Thursday, July 31, 2008

Letter to Prof Phil Barker

I have decided to write a letter to Prof Phil Barker and his wife Poppy who wrote, "The Tidal Model", to see if they can offer me any advice on how to deal with things.........

Dear Phil, Poppy whoever reads this!

My name is A Truly Registered Mental Nurse and I am A RMN working in a Recovery and Independent Living Unit. I have a diagnosis of Bipolar Affective Disorder which was first suggested to me following a episode of post partum psychosis in 2003. I had a episode of mild/moderate depression following the birth of my second daughter in 2005, and a psychotic depression last year. I rejected the diagnosis of BPAD preferring to stick with post natal illness until spring of this year when I began to research BPAD in order to work with people with this diagnosis. To put it simply I had a moment of insight that hit me like a ton of bricks. I had been asked in the past if I had ever been elated? "No -of course not " , I replied, quite honestly. I took the fact that on several occasions I had managed with no sleep for several days, decorated the entire ground floor of my house in 3 days which I rounded off with a shopping spree that I couldn't afford, went off to France on a whim because I wanted a bottle of wine, and have had many wonderful and exciting experiences as me being well -i.e. NOT depressed - Oops.

The reason I am writing to you is I read your book (The Tidal Model Guide), and it's impact on me was immeasurable. It touched me to the core because it's how I like to work, but my way was kind of undefined and without any structure I suppose. However, my approach and way of working does not seem to be going down too well at my place of employment, and I was wondering if you could give me some advice on this. People keep talking about recovery, but I don't understand their version of recovery, and I am becoming increasingly disillusioned with the feedback I have been receiving both directly and more the subtle undertones that I seem to pick up along the way.

I have been advised against getting "deep" or encouraging people to talk about the future if they are in a more acute stage of their illness, or in crisis. I've been advised that we need to get people to take there meds, stabilise them, and then we will have something to work with. It comes across to me as that their vision of recovery is succeeding in making someone adopt our way of doing things because "we know best". I reject this vision of recovery completely. I am also a bit worried that my colleagues think my approach is because I have a mental health issues, and that I am simply a lunatic attempting to run the asylum, a novelty, nuts, nurse. I don't want to compromise myself professionally, but I don't think that their way of doing things is best and I don't want to go along with it although I sometimes feel it would be easier as I'm a bit thin skinned at the moment. There are lots of other concerns and worries I have, and I am going round in circles in my own head trying to make some sense of it all!

I have started writing a blog which reflects my thoughts and feelings in regards to how I nurse, and managing my own feelings about my own issues which are not yet sitting comfortably, but I am trying to come to terms with. I am feeling increasingly confused by how to bring it all together to improve both the well-being of the people I work with, and myself. I won't go into any more details as I'm not sure if this will reach the right person, but if it does I would love to hear from you, and I will give you my blog address if and when you get in touch.

Thanks again for putting together such an inspirational book, and for reflecting in such an articulate and understanding way my own thoughts and feelings on what recovery is all about.

Best Wishes

A Truly Registered Mental Nurse


I have just come home from work early due to having a bad headache. I think it's probably due to stress. Just feeling very confused and uncertain sometimes about what I'm doing both at work and with my own head. Lots of stuff going round in my brain and having trouble finding any answers. I did however speak to a colleague a work who happens to be a clinical psychologist and I found that so incredibly helpful.

I am working with a patient (I shall call him Carl) as a named nurse who had a diagnosis of BPAD Type I. He is elevated in mood at the moment, however I have been spending time with him in order to develop a good therapeutic relationship. Or, just to hopefully become someone he feels he can talk to and trust. I have spent time with Carl over the course of the last couple of months doing in reach onto the acute ward, and now he has finally been admitted to our Recovery and Independent Living Unit.

Since then I have tried to spend time with Carl in order to learn about his life, his experiences and his views on both the world and how he fits into this world. Due to the fact he is at the moment a little elevated in mood, I have used the Tidal Model Holistic assessment as a template for our time together. Conversation has a tendency to digress as Carl has a viewpoint, most of which are complex and very thought out, on just about everything! These conversations are very interesting, and I feel privileged that he has agreed to share some of his thoughts with me at this time.

During our sessions we have talked about mood, illness, wellness and how he sees himself. He rejects the diagnosis of BPAD and feels that the people who are saying that he is BPAD are merely justifying their jobs. He believes he has lots of potential and could achieve almost anything if he put his mind to it, his ultimate goal creating a Utopian society full of love and peace. His ideas on how to achieve this are in my view naive and over simplistic, but all the same they are principled and show that Carl's morals are certainly in the right place.

I find his hope and optimism about how he believes he can change the world wonderful to listen to in a sense, because his thoughts and ideas seem very pure and ignore all the real life political stuff that would make many of his suggestions unworkable as they do not take into account the certainty that the entire population is not going to agree with him!

The problem I have found at work is that it seems to me the rest of the team do not see this way of working with him "appropriate". I am putting that word in inverted commas because I hate it with a passion, and hate myself if I accidentally slip up and use it. I discussed a plan of care and way forward with the psychiatric registrar Dr. Chilled. He is a very nice compassionate man, and I believe he genuinely wants to do good and promote well being. Basically, when I showed him the work Carl and I had done, and the pictures that we had drawn together, which once Carl explained them, helped me understand where he was coming from, I was advised not to do this "deep" stuff as he was too elevated in mood and we needed to wait for him to take more meds to bring him down. Trying to make Carl develop "insight" was the key to helping him, as he would then take his meds and accept his diagnosis. When I said that I had found out what hobbies and interests Carl had, and I was currently looking at ways in which to facilitate him in developing them I was advised against this as "he starts enough things off on his own without us starting more off". When I said that I had talked about discharge planning with Carl, to find out what it is he wants from his time on the unit, I was basically advised that it was way too soon to talk about any of this stuff -we just had to focus on bringing him down. I'm really shit at putting together my thoughts on why I'm using the approach I'm using because I just come across as someone who doesn't know what I' m doing. So I kind of ended up sort of agreeing with Dr. Chilled, although I did say that I would continue to develop my relationship with Carl by talking about things he wanted to talk about.

