The following week in clinic, Ken asked me how I got on, and I
simply reported that the system was all new and might take me some time to
grasp, but I had sat in on a staff meeting, done the tour of the ward, met some
of the children and parents and “hoped I might be useful”. He smiled and
changed topic.
When I returned to Lanthorne, the first thing I noted as I came
out of the lift was a pile of faeces against one wall of the corridor. I found
a nurse who grumbled about ‘Peter doing his thing again’ and said she would
deal with it. I joined the meeting. They had completed two case discussions
despite the fact that I was not more than 5 minutes late after my diversion,
and again I was sat on the last available chair at the back. I listened
carefully to how the cases were handled and was impressed with some of the
changes reported in a couple of children to whom I had been introduced the
previous week. The teacher was particularly pleased with a sudden beginning of
excitement to learn in one of the children.
When we got to Peter, the discussion seemed very limited; they had
‘a program’, and needed to keep it going. I felt obliged to briefly report what
I had seen on leaving the lift to cries of “Oh, not again…” and a couple of
smirks. One of the staff was clearly angry, and began with “That makes me
really cross. I told him what…” cut off by the charge nurse. She turned to me
asking whether I had had any experience with ‘encopretics’? I said I had two
small boys at home and that Jan and I had had some fun with potty training,
reading favourite books or playing favourite music and rewarding anything that
looked like a success. But no, I had not yet had experience working with
‘encopretics’. She looked away saying “I think we just need to keep on with the
program, but getting angry with him will not help!” It was not until the
following week that one of the nurses let me know quietly that she had
suggested to Peter that they could read a book together while he was on the
toilet, and this had been ‘fun’. He had had two ‘successes’, and enjoyed a
biscuit from the ward kitchen after each occasion. She had discussed this ‘new’
idea with the parents, and three weeks later they were keen to have him home
after a successful weekend visit (and an admission of four months). I never did
really find out what ‘the program’ had been.
One of the recurring problems discussed in meetings was how to
gauge when a young person had recovered. Was there an optimum time that would
give confidence that change had occurred? How many symptoms needed to improve
before parents would accept that their child had made sustainable progress? Who
would be the judge of any given behaviour? Did it have to be a consensus score?
Clearly it was the nurses who spent most time with the patients, so it made sense
for the score to be agreed amongst them. With the charge nurse’s permission, we
began the idea of charting key behaviours once a week in the meeting with an
agreed score for each of them from 0 to 10 on severity. The most severe behaviour
would probably occur before or around admission (and could be scored 10), and (hopefully)
become less severe or less frequent with therapy and as time drew near for
discharge. There emerged a rule of thumb that once each of the behaviours were
down to 3 or 4 out of 10, discharge could be discussed with parents. Very crude
sort of measure, yet pragmatically useful, and it became part of the language
of team meetings.
There is, of course, nothing new in the world. Others had
apparently devised a formal scale some years before (Honigfeld G, Gillis RD,
Klett CJ. (1966). NOSIE-30: A treatment-sensitive ward behavior scale. Psychological
Reports. 19, 180-182). This was a 30-item ‘Nurses Observation Scale for
Inpatient Evaluation’ geared to measuring behaviours in adults with Schizophrenia.
I do not believe I had heard about this formally or informally at any time
prior. And in fact, given the content of items, the original scale would not
have been of much use at Lanthorne. Our scale was developed for use with a wide
array of children and their problems, was pragmatic, flexible, very brief, and
focused on key behaviours (rather than symptoms of one disorder). It was also
very much a consensus measure, and the process of scoring was as important as
the ultimate total score. As befits the times, we would never have ever
considered publishing such a thing.
At my third weekly visit, a young woman of 15 called Jenni was
discussed in the team meeting. She had attempted suicide at home following
recurrent arguments with her mother and was thought to be in serious danger.
She had only been in a couple of days, but no-one felt they had made any
headway in developing a relationship. She refused to talk, was sullen and
resentful and refused to leave her room even for meals, which were barely touched
even when brought to her room by a nurse prepared to sit with her. Night staff had reported she prowled around
the unit at night and they thought she was investigating avenues for escape.
The unit had always been secure with windows that had limited ability to open,
and access to the two lifts only available by key. These were worn on a lanyard
around the neck of staff members. To date I had not yet been trusted with my
own key and always had to ask a staff member to escort me into the lift and down
to the ground floor. There were external emergency stairs, but the door was
always locked, keys were kept in the charge nurse’s office, and I am not sure
that Fire Drills had ever been thought about.
At the end of the meeting the charge nurse said that Dr. Fraser
had suggested to her it might be a good idea for me to attempt some sort of
therapy for Jenni; she did not look convinced. I simply said I would be
delighted to see her. I read through the referral letter, some comments by Ken
Fraser, and the daily nursing notes. There was a hint of angry trouble between
Jenni and her mother’s boyfriend, the father having left the family home some
years prior and not kept in contact.
I knocked on Jenni’s door, taking over the chair of a nurse who
had been sitting with her. I explained who I was and how I thought I may be
able to help. I told her that I had read through the notes, but people seemed
to be perplexed about what had led to her trying to take her mother’s tablets.
No comment or response. No eye contact. Not even a flicker of a reaction to
anything I said. Just a dead look straight ahead. We sat in not very
companionable silence, with me trying various speculations about what might
have happened, and how I imagined she may have felt. No response. The chair was
by a window, so I was able to look at treetops and distant roofs while trying
to find another avenue. After nearly an hour of trying I explained that I had
to leave, but that I would return the following week. In the meantime, I hoped she
would get lots of rest, and perhaps get to know one or more of the nurses. No
response.
I reported back to the charge nurse, and detected a hint of amused
satisfaction. Perhaps I made that up.
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