The CMHNN are proud to present UK-based Andrew Hanson’s nursing story. We believe this kind of long-view is rare and important to us as a profession. Many times on this website we have re-asserted that critical thinking is not new in mental health nursing. The thought-provoking account below especially speaks to the idea of progress in all its guises, not least the role of the ‘care-coordinator’ and new forms of institution. As ever, please feel free to respond. If you are in the UK and have experiences like these – or indeed, different ones – why not write us a similar piece? To our readers in Australia, the USA, Canada, New Zealand and elsewhere: how well does this fit with your experiences? We would love to hear from you, too.
We want to recognise Andy’s inspirational commitment to mental health nursing and to those deemed to be in need of our services, and, as he puts it, to ‘relationships’ rather than ‘tricks’. In honour of Andy’s Yorkshire roots, make yourself a good brew and read on…
The need to construe the past as a forbidden place where only bad things happened has been an influential idea within British mental health services for the last 34 years. In my nursing career as a psychiatric nurse, which has spanned this time, we have become obsessed with the idea of continuous progress moving ever-onward to some sunny upland where the nation basks in perfect mental health. I do not find the idea convincing, mental health has undergone radical change in the last 34 years and yet it has remained the same in many ways. The institution that regulates mental health care in Britain has not been dismantled it has been re-shaped and is in many ways more coercive than the brick-built asylums.
The psychiatric hospitals I worked in in the late 1970s and eighties were attempting to move some way from a past that was marked by scandals and failed physical treatments from Lobotomy to Deep Insulin Coma therapy. However, the state of some of these institutions was a national disgrace as had been pointed by reforming psychiatrists and movements such as MIND throughout the 1950s and sixties. The institutions had been left to drift, in many ways, since Enoch Powell announced their imminent demise in his infamous “Water Towers” speech of 1961. The alternative to them had not been designed nor was it the subject of any comprehensive research.
I first worked as a Nursing Assistant at De la Pole hospital in Hull, but I trained to be psychiatric nurse in York as I had a history of epilepsy, which luckily, as it turned out, prevented my training at De La Pole. Epilepsy was still subject of stigma by the recruitment medical officer for De La Pole. I have worked in all aspects of mental health care since completing my training and have managed services, rising to the dizzying height of Directorate Nurse for Guild NHS Trust in the 1990s. I have also whistle-blown on a failing service and currently work as a CPN in Bolton.When I first began my career as a Nursing Assistant in 1979 at De la Pole Hospital in Hull the hospital centred round the personality of reforming psychiatrist Dr Bickford, who had unlocked the hospital’s wards and championed meaningful activity as part of the therapeutic milieu. We played hockey with patients, we gardened with patients, we country-danced, we administered medication, we made beds, we walked with patients, and we attended lectures with patients and attempted to keep them occupied and busy. These were all nursing duties and the key part of the job which nurses fulfilled. We also participated in Electro Convulsive Therapy on a grand scale and utilised large doses of psychotropic medication.
The approach of Dr Bickford was on reflection, neo-colonial, like a missionary; he knew what was best for his patients even if they didn’t agree. His zeal and personal commitment could not be questioned. Given what he faced on taking up his position back in the 1950s, he had to be driven by a vision in order to make any sort of innovation or lasting changes to the grim reality of care in psychiatric hospitals as it was back then. Such an approach was based on active persuasion and today the routines and activities would probably be condemned as coercive and a violation of human rights. However, by comparison it would be a revelation compared to the poverty of approach which faces many patients on contemporary locked acute admission wards. The admission ward is currently the last place many people want to work when I was commencing my career it was the place everybody wanted to work.
…today the routines and activities would probably be condemned as coercive and a violation of human rights. However, by comparison it would be a revelation compared to the poverty of approach which faces many patients on contemporary locked acute admission wards.
I was lucky, my training was at York school of nursing and the mental health services in York at that time were some of the best in the country, community services were well advanced, and standards of care were generally high as the hospitals were comparatively small compared to the urban centres of Sheffield and Leeds. Currently York’s mental health services are subcontracted from Leeds – not a very happy arrangement, I understand.
