Windows of Madness (part four)

The Unit
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.

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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.
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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.

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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.
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“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.
“Ah…..yes……” he sighed. “It’s actually a seventeenth century family heirloom, recently valued by a leading auction house at around £10,000. But I wouldn’t part with it for the world, of course.”
“You’re keeping it for posterior (posterity), then” said Sid (the old jokes being the best).
“Well….. certainly it’s proven useful in the past for those little spasms of intimate itching that occasionally occur, but I…..er….I must get on now.”

Richard was a cubist painting on legs, dark-suited in all weathers, slicked back and moustachioed. Unlike his fellow male managers, who advertised their wild individual personalities with a coloured tie each, he preferred to cultivate a full set of John Bull mutton chops, leading to his affectionate nick name – merkins. He was quite personable off duty, but a notorious pigeon-brained bureaucrat on the unit, bobbing and weaving his way through the working day like an old sparring partner on autopilot, but never quite nimble enough to dodge the fatal uppercut. To everyone’s ill-concealed amusement, his habitual failsafe expression was always “don’t worry, I’ve got it in hand”.
It was an obvious Freudian confession.
I mentioned that the drains were still offensive to the nostrils, and he reminded me for the third or forth time that the drains were far worse at his last unit. The system there had old, small bore pipes which were never intended to handle hospital waste, so the decision was made to pressurise the system with a pump. This was cheaper than laying new pipes, and should have propelled waste material through to the main sewer more efficiently. Instead, the pipes could not take the pressure and waste matter from one toilet area ‘backfired’ through adjacent pipes – blowing toilet seats off their hinges and pebble-dashing the inside of the entire block.
Richard then advised me that he had a lot of work to do in the other office upstairs, with ‘personal development plans’, ‘investors in people’ ideas, ‘improving working lives’ policies, and ‘democracy in the workplace’ initiatives; so he would leave me to it, if that was all right. I smiled as he left, not so much because of the perfect irony involved, but because I knew his office doorway was currently blocked with pin boards and chairs. He actually made short work of shifting the obstruction, but then discovered that he’d cut his finger badly on a rogue screw. Returning to the downstairs office in a foul mood, he hollered:
“ Where’s that bloody health and safety report book, I’ve cut my bloody finger!” and “Get me a plaster from the clinical room, will you?”
I pointed to a box on top of a dusty shelf, and went off to the clinical room as requested. We had oxygen cylinders, portable defibrillator, four stethoscopes, and about two hundred incontinence pads, yet no sticking plasters. I took some cotton wool back to him, and discovered that he’d cut another finger on a staple sticking out of the health and safety book box. The air was blue, so I set off down the corridor to make sure all the patients had been offered the toilet after breakfast, freezing in mid stride when an air raid warning siren appeared to explode in my left eardrum. Retreating quickly to kitchen, I remembered that it was the fire alarm test morning, and that for fifteen minutes the alarm would be turned on and off by serious looking, blue-coated hospital engineers with red clip boards who were apparently unconcerned that the main display board had clearly shown ‘fault’ for six or seven weeks. They were also oblivious to the fact that some patients climbed the walls while this performance was going on, and that by the time they’d finally concluded that the alarm was working, most people on the unit were probably too deaf to hear it. It was a superb accompaniment to the workers’ drills and hammers, and my mind felt as though some fiendish oriental torturers had exposed my brain tissue and were now stretching my neurones on a rack. It could not possibly be any noisier, and yet this was supposedly a haven for mentally unwell people.
It was more like the new Bedlam.
“Will this noise ever stop?” bellowed Hettie in my ringing ears.
“I don’t know!” I bellowed back
“I need tea now!” she returned.
“We’ve just come to test the fire alarms!” shouted the two blue-coloured men.
“Do you think they’re working?” I responded through cupped hands.
“I’m going to discharge myself!”
Just then, being almost next to the front door, I was able to detect the comparatively faint buzzing of the doorbell. I opened the door, and was confronted by a large party of self-important looking people who announced themselves as the Mental Health Inspectors, here on an unscheduled visit.
“Welcome to the unit” I mumbled.
The inspectors’ function was to check on the status, conditions and welfare of all patients, and to furnish reports and recommendations to Trust management. They had statutory authority and their findings were always made public, so they had the rare power to wake up our hospital administrators from their flip chart dream world; a fact confirmed by the bobbing head of a humble looking senior executive in the background.

