All posts by Tony

A Tough Question

Gautier - Salpetriere

“So, what is madness?”

This was the question posed to me by a friend. Obvious and easy answer I thought, seeing as this is part of the job I do day in and day out.

“Well, its…” and then I stopped. I couldn’t answer it. Not if I wanted to produce an accurate and true answer. What is madness? Is it simply when people are not acting in their normal fashion? If that is the case, then we are all mad as when we are angry or upset then we do not act in our normal manner. ‘Road rage’ means many people are mad if the ‘normal’ fashion definition is accepted as well as love.

Is madness not conforming to the norms of society? Well, many people I know have speeding tickets so either they are mad because they have broken the law of the society or they are the sane ones because speeding tickets appear to be the norm! And what exactly are the norms of society anyhow?

So, is madness an illness? If it is then rates of this illness would be fairly consistent across the globe but we know that depending on where you live defines your illness. For example – schizophrenia. If schizophrenia is an illness then why are there different diagnostic criteria in countries around the world? Why do immigrants show higher levels of this illness but not in their own countries?

Do medics define madness? Insight appears to be on the diagnostic criteria for most illnesses (or the lack of it to be precise). I once read (Ron Coleman) that a patients level of insight simply depends on the extent to which a person agrees with their doctor – disagree with your doctor and you are obviously lacking in insight and are therefore mentally ill. Or agree with the doctor that you are ill and you are again obviously ill. So madness cannot be defined by doctors (as any reader of Thomas Szasz will understand).

Perhaps madness is the system we live in, where budget cuts mean people are unable to access basic and fundamental needs/services yet some people are paid millions to kick a ball around a pitch.

Perhaps madness is trying to define madness.

I still cannot answer this question satisfactorily.

Do you have an answer?

(NB we have a temporary fault blocking comments – hopefully this will be resolved soon)

Image above from Wikimedia commons:

“English: 1857 lithograph by Armand Gautier, showing personifications of dementia, megalomania, acute mania, melancholia, idiocy, hallucination, erotic mania and paralysis in the gardens of the Hospice de la Salpêtrière. Reprinted in Madness: A Brief History (ISBN 978-0192802668), from which this version is taken.”

Wake up and smell the (decaffeinated) coffee.


So Great Britain isn’t so great after all. Perhaps this isn’t news for many but I was very surprised to read that Britain is well down the list on the WHO league table of health care

(see link and go to p18)

I always thought, in true English stiff upper lip and arrogant fashion that ‘we are the best’ and Johnny foreigner should be envious. But hold on – it turns out that Pierre, Gustav and Ricardo all enjoy a far better health system that poor John English. It turns out that we are 17th and that our partisan friends in Europe have a far better time than us.

Why is this? Well, I have the answer.

You see, England once ruled the waves and Queen Vicky dominated the world with the Commonwealth reaching all corners of the globe. England was the dominant world force and when Britannia spoke, all listened in trepidation. But all we did was speak and not act. We were so confident that we were ahead of everyone that we didn’t try as hard as the others – and try they did.

The result was the rest of the world very quietly, caught up with this country and left it behind.

Unfortunately I think that this is true of many facets of life in this country not just health. Perhaps there is some solace in the countries that we are ahead of – two countries placed in the 30’s caused me even greater surprise (and delight admittedly).

So what next? I would like to think that we are waking up and realise that arrogance does not make a world leader. Hard work, effort and a driven desire to be the best makes the leader – the question is, are we waking up to the smell of coffee or pressing the snooze button for ten more minutes sleep?

A confusion of words?

The tower of Babel (engraving by Gustav Dore)

I am fascinated by the use of words. Well, I should say that I am fascinated by how people use certain words to present a desirable image of themselves. An everyday example is the obvious one of politicians – you can see them deliberatel pausing several times in an interview to think carefully about what words utter from their mouths.
Rightly so. We all know how easily people can be insulted over a few words (ask Mr Clarkson from Top Gear about this) and so choosing our words is vital.

Using the wrong word can spell doom. I recently marked an assignment where a student ‘psycho-educated a patient on holidays abroad’. Yes this could be psycho education before someone comments but in the context of the essay it clearly was not. Put simply, if you do not know what a word means, then don’t use it as incorrect use sends a very clear signal of the level of your knowledge on the subject!

