Windows of Madness (part 9)

The Unit
2007

Three days later.

After two hours with the Health and Safety team across at the new ward, I’d eventually discovered (via three brainstorming sessions, a seminar, two coffees and a workshop) where the fire doors and extinguishers were located.

“Couldn’t you have just given us the basic information straight off?” I unwisely enquired.

“Er…..well….I suppose so, but it wouldn’t have been so much fun would it?” said a red-faced blue stocking with brown hair and black looks.

“Ha ha ha” we chuckled.

“And what on earth would we have done with the rest of the day?” added her colleague.

“Of course, of course…… I do apologise.”

“Besides” added the trainee Health and Safety Officer “We didn’t know where the fire exits were ourselves until we had the workshop”.

* * *

I now stood at the bottom of the unit staircase and listened as a mournful wail drifted down from far above, as though some poor creature from another planet was dying of loneliness in a mountain cave, but then I realised that it was only Gerald accompanying himself on the violin.
---------------------------------------------------

Gerald
1966

Gerald had always looked a bit odd, with his huge aquiline nose, goblin ears and hooded black eyes, but he was privately schooled and generally isolated in the middle of his parents’ manorial estate, so nobody really knew much about him. He spoke with an aristocratic ring straight out of Eton, often carried a violin case, and sat bolt upright when the old family Bentley made its way through the Elizabethan gatehouse on its way to town.

It was a shock, therefore, when a local farmer found him sitting stark naked on a motorbike, hurling silver candlesticks through the farmhouse windows at 1 o’clock in the morning. Gerald had apparently fallen out with his parents, and decided to exact an oblique revenge on them by annoying the neighbours and embarrassing the family name. This was vaguely rational, but when he repeated the behaviour later in the week, and then compounded it by being scratching his name on the farmer’s Riley Kestrel, the police were called in to investigate. They soon ascertained that Gerald was not entirely well, and the family admitted a history of similar incidents over the years which had been skilfully hidden by his parents or diplomatically overlooked by the well-wishing local community. But things were getting worse, and the strangely withdrawn child had now become a bizarre, unpredictable adult, frustrated by his inability to understand things properly, and angry with the world.

His parents were persuaded to approach the mental hospital for help, and Gerald spent a short time on the ward receiving drug therapy. Unfortunately, he continued to deteriorate and by 1972 he was considered chronically ill, wrapped up in ritual behaviours, and increasingly explosive. He retained many skills, though, and was often heard playing classical music on his violin, or discussing restoration history, as he walked endlessly around the hospital day room.
---------------------------------------------------

I mentally applauded him for his efforts, and then moved on to the office for the lunch time hand over, making a note in passing that the Reality Orientation Board still had last week’s date and weather on it (appropriately enough ‘high pressure, with an odd shower’). Seeing the in-coming nursing assistant, I said:
“Welcome to our exclusive club”
“What? The mile high bestialism club you mean?” he replied with razor sharpness.
“No. The ‘I actually turn up for work’ club.”
“Ah.”
Office culture probably wasn’t as advanced at the unit as in a bank, building society or insurance office, because we were too anarchic and self-seeking to really have a discernible culture. Nevertheless, it was impossible to escape the working day without some form of badinage, plenty of ritual complaints and a pot-pourri of petty politics, as people strove to gain their little psychological advantages. We also had some classic many-skirted princesses and multi-shirted heroes, including two chaps who came to work like eighteenth century aristocrats visiting a bordello, reeking of so much after-shave that a naked flame would have blown the walls out. Generally speaking, if you were a fully paid up member of a witches’ coven (or the warlocks’ equivalent), you would fit in seamlessly.

You would be welcomed, hideously.

However, one activity which we certainly had in common with other offices, was the ritual of gift ‘collection’ for staff who were leaving, and because we had such a high turnover of disaffected personnel, these collections occurred with blurring frequency. At one time there were so many going on, and the anticipated donations were so high, that we were almost working for a net financial loss. Even temporary staff were expecting to go away with a 100 piece Crown Derby dinner service, or a day at Silverstone in a Ferrari F1 car, and they even had the cheek to demand a product change if they didn’t like what we gave them. I mentioned the current collection to my new colleague, who was notoriously parsimonious, and he said:

“I’d love to contribute, but unfortunately I’ve left my wallet at home.”

