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In 2018, Christie Watson’s memoir about what it means to be a nurse became a publishing sensation, spending more than five months in the bestseller lists. The Language of Kindness: A Nurse’s Story was tenderly distilled from the two decades that Watson had worked for the NHS, capturing the essence – and importance – of what it means to care for patients. Counsellor Bella Jackson will presumably be hoping that her account of two years spent training as a mental health nurse will resonate in a similar way.
Jackson worked in social care for five years before embarking on her nursing degree. The book is “pieced together from scattered notebooks and scribble”. But from the outset, it is not entirely clear what is fact and what is fiction. She explains that she has constructed three “composite” settings from her contemporaneous notes: an acute psychiatric ward, an A&E department and a community psychiatric team. Although based on real situations, the stories she tells are also composites in which names and identifying details are changed. Similarly, the healthcare professionals depicted are “generic”.
The verisimilitude of what is described matters greatly because it is used by Jackson to mount a furious assault on the failings of modern psychiatry. The gross underfunding and understaffing of NHS mental health services is, she argues, “only half the story. The other half is messy and confronting. It is philosophical and systemic. It is uncomfortable enough to make us look away sharply.” Without spelling out exactly what she means, she sets out to document the messiness unflinchingly.
Entering the ward on day one triggers a powerful childhood memory. As a six-year-old child, Jackson accidentally locked herself in a bathroom while her parents hosted a raucous party. Recalling the overwhelming panic and powerlessness of being incarcerated causes her to reflect on the ward patients’ plight: “It’s easy to walk in and out of a locked ward and forget the significance of that power. Does The Door protect the vulnerable people inside from an unkind world? Or does it protect our fragile society from the people who embody its failings?”
Jackson’s answer to this question is emphatically the latter. Seen through her eyes, locked psychiatric wards are bleak, punitive places patrolled by staff who are – with only rare exceptions – at worst cruel and at best indifferent. In the first few pages, psychiatrists are set up as uninterested, inhumane, work-shy pill-pushers. A patient spends hours hovering by the door, trying hopelessly to catch the eye of the consultant psychiatrist as he “flitted in and out, always with somewhere else to be”. When another patient recounts a harrowing tale of homelessness and childhood beatings, the same consultant merely shuffles his papers as if the patient “were absent”.
Nurses are, if anything, even worse. A particularly aggressive nurse called Leon tells Jackson that he hates the ward because “these patients get away with anything they want … asking what this is, what that is. What the fuck?” Two healthcare assistants laugh together about forcibly injecting patients with rapid tranquillisers.
Amid the racist, abusive and offensive staff, who mock, belittle and chemically cosh their patients, are individual tales of heartbreaking social and psychological circumstances. Patients have experienced sexual assault, childhood abuse, domestic violence, poverty, exclusion and multiple suicide attempts. All of this is ignored by staff. High doses of antipsychotics leave the patients drooling and gurgling. One man has the face of “a tired waxwork” while others “remained shapes against the blank walls”. Jackson finds herself frequently intervening to stop a trigger-happy nurse or doctor casually slapping a potentially life-changing diagnosis such as psychosis or bipolar disorder on to a distressed patient.
The problem with this account, for me, is that it doesn’t really resonate with my experience. I spent my first rotation as a junior doctor in psychiatry at the same time Jackson was training. I simply didn’t see the kinds of abuses Jackson documents – despite being a former current affairs journalist who was, and remains, highly attuned to the power dynamics inherent in medicine and potential injustices against patients. A particularly extraordinary moment is when Jackson describes a nurse telling her about a junior doctor “who used to legit say, ‘Let’s quetiapine them today!’ And I asked him why quetiapine, and he said, ‘They put you in the best hotels for conferences.’” Really? That kind of pharma corruption was rooted out long ago – and I can scarcely imagine a junior doctor of my era using such a ludicrous phrase.
Jackson has sacrificed complexity for polemic. The crux of her argument is: “The medical world doesn’t really know what to do with distress, so we drug the person, because that’s what the medics are taught to do.” But the truth is not this simplistic. Psychiatrists do indeed have an almighty power to do things to patients that in any other context would be considered human rights abuses – restraining them, injecting them with drugs, depriving them of their liberty. Yet this is because the most seriously unwell patients often have no idea they are ill and will not engage with treatment voluntarily. Sectioning a patient is a last resort, not a cavalier act of malice. And though talking therapies are desperately lacking, this is due to endemic underfunding, not because psychiatrists regard them as pointless. Most of the psychiatric nurses and doctors I worked with were decent, run ragged, and longed to be able to offer their patients more.
The truth is, we still understand very little about the root causes of serious mental illnesses and are painfully aware of what blunt tools psychotropic medications are. Jackson implies that treating serious mental illness is simply a matter of listening to, believing and empathising with patients. If only this were true for bipolar disorder and schizophrenia. There is much to be fixed in NHS psychiatry, but I’m afraid this book feels like scaremongering.
Fragile Minds: Stories from an NHS Mental Health Ward by Bella Jackson is published by Doubleday (£20). To support the Guardian, order your copy at guardianbookshop.com. Delivery charges may apply.
In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. You can contact the mental health charity Mind by calling 0300 123 3393 or visiting mind.org.uk
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