One phrase that irritates the hell out of me is ‘1:1 intervention’. I saw a football match the other week where the result was 1:1 so if a nurse says they had a 1:1, does this mean they played football? What is so wrong with saying ‘I spoke with…’ or heaven forbid whats wrong with saying ‘I chatted with…’? I am extremely proud that I have never conducted a 1:1 intervention with a patient but I am equally as proud that I have chatted with many over the years. I think that the meaning of ‘1:1 intervention’ has been lost/warped over time, this is evidenced by a student seeing me and explaining how they had a 1:1 with a patient and their family. I explained that one to one means a private chat between two people but this was lost on the poor soul because his mentor (a nurse in practice) had informed him that this work was indeed classed as a’1:1’.

We also ‘ob’ patients. The phrase ‘observe’ has been lost or to be precise the meaning has been lost. To ‘ob’ someone is simply to aimlessly follow someone around with the bizarre belief that this helps. What is wrong with chatting anyhow? Chatting with someone allows for the assessment of memory, orientation, delusional ideas, concentration, anxiety, paranoia – well the list goes on. It is the skilful nurse who uses these informal opportunities to gather information and to develop the greatest tool in a nurse’s armoury – the therapeutic relationship.

So why do we use these words? Well, I believe it comes to us as nurses losing our sense of self pride. What is wrong with saying I chatted with Fred? Answer – it simply doesn’t sound professionally credible. Are we scared that other health professionals may say ‘but talking isn’t really work that a professional does’ and so we disguise it by saying we conducted a 1:1 intervention? Perhaps those who are familiar with a previous post “Registered Nurse Plumber” may already know the direction that I am going.

Who do you want caring for you and your loved ones – the nurse who conducts 1:1 interventions with patients or the nurse who chats with you?

Public Spending? stop moaning


Like many others, there was a time in my life that I was skint. Didn’t have two ha’pennies to rub together (to use a colloquium of my mother’s). I’m sure many of you are nodding your head in agreement, with a sorrowful sigh of remembrance.

But I wanted my ha’pennies – to be precise I wanted thousands of the little blighters and more. I wanted a new car, new suite and I wanted to decorate the front room. I wanted to go out and party and spend obscene amounts of money, still leaving a handsome amount in the bank. I wanted the high life and then some. I wanted my cake, yours and still have the cakes sat in the kitchen.

Unfortunately as everyone knows, what you want and what you can have are two distinct ideas that are rarely, if ever compatible.

Not good enough I thought. I wanted this life and so I planned to get it with precision that would make Machiavelli proud. I stopped my subscription to several magazines/newspapers and acknowledged that I don’t have to eat out several times a week. Walking rather than the car became the norm and perhaps I didn’t really need another CD.
I’m sure you get the picture.

Still not good enough though. I took on a part-time job and also worked from home on a rather unwholesome project. If I could have, I would have sold my grandmother for one of the sacred ha’pennies.

And the result?…

Well, I’m sure you can work this out. Put simply, I slashed my expenditure and increased my income. There is nothing amazing with this though as this is an obvious thing to do so I am amazed that the Governments spending cuts have been met with such outcry and derision. The country is skint and doesn’t have two ha’pennies to rub together. We are in a major financial problem that requires a major financial solution. This is not rocket science – if you don’t have the money, then you need to cut back on your expenditure and increase your income.

So if you are one of those people moaning at the harsh financial decisions that the Government has made, just open your eyes. Despite its many problems we still have the NHS. We still have a police force. And roads. And armies. And society. Etc etc.

We are living in harsh times and a harsh solution is needed. Stop moaning please.

Registered Nurse Plumber?


I have noted with interest over the years that nurses (and I am one)  have had an attitude of “I can do that. Give me that job” and indeed nurses have expanded their role quite considerably. When accused of trying to be ‘mini doctors’ nurses have responded ‘no we are maxi nurses’.  We have clearly demonstrated that we are capable of so much.

So…with the latest MHA nurses can (after appropriate hoop jumping) can be the responsible clinician or the approved mental health professional, posts previously filled solely by doctors and social workers.

Surely nurses (and the Act) are missing the point?

The greatest strength of any team revolves around the idiosyncrasies that each individual brings to the table but now, oh no, we are removing this uniqueness to leave one ‘new’ professional that simply changes hats to fit the job in hand. 


I am strongly in favour of social workers retaining their role – it is after all a vital position to ensure that the medical model does not dominate. I remember as a newly qualified nurse being impressed by a social worker refusing to ‘sign off’ a detention after two doctors had recommended it – this social worker exerted his own standards and whilst I disagreed with him, I thought that he was doing a splendid job that he was trained to do. He was able to step away from the medical needs and look at the social needs in a wider context.