“Well, I can pay in £5, and you can repay me later” Sidney teased.

“Eh? Oh, w-well there’s no need to bother, I’ll probably drop it in later. N-no need to put yourself out on my account” he spluttered.

“You know, I didn’t really believe it when somebody told me that you reused your condoms” I said “ until I saw them hanging on the washing line one day”

“Get stuffed”.

“Then there was that story about you using charity collection bags for your own rubbish.”

“Well, everybody does that”.

Yes, but not everybody then puts the bag out for the charity collection man to dispose of.”

“You’re shite” remarked Sidney.

“Eh?”

“You’re tight. Tight as a duck’s ……”

“Shall we proceed?” I hurriedly interjected.

“And why the hell are you wearing that bloody great sombrero, false Frank Zappa moustache and chrome plated six-guns” Sidney continued.

“Oh…yes…..(self-effacing smirk)…..I’ve just been to the local auditions for the ‘Hex Factor’. I could be next year’s mega superstar hero the judges said.”

“Congratulations.”

“And even in the extremely unlikely event that I aren’t chosen, it will be such tremendous fun anyway.”

“ Ha ha ha ha ha” we chortled.

I then recounted the events and non-events of the morning, after which my new colleague said:

“Oh well, it seems quiet enough here now. Why don’t I take Stuart out for a drive ‘round?”
---------------------------------------------------

Stuart
1963

Stuart stared out of the cracked farmhouse window at the deserted fields and the purple moors beyond, hearing the wind whine around his creaking outbuildings and the rusting old tractor with its seized gear box and flaking red paint. The ancient oak table stood firm and square in the centre of the room, contrasting oddly with the walnut of an elegant writing desk and the brightly coloured glazes of some Satsuma china dotted around distant shelves. The desk was now strewn with faded love letters from his dead wife and a collection of silver framed wedding photographs, all gathering dust in the gloom.

Every dog-eared book, chipped plate, and bent spoon continued to remind him of the woman he loved, and when the silver framed images came into view, he stifled a pain no opiate could touch. The neighbours still called around sometimes, but he had driven most of them away with angry rebuffs, unmanly tears and wildness, while the farm remained neglected, the bills unpaid, and the house a midden. With filthy clothes, half grown beard and matted hair, he left his food barely touched and endured a sleepless purgatory of sweet memories, and self blame. His blunt earthy nature had never allowed him to reveal his love, or to really believe in Heaven, and now he suffered.

One day, he walked up onto the moors and found one of his sheep caught up in a twisted fence. She was quite dead, and had probably suffered for hours while the blood drained from her lacerated body, but around her flanks Stuart noticed the tell tale signs of dog worrying. He was incensed, and as he began to march around his boundary looking for further victims, he was amazed to see a group of youths and two dogs chasing across the fields towards him. Sheep were fleeing in all directions, and Stuart yelled at the top of his voice:

“ Stop! Stop!…..Stop, or I’ll fire!”

But in the wind and the rain, and intoxicated by their game, the youths did not hear, so Stuart raised his shotgun and downed the first dog, sending one of it’s front legs looping high into the air, and over the shocked white faces into a stream behind them. The youths turned and fled, holding their ears as a further round burst over their heads, sprinkling them with spent shot.

And a spent life.

The police soon came around to the farmhouse, and were experienced enough to recognise a broken man. They were kind, and aware of his history, but
were forced to take him away to a ‘safe place’, where two doctors admitted Stuart to the local psychiatric hospital for treatment. It was clear that his mind had fractured under the weight of anger, loneliness, financial pressure and guilt, and now he was spiralling down into serious depression. His personality never truly came back again and after a year the neighbours stopped calling altogether; they just didn’t know what to say to a man who said nothing. They were slowly replaced by the concerned faces of R.S.P.C.A. officers and court officials, who in turn gave way to social workers and nurses, who eventually led him away to the hospital for the last time.
---------------------------------------------------