The central aspect of the job of psychiatric nursing in those days was that you were part of a community, a hierarchical and often abusive community but one in which you did not work alone. This could be a major drawback at times, it could hamper change, it could hide abuse, but when it worked it could make the job of mental health nursing rewarding and more enjoyable. A good team could make a huge difference to patient care and innovation was encouraged in a progressive hospital. The institutions were beginning to acknowledge the criticisms of the anti-psychiatry movement, MIND and writers such as Irving Goffman. I think we saw ourselves as change leaders pitted against the monolithic institutions we trained and worked within. A unique account of this period can be found in “Buster’s Fired a Wobbler” first published in 1989, a brilliantly written book by Geoff Burrell, a qualified mental health nurse.
I think we saw ourselves as change leaders pitted against the monolithic institutions we trained and worked within.
As I remember, and of course as we know memory is not reliable, we were all more political then, the unions were more active, and miners stood on nurses’ picket lines in the 1982 NHS dispute as nurses in turn stood on theirs in 1984. As student nurses and young staff nurses we felt we had to challenge the status quo which was often represented in the physical form of Nursing Officers who patrolled the corridors and ambushed unwary nurses, looking out for misdemeanours such as wearing too much make up or exhibiting dyed hair, but whose actual main job remained a mystery to many of us. Equally, the status-quo could be made up of nursing staff grown too comfortable with their way of doing things.
Since the Griffiths report written by a former Manager of Sainsbury’s during the early 1980s, managerialism has become endemic within mental health services, the new breed of managers first spotted in the early eighties put up barriers or built walls between their offices and the patient areas of the hospitals they were closing. They simply couldn’t be bothered to relate to patients who were often troublesome, noisy and demanding. Now we have managers for everything. They chase key performance indicators like the Holy Grail, they pursue us for clusters, mechanisms of a highly dubious reliability, used to describe client characteristics and thus inform payment of team performance. There is a managerial emphasis on the production of such indicators to prove efficacy of team working. Computerisation of care has allowed the ticking of boxes to become the main role of mental health nursing in community settings.
The Consultant Psychiatrist was traditionally the tribal God and he (they were usually male), could get away with most things as was shown by the Kerr Haslam Inquiry (2000) into two consultants working at Clifton hospital York who were routinely sexually abusing female patients over a period of 20 years. Consultants did not hire or fire nurses, but they could ruin careers of those they did not approve of or who threatened them.
The closure of the big hospitals was viewed as a political action by those of us in the middle of it, there was no real consideration of what would replace them or how patients or services, would cope. It was also executed at the same as the communities that mental health service users were being discharged back into, were under a sustained attack from neoliberal policies that placed many of them especially in the North of Britain under severe strain.
Now we have managers for everything. They chase key performance indicators like the Holy Grail…. Computerisation of care has allowed the ticking of boxes to become the main role of mental health nursing in community settings.
The hospital closure plans were a cynical cost saving exercise. Though most of us would condemn the institutions as “bins”, no real planning was in evidence when it came to redesigning services. The huge money-making companies such as Partnerships In Care that run much of the private hospital provision now contained within contemporary mental health services is evidence enough of the total lack of thought that went into the whole process of institutional closure (or was that the actual point?).
Tricks vs Relationships
I have managed in-patient and community services and worked at a reasonably high level in NHS the mental health services management. I have whistle-blown on a failing service, I have taught in higher education and I have returned to clinical practice as my career draws to its close. The truth for me about the role of mental health nursing is that you have only really yourself, your knowledge and resources to use. Medication as we know has a very feeble evidence base (other than the harm it causes to the physical health of the client) and the definitions we use to classify individuals said to be mentally ill are nothing more than a kind of shorthand that refers to the perceived presence of symptoms that or might not might indicate that an individual may be mentally unwell. We have no clear indications at this point of what mental illness looks like; we have no scans or blood tests that conclusively prove an individual is mentally unwell and will respond to this specified medication or that treatment plan. We still lock up the very seriously mentally ill and agree that they have a poor prognosis. But this is nothing new for mental health nurses it has always been this way. It is the relationship you attempt to build with a client that counts. We have tricks we have learned, therapies and methodologies of different approaches but they mean nothing if the relationship fails.
The truth for me about the role of mental health nursing is that you have only really yourself, your knowledge and resources to use.
In contemporary community mental health provision, the key worker or care coordinator may be a mental health nurse or a social worker or an occupational therapist, we all do largely the same job. This seems to me an intrinsic waste of skills as we have not undergone the same training and have different strengths. We used to have dynamic and creative OT departments that offered activities that drew on people’s skills and talents. We used to have social workers who were experts in housing and benefits as well as being therapeutic agents.