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Daily Post, 25th. March 2004
Huge Increase in NHS Managers
There has been a 59% increase in the number of NHS bureaucrats since 1997, recently released figures have shown. This far outstrips the percentage increases in nurses and medics over the same period, and lends further weight to the argument that administration, red tape and paper pushing are running out of control in health care. There are now over 35,000 managers in the NHS, and some have received salary increases up to 30%.
Chief Executives can receive £100,000 per annum.
Bruce G------
Current Affairs
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They had apparently been waiting for some time in the snowstorm which now beat against the unit, and were in consequence even more menacing than usual. I beamed delightedly at the Hans Christian Anderson giant who led them in, apologised for the inconvenience, and ushered them through the mayhem towards our main office. The ambient row continued as the regal procession made its way around buckets, ladders, furniture, paint pots, one histrionic lady who was taking the opportunity to lie down in the corridor, and various ancillary workers who bowed their heads appropriately. I quickly tracked down Richard, who had somehow got wind of the inspectors’ arrival and was now frantically searching for a priest hole to dive into, and left them to it. My parting impression was one of Richard (with hands bandaged like a boxer) dancing uneasily in the electrically charged atmosphere of a star chamber.
“Yes, I’ve got it in hand.” I heard him say in the distance.
“What a shite that inspector is” commented Sidney.
“Quite probably” I agreed.
“Yes, I haven’t seen anyone that height for a long time” he continued. “He must have giantism or something”.
I organised some tea and coffee for the visitors, not so much out of courtesy, as a wish to buy some time while I planned my escape. Care plans were always written using ‘defensive documentation’ techniques to ensure that officialdom couldn’t scapegoat the staff without a struggle, so I felt reasonably confident that my paperwork was watertight; but I’d still rather have been on Mars. Sadly, much more effort went into meeting the needs of our financial planners, legal experts, managers and auditors than into meeting the needs of the community as a whole, otherwise we would have certainly thrown off the bureaucratic fetters by now and used a ‘rehabilitation’ model which actually worked in some way. But alternative ideas were virtually outlawed, ‘opinion’ was a dirty word and care plan entries had to revolve around factual descriptions of what was already happening. This was simply a formula for clinical inertia, so I sensed that I should probably keep out of the inspectors’ way in case my exasperation boiled over at P45 expense. Besides, the two Trust managers were about to be hung, drawn and quartered, and I’d rather not distract the executioner with a flasher’s sideshow.
So for half an hour I moved around the unit like a commando, concealed within dust clouds, tying shoelaces behind armchairs, inspecting far off bedrooms, and visiting the lavatory with octogenarian frequency. Running out of ideas, I finally seized the menu sheets while the office was empty, and slowly toured the unit asking patients what they would like for their evening meal. Some patients gave entirely rational answers, while those with more serious cognitive damage often struggled terribly with the simplest enquiry. I had just reached the most challenged patient of all, when I sensed one of the inspectors sliding silently towards me like a tobacco-stained boa constrictor on the look out for easy meat. Rather than short circuit my enquiries by simply completing the sheet in accordance with my observations of the patient’s previous preferences, I now had to put on my politically correct and untouchable hat on, so the inspector would be impressed. This meant going right through the menu sheet, item by item, so that the patient was exercising ‘free choice’:
“ Now then sir, would you like chicken soup at tea time?
“Aye” (so far so good)
“Would you like shepherds’ pie….”
“Aye”
“Or cheese omelette?”
“Aye”
“Or a salad, or an egg sandwich?
“Aye”
“How about your sweet. Would you like apple pie?"
“Aye”
“Or jelly and ice cream, or cheese and crackers, or a banana?
“Aye”
I felt the boa constrictor coiling and about to strike, but instead, with an empathic smile, the inspector said:
“He’s got a very good appetite, hasn’t he?”
He then rejoined the main group, and I couldn’t help noticing that Richard looked a little disappointed as they all turned away. Moving like a squad of monosyllabic minders guarding two beaten boxers on their way back to the dressing room, the inspectors and the managers quitted the unit for ‘further discussions’. With this glorious reprieve, I circulated around the unit in an unusually excellent mood, and not even the sight of a large stool slipping out of one gentleman’s trouser leg as he walked down the corridor, could fully dampen my spirits. The stool was as hard as a rock, and did not even stain the carpet on impact, so with rubber gloves donned I hardly had to break stride as I collected the offending article like a basketball, and rammed it down the nearest lavatory pan. Happily, Sidney offered to clean the gentleman up, while I consulted the ‘reality orientation’ board to see what sort of social events we had planned today.
For many years we didn’t have an activities notice board, because care on the unit had become polarised around physical and medical interventions, and management couldn’t be persuaded that broad-based care was as important in practice as it was in theory. But after the last inspectors’ report, which was a crushing indictment of conditions on the unit, we had at their insistence installed a daily events board - carefully following the action-packed programmes for some weeks. During that time, the lounges were full of residents playing domino’s, cards and Ludo, or deep in conversation with attentive staff, while the more active undertook regular walks and went on day trips to museums, stately homes and seaside resorts.
But the unit had a life of its own, and when anything new occurred the normal institutional pattern of the place soon seemed to reappear, almost like a monstrous octopus re-growing a tentacle after the courageous hero had hacked the first one off with his trusty knife. So it was on this occasion, as patients gradually got bored with board games, tired of walking, and defensive when talking. The staff too, generally preferred to watch T.V. and chinwag when there was a breathing space, so slowly the social activities degenerated into walks around the hospital site when staff members fancied a cigarette break, and rides in the unit vehicle when staff members wanted a change of scene. This unspoken collusion was typical of the unit, and accounted for a lot of the inertia, as patients, nurses, relatives and managers all shared an interest in ‘no change’.
Our patients were generally frightened of re-entering mainstream life, remaining frozen between ‘improved’ behaviour that might see them move on, and ‘deteriorated’ behaviour that might see them return to more restrictive regimes. Nurses preferred a predictable working day, and quite enjoyed complaining about the stagnation, while some didn’t particularly want their skills challenged by new circumstances. Many relatives would accept the inertia, as long as the patient didn’t land on their doorstep, and our managers were quite happy to leave clinical matters alone as long as the meeting room had plenty of sandwiches and some paper progress was being made with the latest government initiative. Their unofficial motto was ‘ignorance is power’.
The unit was supposed to provide psychiatric rehabilitation services for a local population of 100.000 people, but over a period of ten years it had catered for no more than 30 largely intractable individuals, who had soaked up the taxpayers subscription between them. They were effectively a private ‘club’ of career clients who either remained indefinitely, or returned invariably. Deaths accounted for more movement through the system, than successful onward referrals.
“I need a cigarette now” said the voice that lurked around every corner.
“Follow me, then” I said.
“I’m going to discharge myself” the voice added.
(silence).
Yes, we’d had innumerable meetings with the inspectors over the years, but this time, for the first time, something felt different. There was electricity in the air, a crisis looming, and a fever about to break.
The clock on the landing seemed unusually loud today.
Tick tock.

(to be continued)
full story on www.windowsofmadness.co.uk.
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