The eternal struggles in mental health

In my retirement, I was looking through old papers and I came across the last copy of my book. Leafing through it brought back lots of memories and made me realise that a lot of the issues described in the poems were still taking place today, 40 years later. The struggles of people at the bottom, the economic crisis, different approaches and treatments for people with mental health difficulties, the silent power of bureaucracy, maintaining a work/life balance, staff shortages in the caring professions and so on.

While a lot of these issues are still causative factors in today's mental health crisis, we have in addition other factors such as global warming and its threat to human survival, neo liberalism and global inequalities, a worldwide refugee disaster and the war in Europe.

I remembered also, how the poems had struck a chord with many in the therapeutic profession when the book was first published, and after discussing with colleagues whether there was any merit in having the poems republished, I concluded that they might strike a chord with a new generation facing so many similar issues.

The poems describe the attempt to remain sane while balancing the demands of working professionally, being a shop steward, looking after children and maintaining relationships with lovers and friends.

The poems are centred in the work place – a day hospital in the grounds of a large mental hospital. They were written during a long and bitter struggle (The Ward Battle) over how the day hospital should be run.

The traditionalists, headed by the charge nurse, believed that the day hospital should be run no differently from any other ward in the hospital. The aim was to keep patients busy and the ward neat and tidy. It was based on a medical model of treatment and a political system of control from the top.

The medical model saw psychiatric illness as being similar to physical illnesses such as flu. The mental problem arose from some malfunction of the body which could be put right by the doctor's intervention. This would normally take the form of drugs, such as

tranquillisers, given either as pills or injections, or, if they did not work, a course of ECT. The job of the nursing staff was to make sure the patient was clean, slept, ate his or her meals and did something useful during the day.

The political system which went with the medical model was both hierarchical and bureaucratic. Power was vested at the top in the psychiatrist who laid down the medical treatment. He or she then left the day to day administration in the hands of his or her deputy, the charge nurse. The charge nurse was only expected to keep his or her charges fed, clean and busy. The easiest way to make sure this happened was to set up a tight bureaucratic system which set times for different tasks and where everyone was in an allotted place for the appropriate period of the day.

Within this system junior staff had little capacity to initiate change. In fact, any who tried were immediately seen as being trouble-makers – trying to upset the smooth-running system. Order and accountability were what counted and ever more so as the public expenditure cuts began to bite.

The alternative model which most of the staff believed in (see the poem: How the Day Hospital Works) saw the aim of the unit as being to give patients control of their lives. The political system that underpinned this approach was a democratic one.

As regards treatment, while it was accepted that on occasions medication helped to stabilise patients, the main approach was to work with people through their problems by individual and group therapy. Mental illness was not seen as a physical problem but as arising from difficulties experienced by people in coping with the world. The three most common problems were: how families had treated children; women exploited by men, and people suffering from social and economic disadvantages. In order to tackle these problems, people needed both practical social skills and an understanding of themselves. They also needed to take responsibility for their actions and their consequences.

The political system underpinning this approach was one based on democratic principles where patients were given a maximum say in how they spent their day and in how the day hospital ran. Salvation was not seen to lie purely in the hands of the psychiatrist. Understanding and knowledge were things shared between patients and staff and between patients themselves. If patients were to participate in and control their treatment, then there was a need for openness and flexibility and hence for the minimum of bureaucracy.

There was little basis for compromise between the two systems and hence 'The Ward Battle. The psychiatrist who was new and a bit unsure of himself stayed largely above the struggle. The rest of the hospital management saw the dangers (shades of solidarity, tenants' power, workers' control etc.) and rallied to the support of the charge nurse.

While each of the poems is based on a real incident, they do not attempt to be an accurate portrayal. In addition, names and scenes have been altered to protect people.

Here, I present three of my poems.

• The Barefoot Therapist, by Brian Shepherd, is published by Austin Macauley.

How the Day Hospital Works

So how do we work

In this day hospital

You will be reading about?

 

As will become clear

We believe that

The thoughts and feelings that people have

Arise out of the situations

That they have been

And are at present in.

It therefore follows

That for change to occur

People need to act

To alter the situation.

For example by:

Moving from a hostel to a flat;

Finding a job;

Getting off with someone.

If there is no action

Then therapy becomes merely

A means whereby people

Are persuaded against their real self interest

To accept their oppression.

