Dorothy Rowe

Openmind September/October 2006  

The more things change the more they remain the same. The news pages of the last issue of Openmind carried a report which read, 'Mental health nurses should spend more of their time in direct clinical contact with patients and cut back on administrative duties, a government review has urged. . . Sophie Corlett, Mind's Policy Director, said she was "delighted" at the review's encouragement of a more active role for nurses engaging with patients. "Too often we hear of a lack of interaction between the two, particularly on wards where patients may feel alone and abandoned," she said.'  

Sophie could have said the same thing in the years between 1968 and 1986 when I was working in large psychiatric hospitals. Walk on any ward and what you would have found were the patients sitting somnolently in well-worn chairs and in the office the nurses talking and drinking coffee. Whether you were a patient or a psychologist you approached the door of the office at your peril. You would knock timidly, and eventually one of the nurses would glance up, annoyed at being interrupted. A few of the nurses liked the psychologists, and these were usually the nurses who were very kind to the patients, but most of the nurses saw the patients and the psychologists as nothing but unwanted interruptions to the important things that the nurses were doing. If you were not sufficiently humble and grateful you would be punished. Nurses punished psychologists by advising the psychiatrists that nothing would be gained by sending a patient to see a psychologist. If the psychiatrist insisted in doing this, the nurses saw to it that the patient received a solid dose of a sedative just before the time of his appointment with the psychologist. I won't try to describe the multitude of ways patients got punished. 

Nurses spoke to patients only to question them, give orders, and tease them for the nurses' entertainment. In behaving like this the nurses were carrying out their instructions. In the hierarchy of the psychiatric system nurses were required to speak to patients as their inferiors. Conversation with patients was forbidden. On rare occasions psychiatrists would allow themselves to get in conversation with a particularly interesting patient. They would then express surprise that the patient proved to be an ordinary human. Psychiatrists could risk a conversation because they were at the top, or near the top, of the hierarchy, whereas nurses had only the domestic staff between them and the very bottom of the hierarchy, the patients. They had to keep their distance. 

This way of thinking still pervades some of the psychiatric system, but the nurses' position is even more difficult now. In the bad old days nurses could tell themselves that they had to separate themselves from the patients because the patients had a mental illness. In this so-called enlightened era nurses get two confusing messages. Patients now have some mental disorder which is caused by a gene or some chemical imbalance. This is the same as a physical illness only it affects their mind. However, this mental/physical illness can be cured by talking.  The nurses are told that talking can make people with a mental disorder think differently, and that changing how they think cures their mental disorder. Is there any physical illness you can cure just by changing how you think? Certainly, if you do what your doctor tells you to do while remaining optimistic there's a fair chance that the course of your physical illness will be shortened, but thought alone never eradicated an infection or a cancer.  

It's no wonder that many nurses are confused about what they should do. Having a conversation with someone who is suffering extreme mental distress is never easy. Even if you're not trying to help the person think differently about their situation and you just want to chat, you can find that you are bewildered or painfully upset by what the person is telling you. It's no wonder that nurses, faced with a choice of having a difficult conversation or filling in a boring form, go for the form every time.  

The only way to solve this conflict is to abandon the metaphor of mental distress being an illness and to recognise what it actually is, our response to being hurt, betrayed, abandoned, shamed, humiliated, and finding ourselves unable to make some kind of sense of our lives that we can live with happily. We need people around us who accept us as we are, who look after us when we can't look after ourselves, who understand the processes that lead to our suffering, and who can demonstrate in themselves the courage and wisdom needed to learn from our suffering and face life again. 

Dorothy Rowe Beyond Fear second edition HarperCollins.