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Someone Like You

August 19, 2014

I see Who Do You Think You Are? is back on our screens. I quite enjoy it, but I think it gives the ordinary viewing public unrealistic expectations of what their own family histories might contain. I mean, not everyone is going to unearth a line going back to William the Conqueror via Edward III or even – at the other end of the scale – get the chance to wallow in the deliciously scandalous revelation that they’re descended from a brothel-keeper of Victorian London. The fact is that most people’s ancestors turn out to be much like mine: dull. Extensive research has left me no nearer to knowing where my interest in writing comes from. But what it did do – just possibly – was provide some answers to a rather different question – one I didn’t even know I was asking when I started out.

 
Mental illness has always been an open secret in my father’s family. Just in his lifetime, two relatives have taken their own lives, and others – me included – have at different times been treated for depression. Yet finding a tentative source for all this unhappiness gave me an odd sort of peace. Learning that my great-great-grandmother almost certainly had some form of mental illness for much of her adult life, and, moreover, that this was something that other members of her family shared with her, helped me to place myself within a bigger picture, and opened up the possibility that the despair that I have sometimes felt, far from being random, is actually a channel through which to hear a distant echo of my forebears’ lives.

 
Mental health has just had a rare week in the spotlight. The tragic suicide of Robin Williams was followed by the publication in the Health Service Journal of a shocking report about the true extent of savage cuts in mental health funding and the knock-on effect on patients. The Guardian also ran a series of articles on mental health in which it claimed that ‘less than a third of people with common mental health problems get any treatment at all’ and asked how the public would react if the same were true of the major physical diagnoses like cancer.

 
It was a disparity that was highlighted by Professor Simon Wessely, incoming president of the Royal College of Psychiatrists, in an interview with the paper. Stressing the links between physical and mental illness, he criticised the rigid divisions between the two that have characterised the NHS throughout its history and said he ‘strongly believes in the need for general doctors, nurses, midwives and social workers to have more mental health training and for there to be much greater integration of diagnosis and treatment of physical and mental disorders’. Which raises a very interesting question: how can we best equip nurses to help patients who have both mental and physical health problems?

 
Thirty years of sitting through nursing handovers have left me with the feeling that most general nurses’ understanding of psychiatric illness is little better than that of the population as a whole. I don’t exclude myself from that sorry admission either – my sole brush with mental nursing was an eight-week acute placement in the mid-nineteen-eighties. Whatever I’ve learnt since then has mostly been the result of ordinary life experience. Do I think this is good enough? Of course not – but doing something about it will be far from easy.

 
One possibility would be to employ mental health nurses to act in an ‘advisory’ or ‘liason’ capacity on the general side. Professor Wessely’s example of ‘trials [that] have shown that picking up and treating depression in people with type 2 diabetes improves the control they have over the disease: they take their medication and keep complications at bay’, shows how valuable this could be, but also presupposes that facilities to treat the depression are ready and waiting; and if last week taught us anything, it’s that this just isn’t the case. And there’s another problem too: turning mental health into ‘just another referral’ or ‘someone else’s problem’ does nothing to increase general nurses’ engagement in holistic care.

 
Increasing specialisation in nursing has turned any mention of the words ‘holistic care’ into something of a trip down Memory Lane. Its last ‘moment’ was back in the 1980s when the ‘therapeutic nursing’ movement seemed to offer the promise of some kind of melding of the general and mental health arms of the service. That ‘therapeutic nursing’ failed to bring about lasting changes in the way general nursing is delivered is down to a number of factors, but one of them may have been an over-optimistic conceptualisation of what ‘therapy’ is. For therapy to have real impact, it needs to be about more than hand squeezing and warm feelings. It requires skill. It requires training.

 
So does the answer lie in changes to nurse education? Would nurse education serve us better if it were more generalist (in the sense of embracing all aspects of human health) in content or split only between ‘children and young people’ and ‘adult’ with specialisation in a particular field coming later? Or would that make nursing courses too heavy and unwieldy and produce graduates who were jacks or jills of all trades and masters of none?