Nurses, whilst we strive to be separated from it, are biased in the ways of the medical model -Face it.

What is wrong with being a nurse anyhow? I plumbed in a washing machine the other week but I am not asking to be registered as a nurse plumber. Leave the plumbing to the person who trained to be a plumber and who does it day in and day out and the plumber can leave me to nurse.

And another thing….following on from nurses saying “I can do that. Give me that job” there is the follow up call of “Hang on. Have you seen my workload? I’m not paid enough you know!”

washing machine

Images from Flickr creative commons:

1. Plumber James #2 by MoToMo

2. Plumbing by basykes

3. Day 719 / 365 – Wrong Setting by JasonRogersFotographie

A Critical Observation of Critical Insurance

Like many people, I have a mortgage and with it, the necessary life insurance. With mine, I took out the ‘critical cover’ – what this means is that if I die, the mortgage is paid off and if I become ill and cannot work, then the mortgage is paid off. But stop…if I become ill? No, if I become physically ill. Mental illness doesn’t come into it. It’s not covered in any shape or form. Not even a whisper. Basically then, you are not allowed to have a mortgage AND a mental illness. Don’t even think about it. You are being greedy having both things.

I have thought a lot about this. I understand the need to cater for someone who loses limbs and so cannot work or someone who develops a terminal illness and so obviously has other priorities than working. I understand that many conditions can stop a person from having a sufficient income that allows them to pay a mortgage. 

I also understand that insurance companies would probably be inundated with claims if mental illness was included – I am certain that many dishonest people would try to make a claim by claiming a mental illness. But hang on a minute, we have psychiatrists don’t we? And aren’t insurance companies renowned for putting in clauses? Why can’t there be a clause that states a mental illness ‘that has lasted at least 6 months and prevents the claimant from working and is under the care of an appropriate medical consultant and is receiving appropriate treatment’? Hopefully the false claims would be weeded out – please note that the sentence above is from my insurance documents but is applied to physical conditions.

The insurance company is willing to weed out false claims for physical conditions but will not even entertain the idea of even considering a genuine claim for mental illness. Why not mental illness?  We know that with many illnesses people are simply unable to work but here they do not have the benefit of insurance that others may have.

But I begin from a false ideal, that life is fair.


Pictures from Flickr commons

1. Shark House by Mattyboyjim

2 Wet roofs by diavolo_felice

3. Houses of England by Gúnna

Drug addiction?

Flickr click image
Photo by taiyofj : Flickr click image

There have been many discussions on over reliance/ dependence on medication over the years. Personally, I do think that both public and professionals rely too much on pill popping. I certainly feel a degree of sympathy for GP’s who have a few minutes to decide on someone’s illness and treatment plan. The prescription of a drug is likely to work so this becomes a ‘default’ option (and my apologies to any GP’s reading this.  I am aware that this is very simplistic but it does illustrate a point that is true for all professionals. And patients…well, when I see a health professional I will admit to feeling comforted by popping a pill. After all, a pill means that my illness is treatable doesn’t it?


Click image)
Medicine (photo KB35 on Flickr : Click image)

But hang on. If this deeply held belief that pills cure illness is flawed, then what is even more flawed is the idea that medication even treats mental illness. Lets look at depression. Depression involves the lowered state of serotonin and so all anti-depressants work by increasing levels of this neurotransmitter through one means or another. But aren’t we missing the point? By increasing serotonin levels all we are doing is dealing with the symptoms of an illness, not the illness itself. Schizophrenia treatment is exactly the same but here it is reducing the elevated dopamine.

My point – we are not dealing with illness eradication, rather we focus exclusively on symptom suppression. But this is the nature of mental health problems. It would be foolish to think that a little tablet taken twice a day will be a panacea for all our ills – unfortunately though, this is exactly what people think.

Holistic fantasies revealed

It would be foolish to say that nursing – indeed any health profession I know – offers true holistic health care. Sure, we talk the talk of being holistic. We say that we cater for all needs and care for the individual – a principle that is enshrined in the Code of Conduct. And yes, we have wonderful assessment tools that are designed and tested to identify the areas needing attention. We pride ourselves on how we cater for the idiosyncratic goals of the person being cared for.


But do we really offer holistic care?

Or do we hide behind a false veil of ‘professionalism’ and only deal with what we want to deal with rather than dealing with what the person wants?