The ability to act

Requires people having basic social skills.

Therefore, we run groups for:

Literacy and numeracy;

Cooking and social skills;

Do it yourself and art therapy;

Current affairs and problems of living alone;

Psychodrama and women's health.

It also requires people

To be aware of themselves and others,

 

So we started by doing

Individual and group therapy.

But gradually we made it possible

For therapy to happen

With most people most of the time

Whatever they were doing.

 

Slowly people build up a view

Of themselves and the world

And of how it can be changed.

Then there is nothing for them

But to jump,

And for us to hope

That the safety net we erect

Will catch any fallers.

You cannot wait,

As psychiatrists and social workers seem to think,

Until people are completely sure of what they want.

Think of the last holiday you booked.

Didn't you have doubts

Until the plane actually took off.

In the waiting, before the action,

There are only possibilities and doubts.

 

You don't normally have to go back

To people's childhood roots.

There is sufficient cause for their behaviour

In the worlds that have been constructed for them

.

The people most difficult to help

Are married women with kids.

 

There's no escape.

Nothingness isn't recognised

As a cause for running.

Where could they and the kids go.

Living on S.S. crammed into a single room,

Just isn't worth the leaving.

Most of her friends would think her barmy.

The women's movement

Hasn't made it yet into the high-rise flats.

There's no basis,

It has nothing to offer.

It won't pay the rent,

Look after the kids,

Get her a job.

"I can't oppress another woman

By getting her to do my housework."

All we can offer is a refuge,

A temporary haven,

Until he complains

That the house is looking dirty.

 

We hug people a lot

And encourage them to touch each other.

Before you get horrified

You must remember

That most of our members

Have lived lonely, institutionalised lives

Where no one has fancied them.

If no one likes them

And shows it by touching

How can you expect them

To like themselves.

And if you don't like yourself

Then there's nothing worth saving

And there's no energy for changing.

In fact the only time

Most of the people will have been touched

Is when someone in authority

Has wanted to force them

To do something:

Like being locked up:

Or given ECT;

Against their will.

They will have been prodded,

Poked, herded and held down

Until they have been punished

For turning the jailors into jailors.

You should talk to our patients

About hospital violence

They have witnessed and experienced.

A bit of Rampton lives on in every asylum.

 

It is important to be honest and open.

If nothing else

Our patients are sensitive to vibes.

In the world of the mentally ill

That is the only thing to trust.

In the real world

They always act.

 

You can see it sometimes with the volunteers

Snapping on their bright, cheery face

Thinking that's what's wanted.

But the patients know

And don't come back

.

As staff it doesn't mean

You lay your troubles on the patients.

On the bad days we all have

You just don't pretend

That you're all there

And adjust what you take on accordingly.

 

Patients come from institutions,

From psychiatrists and social workers

Where things are always hidden from them.

They are always writing comments

That the patients never see.

One snatched her doctor's notes.

He called the police

Who charged her with stealing NHS property.

It was the story of her life.

No wonder the patients get worried.

The health workers label it paranoia.

And if the patients try to find out

What's in their biography

By asking different members of staff

They are accused of playing off the staff

Against each other.

As patients can only guess

How those in authority see them

The patients must adapt their behaviour for each

To fit in with what they suspect is wanted.

They record the patient as being manipulative.

 

Often, I lie on the floor in therapy.

It seems to me that patients

Are always asked to sit or lie down

So that they are smaller than the doctor

Who thereby protects himself from attack.

Anyhow how can you do therapy unless you are relaxed?

 

It is important that staff on occasions

Make themselves just a bit vulnerable.

I mean to be fair

We are always asking them to give us

Their life histories as hostages,

When their whole experience

Is those case notes

Become bargaining points for their future.

Should we not give them

Some details about ourselves,

Just a little bit of power

So if we should destroy their trust

They can hurt us just a little.

Would it not make us a bit more careful

When we gossip and betray confidences

Or simply don't care enough?

 

Surely staff have quite enough power

By having titles and a salary.

A bit of scruffiness doesn't do any harm,

Or anything,

Which enables patients to tease us.

It is more difficult

To take someone you can laugh at

Too seriously.

The nicest thing

Is when two of our patient

Fancy each other

And turn themselves on

It makes us all a bit better.

