TRANSCRIPT OF SPEECH GIVEN TO THE 'SELF HARM, ABUSE AND THE VOICE EXPERIENCE' CONFERENCE 31/8/96.

I had a rather peculiar introduction to psychiatry as, before beginning my training I had little practical experience of dealing with mental health problems. I became interested in mental health through doing a degree in psychology and philosophy at the end of which I knew a lot about the theory but nothing about the practice of psychiatry. After spending four years studying logic, I found the way psychiatry is practised rather puzzling. A few weeks into my first placement on an acute ward I began to wonder what exactly it was that we were supposed to be doing. Patients were admitted in a distressed state, and then seemed to stay on the ward for weeks on end for no apparent purpose. As a few of the acutely ill patients took up nearly all of the nurse's time, most of the patients seemed to get very little if any input from the staff. After a few weeks, or when the bed was needed for someone else, they were discharged back to the same situation that had led to their distress in the first place without any apparent effort to find any solutions to anything but their immediate presenting problem. There seemed to be no focus or planning to their care, and it seemed to me that they were supposed to get better by some sort of osmotic process, Just by being there they were supposed to absorb 'wellness'

The main problem seemed to be that the service was so overstretched that it could only respond when people were in extreme crises, and so a revolving door scenario developed. Patients lurched from one admission to the next and were discharged as soon as possible to make a space for someone else, thus ensuring that they were readmitted a few weeks later, thus making sure that the service was so overstretched that it could only respond to people in extreme crisis.

            I found the nursing approach to distressed people also rather strange. We were told that we should not discuss the contents of hallucinations or delusions with psychotic clients, but should reinforce the reality of the situation. This felt very wrong to me. Knowing how much what we perceive is influenced by our beliefs, it seemed to me that my own version of reality was as real to me as anyone else's is to them, psychotic or not, and that by denying that their version of reality had any validity I was simply alienating myself from the patients and marking myself out as someone who was unable to help. It also seemed to me that this approach closed off the most useful way of dealing with people's distress. It seemed obvious to me that peoples' experiences have meaning for them within the context of their life experiences. The only way to explore the distress people feel and to look for possible solutions is to explore the meaning of their experiences, whether or not these are labelled as psychotic.

We were taught to maintain a professional distance in our relationships with the clients.  From psychology research I had done as part of my degree into the nature of self disclosure, and particularly the work of Sidney Jourard, I knew that people are very unlikely to disclose to others unless it is part of a reciprocal relationship. By not disclosing aspects of my own life to clients, I was effectively preventing them from disclosing to me.

It felt very wrong

Far from being the rational and scientific approach I had been led to expect, the use of medication seemed to be rather arbitrary. The clients seemed to have no choice about which medication they were given, and when they took it.  Those patients brave enough to refuse medication were labelled as difficult and sometimes discharged. I found myself  being chastised for telling patients about the side effects of the drugs they were on. I considered this to be a basic human right, but the experienced qualified staff told me that it would just give 'them' the opportunity to pretend to have these side effects. I began to wonder what all that stuff about 'unconditional positive regard' that the tutors in school kept harping on about was supposed to mean in practice.

Like a whole generation of nurses I was taught that if a patient self harmed we were to take control away from them, remove all sharp objects, 'special' them 24 hours a day. I watched as doctors sewed up patients cuts without anaesthetic, justifying their actions by inferring that it was a crude form of conditioning, if you punished people enough for cutting themselves, they would eventually stop. I had severe misgivings about the morality of this approach, but reasoned that the qualified staff I was supposed to be learning from must know what they were doing. Over time it became apparent to me that this approach simply did not work. In fact if anything it made people worse. When patients self harmed they were given lots of special attention for an unspecified period from a few hours to weeks on end. When they did not self-harm they were ignored. This struck me as a crude form of conditioning to reward people for self-harming behaviour. Whether it was intended or not, it seemed to work. What no-one seemed to notice was that the patients only self harmed when they were extremely distressed, and that they became markedly less distresses after cutting themselves. Whatever the reason for this behaviour, it seemed to have the desired effect.

In the big institution 'Cutters' were treated with a special kind of resigned contempt, as if their emotional and physical pain were not somehow real or worthy of compassion because they were self inflicted.

I also came across this attitude in nurses who worked in accident and emergency departments. This special kind of contempt was not shown to patients who abused drugs or alcohol, although their problems were equally self-inflicted. I did not see this contempt shown to those who habitually harmed others.

The staff who behaved in this way were not psychopaths, they did not lack empathy or compassion when it came to dealing with patients with different problems, they just seemed to have a sort of moral blind spot when it came to dealing with people who dealt with their distress by self harming. Most of the nursing staff smoked heavily and spent the evening in the social club drinking, but did not seem to see this as self inflicted self harm, even when they had a hangover.

