Chapter 3

The Unit

2005

Another day, another dime.

Thinking nostalgically of the black dog (it had followed me again this morning), I drew up a chair, ensured there was no trace of human excrement on it, and prepared myself for the report, or as it was usually called in this part of the world 'hand over'. The first wails, shouts and coughs of the shift drifted down the staircase, and on this orchestral background we began.

"You look rather fetching in that Womble outfit, if I may say so."

"Yes, I'm going straight from here to the charity walk".

"That necklace of real bananas is a masterstroke."

"Thank you."

"It should be tremendous fun for all of you."

"Ha ha ha ha ha " we all reflexively chortled.

"But don't forget to collect the sponsorship money this year will you?"

"Er ... no ... of course not."

"It was a quiet night then?"

"Yes, it was basically a quiet night" she said "David didn't sleep much again. He was wet three times, and had a big bowel movement about an hour ago."

"Yes, I smelt it as I walked in" I replied helpfully. "How big a bowel movement?"

"About sixteen inches long and five inches across."

"Fairly average for him then" I observed without a trace of exaggeration.

David

1946

'The White Cliffs of Dover' played on a distant radio while David sat listlessly in the little office attached to warehouse 3, and watched the belching trucks drive out of compound C. He pulled down the short sleeves of his khaki tunic, reached again for the dog-eared letter in his pocket, and drifted off into fruitless thought. The war was over, he had avoided contact with the enemy by being inconspicuously diligent in Supplies, and now all he had to do was wait for his discharge. But the end of the war meant the end of many things in David's life, and now all he had left was a hollow feeling that wouldn't go away, the hot tacky sheets of restless sleep, and a nagging anxiety. His parents had been killed in the blitz, his best friend from school had stepped onto a land mine, and the school itself had disappeared into a crater, having taken a direct V1 hit in the last months of 1944. These were the images of his days and his nights - as love, conscience and memory collided in growing darkness.

He had hated discipline ever since school, but he couldn't act without it, and the prospect of civilian life, job hunting and independence mortified him. He wanted to get married so that a nice girl would look after him, but he could never aspire to the sort of passionate courtship he'd seen on 'Brief Encounter', and he carried his virginity around like a second head. He was tall, stooped, balding and ineffectual, dithering and stuttering his way through the world in a daze of puzzlement and worry. His unattractiveness was slowly turning into misogyny and decay.

There had been one special lady in his life during the war, and they had sometimes gone to the pictures or a dance when their leaves coincided, but his romantic overtures had never extended beyond a private erection in the cheap seats, and now

she had gone. Years of Errol Flynn, cocky yanks and celibacy had taken their toll, and she had written:

Dear Davy,

I'm afraid I have got some good news.

I've met a wonderful man called Frank who wants to marry me. He loves to tickle me with his thin black moustache, and has a case full of nylons and chocolate which he found near the docks. He is so good that he gave me a ring off the third finger of his left hand as an engagement gift, and I am besotted.

I am also pregnant.

If only you had kissed me once in the four years we had together, it could have been so different, but yearly handshakes at Christmas were never going to be enough for somebody hot-blooded like me (particularly when you kept your gloves on).

Goodbye.

Yours truly,

Daisy

David folded the letter carefully away for the twenty-fifth time, thought about his friend from school, and prayed for divine intervention. It came the following day in the form of a letter from his sister, who invited him to stay 'for a few weeks' until he got himself sorted out with a job and lodgings.

Two years later, she kicked him out onto the street, and told him that he was obviously incapable of keeping a job, and that she didn't like the 'unhealthy' way he looked at her husband. David spent ten minutes looking at the closed door and his heavy bags, and finally decided to take a grip of the situation; appearing thirty minutes later on his brother's doorstep instead. As the years passed by, David's siblings all took it in turns to parent him, but as the options ran out he became increasingly desperate to prolong his stays, developing a puppy-like charm when anybody was kind to him, evading challenges with vague quizzical looks and half-deafness; often feigning illnesses.