 
One thing that is certain is that certain is that in the face of the Health Service Journal‘s reported loss of 3,640 nurses from NHS mental health services between April 2012 and April this year, we cannot simply hope that general nurses without specialist skills can plug the gaps by being extra compassionate – to be fair, no one has advanced this as a plan, but Health Secretary Jeremy Hunt seems to have little else on offer. In a week of shocking figures and harrowing personal testimonies, one of the most truly scandalous was his reported remark to Tony Blair’s former director of communications Alistair Campbell that ‘he found it really hard to understand “why someone like you, with the life you have, would have depression”’. I think that tells you all you need to know.

 
My great-great-grandmother was born in 1847 and baptised Theresa. Three weeks later, her mother emerged from the registrar’s office clutching the birth certificate of a boy named Tracey. It was a pattern that was set to continue. Throughout her life, Theresa adopted a number of different identities including Emma and also Rachel. In 1871, she gave birth to a son. There is no record of a marriage between herself and the father, but they remained together for the next twenty years, and she assumed his surname. They never stayed long in one place. Of course there could be many reasons for this – but one must be that Theresa’s illness caused her to behave in ways that made the family unwelcome to their neighbours, forcing them constantly to move on.

 
It seems likely that her husband was her protector. After his death in 1891 she went to the asylum, where she remained until she died herself. By then her sister was also in an asylum; her brother took his own life in 1917. But what angers me the most about the census returns from 1901 and 1911 is that they strip my great-great-grandmother of even that most basic human dignity: a name. She is represented by her initials only – T A

 

In her earlier life, the name she seemed most attached to was one that she must have invented herself. To my mind an ugly word, she was so wedded to it that in the column for ‘mother’s name’ on her son’s birth certificate, she had ‘Theresa’ crossed out and replaced with the one she chose: Treesaw. She was Treesaw; and as such I want to reclaim her. The widow T A in the census returns for the Shropshire and Montgomery Counties and Wenlock Borough Asylum for the Insane is, I believe, Treesaw Adams – mental health survivor, great-great-grandmother, part of me.

 

The Health Services Journal report is paywalled. The Independent reproduced some elements of it, which can be viewed here: http://www.independent.co.uk/life-style/health-and-families/health-news/cuts-leave-nhs-mental-health-services-dangerously-close-to-collapse-9667370.html
For the interview with Prof Simon Wessely, see: http://www.theguardian.com/society/2014/aug/13/two-thirds-britons-not-treated-depression
For the Alastair Campbell article, see:

http://www.theguardian.com/commentisfree/2014/aug/12/robin-williams-tragedy-understand-depression

 

 

 

 

 

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12 Comments
  1. Barbara Bradbury, Halland Solutions permalink

    I am sure that there needs to be a change to nursing education. I have always believed that it was a big mistake to make people choose to specialise as a student and become one “type’ of nurse. I think all nurses should know how to care for ill adults and children who can be considered to be as “normal” as possible when physically well (I use this term with extreme caution, only to try and illustrate my point) so that they understand how ill health and vulnerability affects people, and how they return to their usual state as they recuperate from their illness. This is the norm for the majority of people, I suggest. Once you understand what is “normal”, the affect of ill health – physical, mental or both – is put into context.

    • I do wonder whether a ‘generalist’ training with specialisation later on would help bridge the completely artificial divide between ‘mental health’ and ‘general’ nursing. It might also help the two branches to appreciate each other’s special skills and help them to learn from each other. Unfortunately, we seem to be actively moving away from this model: the ‘common foundation’ approach has come and gone in the years since I did my own training, and now seems to have fallen by the way.
      What I would also say, however, is that if we were ever to return to this type of nurse education, it should not be as a way of producing ‘RMNs lite’ to fill the current gap. Nursing of people with mental health problems requires a high level of specialisation and skill which can only be acquired with the appropriate education and training.

  2. Barbara Bradbury, Halland Solutions permalink

    With respect to your great, great grandmother’s name, and please excuse me for being so presumptious as to offer this comment as, of course, I know nothing of her, I did wonder whether her changing of her name to Treesaw, might actually have been one of pronunciation. In other words, that she thought that Theresa was actually spelt Treesaw. I mention this because I remember a Health Visitor colleague of mine many years ago recounting a story: she was visiting a child and, on looking at this little girl’s notes, said to her mother – cautiously – “Oily-Acha. That’s an unusual name”. The scathing reply was – “It’s Alisha!”