Why do nurses react to self-harm in this way? Part of the reason has to be that they are taught to behave in this way by people that they consider know what they are doing, but I find it hard to believe that no-one else can see through the absurdity and inhumanity of this approach.

From examining the behaviour of others and my own feelings in situations where someone wishes to self-harm I have identified a number of factors that may help to explain this reaction.

In myself I detect a feeling of helplessness when confronted by someone who self harms. They are obviously extremely distressed, and apart from handing them a razor blade there is little I can do to relieve that distress. It makes me feel better if I take control of the situation, special the person. It makes me feel as if I am doing something to help, even if I know that I am probably just postponing the inevitable. A second factor is fear. This is partly fear that the person might hurt you instead of themselves, but I think it is mainly fear of feelings of failure if the person does self-harm. The trouble with being a nurse is that you know that if an untoward incident occurs the management are going to descend on you like a ton of bricks asking you to justify your actions. If we handed razor blades out to people and then subjected them to a torrent of verbal and physical abuse I could understand why nurses might feel as if the they were responsible for people harming themselves, whilst the people who self harmed were not responsible for their actions, but I cannot believe that any nurse would act in that manner No-one comes into psychiatric nursing for the money. Nurses are mainly concerned and compassionate individuals who are doing their level best to act in the best interest of their clients. The reason that the often do not succeed in this aim is that they are trained in a dehumanising system, given role models who continue to deal with situations in the way that they were taught to, perpetuating a dehumanising mode of practice.

Psychiatric nurses have always seemed to shy away from professing to act politically, yet it seems to me that it is impossible to practice psychiatry without acting politically. Just as we all grow up to be reflections of our parents attitudes and values, however much we try to rebel, so nurses come to reflect the values of the management system under which they worked.

 Some years ago the UKCC brought out a paper that suggested that NHS managers should look to world leaders as role models of how to manage their little empires. The managers in the big institution where I trained took this to heart and applied it with a vengeance. They chose as their role model the most successful and charismatic figure from their school history book, Genghis Kahn, and strode around the wards with narrowed, glinting eyes complaining that the junior staff did not stand to attention when they walked into the room, and collapsing in fits of apoplexy if anyone was so disrespectful as to call them by their first name. They sent out memos about how many jars of mustard we were allowed to have in our store room (3) and the number of wipes we could use per patient per toilet round (also 3). The managers kept in their own little cliques and were careful not to become too involved in what their staff were doing as long as they were following the rules to the letter.

We worked in an atmosphere where we knew that however hard we worked, however much care and compassion we showered on the clients, however many times we came in to cover on our days off, cancelled holidays, worked for weeks on end without a day off, there was no danger of any of the managers uttering a word of praise or thanks, but if they caught you sneaking a bowl of trifle that was going to be thrown away anyway, it was treated like the crime of the century.

One day, whilst working on one of the back wards, the hospital manager magically appeared looking rather bewildered. On enquiry it turned out that he was on his way to a meeting and had got lost and ended up walking onto the ward by accident. He left hastily, but later that day £300 appeared with a request to use it to cheer the place up a bit'. That's how in touch the management was with the working conditions of their staff and living conditions of patients.

There were many unwritten rules in the institution, one of them was that if you rocked the boat, tried to get a fair deal for the patients or complained about staff who abused patients rights then they would not give you a job at the end of your training. I was very flattered when, at the end of my training, they refused to give me a job.

Under this type of management system it is not surprising that nurses have difficulty in treating patients like human beings. Disempowered and undervalued by their managers they in turn disempower and undervalue the clients with whom they work. Like the managers, they only look for the negative things in people's lives.

The conventional nursing approach to patients seemed to me to be very problem orientated without any effort to stress the positive aspects of their lives, or to use these to seek solutions for the aspects they found distressing. We were taught that the nursing process was a way of planning, implementing and evaluating patient care. In practice what happened was that the nurses did what they thought was the right thing to do at the time, and at the end of the day when they came to write the nursing reports, looked at the care plans to see which bits of what they had done coincided with what they were supposed to be doing.

In general my experience as a student nurse was that the practice of psychiatric nursing was very different from the theory, and the theory seemed to have no basis in logic or concern for people as human beings. The institutions seemed to be run for the benefit of the staff, and patients, like the staff, were expected to fulfil certain roles, and received short shrift if they stepped outside those roles.