Eventually, the family G.P. brought David to the attention of a consultant psychiatrist, and he recommended that David be admitted to the regional mental hospital for a short period of assessment. David was initially petrified, but he agreed, and then quite enjoyed the extra attention, free meals and regularity of the ward, taking great interest in the behaviours of long-stay patients, and the role of the nurses. His condition deteriorated shortly afterwards, and as frequent temporary stays merged into contiguous long stays, David willingly exchanged the army for the asylum, and felt safe again.

Psychiatric nursing had a complete fixation with bowels, as mental health trained nurses strained to prove their general nursing credentials by making constant references to the frequency, amount, consistency, smell and colour of their patients' stools. Bowel charts, stool samples, per rectum and abdominal examinations all excited the greatest interest and concern, while the administration of enemas and suppositories was a highlight of the week, invariably performed with near religious zeal and reverence.

Huge stool sizes were not in fact that abnormal in psychiatry, because patients often had constipation and sluggish bowels due to drug side-effects and sedentary life styles, leading to infrequent but massive 'clear outs'. Sometimes the toilet would be totally blocked, necessitating a call out for the hospital engineers, and on one occasion the toilet bowl was filled to a level three inches above the seat, needing a shovel to remove the pile. Patients sometimes fainted when delivering these 'babies' because of fluctuations in blood pressure, and one patient was so used to these occasions that he obligingly rolled up his sleeves and cleared toilet obstructions himself, notwithstanding staff advice to the contrary. It was often joked that modern 'holistic' care approaches really revolved around one particular hole, and that this was in fact the 'holy grail' of psychiatric nursing activity. Disappointingly, one of the more sickening web sites had already disabused staff of any claim to record breaking fame, because stools up to six feet long had been recorded in the United States some years earlier.

The night nurse went on to recount that the fire alarm had gone off overnight due to a fault in the circuit and that, as usual, it had proved virtually impossible to persuade most of the patients to leave their beds while the situation was investigated.

"Yes." I remarked, "Once, when we had a fire procedure test, the Fire Officer set off a smoke machine in the kitchen, and just like clockwork most of the patients saw the smoke and ran upstairs."

"I'm only surprised the staff didn't follow them" said the auxiliary night nurse.

"Well in fact they did go upstairs to plead with the patients. If I remember correctly, the Fire Officer and the unit manager were the only ones stood outside when the Brigade came".

"Of course. Wasn't that the day the Fire Officer told staff he couldn't train them to use the fire extinguishers because the Health and Safety Officer had declared it too risky?"

"That's right." I said "They were afraid somebody might get burnt."

And so it went on. The handover was the institution within the institution, serving many purposes beyond the simple communication of relevant information, and usually diversifying well beyond the matters in hand. Because the unit had been totally bed-blocked with intractable patients for many years, the report was robbed of genuinely interesting facts such as clinical progress, transfers and admissions, so it had largely degenerated into minutely detailed accounts of patients' regular day to day behaviour. It was almost as though we were reviewing an episode of 'Big Brother' or some other fly on the wall pseudo documentary, as we tirelessly regurgitated needless observations on the patients' personal routines, repetitious statements, and dietary habits. It was a rut we had fallen into and the report usually contained very little information that the receiving nurses didn't already have before they arrived, leading some to refer to it as 'Groundhog Day'. Tragically, even the patients' most bizarre behaviours, such as screaming abuse across the fence at members of the public, presenting fixed delusions to staff, or attention-seeking incontinence, were all part of a well known pattern which no longer gave the slightest surprise to permanent staff, and was indeed expected at regular intervals. As one person put it, the bizarre had become boring, but this predictability did not mean the report was necessarily a short affair.

