Behind closed doors: what I saw as a nurse on a psychiatric ward

Times

a day ago

'My God, I hope I never get mentally ill,' says a doctor in Fragile Minds, an account of life on psychiatric wards in Britain. You can only agree with her. The book — by Bella Jackson, a trainee mental health nurse so shocked by what she witnessed that she left the profession — reads like a cross between One Flew Over the Cuckoo's Nest and Nineteen Eighty-Four. But as she says when we meet, 'This is now.'
A rape victim is slapped with a diagnosis of personality disorder (PD) and called 'attention-seeking'. Her request to be assessed by a female is refused as she's 'manipulative'. A man dares to tell the consultant his medication is causing chest pain. He's threatened with 'seclusion''. He pleads, in tears, but is made to feel like nothing, bullied into meekly submitting. As he was as a child, you imagine. 'It's re-traumatising,' Jackson says.
Jackson — now 41, a therapist in private practice and mental health mentor, in London — had worked in social care and in prisons for five years when she began training as a psychiatric nurse on NHS acute mental health wards and centres in the south of England 'within the last ten years', she says, vague to preserve confidentiality.
She was stunned by the 'dissociation' of staff. She wanted to believe the doctors knew best, but instinctively felt something was 'very wrong'. Her university tutor agreed there was 'bad practice', but not enough for anyone to do anything. 'There are pockets of good care,' he told her, 'but there is a lot of this.' She thought: 'Can't we complain?' She's taken aside, told not to ask so many questions.
'I want people to see what's happening behind these closed doors,' she says now, so they can 'protect themselves and their loved ones, if they are involved in mental health services'. So they know what questions to ask. Too often, 'We assume the answers we are being given are the correct ones.' She says: 'You need to be curious. When it comes to mental health, the expert on us is us.'
This affects us all. It's alarmingly easy for anyone to be locked away. 'There wasn't consistency — of diagnosis, of sectioning,' Jackson says. 'It was so bizarre to see this incredibly important decision-making be so haphazard.' She witnesses a middle-class student brought into A&E. A spiteful-sounding nurse judges her 'bipolar' and calls a psychiatrist who declares, 'She's totally psychotic.' Jackson says: 'Hasn't she just smoked a load of spice?'
A clinician can argue that drug-taking has 'activated' an underlying illness. People aren't believed. The shrink says: 'She thinks she's a famous singer.' Jackson looks up the girl on her phone — she's a folk singer. Only her family turning up, refusing antipsychotics — and the lack of an available bed — avoid her being admitted to an acute psychiatric ward.
• Read more expert advice on healthy living, fitness and wellbeing
Once someone's in the system, labelled with, for example, schizophrenia, PD (often 'weaponised') or delusional disorder, anything they say can be paranoia. Racism features, a lot. An African woman insists she's been sectioned because her kids want her house. Crazy. But it turns out she's sane enough to get a diplomat from her country of origin to order her release.
Another inpatient, in his fifties, characterised as sharp, witty — 'I understand you, I just don't agree with you,' he tells a patronising nurse — appears to have autism. His family's request for an assessment is refused as it's 'too late'.
Jackson is told 'they don't want the stigma of mental illness''. She saw little understanding of neurodiversity, and cites research that finds misdiagnosis is common. Yet, if a doctor says, ''Oh no, it's not that,' how often do we push back?' Why couldn't his family get him out? 'The legalities around sectioning would mean that it was very difficult.'
On a section, you're deemed unsafe to be outside. 'You'd have to go through a tribunal. Some people did really fight to get their family members out, but a lot of people didn't.' ('How do I argue with a doctor who says my relative is unwell?')
Characters are composites to protect identities, but it all happened, 'all these things were said to me,' Jackson says. She carried around a tatty notebook, 'just writing everything down, because I could not believe what was happening'.
Patients' treatment by staff is frequently callous. 'Some people have good experiences,' Jackson stresses — but Fragile Minds focuses on the worst. The mentally unwell are often traumatised, yet there's no attempt to understand the context for their behaviour. When people go into services, 'they really are hopeful for compassion. It's devastating when they don't get it,' she says. 'It makes me so angry. It can really destroy us.'
