Chapter 4

2005

"Good morning Steven" said the unit manager.

"Oh, good morning Richard. I wasn't expecting to see you on your day off.

"Yes, I've been here since 5.00 a.m. actually".

"Well done, sir. " I applauded "Will you be attending the staff meeting?"

"Staff meeting?" he laughed "Good Lord no, I'm far to busy with practical common sense matters to spend my life chattering."

"Of course sir. I'll cancel it immediately and get on with this morning's discharges."

"Good man."

"By the way, we have three residents beginning part-time work with Parks and Gardens this morning, and one going to the Town Hall for office experience."

"Splendid."

"There have been no staff on long-term sick leave for twelve months."

"Brilliant."

"The new anti-psychopathic medication is working impeccably.

"Superb."

"We now have copies of the new mental health white paper 'Society Needs Care Too – Towards a Balance of Patient Rights and Patient Responsibilities'.

"Fantastic."

"The Prime Minister has this morning announced strong new measures to combat what he called the 'the parasitical, sick society of our times.'

"Fabulous."

"He says the time has come to think as much about our community as ourselves."

"Unbelievable."

(pause)

"And while I have the opportunity, may I congratulate on your recent promotion, sir?"

"Promotion?"

"You appear to be dressed as an Archbishop today."

Oh ... I see ... actually it's because I'm joining the vigil for humankind recommended by the Aging Rockers' Special Executive (ARSE). Why not join us on our remarkable journey, Steven?"

"Absolutely, sir. Nothing on God's earth would prevent me from..."

"Bzzzzzzzzzzzzzz!" "Bzzzzzzzzzzzzzzzz"

"Oi!" shouted Sidney. "Stop day dreaming, there's somebody at the door."

"Sorry" I spluttered, making my way towards the sound of hammering Viking fists and splintering woodwork, wondering why they were so keen to get in this bloody place.

It was the most obvious sign of genuine madness on the unit that some people actually wanted to be here.

The period between 7.00a.m. and 8.30a.m. was always something of a false dawn at the unit; a preamble before the main story. By 8.30a.m, most of patients were up and any additional staff, such as the cleaners, housekeeper, manager, and extra nursing assistant were beginning to arrive. The administrators and medical staff around the hospital would also be starting work, and the 'phone would be springing into life. Visitors and deliverymen, porters and engineers, managers from elsewhere and people who'd lost their way, would all descend on the unit as though something important was happening (like they were expecting ARSE to give a talk or something). A growing cacophony of noise would echo up and down the corridors, sending the quieter patients fleeing into far off corners, while the more theatrical moved forward to button-hole members of their expanded audience with tales of woe, multiple requests, scenes of paranoia and exhibitionist acts. Voices were raised as each side attempted to master the other, orders were barked and complaints shrieked, while nursing assistants adopted their 'lion tamer' postures and patients gathered together in disturbing anthropological groups. I now opened the bulging door.

"Hi" said a yellow-coloured man "I've just come to unblock your toilets."

"Oh" said I. "I didn't know you were coming".

"We're here on unblocking duty once a day now, plus emergencies."

"Fine" I said, admiring the man's industrial size plunger and wondering if it was any good for chronic constipation.

I think most nurses knew that a 'safe, stable environment' was the first principle of psychiatric care, but it was amazing how easily principles disappeared when emotions and habits shouldered in. It was sometimes said that too many staff were far worse than too few, and our unit regularly illustrated the point. When staff were stretched to breaking point, they would at least make sure the patients' basic needs were met, but when superfluous crowds appeared, all sorts of distractions occurred - predominantly gossip, endless meetings, repeated updates and increased levels of patient agitation. This would almost invariably lead to a lower quality of practical care delivery.

Today, however, was extra special because the workmen were coming. The two scruffy white vans (which I had just missed arriving in the car park) contained carpenters and builders who were today starting the latest programme of refurbishment. The unit had a rolling maintenance and improvement plan similar to that of the Forth Bridge, where nothing was ever completed and there was always plenty left to do. The drains, guttering, roof, windows, wiring, central heating system, and plumbing were in a constant state of repair, and never seemed to improve. This was partly because the fabric of the building was old, partly because the patients were incredibly destructive, and partly because the managers responded to every care crisis by launching high profile environmental changes, instead of anything more direct and effective.

The Smoking Room

For many years the smoking room could be immediately identified by its fire door, which was invariably wedged open with a soupspoon, or flattened against the wall by a convenient armchair. Now, a splendid extractor fan had been installed to provide ventilation and the fire door was generally shut, but because people forgot to turn the fan on, the room was almost always fog-bound on entry. Sometimes residents could only be identified by the whites of their eyes.

After fifteen years of replacing burnt carpets, management had decided to tile the area and it now resembled a rather cold changing room at the public swimming baths. The chairs were scorched leatherette, with parallel brown lines running down the arms like notches on an outlaw's cudgel. Cigarette ash covered the floors in drifts of grey snow, the walls were stained a bright nicotine-yellow, and the aluminium ashtrays remained pristine and empty. There was always a collection of seven or eight scummy half-empty cups on the floor - the arcane mysteries of washing-up continuing to baffle most residents.

This was the haunt of hard men, where solitary self-poisoning was occasionally augmented with sanguinary violence, as tab ends were rifled from buckled bins, and pecking orders ferociously restored. One window was nearly always boarded up, adding to the charm.

Just as a single, hard pea could always be found somewhere on the dining room floor, the smoking room would always yield a shard of broken glass to the assiduous cleaner, looking in a corner.