I cocked my ear to the intermingled sounds of drilling, hammering and wailing, and wondered what my colleague’s definition of ‘quiet’ was, and whether he too collected Concorde engines and was therefore perfectly adapted to an unremitting racket. There was little point in denying him the request, however, because there weren’t actually any ‘patient management problems’, and if I’d said no he might have called in sick for tomorrow. Also, if he went off the unit there would be two less people shouting at each other all afternoon, so I acquiesced and contented myself with saying:
“Okay, but if you happen to do any shopping for yourself while you’re re-socialising the patients, don’t put all the Woolworth’s bags down in front of Richard like you did last time.”
I said this because it was often suspected that staff used the excuse of taking patients on recreational drives to disguise shopping trips of their own, as well as visits home, or even running members of their own family about. The unit vehicle had been seen parked outside staff members houses on a number of occasions, and garrulous patients often came back with stories of meeting the staff members’ children, having cups of coffee at the nurses’ homes, been shown around newly purchased flats, going to car boot sales they weren’t expecting, visiting D.I.Y. shops, picking up children from school, and so on. Staff members frequently took twice the expected time to complete a task, and some took so long that they had to return with breathless accounts of terrible traffic jams, being boxed in at the car park, road works, breakdowns, witnessing accidents, and losing their way home. All quite credible, of course….
“Buzzz” went the doorbell.
“I’ve just come to pick up Mrs. Brown with the broken leg” said a dripping wet man wearing a Robinson Crusoe outfit and large silver earrings.
“ I’m afraid there’s nobody of that name or affliction here” I replied. “This is a psychiatric unit.”
“Are you sure?” he said (looking closely at my eyebrows).
“Absolutely.”
The dripping wet man then ambled off and started peering through one of our side windows. He was no doubt in search of Mrs. Brown, but instead collected a nose full of diarrhoea from the downstairs toilet and a hearty “bugger off” from one of the patients.
“Can I be of further assistance?” I called rhetorically after him.
“Er…no… no….thanks.”
“Would you like a look around?” I suggested.
“No…no….that’s fine.”
“We’re having the inaugural ‘Friends of Local Psychiatric Rehabilitation’ meeting next week, if you’d like to bring Mrs. Brown?
“Er…..no…..no….I’m due to give a presentation that evening”.
”A presentation!” I gasped.
“Yes, yes…. I would have loved to come otherwise.”
“The patients have baked a number of interesting cakes.”
“Sorry…..no…..I must go now……urgent appointment.”
“I quite understand” I said.
I really did.
“By the way.”
“Yes?”
“Why are you dripping wet and wearing a Robinson Crusoe outfit with large silver earrings?”
“Oh…yes….ha ha…..I wondered whether anybody would notice. In fact, I’ve just been diving off the pier for a hospital charity. It was an absolutely brilliant day – lots of fun and only two deaths through heart failure.”
“Well done. I do admire really mad people like you.”
“Ha ha ha ha” we chuckled.
Until he realised where he was.

I then made my way to the upstairs office where Richard was dancing for joy in front of the computer screen. Suspecting a new porno site, or a successful bid for Marilyn Monroe’s bra on e-bay, I was disappointed to discover that he had just completed the staff roster for next month. This was no mean feat, of course, because large numbers of staff were always ‘incapacitated’, some had cleverly turned lucrative night duty into a private cartel, and the unit managers themselves were constantly been told to reduce their reliance on agency nurses and overtime. The supposedly finished roster was invariably rewritten dozens of times anyway, as staff dropped out like flies and others swapped shifts as if they were cigarette cards, but I didn’t begrudge him his moment of pleasure and congratulated him in fulsome fashion.
“Thank you.” he beamed. “By the way. We might be getting a kitchen inspection from the Local Authority some time this week, so make sure the floor’s clean for once, will you?”
“It’s fine” I said. ”I always use the sticky sole test anyway.”
“The sticky what?”
“The sticky sole test. That’s where you walk over the floor slowly, and if your shoes stay on, the floor’s okay.”
“I see. …Very well. Carry on.” He said distractedly. “I’m the last person to get inflated about such things, of course.”
“That’s between you, your wife and your surgical appliances” I said to his now deaf ear.
“Things are nicely in hand” he murmured.
“Richard, would you mind awfully if I called you Dick? It seems more appropriate somehow.”
“I don’t think so Steven. Management have to maintain a certain professional distance from the other ranks. But don’t let that interfere with our personal supervision relationship – I’m only too happy to counsel you whenever necessary.”
“Our last personal supervision meeting was ten years ago, Richard.”
“Hmmmm…..hmmmmm…”
“And I could do with some advice right now.”
“Well, I could spare you five minutes” he grudgingly offered “You have looked a bit under the weather recently.”
“A bit under the weather? It’s my annus horribilus Richard.
“Oh my God! There’s nothing worse than piles Steven. Have you tried a spot of ‘Germoline’ on the end of a candle?”
“Er…..
“It doesn’t always work, but it’s a wonderful way to end the day.”
“Er…..right….thank you”.
“Anytime, old boy. Carry on.”