A few years ago, the report was regularly timed at one and a half hours, requiring tea, coffee, soft drinks, biscuits, platters of cakes and sandwiches to sustain the noble throng in their professional deliberations. The patients were usually totally abandoned during these gatherings, until the most aggressive individuals would try to kick down the locked door to request some input from the "busy" people inside. Notoriously, it was next to impossible to contact the unit by phone during these periods, because staff took the precaution of having their meetings down the corridor out of telephone range, and on a number of occasions visitors to the unit came and went without being able to locate a single staff member. In one famous case, staff spent well over an hour nobly debating welfare issues, only to discover afterwards that one patient had fallen downstairs and broken a leg while they were all pontificating. It was only when the growing tumult of (im)patient outrage beyond the door reached fever pitch that staff would reluctantly tear themselves away from the narcotic repartee, age-old complaints and circular analyses to re-enter the fray. Escape from real work and real patients was no doubt an important part of this tradition, but it remained unspoken, like all the unconscious collusions in this weird, dysfunctional place.

Eventually the situation became more than ridiculous, and I remember the day well when one charge nurse becoming terminally frustrated with the excesses of the system. Resorting to a theatrical solution, he simply picked up the care plan folders, read out the names and placed them back on the desk. This, he maintained, covered all the information we needed to run the next shift, and he proved the point by challenging his colleagues to come up with anything new that the afternoon shift wouldn't already be aware of from either their own experience, or the desk diary. There was a resounding silence, and we moved on.

"Here're your keys" said the night nurse, as she passed across a colour-coded mass of brass and steel. "Hope you have a quiet shift".

Feeling my hand move downwards a full inch because of the weight, I bid him, the diminutive Zebulon and their auxiliary nurse goodbye. I then sighed resignedly as I watched their smoking estate cars carefully traverse the frozen car park, and turn through the main gates. Some of the other night nurses were also clearly destined for the charity walk, as they left their wards variously dressed as Barney the Dinosaur, Gandalf, Harry Potter and a Cyberman.

"Ha ha. Tee hee" they chortled.

"Don't forget to collect the sponsorship money again" I called across.

Well, at least they would have lots and lots of fun. That's the main thing.

Isn't it?

Looking down at the keys, I disentangled a 'handy' bunch of twenty for my nursing assistant and considered, not for the first time, why we had so many keys for a relatively small unit. Altogether, there were two hundred and fifty-five keys on the premises, sub-divided into three staff bunches and a special collection which lived in a 'handy' cupboard down the corridor (and through two locked doors).

Technically, the simple act of giving a patient one of his own cigarettes involved the use of four keys, as the staff nurse bunch was used to unlock the door to the room which contained the key cupboard, and then the key cupboard was opened to recover a further key which opened a cash tin back in the office where the valuable cigarettes were kept. This tin was of course carefully secured in a locked filing cabinet where a particular dainty skeleton type key (and safe cracker sensitivity) was used to wheedle the lock into life and finally reveal the prized fag packet – usually empty.

Needless to say, most of the nurses kept the residents' cigarettes on the desktop, hidden behind the computer.

Grimacing, I put the large bunch of keys in my pocket and felt them descend rapidly down my trouser leg and pin my foot to the rancid carpet. They had, I realised, already worn out these trouser pockets, so I picked the keys up and proceeded to carry them about like a Dartmoor jailer. The unit was really an open prison though, because not one of the two hundred and fifty-five keys would lock or unlock the main doors from the outside. It was a standing joke that V.I.P. visitors had frequently been left soaking in the rain because a witty patient had switched the bell off and then bolted the doors on the inside, while deluded patients could freely wander off into the local suburbs to deposit bricks through peoples' windows or urinate in their gardens. This occurred because we weren't physically able (or legally entitled) to lock them in and we didn't have enough staff to observe every patient continually.

"Buzzzzz." Went the doorbell.

"I've just come to check your unit for asbestos" said a blue-coloured man, flourishing his 6"x6" identity card vaguely in my direction and disappearing down the corridor like an express train.

"Okay" I said to silence.