    • It’s very hard to know, especially as I can’t be sure of levels of literacy in my family at the time. However, Treesaw could recognise the spelling she didn’t want – as on her son’s birth certificate – and insist that it be changed. I have no idea why she was registered as a boy – but I can say that other children in the family suffered similar gender-confusion. A son who died in infancy was recorded as female on his death certificate, and children are shown as the wrong sex on census returns as well. In the case of the child who died, a few days later the certificate was returned to the registrar and altered. Presumably someone who could read had got hold of it in the meantime and pointed out the mistake – although you could also argue that this kind of thing was happening rather too often for it to be a mistake.
      My great-great grandmother’s son and his wife (both of whom could read and write) registered their eldest daughter as ‘Treesaw’ – suggesting, perhaps, a conscious choice of spelling in order to honour the child’s grandma. This baby grew up to be my own grandmother, and (quite rightly in my opinion – it is very ugly) abandoned ‘Treesaw’ as soon as she was able, to become Theresa.

  3. Another beautifully-observed and humane piece of writing from Grumbling Appendix. As a mental health nurse, I know we still have a long way to go before we achieve the fabled ‘Parity of Esteem’ where mental health is valued, resourced and understood as well as physical health. More holistic, person-centred nurse education would, I’m sure, help, though mental health and physical health nursing are perhaps always destined to remain two distinct tribes, two different kinds of vocation, attracting people with different aptitudes and interests. For all that, mental health nurses are striving, somewhat belatedly, to remember to attend to the physical health needs of their patients and I hope that nurses working in physical health care will reciprocate by learning to be more respectful and empathic of their patients with co-morbid mental health conditions.

    Robin Williams, it seems, had been diagnosed with Parkinson’s disease but no doubt his suicide will be attributed to his problems with substance misuse and/or his mood disorder which was (in a sense) also his great gift as well as his demise. We all have both physical and mental health difficulties to some degree, Robin Williams,’Treesaw’, you and I.

    • Hi Tony. Thanks for your comments and sorry for the slightly belated reply. I think it’s very important to stay aware that everyone has scars and everyone has at least the potential to develop mental health problems. Receiving a life-changing or life-limiting physical health diagnosis could be the trigger that sets it off. Mental health patients also come with all sorts of physical health ‘baggage’ – they could very easily have stomas, leg ulcers or diabetes – so it’s important for nurses to know what input is needed, as well as when to call in more specialised help.
      Although I realise that this is absolutely not what you were implying, I think the media can give the impression that mental illness is a ‘price worth paying’ for the creativity that sometimes accompanies it. In the aftermath of Robin Williams’ death, I was struck by a lady on the PM programme who said that although she had a mental health problem, she was not creative, and all the talk of Williams’ ‘comic genius’ and ‘irrepressibility’ made her feel that she ‘couldn’t even make a success of being mentally ill’.
      I thought this was very sad – but it reminded me of parallels with those cancer patients who sometimes comment that whatever their personal reaction to their diagnosis, the attitude society expects of them is one of indomitability and fight. To an extent, we are all prisoners of society’s expectations, and nursing has a role to play in breaking that down and allowing people to be themselves. Before we can do that, we need to reflect on our own perceptions and pre-conceived ideas, and nurse education should be a place where that can happen.

      • Of course, there is a world of difference between those exceptionally talented ‘artistic temperaments’, those ‘bright starts’ who are sometimes able to harness and channel their mood disorders (but still are often overwhelmed by debilitating illness) and the many ordinary people who valiantly struggle daily with unglamorous mental health problems, perhaps with little help or support.
        I have also wondered what effect the language used in cancer research campaigns – ‘join the fight’ – has on those people who either feel unable to wage war on the illness or who prefer to manage it with a peaceable acceptance rather answering an urgent call to battle.

  4. “…helped me to place myself within a bigger picture, and opened up the possibility that the despair that I have sometimes felt, far from being random, is actually a channel through which to hear a distant echo of my forebears’ lives.”

