PRETENDING

By Mickey Skidmore, AMHSW, ACSW, MACSW

“Courage is fire, and bullying is smoke.”

-BENJAMIN DISRACHI

Consider for a moment the following scenario …

You are collaborating with another party to secure an outcome that you hope, want, need or desire — something important to you. As a result of your efforts, the other party agrees to provide you with your request, let’s say within the next week. However, a week goes by and they have not followed through. Another week passes, still nothing. After a third week, you mention something to them, and they offer reassurances that it will happen any time now. A month later, after no indication of anything different from the previous four weeks, you escalate. Your follow-up efforts become sharper, more distinct, straight-forward, urgent, insisting — to the point that some frustration becomes evident as you voice your concerns and confusion at this situation. Eventually, several weeks later, they finally provide you with what they promised they would several weeks ago, however, as a result of your follow-up efforts you have now been branded an “asshole”.

This scenario is one of the single dynamics that I detest the most. Where I “become” an asshole because someone else didn’t do what they said they would do in the first place. This is one example of what it’s like to work in the environment of the mental health services of Liverpool hospital.

It has been suggested to me when I attempt to point out issues or convey concerns to staff or management at Liverpool Hospital that I am perceived as “hammering” them with criticism. And this is where the above analogy is relevant. If anyone at Liverpool Hospital would genuinely listen to concerns rather than look the other way, or pretend that it will just go away or fix itself, then I would not feel the need to persist. However, out of desperation to be heard, acknowledged or validated at all, I think sometimes that such frustration comes across as being “hammered” in hopes of being heard or acknowledged.

It is worth noting that Social Workers are trained in system’s theory. Thus, it should not come as a shock or surprise when Social Workers identify systemic issues that arise out of the beauracratic dysfunction that persists, because of two predominant variables:

  1. there is no identifiable role(s) in the organisational set-up or design intended to address systemic issues that routinely and perpetually occur in the in-patient setting within the organisation; and
  1. at Liverpool hospital Social Workers are viewed as glorified Welfare officers rather than respected as Allied Health professionals on par with Psychologists and Occupational Therapists. They are devalued, degraded, demoralised and endlessly disrespected. Thus, when they identify system dysfunction, they are patronised, dismissed and in many cases indirectly attacked and scapegoated.

Year after year, the executive mental health leadership attempts “have your say” surveys to gain feedback from their staff. And year after year, the response to this is significantly low. It’s ironic that they are blind and tone deaf to this response. Because it is common knowledge in the trenches; on the front lines of direct service that the majority of the staff — regardless of their professional discipline, that the staff do not feel safe and often are reluctant to offer genuine feedback, because the fear of the reaction and reprisals — and because the executive leadership have demonstrated time and again, that they really are not genuinely interested in any ideas, observations or feedback that is different from what they’ve already decided. It is commonly understood that what the mental health service at Liverpool Hospital does best, is pretend.

They pretend to meet the primary ED KPI by amassing an army of after hour bed managers to do whatever is necessary (regardless of what policies, guidelines or principles are violated) with impunity and without consequence.

They pretend to be fair and supportive to staff when formal complaints are lodged by “stakeholders”, when in fact the HR machine is designed to provide cover for adversarial approaches and to ensure that the status quo is maintained regardless if it is transparent, fair or reasonable to employees or not. 

They pretend to uphold the principles of recovery within its service delivery, which realistically is a rare occurrence, because consistent and genuine recovery practice is often inconvenient with the day-to-day practicalities of the mental health service.

They pretend to provide inpatient substance abuse treatment to people in spite of the fact that none of the 6 psychiatric wards are designed, intended or specifically accredited or credentialed to offer such service or treatment. Or they pretend to diagnose patients as mentally ill or mentally disordered, when overwhelming evidence suggests their primary presenting concern is substance abuse — thereby reducing or blocking beds for genuine psychiatric patients in the ED.