Although the patients' shouts, wails and coughs seemed to be coming ever closer, I had one quick look at the paperwork to see what lay ahead of me. As most psychiatric nurses knew, the 'main' work was done in the office where endless reassessments, four-inch thick care plans, and wheel barrows full of Trust guidelines and protocols, all helped the practitioner stay away from his or her embarrassingly unchangeable patients. The office was effectively the unit 'computer' where virtual reality took over from the real world, and great strides forward were made in the abstract. Here, the staff could demonstrate immaculate records, action plans and lots of locked cupboards to the numerous auditors and inspectors of one form or another who constantly packed the place like robots at a cybernetics convention.

Curiously, very few methods of measuring patient progress had been developed by the Trust since the Community Care Act (1990), and those that had belatedly appeared were generally lost in the snowstorm of paperwork that covered our desks, leading to a dubious collation of results. People couldn't even agree on how to define community care success, never mind how to prove or disprove its achievement, so nurses continued to pursue the policy like blind-folded men looking for the way home. We all knew, of course, that clinical effectiveness was a poor relation to cost effectiveness, and that it was only if the government eventually perceived community care as too expensive, that it would then change.

The Politics of Madness

When community mental health care was first 'sold' to the public, it was packaged as a democratic, liberal, modern idea, which naturally suited a civilised, progressive society like our own. Dissenting voices at the time warned that governments usually favoured policies which supported their own interests, rather than anything else, and that 'community' mental health care policy would prove to be no exception. They also anticipated a backlash.

And they were right.

Discharging people into the community was in theory a lot cheaper than maintaining the old Victorian hospitals which, by the 1980's, often needed major renovation works. Under the Community Care Act (1990) government agencies were intended to have a much lower (and cheaper) profile, leaving families, charities, neighbours and friends to play a more prominent part in helping the unwell person 'recover' in familiar, homely surroundings. In reality, community mental health services have expanded into legions, and their harassed members are still running around like plate balancers at a circus, striving to keep the myth of social integration even half-alive.

It was expected that 'self-reliant' service users would help to support themselves practically and financially, even to the extent of contributing to the inland revenue and providing a little bit of extra demand in the market place. They were pictured as happy, successful capitalist citizens, leaving behind the backward communal worlds they had previously inhabited, and the unwanted socialist ideas on which they were based. In reality, the financial burden has simply passed straight across to Local Authorities and state welfare agencies, who distribute millions in aid to masses of largely dependent service users, living on open-ended benefits, demonstrating socialism at its worst.

It was assumed that individualized care would prove to be the most effective therapeutic approach, because it emphasised the idea of self-improvement and dovetailed nicely with the individualism of modern society. This would stop policy-makers and clinicians wasting time on the fictitious social and cultural causes of mental disorder, such as inadequate socialization, gender/class/culture conflicts, secularity, materialism, alienation and community disintegration. Instead, there would be cohorts of beautifully rebuilt ex-patients coming off therapists' couches, achieving their challenging personal ambitions in a perfectly conducive social world. In reality, the social fabric has rotted away to threads, many ex-patients can't cope with their individual isolation, there is more recorded mental disorder than ever before, and now even the policy-makers can sense it.

There was certainly method in the government's madness.

But madness in the method.

I picked up an assortment of expensively headed Trust memoranda from my pigeonhole and read part of the first one:

"Improve Communications by not using Jargon"

Putting this rare gem of wisdom to one side for later scrutiny, I then moved on to the next memo:

" ... A process pathway details the steps involved in the management of care. It should include those steps which add value to the patient's journey ... A clinical pathway enjoins all the anticipated elements of care and treatment of all members of the multi-disciplinary and inter-agency teams. These are specific to a patient or client or person of a particular case type or grouping (see needs pathway) within an agreed timeframe, for the attainment of agreed outcomes. Any variation from the plan is documented as a variance, the analysis of which provides data for the evaluation of current practice..."

