All cases discussed in this book are real life situations. However, in order to protect the identity and the privacy of the individuals involved, their names have been changed. The venues where the admissions took place, as well as the other therapies that they were encouraged to access have also been altered. The intention is to prevent the disclosure of anybody’s personal details.
To further protect our patients’ privacy, some aspects of their presenting problems on admission have been altered for the anonymity of each of the cases discussed in this book.
All names used in the book are fictitious. It is hoped that any resemblance to the identity of anyone living or dead is unintended and regretted. The use of names was supposed to help to present the stories in a more realistical way for the benefit of the target audience. The book does not attempt to ridicule human suffering. It would be irresponsible to use this forum to ridicule anyone. The intention is to present pictures of cases as near as possible to real life situations, yet, without compromising the identity of the patient.
The stories in this book represent real life experiences of patients at various mental health hospitals. They have been retold here in order to show the lighter side of some challenging situations that the staff on mental health wards face day after day. The challenges range from tragic and extremely violent situations, to the down-right hilarious. Some of the latter have been described in this book, not to ridicule, deride or to denigrate, but to demonstrate that it is not all blood, sweat and tears on these wards. There are occasions for laughter too.
Secondly, it is not the intention of the writer to attempt to give medical advice or to diagnose mental health conditions. Rather it is a humorous account of some cases that were treated in some mental health wards. Some of the cases described here have been modified to highlight how ordinary day to day issues could sky rocket into serious problems if they are not addressed appropriately at the outset. Many of them could have been resolved if simple common sense was applied by those who were aware of the issues at the beginning or who were in close proximity to the scene of the incident. Sometimes, those who were directly involved may have been overwhelmed by the situation in which they found themselves and they could not think rationally. In such situations, someone else might have to step in to call for help on behalf of those who were directly affected.
Some of the cases are so emotionally draining that looking at the lighter side of things becomes a coping mechanism or those involved may find themselves sharing the emotional fall out from extremely difficult situations. This is where it becomes important for staff to maintain a professional distance between themselves and the patient or their relatives. If care is not taken, it may not be possible to provide as well a care package as will allow them to maintain the assistance that the situations call for. In simple terms, it has to be a nurse-patient relationship rather than a patient-patient relationship. Empathy often helps to understand what the patient was going through but if the aim was to nurse a patient back to health, a fine line needs to be drawn between sympathy and empathy.
As stated earlier on, the accounts of the cases described in this book do not represent or attempt to give advice on treatments for the various illnesses described here. They are not to be taken as templates for diagnosis or treatments of any mental health problem. The aim here, again, as stated earlier is an attempt at giving humorous accounts of the lighter side of what are, in fact, serious cases. The stories are not to be taken as gospel truth because they have been watered down. Anyone who really desires to learn about or to gain further understanding of mental health issues should make an appointment to see a psychiatrist, or better still, apply to study psychiatry at a university.
The book is aimed at nursing and other ancillary workers in mental health services. It is hoped that they may see the funny side of these stories as an encouragement to uplift their spirits in this challenging field of work. In some instances, there are anecdotal references to specific issues. However, the use of psychiatric diagnostic terminologies and names of pharmaceutical preparations have been generally avoided. The idea behind the omission is to avoid misleading vulnerable people from buying such drugs online via the internet. It is an accepted reality of our times that there are people who would buy drugs off street peddlers or over the internet for self-prescribing and self-medication. The writer makes no claim to be a psychiatrist or a pharmacist and she would like to encourage interested parties to seek professional help if this is their intention.
It is hoped that these stories will resonate with people who work in this area and perhaps encourage them by the mere understanding that other people can begin to have an idea of the nature of their jobs. It is sincerely hoped that they enjoy walking down memory lane as it were, and drawing strength from the successes that they achieve from day to day.
To put things in perspective, if I ask you who you are, you will most probably tell me your name. However, that is not the whole story because although that may be your name, you are much more than a name. You belong to a family. You have a culture, perhaps, a religion, a social standing, an educational background, a professional and maybe some other backgrounds as well. These features together with your life experiences define who you are. These are what form the baggage that each of us carries with us wherever we go.
Each person is a complex but unique individual. No two people, including identical twins are exactly alike. Each of us lives in his/her own ‘private’ or ‘personal world’ but are also able to step out of this ‘personal world’ to interact meaningfully with others in the ‘common world’ shared by all. Other people with whom they interact would have to do the same so that they can all live in harmony in the ‘common world’ in which they find themselves. Each person’s baggage determines how they perceive events; it also follows that each person may see things differently. Our perceptions of events depend on how other people around us and the events in their lives fit into our ‘private world’.
