Reflections on Resistance

Simon Adam , RN
Here is an emergency department. It is a particular one, though it could be almost any one, for they are all very similar: A regional trauma unit humming with the activity of patients, their families and friends, and hospital staff. To the casual onlooker, the setting, a seemingly politically benign clinical enterprise that depicts patients as passive and satisfied recipients of medical and nursing care, to me, became an environment laden with institutional processes, categories, and priorities. Hundreds of people each week would become the means by which the institution exercises its ruling power and control over the patient, and specifically, over the elderly and the psychiatrized.

In a slow, steady, and rather sobering awakening, I came to realize that the “care” for which elderly patients and patients with “mental health complaints” accessed the institution, they did not receive, and was marginal at best, and at times, outright needlessly traumatic. The department, whose administrative priorities lie in the meeting of Ministry targets, attending to extralocal political objectives often incongruent with those of the patient, and, ironically, aggressively marketing an image of “health care excellence” and “innovation in health care” to the public, is the backdrop against which my resistance efforts to psychiatry is set.

Having entered the antipsychiatry movement as an academic, I became more politically and socially aware of the problems that faced my patients, the problems that the institution created and perpetuated for them—problems that are almost always seen by the practitioner as help rather than harm. Why is it, I would ask, that the bedside practitioner needs to be rigorously politically sharp (most novice nurses are not) in order to see that the care is problematic? How difficult it is for this struggle to prevail, for nurses to come to such an awareness, to change harmful practices, and to transform the system as it is! Where acute care nursing is largely populated with novice nurses with what I call a “politically naïve understanding of the institutional regimes of ruling that subjugate them and their patients”, I also came to experience my resistance efforts being met with resistance. It was not only the resistance of my nursing colleagues, but my own as well, as I grappled with the antipsychiatry movement myself as I came closer and closer to understanding just how radical it is and what it proposes to accomplish. I often found myself asking, how does one do away with a system that, albeit harming many, is also helping some? What will replace the help that the severely anxious young woman, for example, receives in a form of a sublingual relaxant? What about the person accessing the psychiatric emergency service for feelings of danger and fear? I learned to step away from these questions and look at the institution as a symptom of larger problems, and one of which is biomedical psychiatry, where I stopped accepting a regime that marginally serves the very few and harms all others subjugated by it.

Reflections on Resistance

The following is a letter written to a colleague two days after an incident that occurred in the emergency department (of note, the name “Janet” is a pseudonym and not the real name of the individual addressed below):

What happens when an institution preoccupies itself with “patient flow” and the meeting of Ministry targets? What happens when the institution deliberately and carefully deploys resources to disproportionately address acuity and not chronicity? What happens when most of the support is injected into the “trauma program,” and the “critical care program” in an institution that obviously does not only serve trauma and critical care patients?

The scenario above is much too common. The nurses and other staff are so preoccupied with making care ends meet at high-speed with all their patients that the needs of the elderly, often activities of daily living such as feeding, toileting, and ambulating them, often are “forgotten.” Research demonstrates that if such needs are not promptly addressed, they can lead to delirium in the elderly patient (Inouye et al., 2006; Palmisano-Mills, 2007). When there is this acute confusion, coupled with persistent calls for needs that are not addressed, when the patient is delirious and cannot communicate coherently, the restraints come out. Here, we have an elderly man asking for toileting that was met with a diaper, a blanket and a sandwich that he was never given; becoming more and more anxious; and becoming more and more of a candidate to be restrained. The more anxious and delirious he was becoming, the more he fit the institutional category of the so-called “least restraint policy” where the “assess[ed] risk for injury to self or others which may occur in situations such as: falls, agitation, aggression, wandering, and alteration of consciousness” calls for restraining his limbs. Basic needs are de-prioritized in the emergency department. They are unimportant as they relate to acute and emergency patient care, and the idea is that they should not be expected anyway in a department whose mission is to be “saving lives.” Pushing aside such basic needs directly leads to the very “problems” that Janet and I encountered with the man above and with most elderly patients, and are remedied with ridicule, behavior-labeling, and restraints: psychiatrization.

A second clinical case from my experience follows, and this occurred several weeks ago during a late evening shift in the emergency department:

I included this case for two reasons: to demonstrate that psychiatry has the power to colonize the minds of people, in this case, the mother, as to label her child as mentally ill and use psychiatric intervention as punishment; and, to make a case for the need for continued resistance and better patient advocacy.