Stunned for a few moments by the fact that both these items originated from the same organisation, I then tore them both democratically in half, and deposited them neatly in the overflowing wastepaper basket, positioned conveniently close to the desk. Nearly all of my memo's, bulletins, updates and circulars ended up that way, apart from a few which were used for shopping lists at home. The Trust was devilishly clever, though, and made sure the paper was too thick for toilet use, otherwise I would have gladly recycled it. Some staff allowed their documents to accumulate in their pigeonholes for years, working on the principle that this would eventually prevent any further sedimentation occurring because the holes would be impregnably full.

Management countered this by providing the recalcitrant staff with an extra pigeonhole each.

One of the patient's shouts finally appeared on the threshold, and I looked up to see Hettie hovering in the doorway with both her hands writhing about in her underclothes, and yesterday's tea accurately recorded on the front of her blouse. Flinching, because I knew what the response would be, I asked her if she wouldn't mind tidying herself up before she came down for breakfast.

"I don't want to!" she bellowed. "I want breakfast now!"

Using the 'cracked record' approach of repeating myself amiably but assertively, and pointing out the virtues of compromise and composure, I finally prevailed on her to return to her room for a wash and change of clothes. This allowed me to move through to the kitchen and make an initial inspection (i.e. make a cup of coffee).

"I'm going to discharge myself!" Hettie hurled over her shoulder.

Hettie

1974

Hettie smiled as she heard the splashing in the bath, and turned back towards her other 'babies'. There were 23 cats and 4 dogs in her tiny terraced chalkstone cottage, as well as an assortment of gerbils and rabbits in cages along the walls, and two noisy parrots flying about at will. The carpets had long since rotted away under the constant flow of uric acid, and they had now been replaced with shovel loads of sawdust, brought weekly from the local carpenter's workshop. She raked up the caked mass of urine, dung and vomit once a week, and bribed the dustbin men to take it away (against their better judgement) each Monday.

On Tuesday, she went shopping for 'lights' and other waste material from the butcher, continuously boiling this offal in a vast cauldron on her 1950's Belling cooker. The combined smell of stewed lungs and stinking floorboards was overpowering to everyone but Hettie, and in a moderate breeze the reek could be detected 200 yards away. The fumes were now entering the next-door neighbours' attics and condensing as a horrible sticky scum, so the Environmental Health Department and the Parish Council were attempting to take her to court. She ignored each summons when it arrived, putting it alongside the other unopened buff envelopes behind the broken carriage clock, on the white splattered mantelpiece.

"Idiots!" she said.

But later that week a loud, persistent knock was heard on the front door, and when Hettie at last opened it, she saw a man from the Council and two police officers standing on the doorstep. She quickly slammed the door and addressed them through the letterbox, but when it became clear that they were going to force an entry if necessary, she wearily capitulated and let them in. They stood askance at the scene before them, and instinctively clutched their noses as the odour covered them like a mouldy blanket, and the cats circled their legs. Over the years, all Hettie's furniture had been burnt on the open fire, and now only a brass bedstead occupied the room, covered in grey sheets and sacking. In the back yard they found the skeleton of a donkey, and upstairs they discovered a half grown alligator in the bath.

Hettie refused to co-operate with anybody and instead took refuge in a series of bizarre delusions about the 'communist' authorities and her own 'royal' status, so she was taken into psychiatric care under the Mental Health Act. It later transpired that she had been jilted at the altar in 1959 by a philandering cobbler, and this had unhinged her rather delicate psyche in the direction of loyal animals, social insularity, and general misanthropy. Because she was intelligent, and living in a rural backwater, she had managed to avoid or ignore public opinion for many years, and would probably have continued to do so, if her old friends had not been replaced with commuting yuppies.

"Do you want decaffinated?" I asked my nursing assistant.

"No, full strength please." he replied, adding after a pause "That'll be my turd."

"Pardon?"

"That'll be my third cup this morning" he corrected.

I said nothing, remembering the curious range of Freudian slips Sidney often produced during the working day. He was a real veteran of psychiatric nursing, with a career stretching back almost 40 years, and while most of his contemporaries had moved into different fields, escaped through promotion or retired early, he had somehow survived the worst experiences the asylum could offer, hanging on for full pension like an old bloodied bull dog on the burglar's arm. But his resilience had come at a price, and now the four decades of filth, horror and stress which packed his unconscious mind were slowly seeping out; tripping and stalling his intended speech with tragic-comic mischief. A bit like a half mad beast reaching through the bars of a cage to scratch its own keeper.

