People imagine mental health nurses like me as kind and gentle, as mother figures in uniform. What they don’t see is the harm we do to our patients: we lock them away, we restrain them and we take away their freedom. We do this in line with the law and we firmly believe we are doing the right thing. We are not “nice”, but when I look at my colleagues, I see strong, selfless, determined heroes.
I wish I could offer service users something better: a peaceful outdoor space, their own room, something less clinical than easy wipe armchairs. Most of them do not even agree that they are unwell and this deeply felt sense of injustice permeates the ward.
I remember one woman, Sarah*, was so psychotic by the time she entered hospital that she was not eating and had not washed in weeks. She could not see that she was unwell and was convinced we were trying to harm her, so would not accept medication. You could see how much she was suffering from her disheveled emaciated body to the distant horrified look in her eyes. We couldn’t just leave her like that. Her psychiatrist decided we needed to give her a long acting antipsychotic injection. She would need this to treat her psychosis.
The time comes to give her the injection. Despite doing everything we can to persuade her, she refuses to accept it and we have to do it under restraint. She is terrified and struggling so much to try to get free that we need five people to restrain her so she is lying on the floor. Her injection is licensed for the top of the buttock only, so we need to lower her trousers and underwear to administer it. We constantly check our techniques and her posture. We make sure that she can breathe freely and that we are not damaging her joints. She needs to be very still so we can inject her in the right place and not near important nerves or arteries. We explain this and try to reassure her but she remains terrified of our intentions. She lets out a primal wail of fear and then starts to scream. The room smells of sweat and anxiety. But we still have to inject her. I stay with her afterwards and she cries uncontrollably.
What really cuts right through me is that restraint is not some awful mistake, it is a carefully planned intervention. Everything in your being wants to stop this, to let the poor women be, but you have to carry on because you know it’s the right thing to do. It takes more than “niceness” to be here, you have to have a heart as big as the earth and, at the same time, be made of stone. Of course it helps that I found out a few months later she was rebuilding her life again: she was eating normally and looking after herself.
In my experience, there are very few decisions in nursing that weigh on us more heavily than whether or not to restrain someone. By the time someone is in hospital, they are often in extreme states of crisis and all the kind words in the world will not persuade them to take medication.
Prevention, in mental health, is everything. If we catch people in the community, as they start to deteriorate, they are more capable of engaging with services, of expressing their wishes, of maintaining their dignity and autonomy.
In the case of Sarah, and so many others, services were so under pressure that there were not the resources to catch her at this tipping point. The answer is not just medical intervention, it’s about keeping Sarah well by supporting her to live a rich and purposeful life.
Now, with so many cuts to social care, she is increasingly isolated. Real terms spending in mental health services dropped by 8% between 2011 and 2015. The success of these savings is constantly being rated against efficiency criteria like length-of-stay and symptom reduction but, for me, the real human cost is harder to quantify.
*Not her real name
Some details have been changed
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I hate restraining mental health patients but often it"s the only option
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