The drugs do work

When I tell people that, as part of my psychoanalytic training, I have the privilege of observing ward rounds on a secure psychiatric ward in a big London hospital, they shudder. “I wouldn’t dare go in. They might not let me out!” one friend said. So many of us are in some kind of therapy that the idea of tipping over the edge into real psychosis, of being sectioned and treated forcibly on a ward full of maniacs, is a nightmarish fantasy we prefer not to contemplate.

The reality is that, for many patients on the ward, being sectioned turns out to be a solace. It is the only way out of a state of mind that has become unbearable: the last resort. Here, someone else will take responsibility. As the psychiatrist I am assigned to observe puts it: “This is a place where people can allow themselves to disintegrate and we help them put themselves back together again.” This is usually achieved by administering a large and ongoing dose of anti-psychotic medicine.

When I started observing ward rounds I was shocked by the extremity of suffering—and that the recommended treatment was powerful drugs. I had thought that drugging people up to the eyeballs, especially against their will, was the antithesis of psychoanalysis. (Not to mention that when a 6ft 4in body builder, restrained by a posse of policemen, doesn’t want to be injected, he really doesn’t want to be injected.) But I had never seen seriously mentally ill patients close up. When the extent of someone’s contact with reality is that they don’t bump into the furniture (much) and they routinely pour bleach into their eyes to cleanse the demons, talking to them about their early life is patently absurd. The psychiatrist I observe says psychosis is as dangerous as cancer and must be treated as assertively—with the right medicine.

There was a broken and silent 20 year old who seemed almost catatonic following a suicide attempt. He mumbled something about his mother who was, it turned out, waiting outside the room. She came in, a disturbing and chaotic alcoholic, pleading and desolate. As the nightmare was played out right there, it was easy to see how her son had reached a state of such desperation. The psychiatrist said; “I think we’d better increase his dose.” I was still sceptical.

Yet within a month he had made an astonishing recovery. He was smiling, chatting, and (interactivity being a key indicator of mental wellbeing) when someone said, “Hello, how are you?” he replied; “Good. How are you?” This is an experience repeated with patient after patient. I watch the delusional ones who think they are Jesus, who believe the CIA has sent them on a mission and hear the voice of God or Satan, terrified people pursued by imaginary foxes, bad doctors, spies, masons, torturers and devils, and I often see the incredible transformations worked on them by the drugs and the containing environment. It is so important for patients truly to be thought about, often for the first time.

Of course, not everyone stays better. There are patients who come back regularly (often because they stop taking their medication), their brains further damaged by each psychotic episode. After a few too many hospital admissions it starts to become clear that some might need to be embraced by the NHS long-term. When someone who has been brought up by abusive drug addicts or alcoholics, has been traumatised in care, has had no education or has used drugs from an early age becomes seriously mentally ill, it is hard to imagine a future that does not involve lifelong medication and support.

If you read the tabloids, you would imagine that violent psychotics were virtually ignored by the NHS; thrown out on their ear to commit hideous crimes against God-fearing citizens. I would not have known, before starting my observations, whether or not this was true. Now I know it is not.

A few weeks ago, the acutely distressed relatives of a newly discharged patient came to the ward. Their daughter, they said, was threatening them with knives, injecting herself with animal tranquilisers and banging her head against the wall. Half an hour was spent discussing the patient, who had seemed well when she left, and it was decided that the situation was serious enough to call the police and have her brought safely back to hospital.

Safety is a major issue. The psychiatrists, nurses and other healthcare professionals are often at risk of attack from seriously disturbed patients and there are panic buttons and burly nurses everywhere. Both are used. I have seen the psychiatrist spat at by someone who believed his blood was being sucked out of him by the mattress, and terrifyingly threatened by a patient awaiting trial for a vicious assault. Patiently, she says; “I think you are very unwell at the minute.” They say they are not. She says; “I think we’re going to have to agree to differ there.”

One can only bow in humbled admiration at the extent of the care available for every patient who comes through the door. Each crushed, raging and dishevelled person is thought about with genuine concern and attention; bag ladies in filthy clothes, university students with piercings and Dr Martens, young men with drug and violence issues, old men who have ended up homeless and confused. Advocates set out the case of patients who prefer to be spoken for, interpreters help those who don’t speak English, housing officers help the patient into the right accommodation after hospital, community care co-ordinators help discharged patients with their daily lives, and day centres provide a focus for people who continue to need a structure.

Although it is a tragedy when a mentally ill person disappears from the system, stops taking their medication and does something terrible, it is also a miracle that so many are cared for so well and by such dedicated teams. This is so often overlooked.