I carried on all the way to the next desk, and began flicking through the vacancy sheets which had recently arrived. All the staff did this religiously, either because they wanted to leave immediately, or because they wanted to leave a good deal sooner than that. I waded through the usual stream of secretarial jobs, senior executive gravy trains and foreign legion posts in hellhole dementia wards, and pushed it to one side. Unfortunately, we didn’t get the ‘Nursing Times’ any more because all the staff made for the jobs column like vultures descending on the carcass of an elephant, so Richard cancelled our subscription to make sure we didn’t leave en masse one day. He needn’t have bothered, because most of the staff just went through the motions, joyously imagining the successful interview, the nonchalant resignation tendered to indignant managers, the insanely jealous colleagues, the perfect job satisfaction in their new action-packed role – and then they woke up.
‘Ideal’ jobs in psychiatric nursing were rarer than hens’ teeth and staff either discovered this chastening truth the hard way, or they played mind games with the vacancy sheets and stayed where they were with the devil they knew. Still, I wasn’t as badly off as the fire-eating striptease artist I read about the other day. She not only had to work with a Bengal tiger and a sexually aroused python, she had to play flute and saxophone in the intermissions too.

I was just about to leave, when Richard said:
“Oh, by the way. I’ve got one or two little jobs for you to do here.”
An hour and a half later, I had finished transferring lots of old nursing notes into archival boxes, using W.H. Smith circular reinforcements to patch up the existing sheets and dividers, and adding up how many hours of overtime and agency nursing we had used for the last five months (a lot). I had also toured the entire unit documenting how many chairs, tables, wardrobes, beds, cupboards, dressing tables, pot plants, cookers, desks, monstrous food warming machines, shelves, and filing cabinets we had, comparing these figures faithfully with those gathered six months earlier, and accounting for any differences. I had additionally, checked through the maintenance book to see how many maintenance jobs were still outstanding (a lot), I had filled in the monthly patient status form which told us how likely the patients were to move on and why they weren’t, and I had undertaken to audit the care plan entries of my colleagues during the next week, so that we would know whether blue pens had been erroneously used, abbreviations had crept in, or any other capital crimes had been committed.
I didn’t challenge Richard, as I had many times before, with the reasonable contentions that some of these jobs were unnecessary, some were his, some should be given to a ward secretary not a clinician, and some were perfectly mindless. He refused to accept the view that somebody with a £100.000 nursing degree shouldn’t really be spending long periods wrestling with W.H. Smith’s sticky reinforcements. Today, I allowed myself just the one comment:
“Let’s face it. These care plan binders are so thick and heavy, they’re bending open the high tensile steel rings. We can’t really hold back the tide for much longer with paper reinforcements”.
“Hmm….hmm. Well, do your best. The clinical auditors may be coming soon, and we need the records to be as complete as possible.”
“I can only try.”
“I’ll give you the thumbs up then old boy.”
“I’d rather you didn’t, if you don’t mind” I winced.
“Okay, I know we’re under pressure while the inspectors are here, but we must prioritise things. Correct documentation comes first at all times – you know that.”
“We must make sure the big thing’s in hand, even when the little things aren’t you mean?”
“Quite so.”
---------------------------------------------------