As well as the fear of the consequences of someone in our care self-harming, there is also the fear in ourselves of how we will react. I once saw a nurse let out a shriek and fall to the ground in a faint when a patient showed her that she had cut her arms. I guess that in some way we are all afraid of reacting in this way. In part at least, the severity of this reaction must be due to cultural factors. We live in a society where we are rarely exposed to the sight of severed flesh. We buy all our meat in neatly packaged polystyrene containers covered in cling film. The Process of killing animals and chopping them up is kept hidden from us. The only situations in which we are likely to be exposed to this sort of thing is in situations we associate with fear and danger, for instance accidents or horror films.

Another cultural aspect to the horror reaction to self-harming is our society's attitude to the body beautiful. Western culture has always idolised the female body in its various forms, and we are bombarded with advertising, magazine articles, T.V. series etc. that give the message that the most important thing a woman can do is be beautiful. Given this cultural idealisation of the perfect female form, as demonstrated daily on page 3 of the sun, the deliberate scarring of ones own body is definitely taboo. This leads not only to the reaction of horror when someone breaks that taboo, but also to a feeling of lack of understanding as to why anyone should want to do so.

In some way it may be that the breaking of this strongly held cultural taboo is the mechanism by which people who self harm gain some relief from doing so. The act of deliberately cutting ones own flesh stands as an expression of how distressed the person is. In our society there can be no greater demonstration of distress that deliberately scarring one's own body. I would make a guess that in other societies, for instance in Sudan, where skin scarring is a common form of body adornment; the act of self-harm would be less meaningful.

This leads us to look at the differences in self-harming behaviour between men and women. Very few men self harm in the same way that women do. This can partly be explained in terms of the cultural taboo as there is not the same idealisation of men's bodies in our society, so perhaps the meaning of the act is less powerful for men, indeed in some male macho circles scars are a source of pride. It seems to me that men do self-harm, but they do it in a different way from women. Men tend to externalise their anger and deal with their distress by being violent to others within culturally acceptable norms. These range from drinking heavily and getting into fights to taking up rugby or boxing. Perhaps some men cope with their feelings by channelling into ruthless ambition. Men have a culturally acceptable way of punishing themselves that are not open to women. Unable to ritually harm others as a way of coping with their distress, women are left no option but to harm themselves.

What then must we do? It is apparent from the writings of a number of people who self harm who have survived the ravages of the conventional approach to treatment that this approach is at best worse than useless. The reasons why people self harm are very complex, and I don't profess to understand them all, but at least part of the reason is that people feel that they are worthless, that they are incompetent and incapable of taking control of their lives. They can only gain relief from their distress by cutting themselves, but feel stupid for doing so. Given that this is the case, treating these people as if they are incapable by taking control of their lives by taking control away from them, treating them as if they are stupid by shouting at them or becoming annoyed when they self harm, treating them as if they are worthless by deliberately sewing them up without anaesthetic probably isn't going to be the best way of going about trying to help them to stop.

I now manage an eight-bedded support bed unit called Dryll y Car. The building was previously a bed and breakfast establishment, and we have tried to keep it looking as much like a guesthouse and as little like a hospital as possible. We have tried a very different approach to dealing with our client group. We are committed to developing partnership in care between staff and clients. We work by giving the client choices about how they are treated. It is always clear that clients retain their personal power to choose.

When we set up the unit 3 years ago we were given the chance to start from scratch to create a new service. We were also extremely lucky that all the staff working on the unit shared a common interest in using innovative approaches to mental health care. We took time to examine our experiences of the conventional psychiatry and work out how to provide a good experience for our clients

The management style is one of a flattened hierarchy so that the line of responsibility is clearly defined from consultant to manager, deputy manager, staff nurses and health care assistants, so everyone has a clearly defined role, yet everyone's opinion is equally valued.  Just as we empower our clients to take responsibility or their lives, so we empower our staff members to undertake new initiatives, and support them in developing these initiatives in their own way. As we empower clients to own their own experiences, so we empower the staff to own their own initiatives.

 All members of the team have had input into the way the unit is run, and the type of service that we provide. Staff development, both personal and professional, is an important part of the functioning of the unit, and the staff are gaining knowledge in a wide range of areas that help us to provide a better service. This ranges from courses in computer skills to alternative therapies such as massage and aromatherapy which helps to broaden the range of support that we provide.

We are very aware that to provide a good service means getting away from the traditional approach of responding to crises which means taking steps to keep people well.

