everything I had done before – all the pints I’d pulled and the letters I’d typed, all the innocent bystanders I’d chased around department stores – had given me communication skills and an understanding of people you could never teach to someone in a lecture theatre. Everything had happened for a reason, after all. I could finally put the life I’d had to good use.