There have been a number of recent articles about in-patient beds in psychiatry that seem to have hit me harder than usual. As a psychiatrist I have known for ages that bed numbers are shrinking, leading to ever-increasing pressure on clinicians to keep patients out of hospital. I have seen it first-hand where I work – although I don’t myself work on a general adult psychiatry ward, I have friends and colleagues who do, and I sometimes visit patients in that part of the hospital. There always seems to be a feeling, in many large services, that somehow we will scrape through. But it doesn’t seem so certain any more. There is a shocking lack of nurses, difficulty recruiting psychiatrists and, ultimately, a potentially devastating impact on patients.
I don’t know how to solve any of this. There are so many factors – not enough nurses and doctors being trained, funding, expanding definitions of mental illness, pressure on primary care, deprivation – that I don’t even know where to start. But what I do know is that those people who are admitted to the wards are some of the most unwell, and when you start chipping away at that group, two things happen: the first is that the in-patients are even more unwell, the second is that there are a lot more unwell people not being admitted. Clinicians are affected by resources, however much they don’t want to be, and they have to make some difficult choices. There are some very good community intensive care and crisis teams, but they too are being hit by the same bullets.
I was first admitted to a psychiatric ward in the nineties, and it was no picnic even then. The décor was grey and tired, my memories, such as they were, are mainly of endless days, where time moved so slowly that it was unbearable. I sat doing nothing, mostly, interspersed with periods of terrible agitation, where I walked and walked, going nowhere. It was a prison. During my stays I was, at times de facto detained (and actually detained at least once, albeit briefly), and the stairs led to a kind of freedom that could only ever disappoint. But why keep people next to an open exit that is prohibited? I don’t remember any activities, or speaking to anyone very much. It was odd; prior to being admitted, I would feel so awful that it was hard to see what else to do – it was a sanctuary of a kind, I suppose. But it was an intolerable one.
There were occasional kindnesses – one of the nurses rubbing my feet when they ached from pacing, being allowed to go first to ECT. But it was mostly grim, broken only by visits from family. There was pressure on beds even then, and if you went out on pass you might well find you had been moved to a different room. This may not seem too bad, but it was your only space, and the move was usually into a larger dorm, which wasn’t easy.
A later time I was admitted out of area, as I was by then a psychiatrist myself. It was a brief stay, as I found it unbearable being away from family, and left as soon as the threat of detention had lifted. But it was a bit different – I had a one to one with a nurse, something I had never previously experienced, there was also some occupational therapy, and we were actually taken on a trip to an art gallery. I don’t remember any enjoyment, but it broke up some of the interminable boredom, if nothing else.
My last admission, when I was a consultant, was also out of area, but to a different place. I don’t remember much, due to the usual ECT amnesia, but on one occasion a woman came and put hot stones on my back. I remember it because she was so kind – it didn’t cure my illness, but it was so worth it.
I’ve managed to stay out of hospital since then, thanks to out-patient ECT. Even at these times, it seemed as though belts were tightening – other than appointments with my psychiatrist, there was no other support. I think my family might have benefited, not just me. But I’m very grateful that I was able to stay at home.
The problem is that I know that I could get ill again, and that I could be very ill, and I’m frightened about what might happen. My psychiatrist is my only contact with services, and he might leave, or retire, or just discharge me. I am the opposite of a pushy person when it comes to healthcare, and I get phobic about phones. But even if I managed to access psychiatric care – what then? If I needed to be admitted, would there be a bed, and where would it be? Would I know anyone? The wards are crammed with very ill and disturbed people, and are chronically understaffed. I would be frankly terrified to be admitted now, and the more I see and hear of what is happening, the worse it gets.
I think the current crisis has brought back some of the horror of my earlier experiences – it may well be unhelpful to think about it, but I work in a hospital, and can’t easily get away from what is happening. Every day I walk past the unit where I was a patient – I had long come to terms with this, but it’s bothering me more now. And I know the horror was in most part driven by my illness – the place now looks boring and bland. But that’s my point, really – these wards contain so many people’s individual horrors, and there needs to be enough beds and enough people to carry all this and care for them. Otherwise we lose our humanity.