Whenever the drains were disturbed by heavy rain, the wonderful scents of hydrogen sulphide and methane wafted lazily in through the windows, while the central heating would invariably provide staff with heat stroke in the summer and hypothermia in the winter. The leaking roof was guaranteed to set of the smoke alarms at the dead of night, and loose slates blew around like gigantic razor blades whenever the north wind howled. The patients regularly broke windows, pictures and toilet bowls, ripped bathroom fittings of the walls, kicked holes in plasterwork, and stubbed cigarettes out on the carpets as a matter of course. They also went through two specially treated lounge suites a year because the fabric was eaten away by urine; polluting the whole room like a child's stink bomb. The bills were horrendous I'm sure, but we could only guess at them while the managers sat in Nirvana and poured taxpayers' money into the bottomless pit.

I'm afraid our Trust administrators were much too interested in drinking the coffee machine dry while they moved paper around in monthly circles and proved conclusively how useless business degrees were in health care. When the inevitable crises occurred (usually in the form of cataclysmic reports from independent official visitors) they then always reached instinctively for the taxpayers' chequebook with a view to immediate impressive building works. As amused spectators, we would watch the vases of exotic flowers, pot plants, prints of local scenes, and six canisters of air freshener predictably appear on the unit before official visits, and the new curtains, chairs, carpets and wallpaper appear with equal predictability afterwards. The net result was a clinical area frequently turned into a building site, and another shed load of money vaporising in the public service sector 'black hole'. Today was one of those days.

"I need tea now" demanded someone behind the workmen.

"Have you ever made a list of all those things you want to do before you die?" asked Sidney.

"No, not really. Have you?"

"I spend most of my spare time doing it actually."

"Oh."

"I'd like to swim with dolphins of course."

"Of course."

"And to go to Hollywood."

"Naturally."

"And to have an intimate dinner party with some witty TV celebrities."

"Yes?"

"Well ... that's as far as I've got, Steve."

"That's it?"

"Er ... yes. I think so."

"You may as well die now then, Sid."

"Ha ha ha ha!" we laughed.

Thoughtfully.

Within a short time, the workmen had roped off the main staircase so they could make the banisters higher, closed the smokers' lounge for redecoration, and locked up the male toilet for 'extension work'. Half an hour later, one patient had hit another because he couldn't get into his usual smoking area, one confused lady had become entangled in the ropes barring the staircase as she attempted to walk upstairs by the only route she could remember, and one man had used the carpenter's tool bag as a lavatory because he couldn't get into his usual toilet. This patient then underlined his point of view by going outside and bombarding the two scruffy white vans with flowerpots. Luckily, there were so many dents in the vans already that no litigation was likely, and the builders tolerantly shrugged it off. They were destined to get used to this reception anyway, and no doubt they were receiving double pay for the job. All the radios were turned up to combat the ambient row, and I could just make out someone saying:

"The body of a women who hanged herself in a Paris art gallery was mistaken for a modern sculpture for a two days."

Just before they took the drugs cupboard off the wall, I administered the patients' medication and reflected on one of the many circular changes that characterised psychiatric nursing. Drug therapy was largely unsuccessful for most types of serious mental disorder until the 1950's, when the introduction of Chlorpromazine and other anti-psychotic drugs then helped to control the symptoms of schizophrenia. Although this innovation helped the movement towards 'care in the community' because patients no longer needed to be in custodial settings, the new freedom of community care then led to problems with medication monitoring and non-compliance, with associated relapses.

A zero is a circle and a circle is a zero.

The Types of Madness

Traditionally, mental health problems have been divided into 'psychoses' and 'neuroses', plus a more arguable category for 'personality disorders'. The psychoses are serious mental disorders where the person loses touch with reality for at least part of the time (e.g. schizophrenia and manic-depressive psychosis). Neuroses are less serious disorders where the person stays in contact with reality, but with unusual difficulty (e.g. phobias and obsessions). In practice, people often present with combinations of psychotic and neurotic characteristics, leaving the 'classic' typology as more of a framework than a blueprint.

So, when a conscious person sees things, or hears voices, which nobody else in the room can, this behaviour departs from reality (psychosis) and when a person won't enter the room because there's a cat or a spider in it, this stretches normality to an unusual degree (neurosis).

But what about the 'normality' itself?

Is it really a firm set of physiological processes, or psychological rules, which 'mad' individuals simply deviate from?

Perhaps.

It is also a diverse collection of social beliefs and values which change totally through history. Here, madness can lie as much in the making of norms, as in the breaking of them.

Just look around, and see.

"Buzzzz" went the doorbell.

"I've just come to fix your filing cabinets, mate" said a red-coloured man.

"An emergency then?" I quipped.

"Vacant" he looked.

"My radio's broken" interceded Maddie.

The volume had been turned down to 0.

The medication round was reasonably uneventful, with only one stentorian refusal, five clumsily dropped tablets, two tablets spontaneously dissolved in a poorly dried medicine pot, one lady who specialised in 'slow motion' tablet taking (ten minutes), and a temporarily missing person. Drilling and hammering continued to reverberate around the unit, and I began to wonder whether the doctor would prescribe a painkiller for me, but instead Richard arrived and said:

"Everything going to plan, eh?"

"Yes", I replied "but it's the plan which seems to be the problem."

"Don't worry, we'll get our reward in heaven"

"I won't wait here for it then, Richard."

"The patients always come up trumps, anyway"

"Trumps are usually only the start"

"Most droll" he said.

"Yes, Steven's a real shit" said Sidney.

"Pardon?" we said.

"A real wit" he repeated.

"And don't forget" Richard cautioned "Dr. S-- is doing a presentation tomorrow."

"A presentation!" we gasped.

"Yes, 'The effects of low dose neurocyclotetrashite on delusions of grandeur: a self-report."

"Right, boss".

(pause)

"That's a nice pen, Richard" I said, looking at his 1960's gold-plated Parker.