Strangely enough, when people are under tremendous pressure they tend to recoil into their ‘private worlds’. They begin to interpret events from the narrow perspective of their ‘private world’ sometimes in total exclusion of the ‘common world’s’ perspective. While living in their ‘private worlds’, it may be difficult for others to see things from the narrow perspective in which they now see things. They, on the other hand may not understand that the ‘private world’s’ scope narrows things down to such an extent that the two world views would be heading for a head on collision. This is how and when a crisis occurs and most people in the ‘common world’ perceive the person in his ‘private world’ as behaving oddly or even “mad”. The word “mad” is seldom used in mental health settings. First and foremost, madness is not a diagnostic label. Secondly, anything can go mad; for instance the weather goes mad when it rains while the sun is shining brightly all happening in the middle of winter! Thirdly, the word “mad” refers to chaos rather than an illness.
Each patient whose case was discussed in this book was living in his or her ‘private world’ when they were admitted into hospital. When they made sufficient progress in their recovery, they were able to step out of their ‘private worlds’ and into the ‘common world’ which they share with the rest of humanity. They are now able to recognise their misinterpretations of events which led to their admission into hospital. Some of them find their presentation at the time of their admission, quite funny, hence the title of the book – “The Flip Side of Seriousness”.
These presenting problems are usually reviewed in the discharge ward round also referred to here, as an exit interview. The rational for these ‘exit interviews’ is, firstly, to enable patients to gain some insight into their presentation at the time of their admission and secondly, to perhaps help the person to learn from the changes in their behaviour now that they are fairly rational, stable, and in their right minds. Thirdly, it also serves as a means for relapse prevention in some cases.
Just a word of caution, research into the prevalence of mental illness in the wider society, indicates that one in every four people in the general population is likely to suffer from a mental health issue during his/her life time.
IT’S A BABY!
THE PRESENTING SCENARIO ON ADMISSION:
Danny was admitted in a manic state. On admission, he presented with an elated mood, grandiose ideation, and a degree of disinhibition. He was also easily distracted and interfering. He was well known to mental health services, having previously had several admissions into hospital with similar presentations. He had been doing well but had recently become highly excitable and unmanageable at home. His behaviour had become so disturbed and threatening that his pregnant girlfriend feared for her safety. There was a high risk that he might become physically violent towards her as he believed that her pregnancy was the cause of his current problems.
BACKGROUND TO THE PRESENTING PROBLEMS:
Danny has worked as a clerk at various places but he found it increasingly difficult to hold down a job for more than a couple of months. His behaviour was such that he was quite difficult to be with. He was too highly strung and quarrelsome. He was easily provoked, argumentative and disruptive at home. At work, he was often in trouble for frequently being absent from work and for the poor performance of his duties. He was unable to concentrate on one issue at a time for a considerable period of time. He tended to jump from one topic to another without successfully completing any one task or story before taking on another. His last employer tried to help him by sending him to a number of courses to help improve his performance at work but he came back without completing any of the courses he was sent to. In his view, the tutors did not like him. The fact, however, was that he was unable to cope with constructive activities or to concentrate on one task long enough to bring it to a conclusion. After a couple of months, he stopped showing up at work altogether.
At home, he still behaved like a teenager. He still expected his parents to continue to provide for him even though he was now a fully grown man. When he left his last job, he stayed at home most of the day and went out in the evenings. He applied for unemployment benefits and was overjoyed when he received the first instalment of his benefits. He kept the payments he received for his personal use as pocket money and refused to make any contribution towards his upkeep or that of the family home. He also refused to contribute to the physical maintenance of his home, such as helping out with cooking, gardening or any other house work. He frequently flared up when his parents asked him to pay for anything or to perform any chore at home. In order not to provoke him into an uncontrollable rage, his parents did not insist that he should make some contribution towards his keep. He spent his benefits to himself without any consideration for the sacrifices made by his parents. Gradually, he became involved in more altercations both at home and with his friends when he went out in the evenings. His parents began to find it too difficult to manage him at home and they suggested that he should make an application for his own separate accommodation. In response to this suggestion, he smashed up nearly everything in the house.
His parents realized that his reaction to their suggestion was not normal behaviour and that something was wrong with him. They called the police to help prevent further damage to their home. When the police arrived, Danny tried to run out of the house but was stopped by two police officers. He was partially restrained, cuffed and escorted into the police van. When they arrived at the police station, he was assessed by the Force Medical Examiner (FME) commonly known as the police doctor. The police doctor identified symptoms of a hypo-manic state. He was deemed to be mentally unstable and was referred to the A&E department of the local hospital for further assessment. After a second assessment by the mental health professionals there, it was decided that he would benefit from a short admission into hospital for a full assessment and a review of his current treatment.
