Depression Squared: Who’s Who
I have written already about what life is like inside a psychiatric ward, and also about the role of therapists in delivering a talking cure. But now I want to give an insight into the granite structure of the hospital class system which shapes how care is delivered.
Hierarchies exist in every hospital system. Anyone who has worked there or been inside the system for any length of time knows that. But perhaps they become more extreme — and certainly more noticeable — when body and soul are at stake.
Within a psychiatric ward doctors play God. Or at least a slightly swaggering, glamourised version of all-powerful divinity. One drug selected here, another there; a signature to release a patient, another to keep them in. They are not unfeeling, but there is a hard outer shell which all doctors working with psychiatric patients seem to grow, perhaps to protect themselves. I imagine it can’t be easy, acting as the sponge to so much negative energy, anger and angst, day in day out.
It means that the doctors, even the friendliest, are remote. They go by their surnames. They act as stern adult rather than friend. And they are elevated further by those around them in the system who depend on them to resolve situations. Only a doctor can provide a sleeping pill on a sleepless night. Only a doctor can step in with an SOS tablet when the world just becomes too much.
Therapists are the next level of elevation. A typical patient spends meaningful time — hours upon hours — with their therapist. And yet they will generally know remarkably little about this individual who means so much to them. The therapist needs to absorb and to reflect emotions. They act as the best kind of best friend — but it’s impossible to forget they are paid for the role, and end the sharing conversation at the given time.
It is a difficult transition from those depths of seemingly shared feeling back to the everyday as the moment of ending comes around each session. So therapists need to be tough enough to batten down when necessary. They are not all-powerful super-humans like the doctors. They make notes, never referenced or read in the patient’s presence and so become the chroniclers of your darkest depths, on behalf of the Establishment, for which they represent the friendly face.
The nurses in psychiatric wards, both male and female, tend to be a glamorous crew. Perhaps they stand out more because of the dowdiness of their patient population. But they arrive on shift fully groomed, the women all made up, with manicured nails, and an air hostess smile plastered on to their face. It rarely wavers whatever emotional baggage they encounter, however sad the faces that come to them may be. Not because they don’t empathise, but because a part of their role is to accept all that comes to meet them and to neutralize the pain.
They care passionately and deeply, about every one of the patients in their care, or at least they succeed in giving that impression. They will paint nails, cut hair, dispense tablets, serve food, and wipe away tears as needed. They never falter or tire that anyone sees. They have perfected the art of being there when needed, checking in on patients. Even when pre-programmed to ask how someone is every two hours, they mostly succeed in sounding as if they mean it.
Their power is not to be underestimated. They are the eyes and ears of the system, feeding back freely on the good and bad to those higher up. Their impressions and their judgement matter. They notice things. But not everything. It is possible to copy their own style and put on a smile to tell them that everything is just fine. It is possible to lay low and to lie, and sometimes they are too busy to notice the difference.
They deliver when asked. If a name is flagged, they will focus on it. Otherwise, there are crises to deal with on every shift — but the near misses may not get noticed. In large part, they simply do what they are told, and individual care may therefore depend on the effectiveness of lines of communication.
Patients are a disparate mob, each living in a separate hell. They divide into the long termers, and those who are just passing through.
The latter are loud, dressed in their own clothes, in and out before everyone even learnt their names. They complain, they fight the system, they tell everyone what is going on with them, they go.
Those who spend an extended time as in-patients act differently. They may pass the time in relative silence, dressed in the uniform of the place, closed off from most others there, submitting themselves to the rhythm of the days, resigned to more days of nothing. They do not talk because there is nothing new under the sun. They have learned not to care what they look like as they drift through the twilight familiar world of the ward.
A certain rapport builds up between long-termers and those involved in their treatment. Each one gets to know the other’s rhythms. Certain nurses seem more “simpatica” — approachable when the world just gets a bit too much, or to ask for advice. A shorthand creeps into dealing with each other, perhaps unsurprising given the concentric circles everyone moves in, ripples slowly moving outwards until it all feels safe again.
Obviously the patient sits at the centre of psychiatric care — but sometimes the idea of the patient rather than the reality dominates. Patients are awkward people with unexpected corners. They can go with the flow most of the time, most of them, but they can also kick against the system designed to lull them into security. When that happens, there are a number of possibilities. But essentially a message goes up the chain to alert the grown-ups, and in extremis they arrive to turn the temperature down.
Psychiatric nurses and doctors have a steely core untouched by the extremes they encounter. They have seen it all before. They can manufacture the illusion of interest, but a patient is caught in their gaze only momentarily, and then the roving spotlight moves on and the game of chess resumes with its ordered ranks and files and the patients the pawns — powerless for the most part unless a player decides to give them wings.