They pretend to value professional Social Workers as part of their interdisciplinary team, while devaluing and degrading them at every opportunity as evident by their insistence in clinging to an outdated welfare worker model rather than understanding and recognising Social Work as a distinguished and legitimate allied health profession that offers unique perspective and contributions unlike any other discipline.

For example, after losing a political dispute with the main Social Work department over Social Work coverage in the ED, and after more than a year of ongoing conflict and dysfunction with the PECC unit, which seemed to take issue with several different Social Workers on the MHU staff, the conflict came to a head. The NUM of PECC took the position that Social Workers were not needed on their unit, and they would make referrals to the Social Work Team Leader for any issues they could not manage. 

One of the MHU Social Workers stepped forward to do a research/quality improvement project partly in response to these issues. After much deliberation around how to accomplish a realistic project, they arrived at the idea aimed at identifying pathways for Social Work referrals in the PECC unit. 

This is a classic example of how the leadership of Liverpool hospital pretends. Rather than acknowledging the obvious — that allocating a Senior Social Work position (as is done in other hospitals — Campbelltown for example) and allowing them to function and practice as an independent practitioner rather than an accommodation officer, real estate agent or glorified Welfare officer, there wouldn’t be a question about referral pathways, as every patient in PECC would be seen by the Social Worker. 

Instead, the leadership of Liverpool pretends to undergo a quality improvement project to determine something that was already in place (for the PECC unit to contact the Social Work Team Leader with “Social Work” referrals). In other words, the dysfunctional system dictates for the process to go to elaborate appearances that they are doing something about a problem, all the while actually ignoring the dynamics that they could be addressing in straight-forward ways. 

Another example of pretending is the execution of the Gold Card Clinic, an initiative born out of a research project from the Personality Disorders Institute of the University of Wollongong. My understanding of the recommendation that came from this initiative would have resulted in a full-time position to coordinate a hand full of part-time contributions from existing staff. I also envisioned a minimum of one year project to properly execute the roll out of this new service approach. The Liverpool leadership however, put out an EOI — twice, where they expected interested parties to take on these extra duties — in addition to their current duties, with no adjustment in their compensation. (Who in their right mind would agree to do two jobs and only get paid for one?). Yet another classic example of the leadership pretending to add value to the service, while being completely blind to the optics that they’ve done so at the expense of their own staff.

A few years ago there was talk of criterion-driven discharges in the acute wards of Liverpool coming from the Health Ministry. Any discharge planner would tell you that the discharge process begins at the time of admission. However, only doctors admit patients to the hospital. And in the absence of clear psychiatric admission criterion, such talk rings hollow and is viewed as yet another example of pretending to address a problem that many would suggest is backwards. Furthermore, in the absence of admission or exclusionary criteria, the focus defaults to a more risk averse approach, which in many cases contributes to inappropriate admissions.

I have heard more than one physician convey their views that “it’s a public hospital system … if they want to be admitted, admit them … you should admit them all …” Yet once they are admitted, whether appropriate or not, it can be difficult to discharge them (as the hospital often tends to assume responsibility for nearly every aspect of their life rather than an acute psychiatric condition). If the focus was placed on admission and exclusionary criteria, the number of inappropriate admissions could be culled significantly and there would be less of a need for criterion-driven discharges.

These are but a few of the examples reflecting the level of pretending that occurs on a regular basis within the mental health service of Liverpool hospital. However, there are also external stakeholders that collude with this dynamic of pretending as well, suggesting dysfunction within their own respective beauracratic systems.

The official visitors pretend to provide a layer of impartiality and advocacy by interrogating the staff about why patients are caught in the quagmire of systemic dysfunction, rather than holding the executive leadership accountable or inquiring directly to external stakeholders why they don’t always seem to provide what they say they will. 