Most are 'boxed into a diagnosis' and medicated, often oversedated. Jackson and another decent nurse question a young man being given four daily doses of lorazepam — a benzodiazepine — as he can barely stand. They're ignored until he nearly drowns shaving — collapsing unconscious face-down in his sink.
'These medications do help a lot of people,' Jackson says. But many have severe side-effects, and also they're used 'punitively'. She saw medication used 'as a restraint on wards, to calm people down, to shut them up, put them to sleep. It's used by force, it's used through coercion — very different to someone choosing, and saying, 'This helps me.''
• Our new health crisis — we're diagnosing too much, too early
One nurse says: 'I'm all about a good injection.' To Jackson's horror that a woman prescribed the antipsychotic clozapine has undergone a drastic mental and physical deterioration on the drug, her doctor responds Orwellian-style: 'I think she's got better.' Soon after, the patient dies.
Jackson hopes it doesn't come across 'that the staff are demonised'. She says they're exhausted, overworked, and don't receive adequate psychological training or support to withstand working with distressed, unwell people and remain empathic.
'You needed a shield, almost, an absence of feeling. And what that created then was very much an 'us and them'.' But it wasn't just no empathy — your book describes cruelty, I point out. 'I think there was some cruelty,' she says slowly. 'You saw prejudice and bias, and cruelty.'
She suspects much of it comes from emotional burnout, 'and being asked to do things that feel morally dubious — if they're asked to restrain someone and inject them against their will, what does that do to a person?'
You can't then be all chatty and empathic with that patient. It's upsetting to dig deeper. Numbing yourself is 'survival mode'. So, 'You almost become this jailor.' Plus, psychiatry is hierarchical. 'There's a cruelty that comes from unchecked power. It was easy to forget that it was a person in front of you.'
Ideally — 'and these things are being fought for, in the wings' — there'd be more access to psychological therapy, family therapy, arts therapy and peer-to-peer support. We need to help people to find meaning in their lives, acquire skills, agency and self-esteem, she says.
'These are all parts of us that we need to rebuild once we break down, and we can't do that stuck in a ward where there's a TV screwed to the floor and some non-throwable furniture and there's nothing else to do other than take your drugs and sit still.'
And yet, she stresses, it's complex. 'The need to think about what someone's been through, and emotional connection, empathy, is so important in recovery.' But crucially, 'There's all sorts of risk with mental illness and mental distress,' so as a psychiatrist you're assessing risk: 'Is this person going to harm themselves? Harm others?'
• Six-day waits and security guards: the mental health crisis crippling A&E
A key question. A recent NHS survey found one in five people in Britain have a mental health condition and in 16 to 24-year-olds it's 25.8 per cent. But for all those who think, this could be my child — there are those thinking, 'What about the likes of 'the Nottingham killer'?'
This paranoid schizophrenic patient, repeatedly sectioned and with a record of 'extremely serious' violence, was allowed to stop his medication and go free (despite warnings from his family). He murdered three people. We've all seen their faces. Their grieving families.
Many patients Jackson encounters exhibit disturbing, frightening behaviour. Some are misunderstood rather than psychotic, she believes — and some are dangerous and violent. Not everyone can recover, surely? 'I agree with that,' she says.
So when does giving the benefit of the doubt put others at risk? Jackson stresses she's not denying that some people are very disturbed and need monitoring. 'And we can wonder about what happened to them.' Distinguishing between the dangerous and the harmless, 'figuring out what the dangers are and the risks', she believes, requires 'exploration and curiosity and needing to look at the context and seeing everyone as individuals'. Not, as she saw, 'a blanket approach'.
She says: 'The 'how do we get it right' question is something I can't answer.' Having left the profession shortly after qualifying, she still feels some shame that she was 'too crushed' to stay within it. But she remains 'honoured' to help people with their mental health. ('I am not a 'silent therapist',' she promises, on her website, 'and will bring warm, gentle inquisitive exploration to our sessions.')
Meanwhile, what Jackson is certain of is this: 'The system we have now is not making it safer for people. It's not reducing the number of suicides or violent crimes. What we're doing now isn't working.'Fragile Minds: Stories from an NHS Mental Health Ward by Bella Jackson (Doubleday £20) is out now