The way we work is to offer our clients an initial period of admission, usually one or two weeks, followed by a series of planned admissions of one or two weeks. Each admission is planned to coincide with when the staff members they are working with are on duty, and each admission has an identified purpose. On admission clients are given a discharge date. On that day the care plan is reviewed and the next admission and discharge date arranged, along with a plan of care. Clients go home with a commitment to support from the unit should they need it prior to their next admission. Clients can telephone the unit at any time when they are at home, and one bed is kept open for a 72-hour admission should any of or clients feel the need. In practice because this level of support is available, it is very rarely used. Clients are encouraged to contact the unit for support or admission before the distress that they experience reaches crisis proportions. Very often a few hours spent on the unit or with a member of staff is enough to avert what would otherwise develop into a crisis that in a conventional system would require a lengthy admission.

Because we plan the care that we provide several months in advance, and because we aim to keep our clients well rather than waiting until they are absolutely desperate until we respond, the service does not become overstretched, and the level of support that people need in order to stay well is always there for them.

Despite the fact that new clients are being referred constantly, the unit does not get clogged up with the same old faces coming back time after time. Because the time we spend with our clients is planned and focused, we are able to deal with the roots of their distress, not just the immediate manifestations. Because we empower people to take control of their own lives they move on, out of their victim status, so that they no longer need our support.

What we do do is treat the distress, not the behaviour. We spend a great deal of time with people, both when they are distressed and when they are not.  As they get to know us they become able to discuss the thoughts, memories and feelings that lead to the distress. Very often it is the first time they have been given the opportunity to explore the meaning of their distress.

What I am arguing here is that nurses can only empower clients, treat them as human beings and take them forward out of their victim status if they in turn are empowered and treated as responsible human beings by their managers.

As the old asylums have closed down, the new Health Trusts have invested money in new services in the community. In this purchaser/provider system the  Trusts are supposed to be run as a business.

Now any true business man who is investing his own money in an enterprise knows that investment involves risk. The higher the risk, the higher the potential return on the investment, and the higher the risk of failure and/or loss. The trick is to determine the right level of investment to gain a reasonable return on the investment without undue risk. Investing money in an enterprise that has no risk but has no return is pointless, you'd be better off leaving the money in the bank.

The old asylums that are closing down were originally intended as enlightened places  of  'moral treatment' that was a revolution in its day. It did not take long for them to become places of incarceration. This became an exercise in containment of the mentally ill rather than investment in their treatment and care.

In my experience the old asylums were run for the good of the ancillary and administrative staff, with the nurses and patients coming at the bottom of the pile. Beneath the surface veneer of  caring for patients, the nurse's real role was to establish her place in the hierarchy and maintain the status quo. As long as everyone followed the ward routine everything was fine, but anyone who protested about the injustices of the system, stood up for patients rights or tried to change anything (God forbid!) was at best tolerated but ignored.

In the words of one ex-patient 'Nobody ever tried to explain what the nurses were for, and I never worked it out. They seemed to me to spend most of their time trying to retain their rank in the hierarchy, trying to prove that they were coping and that we patients were somehow broken up and in need of their guidance.... Nurses and psychiatrists had far greater social and mental problems than many of the patients. The only difference was that the patients admitted their problems and the staff did not.'      (Mason 1991)

Asylums were places where nobody took any risks and nobody, staff or patients, really gained anything. To me the whole system seemed to be designed to send everyone mad and make sure that they stayed that way despite the best efforts of everyone involved. If this was the object of the exercise, it was very successful.

With care in the community we are entering a new era of revolutionary 'Moral Treatment' with support bed units springing up all over the country. The trouble is that they will be staffed largely by managers and nurses who are being transferred from the asylums and whose training and work experience is steeped in the institutional and disempowering ethos of the asylum. Thus we are in danger of spending a lot of money creating mini asylums in the community with the same ethos of no risk, no gain.

If Care in the Community is to be a worthwhile investment in the future of mental health care then nurses and managers are going to have to learn to take greater risks in the way we approach our client group. Taking risks means allowing the people in our care to be in control of their own lives, not us being in control of theirs. It means allowing people to make mistakes and learn from them. It means not just listening to people, but hearing what they are saying. It means allowing people to own their own experiences, be responsible for their actions. It means recognising the validity of other's experiences.

For nurses this is not an easy thing to do. It means a far greater degree of individual responsibility than the traditional role, it means giving more of yourself. Sometimes it means sticking your neck out. This is only possible in an atmosphere of mutual trust with ones colleagues and  with managers that recognise that we are not responsible  for decisions that service users take about their own lives.

This may sound like pie in the sky to a lot of people, but here in  Gwynedd it is a reality. We really are doing all these things, and it really does work. It really is possible to take this approach within the health service, we have proved it.

If we really are committed to moving mental health care forward then we must learn to relinquish control and deal with people as people. It may be harder work, but believe me,  it's also a lot more fun.