Danny was eventually transferred to one of the acute mental health wards at the local mental health hospital. After a short period of observation on the ward, he was diagnosed to be suffering from a mood disorder known as a hypo-manic state. He remained in hospital for a few weeks during which time, his parents were seen in ward rounds nearly every week. In the ward rounds during the course of his various admissions, his parents provided useful information about the onset of Danny’s illness, his family history, his childhood milestones, the level of his education and his performance at work. At the end of all the investigations into the causes of Danny’s illness, the opinion of the ward team was that his major stressor was an extremely low stress threshold due to poor impulse control.
In conjunction with the medication that had been prescribed for him, they identified further activities which they hoped would help Danny to remain well post discharge. The activities included breaking up his week into three blocks to help improve his educational level; day centre attendance for recreational activities and life skills acquisition to prepare him for independent living. The ward psychologist felt that in addition to this treatment plan that had been prescribed for him that Danny might also benefit from a psychological input to help him to gain more insight into his behaviour and to help him better manage his impulses and his stress levels. He was discharged back to his family after a two months stay in hospital. That was about six years ago.
At ward rounds during his current admission, it became clear that the triggering factor was that Danny became extremely upset that his girl-friend was expecting a baby. He felt that she should have taken precautions to prevent her from becoming pregnant. In order to enable him to gain some insight into his situation, he was asked what he thought would happen if both he and his girl-friend were not taking any measures to prevent her from getting pregnant. In response to this question, Danny insisted that she should have ensured that she would not get pregnant. After several attempts at explanations about whose responsibility it was to prevent a pregnancy were offered to him, he reluctantly admitted that he could have reminded her to take precautions. That was the extent to which he realized that the pregnancy was as much his fault as it was hers. It was then that it dawned on him that they were both equally responsible for the pregnancy. He conceded that it was also his fault but he went on to add that she should have informed him that she wanted to have a baby as he was not yet ready to be a father. His last statement caused quite an uproar of laughter in the conference room. He was told that couples routinely discussed such things but that the reality was that the baby was almost here. His girlfriend was in the eight month of the pregnancy.
When Danny was advised to either abstain or take other forms of precaution in future, he asked what that meant. After a lengthy explanation was given, he retorted angrily that it would have been easier if the doctors did not use fancy words. He said that he could simply have been told not to sleep with his girlfriend. He then added that he would not abstain because he was not a priest. That was followed by another episode of mirth. After a short interlude, he agreed that in future, he knew what to do as he was not ready to have more babies. That was about six years ago.
It was during his first admission to this ward that Danny met other young patients. He found out that most other patients had their own flats and lived independently with the help of care co-ordinators. He learnt that some of them only visited their families at weekends and festivals and that they also attended recreational activities or classes as part of educational programmes which were organised for them by their care co-ordinators. He joined ward based activities and realised that he was actually good at some of them. He enjoyed such games as table tennis, snooker and quizzes. He was surprised when other patients were visited by their girl-friends because his parents were his only visitors. He began to look forward to going home and perhaps finding a girl-friend too. Before he was discharged, he was allocated a care co-ordinator for his after care. The name of his care co-ordinator was Simon.
A few months after he was discharged from the hospital, Simon helped Danny to secure his own accommodation. His benefits were also reviewed to reflect his current needs. In order to prevent a relapse, Simon also visited Danny forth nightly to ensure that he was compliant with his treatment regime. Danny was encouraged to visit Simon at work every other week. This way, he had weekly contact with Simon. During this interlude, Danny met Moira at the day centre and they become friends. Eventually, Moira became Danny’s girl-friend. As Danny was doing quite well under Simon’s close supervision, both Simon and Danny reached an agreement to reduce the weekly contact to monthly visits. In essence, Simon visited Danny once monthly while Danny visited him once a month.
However, the plan fell apart when the contact between Danny and Simon was extended by Simon going away on holiday. While Simon was away, Danny suffered a relapse and was re-admitted into hospital. That second admission sort of confirmed that there was an enduring mental health problem which required revaluation and closer supervision than his current treatment plan and Simon’s monthly visits. As time went on, Danny eventually had more admissions. The triggering factors varied; ranging from an altercation with his parents, to a fight in the pub, or disagreements over trivial matters with Moira. Each incident began as a trivial issue but quickly escalated into a major incident often requiring the intervention of law enforcement agents. The trigger for his current admission was an elevated stress level which started when he found out that his girl-friend had become pregnant without his consent. He felt that he was not ready for fatherhood and should have been consulted over the matter beforehand.