Working in community mental healthcare keeps your feet on the ground and with low staffing I was at work on Saturday, helping to provide a duty service. We were expecting some abusive phone calls from Pat, one of our service users. My colleagues had administered Pat’s depot injection in the week and this is always a difficult experience. She respects the conditions of the Community Treatment Order under which she accepted discharge from hospital. However she does not respect us and she makes her feelings known. She accuses us of raping her. She makes personal and cruel comments about our nurses. In her view we are subjecting her to a humiliating, abusive and unnecessary treatment; we are poisoning her.
We offer a ‘gender sensitive’ approach to depot administration but getting Pat to the clinic requires two members of staff. She shouts at us when we pick her up, she is sullen and prickly when we try to make conversation. She quivers and screams when she see the needle. Our nurses are very professional in taking on this difficult work, but they do use some dark humour. We wonder if we should ask Pat to complete our patient feedback survey: ‘Is she satisfied with our service?’ ‘Would she recommend us to her family or friends?’
Making clinical decisions is difficult and imposing unwanted treatment is not comfortable for us. However, imposing treatment on Pat is justified by medical understandings. We can, for example, understand Pat to be unwell and we imagine a ‘well Pat,’ who thanks us for treating her and enabling her to have a better quality of life in the community. We don’t actually meet the Pat who is well and we cannot see how she could ever be content or happy with her life. But we talk about ‘treatment resistant psychosis,’ we observe a ‘lack of insight.’ These understandings will be useful when Pat talks to her solicitor and we need to write a Social Circumstances Report for a hearing or a tribunal.
In our handover meetings we agree that progress is being made. Pat’s anger is now directed at us, rather than at her neighbours, or random people in the street. The police have stopped phoning us, now that incidents of criminal damage or breach of the peace are no longer reported. We agree that the treatment we force on Pat is damping down her emotional distress. She still believes she is subject to abuse and that people are plotting against her, but she does not act on these beliefs. It occurs to me that we could justify enforced treatment on moral or practical grounds. We could accept that it is Pat who is angry, not her psychosis. She has endured distressing life experiences and has every reason to be mistrustful, to reject authority and to question our medical understandings.
We did not hear from Pat that Saturday, we had no calls, the phones did not ring. We sat in the bleak office which is now filled with hot-desk computer stations. There was a time when we could personalise our working environment but the office offered no comfort in the dismal rainy day. We found out the following week that there were problems with the phone lines again. Cost savings mean that we have to creatively manage this infrequent problem and the lines were open again on Sunday. Conversations turned to the waste of resources in covering weekends. We usually conclude that the occasional crisis we manage across seven days, along with the daily delivery of medication, make the seven day service worth the investment.
We anticipate better engagement this week when Pat gets her benefits payment. Although we are ‘agents of the state,’ who ‘oppress and abuse her,’ she now accepts our support in shopping and organising her bills.