Bedroom Number 8

There was a 1960’s Olivetti typewriter on the dressing table, with a half finished letter cock-eyed in the carriage and three keys locked together in one metallic embrace - the consequence of a large yellow index finger striking them simultaneously. In the wardrobe lay three large sacks of letters (dating back to 1971) which had never seen a stamp. There was no need for the mail, when a man was corresponding with his past.
Cassette tapes, toiletries, cups and matches lay confused on every horizontal surface, while the man’s clothes modelled Mount Blanc on the floor, and his ‘patient’s charter’ fluttered in the breeze – countersigned by a key worker who emigrated to New Zealand in 1999.
On the bed, lay the man himself, trousers and underpants down to his ankles, waiting for his regular intra-muscular injection, fast asleep.
---------------------------------------------------

I grimaced at the patient’s file in front of me; the great wedge of admission forms (eight pages), global assessments, risk assessments, Care Programme Approach assessments, Health of the Nation Outcome Scales, SCART assessments, bed sore assessments (altogether twelve pages), care plans (four pages), care plan daily record sheets (twenty two pages), multidisciplinary team meeting sheets (eight pages), blood pressure charts, weight charts, pathology test records for possible urinary infection, blood counts, drug levels, and physical examinations (in total ten pages), Care Programme Approach records (Six pages), Correspondence (Seven pages), personal finance receipts (four pages), a pair of broken false teeth in a plastic bag, and the seven cardboard dividers which attempted to structure this ridiculous monster.
I then thought about the patient in question; a fifty year old man who had a long standing inadequate and manipulative personality, no suicidal ideation, went on home leave every weekend, was physically fit, who had been on the unit for almost a decade without significant change, and who would have been transferred to a private sector hostel years ago if there had been the funding available to do it. This man was not acutely ill and he didn’t really belong in hospital at all, and yet we continued to treat him as though he had just arrived as an emergency admission on a stretcher.
He didn’t need the heavyweight ‘everything but the kitchen sink’ nursing care plan, because he didn’t need the hospital environment at all, yet instead of making a common sense adjustment to his care we continued to submerge him under a sea of medics, tests, re-assessments, specialist referrals and weekly multidisciplinary meetings, simply because that was our professional ‘role’ and we were too inflexible to change it. Due to the absurd overkill involved, the man had slowly become conditioned to think of himself as a desperately ill and permanent hospital patient; one who could no longer conceive of a future beyond the unit, even though one day he would no doubt be rocketed into the private sector where no such attention would be given.
The hospital type environment of the unit often led people with personality problems to adopt a ‘sick role’ perception of themselves, as this made it even easier for them to opt out from any personal or social responsibility. In that sense, the unit was actually manufacturing madness instead of treating it, and lengthy hospital stays remained a key factor in the development of over-dependence amongst our patients. This was why I remained unimpressed by the vast care plan files, because I knew that these mighty tomes were ultimately intended to meet the pedantic needs of auditors and lawyers, not patients.
“We’re back” said my colleague from the afternoon shift.
“How did it go?” I enquired.
“Oh, I’ve hired a Michelin Man costume for the next charity walk and made an appointment for my hair to be tinted. I’m a really mad sort of person you know.”
“I was referring to the walk with Stuart.”
“Oh…right…. no problems. He was absolutely superb in town.”
I glanced at Stuart who was stood behind, and noticed that a large wet patch had formed around his crutch area, that his hands were shaking uncontrollably, and that saliva was dripping constantly from his mouth. Everything was relative in psychiatry, and I knew that my colleague was pleased because Stuart hadn’t attempted to run off, hadn’t become angry or agitated, hadn’t stolen anything, and hadn’t been incontinent of faeces in the shops. His term ‘brilliant’ still seemed a little extravagant, though, and it occurred to me how often we compared patients’ behaviour with other abnormal behaviours on the unit, rather than with standards in the outside world. This was not perhaps a great sign of community care success, where ‘integration’ with the outside world was the main guiding principle.
