Cellar Door of “Not Another Nursing Student Blog…” has been writing an alphabet of secure psychiatric services, which is mostly applicable to any mental health unit, lately. She’s by now arrived ad D, for diagnosis, danger, drugs and (hopefully, eventually) discharge. However, last night I realized that there is one D that pretty much describes the patient’s engagement with staff, whether the people who tout “rehabilitative” treatment like it or not: dependence.
For clarity’s sake, I am not referring to anything within the patient’s mental or physical condition that causes them to need help with basic self-care, to a feeling of insecurity when staff are not nearby (you know, another patient might actually just kick off that very moment!), or to overreliance on the day-to-day institution structure (so what have you got besides your daily 10:30 coffee, if activities are scarce and you still get kicked out of bed at 8:30 to “stay in the habit”?). These all fall under what nurses mean when they refer to their patients as “institutionalized”. What I actually want to talk about, is the dependence that comes when staff decide, openly or covertly, what’s best for you. And sometimes, practices aimed at preventing “institutionalization” actually fall under this heading, too.
I remember in the early months of my hospitalization often arguing with one particular nurse over whether I should go to recreational therapy. He thought I should, in order to distract myself from bad, meltdown-provoking thoughts. He had a point there, but he didn’t know that I spent most of the time at rec therapy just sitting around doing nothing, and this gave me at least as much opportunity to go round in circles of negativity as just staying on the ward would have. The same nurse proposed almost every week during domestic meeting, that the ward enforce that everyone starts dinner together with a moment of silence and waits for everyone else to be finished before leaving. This was not a matter of cutlery being counted – my ward was not as secure as Cellar Door’s -, but rather, that the apparently “normal” standard of conviviality had to be enforced. The nurse’s argument, after all, always went: “You would do this at home, too.” Now I had practical objections to this rule (that never got enforced during the time I was on that ward): there were always quite a few very unquiet patients, who would not be able to wait for everyone else and who would likely be creating trouble over dinner. I’d rather have the ability to leave before someone starts acting up. Besides, this isn’t home: at home, I for one live alone so don’t have to wait for anyone, but supposing I did, it would not be for sixteen people. “Real-life” scenarios just don’t get carried over to the institution just because the staff proclaim to prevent “institutionalization”.
Of course, these are very minor things, and when I started this post, these were not really the things I wanted to talk about. Rather, I wanted to point out that, just because staff have supposedly embraced “rehabilitation” – which, according to the former student nurse here, doesn’t mean enforcing “normalcy”, but taking the patient’s wishes and goals as a starting point for treatment -, doesn’t mean the staff no longer dictate patients’ lives. Quite strongly so, in fact.
First of all, if you are “dangerous” – ie. if the staff find you annoying (I am the only one who uses the word “danger” in reference to my current time-out threat system, purposefully taking the law literally as it is meant) -, patient rights go out the window right away. It doesn’t matter that you’ve always been informally committed and therefore have to give informed consent for your treatment: “There is no alternative.” So, there. Now of course, the very fact that I’ve been a voluntary patient for two years – and only got threatened with a section once -, may be an explanation for why I let this happen to me: I dread being kicked back to my home, especially with no time to arrange for home support. I’m not sure if the staff instilled this dread in me, since I already told them right away two years ago, that going back into my own home wasn’t likely going to work out. In this sense, maybe I am weaker than the average psych survivor whose writing I read online – or maybe they aren’t involved in institution dynamics when they write anymore.
Secondly, even if you are not “dangerous”, staff might use your weaknesses against you in forcing you to comply. The threat of forced discharge, with very little prep time, has been used to me by my former ward’s social worker a few times, if she wanted me to sign some application form. As I wrote above, maybe it’s just me, but I always at least partly complied if she used such a threat. This social worker was also consistently referred to by everyone as “advocating for my interest”, and it was hard to deny this without offending her, since she did go to great lengths to advocate for me in some areas. Besides, she was the only one who could get me in touch with possible community care agencies, so if I wanted to leave, I needed her anyway. You know, even with all the relevant legal knowledge – I know more about mental health law than quite a few staff -, it is hard to defy someone whom you are dependent on in so many ways. She only used the suggestion (not a threat, just a suggestion in my file somewhere that I wouldn’t have known about if someone else hadn’t read it to me on my explicit request) of limited guardianship once, and I knew full well that this would not have stood any ground had it been taken to a judge. Nonetheless, I was scared.
Lastly, of course, there is no need to use the law against you at all. I can be intimidated by an authoritiarian voice, that says: “No arguing. It’s just a statement. I have decided.” Legally speaking, the doctor hadn’t – the matter concerned my second time-out plan, which I had to give consent for -, but by the time I’d processed what she’d said, she was gone (another tactic: scheduling appointments at 4:45, so that you will already be getting ready to leave). The on-duty staff made it worse, when the nurse who’d attended the discussion with me, refused to talk about it with me because she wasn’t the nurse I’d been assigned to – so why did she attend an important discussion with my doctor in that case? Another “no arguing” and the suggestion that I just might end up in time-out if I continued to act up, and I was silenced. Think this wouldn’t happen now? Think again: I so vehemently told the staff that I’d keep asking for a proper explanation of my third time-out plan until I got one, had been sectioned, had been discharged, or the plan had been abandoned. One nurse told me she’d ask my psychologist about it, but she probably didn’t. Then again, I’d rather keep the relative peace that I’ve been in for the past week, then get another blunt non-explanation like “There is no alternative”. Maybe I get off the plan sooner this way. Probably not. Really, I hate myself for being dependent.
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