Let me explain.


Holistic health care means caring for all health needs. What about sexual health? I, and every nurse I have spoken with, have never asked a patient about their sexual health needs. What a minefield that would be! Imagine the legal problems I would face if I asked a female (or a male for that matter) if she had any sexual needs that she would like me to address whilst she was on the ward. Would my plea of holistic health care be enough to satisfy a judge that I am not a perverted sexual predator? Unlikely. Would the NMC jump to my defence as I have upheld the Code?


And please, don’t make me laugh by saying that we at least cater for religious needs. It strikes me that if you are not Christian or Muslim then the health services either cannot or do not want to help you with your religious needs. But even these two religions only have a token gesture made to them. The problem here is that it would take effort to organise and money to pay to allow people to practise their religion – two commodities that are in precious short supply in the health care system.


Of course, we have iatrogenic conditions and nosocomial infections – it is particularly worrying that professional caused conditions and hospital acquired infections are so common that we have words dedicated to them. So do we even offer physical health care?


Holistic health care is an ideal that we should (and do) strive for. But lets be realistic – it ain’t here yet.



A sporting yarn

There was once a cricketer who enjoyed his sport and got rather good at it. One day, the cricketer bumped into a footballer and said“Hello, I’m a professional sportsman just like you!”

A jolly good cricketer!
A chap playing cricket

The footballer looked at the cricketer with great disdain.

“No you’re not”
“Yes I am” cried the cricketer in dismay.

The cricketer went away and thought long and hard about what the footballer had said. He had spent years studying and practising his sport and wanted to be respected as a professional sportsman. How could the footballer treat him so? To prove his merit as a professional sportsman, the cricketer decided to learn to play football – if he could do this then he will be respected as a professional sportsman he thought.

After some time, the cricketer had indeed learnt to play football. He found the footballer and said:

“Look, I can play football just like you! Now do you see me as a professional sportsman?”

The footballer still had the look of disdain and said sneeringly

“OK. Whatever you say.”

And the cricketer continued to play football.

The cricketer stopped being a cricketer. He forgot to do what he was supposed to do. And the relevance….have nurses forgotten the nursing role? Are we trying to be every other profession (and one in particular) because we suffer with a pervasive lack of professional confidence? It seems to me that as a profession, we are ashamed to admit that we are a caring profession. Perhaps that nursing is the only health related profession where the entry level is not graduate (yes it will be changing shortly) has left us feeling a little embarrassed?

Some other chaps playing footie
Some other chaps playing footie

Health Promotion?

I’m getting a bit tired of the emphasis on just promoting physical health – what about mental health? Of course, five portions of fruit and vegetables are important, so is not smoking etc – of course mental health nurses have a role in this, but…


When I became a mental health nurse, it was because I believed that I could help people in distress. I found that I could easily talk to people and communicate on a variety of levels. I developed the ability to enter into someone’s ‘world’ to see it as they did. Indeed, as time passed I found that I had a particular skill in talking to those who were becoming physically aggressive to de-escalate the situation. I can spot side effects and help people who are experiencing these distressing consequences of the medication that we give. I can help a depressed person out of their hole and assist families to understand.


I have got some idea about physical needs, despite a relative lack of training in this area. I am not suggesting that I couldn’t spot the overweight person who smokes 40 a day and drinks alcohol like it is going out of fashion. Rather, what I am saying is my area is essentially concerned with facilitating people to enjoy their life. To give an example – I do not smoke,  yet I will defend the rights of smokers to do so provided that they understand the potential consequences and do not force me to inhale their smoke. We are adults capable of making a decision. Surely my job is to facilitate the making of an informed decision? The Code of Conduct clearly states that we should respect the right of a patient to decline care yet too frequently if a patient declines then ‘no insight’ is recorded in their notes. I firmly believe that the majority of nurses break the Code on this point.


What about Mental Health promotion? WHO have identified that depression will be the number 1 illness in Europe by 2020 but rarely do I see any health promotion on this issue. The ubiquitous health promotion posters tell me to lose weight, stop drinking, stop smoking, lower my cholesterol, go jogging etc etc but I have never seen a poster saying


‘Hey! Go and chill out!’


And I probably never will. Yes I am well aware that many physical promotion has a knock on effect on mental health but surely we should be promoting factors that are primarily aimed at mental health promotion?


The candle that burns twice as brightly lasts half as long. Personally, I want to enjoy my life rather than extend a miserable one.