Psychiatric terminology has become so mainstream, being used in everyday language, in exchanges with friends, family, and colleagues. We frequently and easily use phrases such as you’re crazy! You need help. You’re nuts; you need to be locked up! Psychiatry and the language of psychiatry has colonized the thinking of so many people that the instant we observe behavior in others that is different from ours or behavior that does not conform to the observer’s understanding of normal reality, that behavior is pathologized: psychiatrized. This is what I experienced in the mother’s case above, that she had decided her daughter must have a mental “illness” based on the mother’s observation of the daughter’s “inappropriate behavior.” When we look at the fight against psychiatry, we, as professionals and activists must understand the power that psychiatry has exerted on the minds of people to take it in as a dominant tool to understand human behavior, thus diagnosing otherwise poorly understood behavior as mental “illness.” In this case, my resistance against psychiatry was not directly against psychiatry per se, but rather against the mother’s thinking that had become subjugated by psychiatry.

In an effort to advocate on the behalf of this girl, rendered powerless by the institution (of psychiatry) and her mother, I, as an advocate practitioner, had to understand that the mother’s thinking was flawed and that I not only needed to assess the girl, but also the relationship between her and her mother that was unfolding before my eyes. Triage nurses sit at a pivotal point in every patient’s care in the emergency department. The above situation could have unfolded very differently had I been uncritical of the mother’s understanding of her daughter’s behavior. The institution makes it very easy to categorize patients into preset diagnoses or “complaints” and classify them according to “presentation” or the findings based on the objective assessment of the nurse. I could have very easily selected the institutional category of “Mental Health Assessment” and as part of my assessment, narrated, for example, “patient aggressive, not cooperating at home, high risk for harm to self, may attempt suicide, and requires psychiatric intervention.” This would have taken the girl into a different direction within the institution, and this is precisely what many other nurses, lacking the political sharpness I discussed above, may very quickly do.

Cheryl van Daalen-Smith, RN
Preamble: The journey into my own resistance against psychiatry was an organic one: it evolved as experiences within my career accumulated to the point at which I could not ignore the messages unfolding before my nursing eyes. A general discomfort was always there, and I allowed it to come out and see the light of day. Below you will find a near verbatim transcript of my oral presentation at PsychOUT --no references, not neatly woven together, but ripe with the passion that fuels all that I do surrounding the rights of folks labelled ‘mentally ill’, ‘treated’ or hospitalized.

We originally called this session “Rebels with a Cause”. We know that a rebel is someone who refuses to conform. And in our phone calls to nurses involved in all kinds of movements, social justice movements, anti-poverty movements, who are doing incredible work, the label ‘rebel’ was problematic for some. “I’m not a rebel” is what we heard. So I was going to talk a bit about the gendered expectations that are still found in nursing, to be a good girl, to fit, to be a good person, but we’re now thinking about looking into this a bit more, perhaps in a paper. We want to look at resistance happening in nursing.

So that’s that...

I am very worried about nursing’s complicity in psychiatry and also about nurses’ complicity in psychiatry. In other words, by not speaking up and speaking out, it can be argued that we are, in fact, sanctioning what is happening. So I am going to tell you about some of my efforts and some of my experiences in resisting. I won’t share all of them, and I won’t go too far back, but we’re hoping that this conversation today is going to open a lot more dialogue.

All this could have started when I was told that I was going to have to go and watch electroshock as a student at my nursing school. I didn’t like the word ‘go and watch’. It felt exploitative and felt wrong. And fainting after seeing it and being told that I might not have what it took to be a nurse. I mean, it could’ve started there, but I didn’t have the language yet, and I don’t know when it came. Or maybe it started when there was a measles outbreak, and I was a public health nurse based in schools. So they pulled us all out of those duties, and we then were to immunize all the kids. So rather than my work that involved sitting beside boys and young men and girls and young women, listening to them talk about their lives from their vantage point, my job was immunization for several months. This is typical for those who work in public health, for the primary role of public health is disease prevention. I remember that one of the questions was “Are you on any medication?” And while this is not statistically analyzed, close to 70% of the girls and young women who sat with me at my little table for six or so months in gymnasiums in southern Ontario had been prescribed some sort of an anti-depressant or were on one. So how can you bear witness to that startling finding as a registered nurse whose code of ethics says that you are to be accountable, that you are to ensure that there is no harm is coming to people, that people have dignity, and that you are supposed to be an advocate for social justice? Nursing understands the link between health and social justice. I remember speaking about this to senior nurses, and it didn’t go anywhere. One supervisor completely shut me down.

And this experience of being shut down is not unusual for nurses who speak up. I can’t tell you how many times I was shut down. Just assume it unless I tell you otherwise.

Another experience was when I was working at a hospital, doing admissions of kids diagnosed with blood cancers, and in these admissions, you of course find out their address. I found out that so many were coming from one given town. You have to be a pattern recognizer when you are a nurse, and here was a pattern! I brought it forward in team meetings, saying there is something happening here, pointing out the close proximity of a nuclear power plant to this town, and I was again shut down and was told by the physician in charge of that unit, via the head nurse, not to tell the parents about this finding. We didn’t want to be alarmist.