The idea of Care Coordination emerged in the late 1980s as it became clear that many patients who had been discharged from big hospitals had simply disappeared from services with no follow up. The Care Programme Approach was invented to block this hole, since its inception it has failed to achieve its goal and has been regularly revised. However, the effect of the CPA is to ensure that the care coordinator is accountable to every one for everything; in many cases mental health nurses are accountable to the patient, the NHS Trust, the patient’s family, the NMC, the risk assessment and care planning and clustering process used by the NHS Trust, the MDT, the coroner, the case allocation system utilised by the NHS trust the Mental Health Act the CQC, the housing association, the various benefits agencies, the media, the police, social services, and the frequency of reviews utilised by whichever variant of mental health team they work within and finally internal audit processes. The effect of all this accountability is to ensure that we have become risk-averse in our practise. It is the care coordinator who has become the victim of a hidden institution and it is the care coordinator who enforces its rules, in order to preserve their own professional integrity. Perceptions of risk drive the process while the therapeutic intervention takes a back seat. Foucault and Goffman provide insights into just such a process of power and control within contemporary societies.
…the effect of the CPA is to ensure that the care coordinator is accountable to every one for everything. It is the care coordinator who has become the victim of a hidden institution…
Mental Health Nursing
“Mental Health” was unknown when I started training; we were psychiatric nurses and we nursed the mentally ill. It is now taboo to use the term mental illness, so instead we talk about having mental health. Yet we have embraced the medical model of disease and we listen to experts who are either psychologists or psychiatrists explaining the illnesses to us, we have built the public expectations of a therapy or a medication for everything. We have not identified the causes of this illness or treatments that work consistently on individuals over time. We know that bullying, parenting, abuse, stress and substances can play a major role but we prefer not to examine societal reasons that may exacerbate their existence.
A major reason we use the term mental health instead of illness is so that we can personalise it. It is acceptable to have a syndrome, a condition, it is the individual not the society that is sick. Even the Royal Family have discovered mental health. However, the demographic reality favours the rich; mental illness is linked directly to poverty and inequality and the provision of specific therapies or medications will not resolve these deep-seated roots. It is undeniably true that British society has become less equal over the last 30 years.
A major reason we use the term mental health instead of illness is so that we can personalise it. It is acceptable to have a syndrome, a condition, it is the individual not the society that is sick.
The Victorians and the generation that followed them ascribed mental illness to degeneration of the gene pool and were happy to practise eugenics, suiting their imperialist ideologies. The now long-forgotten Blacker report of 1948 advocated eugenics-based solutions to mental illness for British society. We have moved on from this view but towards an aspirational society, a model to which all our current political leaders appear to subscribe. Where only the strongest win there will be losers. We have created a sense of personal responsibility that has become internalised into mental health models, philosophies and of patterns of care and recovery.
The idea of social degeneration, the weak undermining society, still looms over contemporary Conservative social policy. At the same time as publically advocating mental health projects, it uses every possible mechanism it can enlist to remove benefits from the mentally ill through the ill- informed medical examinations under the PIPs scheme. We are back in the world of the deserving and undeserving poor.
The institutions are also on the return. The large, centralised, state-of-the-art facility is being sold to us as the answer to the entrenched problems of poor acute inpatient care and uniforms have re-established themselves on wards as proof positive that we are really nurses not attendants. The forensic psychiatric institution is booming as the ongoing massive expansion of the Guild Lodge facility on the site of the Whittingham Hospital near Preston well demonstrates. Partnerships in Care – the major private sector provider of forensic psychiatric care – had to break itself up following criticism from the Monopolies Commission, but it continues to make sizeable profits.
The world of British mental health care has become more acceptable and palatable to the public and the media, but levels of understanding of the illnesses and treatments has not significantly progressed. The field has become an area of rich pickings for academics and this has ensured that nurses and therapists are now much more middle class and “professional” than in the days when unemployed miners often worked in the asylums during period of recession. There is much more activity and interest in the subject of mental health, but this has produced hackneyed solutions and meaningless nice intentions. This new attention fails to address the major political issues that contribute to mental illness; unlike the user-movements in America, which are more political, in Britain we tend to fall back on anecdote and personal journeys rather making explicit demands for change.