The desperate woman

The incident

The narrator tells us:

“This episode from my working life in the psychiatric sector goes well back in time. At that time, I was working as second in command in the psychiatric ward of Bispebjerg Hospital, in the closed ward for female psychiatric patients. Nowadays, we don’t have this kind of gender segregation, but this was still the case at that time. Furthermore, it was not so common to have male nurses. We were only a few male nurses at the time.

One evening, a woman in her forties was admitted to my ward. The woman was, apparently, a Muslim woman, since she was wearing a veil. She was accompanied by some family members.

The prehistory was that the woman had threatened suicide. She was very agitated and completely beside herself. Therefore, the family had summoned a doctor at home. Very quickly the doctor concluded that the woman should be committed to a mental hospital. Because of the state she was in, his assessment was that she may be a danger to herself. As you may know, this assessment would be the basis for committal to mental hospital. I imagine that this decision gave rise to the first culture shock for the woman as well as her family.

Anyway, she arrived and was quiet to our ward, where she was installed in a 2 bed room. Then it all started: she would certainly not be installed in that room. She just wanted to get out, and she was tremendously excited and agitated: She screamed loudly. She was kicking at things and throwing all the things she could grab. She shouted in mixed language that she will not stay, and this is not the right place for her.

The whole scenario took place in the hallway between patients´ rooms, and there was now a huge crowd of other patients, visitors and staff members. Some of the other patients tried to comfort her and talked reassuringly to her in order to calm her down. I noticed that even though the staff members did not wear uniforms, she was well aware of who was staff and who were patients and relatives.

She required that we open the doors and let her get out, and so did her family. In all this fuss and discussions we had great difficulties in communicating and massive language barriers. Some of her family members spoke limited Danish, but the woman herself hardly speak Danish. We felt very powerless when trying to explain the rules about admission. We really wanted to do this part of our job thoroughly and properly. But we completely lacked the language to communicate in the way that we usually explained things to Danish patients and relatives We couldn’t explain to the woman and her family that even as staff we had no permission to let her out again from the hospital. We couldn’t explain that we have rules and procedures around this kind of commitment that we simply had to follow.

We were also very uncertain about her mental state and how bad she was. When a person is committed to a mental hospital he or she is assessed to be a danger to himself or herself. This usually means that the person is assessed to be acutely psychotic. Therefore, we were responsible for carrying out a thorough examination and a further evaluation by specialists – and at least stay overnight. We all had the feeling that the woman was not psychotic. But even so, we had no formal permission to let her out again. Therefore, we were quite nervous and uncomfortable about the whole situation, because it broke all the rules we were used to following and all the procedures that we as staff had to answer for.

We realised that we had to get the family members to leave. They really wanted to stay in the hospital overnight, but back then it was out of the question that families and relatives could stay overnight. It was really a shock for the family members that they could not bring her home. Afterwards, we had to medicate the woman quite strongly, and there she was, left alone without any orientation points. Eventually, she fell to the ground because of the strong medicine.

The next day, she was transferred to the open psychiatric ward, where she was relatively discharged. Many patients were revolving-door patients, coming back to the psychiatric hospital several times. But I never saw this woman again. I guess that she and her family were so frightened by this first visit that they would do anything to avoid another hospitalisation…”

1. Identities of the actors in the situation

The narrator is a male nurse, who worked in various types of institutions within the Danish healthcare sector for about 30 years. He specialised early in psychiatry and worked especially, but not exclusively, in the psychiatric system. Today he is 63 years old, and nowadays he works fulltime as a Deputy Centre Manager of a major social psychiatric centre in the City of Copenhagen. The centre offers a variety of services to citizens with psychiatric disorders.

A group of colleagues, all of them members of the professional healthcare staff in the psychiatric ward, where the incident took place. The staff members would include educated nurses and healthcare assistants. All staff members were ethnic Danes. The majority of them were female, and very few of them were male nurses, including the narrator.

A number of psychiatric patients and visiting relatives were present in the situation. Like the professional staff, they would all have Danish origins. All patients were female, since at the time of the incident the hospital wards were gender-segregated. The incident took place in the women’s section. The relatives were of both sexes.

2. Context of the situation

The setting for the incident is the psychiatric ward of one of the largest hospitals in the City of Copenhagen. The incident takes place in the closed ward for female psychiatric patients.

3. Emotional reaction

The narrator and the professional staff felt:

Helpless and powerless, because they had no tools to communicate with the woman and her family – and explain the professional rules about the commitment to a mental hospital in the Danish healthcare system. Usually, even very sick patients would be aware of the process and the meaning of the hospitalisation.

Taken aback by the woman’s violent reaction and desire to get out immediately instead of being treated for her mental suffering.

Astonished by the family’s expectation of being able to stay overnight in hospital.

The woman felt:

Desperate, panicked and totally agitated, when she realises that she cannot leave again – that she is actually incarcerated.

The family felt:

Helpless, anxious and confused by the woman’s strong and inexplicable reaction.