    This line gave me goosebumps.

    I closed down my Twitter account but make sure I keep checking in on your blog as I really, really enjoy your writing. I’m halfway through my pre-reg adult branch training and i’m trying to scour universities prospectuses for post-reg mental health training once i’m qualified -there don’t seem to be many courses available. I can’t stand how ill-equipped I feel in supporting those admitted on general adult wards who also suffer from mental illness and there is no element of practical mental health nursing experience in my programme, bar the odd lecture in theory here and there. It isn’t good enough.

  5. Hi Emily. Thanks for your kind words – lovely to hear from you and glad to learn that you are planning how to progress your career. We need people like you who are thinking hard about the problems in nursing and how we can tackle them.
    It’s quite something to hear a general nursing student say that her training is not equipping her to care for a whole world of patients that she is certain to encounter in the course of her practice. In the old (pre all-degree) days, it was much easier to ‘bolt on’ a secondary qualification to your original branch. A number of general nurses I knew went on to do a shortened RMN course and it was a two-way street: RMNs ‘doing their general’ were a commonplace when I was on placement during training. I’m not sure if the advent of ‘all degree’ was meant to cut off this opportunity for cross-fertilization between the two branches, but there may be grounds to investigate whether it has indeed become an unintended consequence. Perhaps the upcoming Second Willis Review will have something to say about it. Certainly something to look out for.
    Good luck with your search. Keep me posted!

  6. Andrea permalink

    I’m just seeing this now (after emerging from the fog that is finishing placement!) but I totally agree that adult-trained nurses aren’t given enough training in mental health, especially considering a huge proportion of the patients they see will have a mental health problem. I’m training as an adult nurse but I would have loved to have done dual adult/mental health training had it been available in my area.

    As someone with lived experience of long term mental health problems (& also someone who has experienced ignorance/lack of understanding re: mental health from general nurses first hand) I’m probably going to be one of the rare general adult nurses that truly ‘gets’ mental health, but that level of knowledge & understanding should not be the exception- it should be the rule. I feel strongly enough about this that I’m currently mulling over how to get some additional mental health training into uni for my adult nursing cohort – whether through a student led conference, workshops, or even just sessions with service users, I’m not sure. I’m also attending a Mental Health First Aid course in September with another fellow student to see what it’s like, which I’m really excited about.

    Don’t get me wrong- for adult nurses, good mental health liaison nurses & CPNs are worth their weight in gold, but mental health in general isn’t something that should be seen as someone else’s problem. It’s a crucial part of holistic care, and it’s just not good enough to pretend otherwise.

  7. Hi Andrea. Thanks for commenting. Although I agree with everything you say, it’s worth noting that since I wrote this post, I’ve published a guest blog by Florian Nightingale. In it, he argues persuasively for the inclusion of more ‘advanced’ assessment skills in undergraduate general nurse education. The question is – how much can be packed into the pre-reg course and what should its orientation be? It’s a vitally important area because the content of these courses says a lot about what we think nursing is. Is it about assuming more of the traditional medical roles in order to expedite potentially life-saving treatments? Or is it about the less-quantifiable affective skills? Or can it be a mixture of both? Should different universities emphasise different aspects of nursing in their undergraduate courses in order to give students a chance to specialise in an area of interest even before qualifying?

    • That’s a really good point you’ve raised. To be honest, I personally don’t see the core of nursing as being primarily about the ‘medical’ type skills. Clinical skills, advanced or not, are a means to an end, that being the care of patients as people and meeting their needs either via direct care or facilitating self-care. In my opinion, that should be what is focused on during a nursing degree, and it makes no sense to almost completely ignore mental health in a general/adult course, which is a large part of what many patients experience.

      However- I do recognise that advanced clinical skills are really important in order to give the best care possible, and I think they should also be learned much earlier than many nurses learn them, if they learn them at all. There’s probably room for some additional skills (venepuncture being one!) in the pre-reg course, but I would argue for a structured & nationally organised period of post-registration training in which some of these skills can be learned and put into practice, similar to postgraduate medical training but not as lengthy!

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