“I think he needs to change his trousers. I’ll get some medication for the side- effects” I said.
“I need a cigarette now!” interjected Hettie, as I attempted to open the drug cupboard.
“Can you wait just a minute?” I soothed.
“I need a cigarette now! Now! Now! Now!” she screamed.
There was then a scuffle behind me, as Hettie attempted to strike Stuart, blaming him for the inordinate delay in cigarette supplies. We eventually managed to separate the two combatants, and then had to spend ten minutes ‘talking down’ Hettie, before reminding her of her social obligations.
“I understand” she said for the tenth time that month.
Thinking about the two incident forms that I would now have to complete in triplicate, I moved back to the trembling victim of the assault. His hyper-salivation was a side-effect of the main anti-psychotic medication, and although we had drugs which would contain the problem, these drugs had their own side effects, including agitation. As agitation was often one of the patients’ original problems, the whole process could be rather self-defeating, and again illustrated the circular nature of psychiatric activity. Indeed, drug therapy for mental disorders was generally problematical, partly because mental disorder could be caused or complicated by psychological and social factors, and partly because the drug therapy itself was a rather imprecise science. As well as the risk of serious side effects, drugs could miss the target altogether, be tolerated over time, interact with other drugs, or be insufficiently powerful.
“Sooty and Sweep are just capitalist puppets, claims Marxist” said the radio.
“It’s time for me to discharge myself” said Sidney.
He was gazing at a dog-eared photograph of a blond, bare breasted lady in stockings and suspenders, who was draped over a Harley-Davidson motorcycle, drinking frothy lager from a bulbous bottle. In the background was a long-haired biker in studded leather jacket, unflattering thong and jackboots, with a three inch spike through his nose. A waterfall of artificial sweat ran freely over the lady’s tanned shoulders, down her back, and through the culvert of her perfectly formed derriere. Nudity, as always, left plenty to the imagination.
“I didn’t know you were into that sort of thing” I said.
“Oh, I’m not Steven” he said quietly. “She’s my muse.”
“Oh, right……absolutely….. Well thanks for turning up anyway”
“Cheers. Have a good shit…er….shift.”
“See you.”
“Oh, by the way” he said “My wife says your anus is the most important thing in sex.”
“Really?”
“Yes” he explained. “Uranus is apparently even more important than Mars when drawing up your astrological sex charts.”
“Yes, the old jokes are the best.” I laughed.
“Pardon?”
“See you, then.”
“I’m having a game of scrabble with my wife tonight” he called back. “You’ll have to join us sometime.”
“’Goodbye, Sid”
“Now, remember Steve - don’t let the bastards grind you down. You won’t see me tugging my foreskin for any boss.”
“Yes, of course……”
“And by the way Steve.”
“Yes?”
“Have you any ideas for spicing up my love life? I’m afraid my wife and I seem to have forgotten we live at the same address.”
“Er……well I’m not really an expert Sid, but you could try scented candles and a pink light bulb.”
“Oh. That’s worth a go I suppose, but I don’t think virility and girth are really the key problems. Still, thanks for the suggestion, anyway.”
“That’s okay.”
“And another thing, Steve.”
God help me.
“Well….you’re the only person I dare ask….Do you….do you think arseholes deserve rights? Be honest.”
“Oh….you mean conmen, cheats and vagabonds?”
“No. No. Real arseholes.”
“Oh…..perverts, rapists and granny bashers….”
“No. Actual physical arseholes. Anuses.”
“Pardon?”
“You see Steve, I find it terribly upsetting that oral and vaginal orifices always get such a good press, while the poor lowly rectum is forever mercilessly vilified and pilloried. I feel as though I have a calling in life – a sort of holy quest, to defend the rights of all downtrodden and belaboured back passages.”
“Oh….yes…..absolutely….I couldn’t agree more.”
“I knew I could count on you, Steve” he said, a single tear trickling down his old craggy cheek.

That’s just the way I felt. Angry, defiant, and just a little mad.
But tomorrow was the day of the big inspectors’ meeting, when we would all learn our fates.
Tick, tock.
---------------------------------------------------
---------------------------------------------------

(to be continued - part 10 posted 1/7/09)
see www.windowsofmadness for complete story.
paperback available at www.booklocker.com/books/4150.html