Stunned by the hospital’s procedures and their own inability to bring the woman back home again.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

Norms and values from the view of the narrator and the professional staff:

Norms and values of personal professionalism and ability to cope with all professional challenges

The narrator and his colleagues experienced strong feelings of both professional and personal powerlessness, because they were not able to calm and comfort the woman and her family. Confronted with a patient and a family without the usual Danish language skills to communicate, they were left with no other tools to explain the situation. They had to use all their professional authority to force the unhappy family to leave the hospital ward, and they had to bring the woman to bed with a large dose of medication without further explanation, let alone care. Thus, they give up further professional attempts to understand what is causing the woman’s tormented situation.

Institutional norms and values that organisational procedures overrule the personal professional judgment

Furthermore, it gave rise to professional embarrassment that the narrator and his colleagues had to meet the legal rules and procedures despite their professional feeling that it would be safe to let the woman out without further procedures. From a professional consideration as well as from personal empathy, it seemed inhuman to leave the woman so alone, distraught and totally confused without opportunities to communicate. However, the narrator and his colleagues were not prepared to take the risk of breaking the formal rules and procedures.

Norms and values of interdisciplinary and intersectional collaboration

In the situation, the incident also revealed the lack of collaboration between the hospital staff and independent GPs. The narrator and his colleagues didn’t really understand why the GP committed the woman to mental hospital without giving the family any medical explanation or any preparation of what it would entail. Consequently, the whole healthcare system appeared to be totally alienating for the family.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatised", positive, very positive, real, unreal) etc?

The images of the woman go in different directions:

She is deeply distraught at being locked up, as if she feels trapped in a prison.

Despite her despair she is still aware of the environment, with an overview of who are staff members with authority and power.

She makes a scene to get out of the closed department, but still her expression of despair is also an expression of genuine powerlessness, mixed with fear of what might happen that she cannot control herself.

She doesn’t appear to be psychotic, so the narrator and his colleagues have from the very start the feeling that her despair and agitation have other causes.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

Norms and values from the view of the woman and her family:

Norms and values around mental illness

Apparent from the incident, the woman seemed to be heavily burdened by grief and a critical life circumstances which may – or may not – bring her to the brink of suicide. The situation suggests that she was on the verge of a mental collapse and a crisis. But mental breakdown and crisis seemed to be both unknown to her family – and perhaps not culturally fully acceptable.

The woman´s reaction causes deep concern in the family. But it may also cause embarrassment, because it is very difficult to explain and relieve the mental pain, which may seem like an obsession. Thus, the woman’s reactions may appear to be distressing, embarrassing and even shameful, but also frightening for the family. It may be embarrassing, while it expresses a lack of control.

Also, the woman´s acting out is a very explicit way to expose the individual needs. It seems to be a kind of rupture with the collective way of life and socio-cultural traditions, which many Muslim migrant families appeared to be deeply rooted in. Thus, the family would be used to emphasise the collective responsibility and give the family first priority at the expense of individual needs and desires.

The clash between decisions of public authorities and families’ private affairs

By the commitment to the mental hospital, the woman seems to realise that her individual despair and need for support has special consequences in Danish society and healthcare system. In the context of public authorities – like hospitals – citizens are treated on individual, not family-based terms. As an individual patient in the healthcare system the woman will be offered the necessary attention and care that she may be longing for in the first place. But this attention and care will involve an individual hospitalisation in surroundings, where she cannot communicate with anyone, where she is unable to express her feelings and thoughts properly.

Thus, she seems to realise that individual treatment and care is equal to loneliness and social isolation. Furthermore, the commitment to a mental hospital may also give rise to strong concerns and even be a shameful burden for her family in the family’s social-cultural network. So, she screams and lashes out loudly – not only from personal needs, but also from the family´s need to bring her back home from the closed ward in order to recover within the closed framework of the family.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

This incident represents an example of a mutual culture shock. From the intercultural training and learning perspective, it is obvious that the psychiatric system and the staff members were genuinely shocked to face the fact that they were not able to communicate either on professional or on personal terms with the woman and her family. In summary, they realised that they were lacking professional tools – and also professional authority – to cope with the situation.

All the professional competences and – not least – professional, systemic authority came up short in this situation. Usually both patients and relatives would bow to the hospital and professional authority. Patients may be agitated and eager to get out. But usually families would, in cases of compulsory hospitalization, be prepared to leave the responsibility to the professionals. In this incident, the professionals are out of their professional comfort zone. They are powerless and have to use force to cope.

Nowadays, it is unthinkable – and also illegal – that the staff members do not immediately summon an interpreter to support the communication. The staff members would also, generally, have more information about intercultural communication and responsiveness to other cultural approaches to mental illness and family care etc. But still, the incident gives rise to reflection, because even with such “helping tools” the intercultural communication and competence may go far beyond the literal conversation and touch much more intuitive areas. The question will still be left, why the woman reacts so violently before admission, and what life conditions she seemed to be reacting to.