Institutional muting

For some time now, I have been reading through psychiatric nurses’ daily records of patients in  detention. It’s a very sad and, to be honest, distressing read. As I tweeted a couple of days ago, I had never seen so much pathologisation of the ordinary. There are remarks on patients’ walking, talking, even being there. As one of the nurses remarked, a patient was irritating with his person (seriously).

In this post I want to write about one sentence from the notes; it offers good insight into the reality that emerges from the nurses’ notes. So, one of the nurses wrote:

The patient requested a conversation.

Let me offer a brief account of the context.  The note has another sentence which specifies the issue, which can safely be described as rather inconsequential, part of daily routine on the ward. So, the request was for a conversation with a nurse and judging by the issue, the conversation was going to be brief, almost done in passing.

There are two points which I want to make, first about the fact that such a record has been made, second, about what the sentence means. So, first, why would anyone want to make a note like that?

I am pretty certain that your first likely reaction is that the nurse was concerned about the patient. Why would he think that he had had to make such requests? And you could not be more wrong….In fact, communication with patients is commented on very frequently in the notes, but the comments are positive only in those cases when it is initiated by the nurses and the patient is deemed to have responded appropriately. I am yet to see a record in which a nurse comments in the positive about the patient starting a conversation. In fact, patients who talk unquestioned are more often than not ‘talkative’ or ‘verbose’. Basically, if you talk, you have another symptom.

In view of this, I think, noting that the patient requests a conversation is likely to be a note that the patient learnt the rules and stopped talking! Finally, he learnt that uninvited conversation is just about on the pathological side.

And here we come to the second issue. The patient’s request tells us quite a lot about the process of communication. Well, we all know that because of the differential of power in medical encounters, speaking rights are not distributed equally. Clinicians have much more control over the entire communication situation, both the channel and the message. Still, we, the patients, have some rights too. We can ask questions, ask for clarifications or, at out peril, refuse to speak (I would not recommend this in mental health settings, though). But these rights also mean that the channel of communication is open. There is someone on the other side who will actually ‘pick up the receiver’, so to say.

And here we come to the crucial point about the request for conversation. If you need to make it, it means that the channel of communication is closed. You must request its opening. Yes, you could suggest that it is much like having to make an appointment to see a doctor or a nurse in a surgery. Except, in hospital,  you have continual physical access to your potential interlocutors. In other words, even though the nurse can hear you, she (in Poland nurses are practically exclusively female) will not engage. Despite the physical possibility, the channel of communication remains closed. Does it remind anyone of the famous Rosenhan experiment, in which clinicians are described to have strategies of walking through the ward not noticing anyone? It should.

Closing a channel of communication not only means total control over it, but also means a total imbalance of power between the patient and the nurse. Although things are always more complicated, the request for conversation, especially if not granted (the notes do not suggest either way), means that you will be silenced and deprived of any opportunity to communicate with the institution where you are held.

I once wrote a blog about the small things, like shaking hands, which, nevertheless, are significant. Here I also write about a small thing. One sentence! And yet, this sentence shows ways a person in psychiatric detention is cared for.

When I started the project on detention, my main question was whether the people held in secure wards were patients or inmates. Mad or bad? I never expected that the aptest way in which they should be described might be mute.


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