So many boys in the schools where I was working were being prescribed Ritalin, and I noticed this trend increasing and increasing. It was almost as if this was a rite of passage! I spoke up about that and was told I wasn’t being a team player. I was asked. “Why do you have to be like that?” “What? Are you a feminist?”. Like that was going to scare me or silence me.

Another time was when I took a job on a child adolescent psychiatric unit, and part of the required training was ‘non-violent crisis intervention’. I asked to see the agenda so I could see what it was about and was told, “No, no, just go. It’s paid. Just go. It’s two days.” So I went, and it was in the basement of the hospital where there was carpeting and padding and mats everywhere. They were teaching us how to grab kids and how to hold them in a certain way. I said, “I’m not doing it. I’m just not doing it. This is hurting children, and I am a nurse!” There was the argument. They said: “you have to learn how to protect yourself if something happens.” I responded, “Why don’t we prevent it in the first place?” I don’t think that is what a nurse is supposed to do. I didn’t go to school to learn breaks and holds and this kind of thing. So things didn’t start off very well right there. A non-conformist during orientation? Not good.

Then at another institution, I was getting the Compendium (Compendium of Pharmaceutical Specialties) out when a patient I was caring for was getting a new drug.

I would write down information about the drug including the side effects and was sharing that with families. I would say: “Your son is being prescribed this medication. Do you have any questions?” Would explain the medication, its indications and its side effects. It is in our standards of practice, and it is in our code of ethics to do this, because we are the ones who hand the medication or administer the medication to the individual. We need to ensure informed consent. If you administer this medication, you have to ensure informed consent. So naive me, explained meds, discussed side effects, offered to have the pharmacist speak with families, and brought back their questions to report. What happened next? “Reprimanded” isn’t even the right word. I was shut down and told that is the physician’s responsibility. I explained that I understood the trio of responsibility when it comes to medications, i.e. prescriber, dispenser and person administering the medication. All three of us, I explained, are responsible for informed consent. I also pointed out in my beginning advocate’s voice that most families did not have a medication explained to them, but rather were told “your child needs this” or “I’m prescribing x or y” and that was it. This is not in disrespect to physicians. I believe that the general public must take it upon themselves to ask more questions rather than to expect being told what to do.

So that happened. I still maintained my employment.

My biggest experience was with my entry into the antipsychiatry movement. I was working at an institution, and an eleven-year-old boy came in. He was wheeled in and, he wasn’t walking or talking or toileting or anything. He was shut down. He had for all intents and purposes shut himself down, which is a safety mechanism. It’s a language. Something is going on in his emotional surrounding. Something else is going on. Within 24 hours, that young boy who wasn’t walking, talking, toileting, eating, and was wearing sunglasses and a baseball hat was guerneyed to an adult hospital for shock. And it wasn’t recorded in the chart. He was sent several times.

I spoke up. Why can’t we give him some time? Why can’t we let him settle in and get used to us. Why can’t we work to build trust, and slowly, let him guide us to the true cause? I knew that I was on shaky grounds and quite alone in my emergent critique, but you know, I can still see his face now. Well sure enough, after a few sessions—and no I don’t call it therapy, I call it shock—he started to walk, and talk, and toilet and took his sunglasses off and his hat off, and he ate, and eureka ! “Look, he’s better.”

So I ask: Can we not provide a safe haven? Can we not facilitate him to follow his own path of readiness and respect when he’s ready to share? If he’s ready to share, what’s going on? Something’s going on. And there were so many flags stemming from the behaviour of his family that I grew more and more uncomfortable. My nursing gut and all of the signals of my nursing instincts were telling me that there was so much more than his presenting ‘language’, if you will, language of being totally unavailable and as invisible as he could humanly make himself...

They sent him home!

So that was my entry....

What do I know about psychiatry? I’ve not been hospitalized, as many of you have. But who knows how your life might turn out? I decided for him that I had to try and do something. So for now, I’ve been doing some work around trying to prevent boys and young men... girls and young women from being rapidly prescribed psychotropic medications in the first place - from being pathologized and medicalized.... “This pill for every ill” mentality is now targeting children and youth, and I’m so gravely concerned. I’ve been doing work around de-pathologizing girls’ and women’s anger, because I feel that girls and young women get anesthetized by societal and gender-based expectations to never be angry, when we know that anger is a message and a safety mechanism, and must never be dismissed.

The last thing I want to say, at least for now, is that you wait for a forum like this as a nurse to speak up and speak out because your colleagues sometimes think you’ve got a problem. They ask, “What’s your problem? Why are you a radical all the time?” Radical? “Radical” means that there is a norm and a non-norm. So scrap that...