Baselines

If you’re going to last in this job, you have to accept there are some things you cannot change.

a) it’s inevitable that some patients will top themselves,

b) that some patients have symptoms (both positive and negative) that will never improve, resolve or remit. (*) Which means they are never going to get better than they are right now. There’s only one direction of travel, they are definitely going to get worse as time passes,

*) reasons can be simple downward drift, multiple relapses, medication resistant symptoms, drugs…

c) and there are many, many (so many that MoPs cannot conceive of the numbers) patients out there, living chaotic, mad, neglected, alcohol and drug fuelled, abusive and abused (etc) lives that

i) the newspapers wet themselves about the state of these patients and accuse us (MHS) of anything and everything, including ‘not doing enough’ (one of their favourite meaningless accusations) but even so,

ii) you, the CPN (*) cannot do a damn thing about any of it. And that was true before management ruined our job. Even back then, you still couldn’t help them. They live in chaos and the only chance we get to intervene is when they are arrested or relapse and get sectioned (which nowadays is a naughty, coercive no-no). Sometimes you get a phone call from a neighbour or relative with something that allows us to admit them. It’s in hospital, during the quiet, boring, sober hours of ward life, that nurses, doctors, psychologist sometimes get through to them. That’s presuming they’re are somewhere they can’t score drugs or alcohol. It used to be a given but certainly isn’t nowadays.

*) CPN = Community Psychiatric Nurse. CCO or CCM = Community Case Officer or Manager is the equivalent for non-nurses, e.g. Social Workers, Occy Therapists.

These states are what we call ‘baselines.’ For the idea to be of any use, there have to be plenty of professionals who’ve remained in their job for years (*) because that’s how they gain a full, ongoing, current picture of the patient’s ups and downs, how they know what is ‘normal’. Remember, loads of our patients never achieve full sanity, full remittance of symptoms, a return to normal life. Hence the importance of someone knowing where their baseline is. An example of when this works is when the patient’s experienced CPN attends the ward round where they are considering discharge. Let’s say the patient was new to the doctor and nurses on admission, he’s improved on medication and the quiet ward life but they don’t know if he’s only halfway there or back at baseline. The CPN can tell them. That’s if she hasn’t had to can the ward round because management have just dumped an extra half dozen on her caseload after someone else resigned or was sicked off.

*) not helped by overpromoting young women to management jobs before they’ve even been grounded in mental nursing’s fundamentals. Also not helped by those young nurses being dumped with a massive student debt making them eager to climb the earnings ladder as quick as they can.

NB there’s another category of patient, usually schizophrenic, with treatment-resistant symptoms, living ‘in the community’ who have achieved the rare state of ‘happily mad’. I remember two brothers, mad as hatters, living in a mobile home (some caravan parks can often be an accepting community with a lot of other societal drop-outs, alternative types, alkies) who were living their best life. They both had responsibilities (e.g. one cooked) and though the bedsheets were black as pitch and you and I wouldn’t have accepted a cup of tea from them, they were happy and purposeful and harming no-one, certainly not themselves. They did NOT need admitting because middle-class pearl clutching women become horrified that they are not living sweet middle class lives and getting their five-a-day! Those men’s lives were as good as it was possible to get. Of course, they still need a CPN checking in on them from time to time, and they still need a regular psychiatrist’s review, medication review etc. We must check whether a new ball of chaos they can’t handle has dropped into their lives and overloaded them, e.g. has an ex reappeared on the scene, has a bureaucrat shortened the interval they have to re-apply for benefits? If not, we must accept that kind of patient is at baseline and leave them be. Intervening upsets the degree of stability they have achieved.

Next problem – patients who remain dangerous at baseline. This is where the least restrictive policy has really dropped you and your loved ones in danger. Currently, there is a Guardian-BBC led crusade against IPP sentences (Imprisonment for Public Protection). The objections focus solely on the dreadful suffering of the poor imprisoned dears who haven’t lifted a finger to reduce their own dangerousness,

Here are a few quotes from the usual suspects –

Lord Simon Brown, UK Supreme Court Justice (*) – “I have no hesitation in describing the continuing aftermath of the ill-starred IPP sentencing regime as the greatest single stain on our criminal justice system.”

*) The invention of the UK Supreme Court was another of Princess Tony’s nails in the British Constitution’s coffin and a method by which his mates could more easily be granted senior judge positions in the new bureaucracy.

Centre for Crime and Justice Studies – ‘Indeterminate sentences across the UK could amount to psychological torture…’

Howard League. ‘IPP sentences came to be used as preventative sentences, imposed because of concerns about what someone might do rather than as a proportionate response to what they had done.’

I call bullshit. Try this instead Howard. ‘IPP sentences came to be used as preventative sentences, imposed because of concerns about a criminal repeating exactly the same offence as he’d already been convicted of ten times before and his repeated refusal to even try to imagine what his victims had suffered.’ 

I can’t find any quotes from the little girl who wasn’t raped because the monster wasn’t released from prison. Or the mother who wasn’t so traumatised she couldn’t work the front counter ever again because a post office armed robber was let out yet again on the promise he had truly reformed this time, honest guv. Um, hold on, I probably need a time machine for that.

And for years now Britain’s mental health services have adopted the same ‘perps rate higher than victims’ value system. And managers and regulators are rewarded for it.

Read on in ‘Baselines Part II