Though we have to be careful

Not to rush in

With our analytical clippers

And chop of its head

 

Notes on Working

Notes on Working

Sometimes when I get home

I just fall asleep,

Too tired to talk to her,

Too tired to screw,

And even the knob

Of the mindless television

Is too far away.

 

She said, "Take the day off.

I want you to look after me.

I've got as much right

To your time as they have."

 

How do I explain I can't.

The patients don't stop coming.

If I stay away

It's the other staff who suffer,

Coping with my load.

 

If they become pissed off

The bitterness replaces the love

And without the love who can heal?

Then we become closed and divided

And without openness there is no trust.

Without trust who will talk?

Or let their feelings go?

Who can then grow?

It takes time for them and us both

To learn that we don't

Have to exercise our power

Remain the psychiatric jailors;

That some of us some of the time,

Will betray our employers

And fight alongside.

Otherwise

What's the point of being at work?

 

When there's a day's holiday

I'm too tired to enjoy it.

My head aches.

All I do is sleep.

 

Sometimes,

We the staff

Are treated more childlike

Then the patients.

They are told to stand on their own feet,

To make their own decisions.

We have to beg for permission

To change the way we work,

To be allowed to work collectively.

No wonder we are rebellious,

That hospital wards function like prison.

There are meetings most nights.

Left caucuses, rank and file gatherings,

Shop steward's committee, cuts group.

And then at work, amidst therapy,

The phone rings and it is a member's grievance,

A confrontation with management,

A struggle to be won or lost.

 

Sometimes the mind won't switch, click on.

The union, meeting seems unreal

Beside the individual's pain.

Other times I want to hide,

It all becomes too much,

Occasionally, with others,

I feel strong.

Then, wherever it is

They can be taken on.

 

The patients ask for trust, care affection and love.

All finite things

That need watering to survive.

Which is why the staff

Need first to love each other.

For criticism can only be taken

Within a deep bed of affection.

 

Leave me alone!

I've got my kids to worry about.

I'm sorry I'm irritable,

But Jane was upset this morning,

She's expecting her first period,

You want me to stay late and talk of solidarity.

Who is going to get my kids their tea?

 

Except for the May Day parade

Union meetings are drab childless affairs,

Composed of the unmarried, the once married,

And the unhappily married with widowed spouse.

The creche is non-existent,

The babysitting service unheard of.

It's a funny kind of socialism

Listening to the spokespeople of the different factions

Arguing the merits of their case,

Fighting for positions.

 

I work best the nights I sleep alone,

Don't bother to use the phone,

Control my commitments.

 

Sometimes I just want to fuck all night,

Or there's a crisis to be talked through,

Or we just snap and sleep stays away.

but next day they're all there,

Difficult and disturbed as normal.

All I can do is coast.

And hope that my friends

Will pick up the slack,

Cope with the crises.

The alternative is to wish

The difficult ones would go away,

Leaving the institutionalised

Who can only see and feel the grey

But then what would be the point?

It is as they say,

The integration of the personal

That will win the day.

 

If the staffing ratios were okay,

If we got paid a decent wage,

If the holidays reflected the emotional toil,

If, if, if, if,

If we were not paid to be warders,

If women were free,

If the revolution had come,

Then it would not be so hard,

Given there are only 24 hours a day,

To achieve the balance

Between work, friends and children,

Lovers, political activity,

Being alone, surviving.

 

I had a dream

I walked to work

With the dream in my hands

That when I told management

I was thinking of leaving

They would be so concerned

At losing someone of my ability

That they would beg me to stay.

 

Silly me!

 

I soon awoke.

There were no phone calls,

Just an offer to write a reference.

 

In the end

I, or any other individual, didn't matter.

All that did

Was that there were 6 staff

Looking after 40 people

So that the books balanced

And the hospital wasn't falling too far behind

Other hospitals falling behind DHSS guidelines,

And papers could be written for area committees

Convincing them

What a good job the authority did.

 

With so many teachers, social workers

And other graduates out of work

I was easily replaceable

(And with a bit of luck

My successor wouldn't be as militant).

So why waste money

On staff support or training?

If I or others got pissed off and left

It was three months' salary saved

Before the job would be filled.

 

And every little bit counts these days if there are not to be compulsory redundancies said the chairman appealing to the union that he was doing his best in the face of the most vicious attack on working class living standards since the 1930's.