He looked a bit like Ziggy Stardust through a fisheye security peep-hole, stuck unapologetically in the 1970's, but with a cracking, dusty husk, somewhat reminiscent of the girl who aged horribly when she unwisely left the magical confines of Shangri-La.

"There you are" I said, handing him the hot cup.

"Wanks a lot" he replied cheerfully.

"Don't mention it?" I said.

The kitchen itself brought back many happy memories, and for a short while I revisited the time when the unit had been a therapeutic community, with patients expected to make their own meals, clean the unit, challenge each others' excesses, and generally take collective responsibility for their own lives. In those days, 'patient rights' were even more important than bureaucratic controls, and the kitchen was always unlocked to allow patients free movement. But the principle had its drawbacks as demonstrated by one patient who would often refuse to leave the kitchen having once entered it, and another who would examine the contents of boiling pans with her bare hands. One man had a habit of evacuating small pieces of faeces with his fingers, and then entering the kitchen to stir the gravy without the aid of a spoon, while another was famous for urinating in the fish tank, and sometimes feeding the fish with sandwiches, tea bags, chips or (on his birthday) lager.

The kitchen in those days was overworked, grubby, and rather old-fashioned, so following a couple of unflattering inspections from the local council our senior managers authorised a lavish programme of improvements. The place was entirely gutted and rebuilt, with stainless steel work surfaces, state of the art cookers, and a fantastic extractor system which looked like the conning tower of a submarine bolted onto the ceiling above the ovens. It was so powerful that the ceiling tiles visibly shook when it was turned on, and people under sixty kilograms in weight were banned from standing near it in case they were sucked into oblivion. Needless to say, the same managers who had agreed the expenditure then agreed that most of the patients were incapable of making meals, so that cooked food should be henceforth brought in from the main hospital kitchens. Now the place looked like a disused rocket range in Arizona, and when the stock items arrived (e.g. tea, coffee, sugar) they occupied about one tenth of the space available, disappearing into distant corners alongside the odd vintage tin of baked beans, and other isolated collectibles.

Sidney joined me in the kitchen and said:

"Have you heard of the six second rule yet?"

Suspecting more insane bureaucracy, I naively replied:

"No"

"Well, according to a bloke on telly last night, some cafés have a six second rule. If the waitresses drop food on the floor and it's down there for more than six seconds, they play safe and don't serve it."

"Under six seconds on the floor and it's okay then?" I enquired.

"That's it."

"If only we were that careful here" I said.

The kitchen radio then announced:

"Apparently, tents are to be erected in hospital car parks for patients waiting to be treated. In the latest symptom of the N.H.S. budgeting problems, patients will be housed in special inflatable shelters until space is found in Accident and Emergency."

Looking at each other without comment, we finished our coffee and made our way upstairs to 'assist patients with their hygiene needs'; a delightful euphemism for activities such as bum wiping, bed-changing, shaving, bathing, dressing, laundering and sweating a lot. Although technically a community 'rehabilitation' establishment, the unit was in fact a continuing care ward mainly populated by people who had been in-patients for an average of around twenty years. The rehabilitation tag was really a product of wishful community care packaging, which had occurred when most of the patients were transferred from the closing regional asylum, and it was based on the 'principle' that patients could be de-institutionalised at the rate of two years rehabilitation for every year of previous institutional living. Given that the average age of patients was about 50, and they had been institutionalised for 20 years, this meant that they were expected to be fully functioning members of society by the age of 90. It was not an auspicious start to our project, and the reality was one of continuing supportive care for people who either couldn't or wouldn't change their way of life. Consequently, many of the patients were still incapable of meeting their hygiene needs independently, and the nurses were still very much in a job.