Also, I spent some 1:1 time with Carl on Tuesday during the morning which was meant to be 1 hour, but spilled over by 20 minutes. Later in the office a couple of digs were made that, "she (me) hasn't been around all morning", "Can't spend too much time with one patient as there is work to be done", and me developing a horrible feeling it the pit of my stomach that:

a) My colleagues think I'm emotionally over involved

b) My colleagues think that I'm lazy because I wasn't doing what they are doing(?!?)

c) My approach is in fact -WRONG - and I should be doing it "their way"

d) I am emotionally over involved because I am genuinely interested and I do care and think I really understand what this man says to me, even though I don't agree with everything he says. I can SEE where he is coming from -(I think).

e) And finally, am I becoming paranoid about this, which is effecting my own mood which due to recent events and medication changes I am a little more vulnerable than usual.

I gt soooo frustrated and angry at the moment. I have a laugh and have a very black sense of humour, but some of the things I heard said just make me feel so uncomfortable. For example, A staff member telling a patient in a crowded dining room to "eat properly-it's disgusting to watch you eat with food spilling everywhere -like an animal!" The patient then said "Oh fuck off". The patient was then berated for "inappropriate behaviour" and she then stormed off leaving her meal and was in a bad mood for the rest of the shift. This was handed over as the patient being verbally abusive and inappropriate.

I'm not at all sure about this.

There are so many incidents of this it's unbelievable. If a patient swears they are told to "mind their language" or that its "inappropriate". Put their feet on a table it's "unacceptable and disrespectful". And then the staff proceed to go in the office, swing their own legs onto the desk, and punchuation their conversation with swear words and "inappropriate behaviour". Now I swear and have a laugh, but I try not to be a hypocrite and "tell off" patients who do it. Don't we all have a right to express ourselves in our own language? I suppose I am able to identify when it is OK to act like this, but from the patent's point of view, they must see us as behaviour police, or feel like naughty kids at school. I'm so frustrated at all of this because I don't know what is right, and if I am right in this I don't know if my skin is thick enough to handle this.

Last week I was told I would be having management supervision by my manager. I had been very confused by how to handle another patient I shall call her Joanne )in a way that would promote her recovery (she was very hostile and verbally abusive) and on discussing the situation with several colleagues and looking at careplans it transpired that no-one had a clue what we were doing, and there was lots of different personal feelings about this individual and her behaviour and personality vs illness. So I put my thought down, and asked others to add to it. Apparently this was a BAD IDEA because

a) it was treading on other peoples toes.

b) no-one else had mentioned there was a problem, so there wasn't a problem.

c) As i only started in early spring so i didn't understand the situation.

d) i should have asked for clarification from the named nurse team (on annual leave by the way).

I cried. How pathetic is that. I cried because I thought I had upset other people, which was the last thing I had intended to do. My manager did say that it was a good piece of work, but I later found out that it hadn't even been referred to during a case conference held at a later date. Perhaps this was because it contained too much of the patient's views, and put some of the teams negative feelings about this patient on paper. I still don't know even now. I was told that the TEAM had a very clear view of where things were going, and that was just to get her through the crisis. When i said that I had talked with her about discharge and future, I was told that we (the team) had no idea what was happening there and to just focus on the crisis. I said that I felt if the crisis was handled with an eye on the future this may have a better outcome for the patient. I was told that I was focusing to much on the BIG PICTURE yet I should just focus on the moment. I continued to try and restate what i was trying to say but felt that my manager though that I really didn't have a clue and I was probably one to watch. (For the wrong reasons).

I ended up apologising, and saying that I'm just getting used to their way in working, and in acute we were less precious about the named nurse system, and even on admission we began to consider discharge.

So I feel alone at work. With exception of the clinical psychologist who reassured me that the way in which I was working was a good thing.

I told her that I felt like a fraud, I felt more comfortable with the patients than the staff, as if I could be myself. I felt more accepted by the patients, and enjoyed their company and conversation than the staff. That I love hearing their perception of the world, and thinking of ways in which I could help them perhaps see things in new ways which might mean they are more likely to achieve their goals in life.

I told her I felt like I was hiding. You are either a patient or a nurse. So you are best to put yourself across as a nurse because you can't be both. I feel ashamed of this shame I have. I would love to reach a point where this whole mental illness thing and my diagnosis sits comfortably with me, as a nurse and as a patient. I don't want to become an aggressive campaigner, I just want to feel comfortable with my own brain the way it is. I want to be able to say "I'm a nurse and I have experienced mental illness", to colleagues and patients alike.

The wards Consultant Psychiatrist. Dr. Hippy I shall call him, had a chat with me about these thoughts I had been having, and the fact that I was worried that my own experience and the fact that I was currently trying to deal with my own problems would mean I was a not so good nurse. He suggested that I see myself as duel qualified - a term I liked.

Carl asked me why I seemed to understand what he was saying. He said I was like him. He asked me if I had BPAD as I seemed to know a lot about it. I laughed it off because I couldn't bring myself to say no. I lied to him. He told me to be careful or they will lock me up too if I don't stay boring like everyone else.

Maybe he's right.