The Mental Health inquiry process pretends to uphold the principles of least restrictive care, yet rarely, if at all do they ever discharge patients when this principle falls short. And they look the other way or pretend even harder when they rubber stamp the fraudulent practice of allowing someone to be diagnosed as mental ill when the evidence is overwhelming that efforts are being made to detain them is in order to contain their substance use.

The Public Guardian’s office have a peculiar role in that they are charged with approving the decisions affecting patients lives, including where a patient may reside, yet they hold no direct guardianship responsibilities other than decision-making. As a result, they participate in this process by allowing the hospital to be used as an extended hotel (for years at times) because the external stakeholders that are responsible for placements are content to let patients reside in hospital settings indefinitely.

For just short of a decade, I have operated on a false premise in hopes of seeking some indications of reasonable logic in a deeply flawed and dysfunctional mess. I naively and steadfastly clung to my Social Work training. Among the numerous theoretic frameworks, models and approaches within the mental health field, system’s theory is perhaps emphasised more than all others in preparing Social Workers for professional practice. I held to the notion that sound and reasonable input from an Allied Health perspective would, after some debate and discussion result in gradual and modest system’s change that ultimately would enhance the service, for both staff and patients alike. However, I have finally come to the realisation that experience, clinical acumen and critical thinking are not well received or welcomed at Liverpool Hospital.

Furthermore, the reason this approach is unlikely to succeed is because it is not a healthcare system, but rather a political system. Part of the pretending is that this is a massive political system masquerading under the guise of being a medical model. Thus, regular and normal strategies of straight-forward logic do not apply to political systems. If there is such a thing as political logic, it adheres to its own rules and principles and tends to change when political parties and power change. Attempting to effect change management with health care principles is not likely to apply to a system with political appetites.

Another component of pretending involves the HR system. Relying heavily on an obsession with secrecy; insistence on anonymity; and lack of transparency, the HR system is set up to provide cover for and to defend and protect the status quo of the mental health leadership. The organisational system of Liverpool hospital literally does not have a structure to address a plethora of systemic problems, issues and dysfunctions — many of which are self-inflicted. There is no identified place, person, or role to address the damage that occurs on a regular basis. Coupled with the top-down dynamic to protect and enforce the primary hospital KPI, the system adopts an equilibrium of looking the other way — pretending that it is a viable and functional mental health service, when in fact, it is a broken institution with powerful obstacles to repairing it. And while this might play out satisfactorily with politics, it is nothing short of a “train wreck” for the mental health service (Skidmore, 2020).

This system which has attempted to serve largely psychotically mental ill patients is beginning to mirror the people it treats. When it blatantly is hypocritical and indifferent to its own policies and procedures; and when it advances false beliefs that is firmly maintained even though it is contradicted by social reality, it could be viewed as being delusional. It could also be argued that this system could be compared to a cancer that is rampantly metastasising and spreading. In either scenario however, a profound sickness is present and spreading within the mental health service of Liverpool hospital — and pretending will not alleviate it.

As a result of these dynamics, the working environment of the mental health services of Liverpool hospital has become a toxic, corrosive, hostile, dysfunctional and frankly an unhealthy place to work. The frontline workforce is largely demoralised. And while I have only worked there for eight years, my sense is these dynamics have been at play for some time. It is unclear if this has always been a dysfunctional place to work; or perhaps it’s getting worse. Yet, when someone calls attention to problem areas, or attempts to address these concerns — in an effort to improve, correct, change or heal these broken patterns within a very sick system, the system resorts to relying on misdirection, falsehoods, and logical fallacies that they’ve always used to side-step reality and pretend they are providing a quality service. Make no mistake about it, they also employ the age-old tactic of bullying as well — an attitude that is cultured and fostered from the top down.

Beyond the context of the working environment of Liverpool hospital, is the larger issue that these disingeniune efforts at pretending obscures or threatens the core values the hospital professes, and perhaps, truth itself. In my interactions with HR and the EAP it was expressed to me that the psychiatric/mental health services experienced pervasive issues that resulted in a separate department or division being created to deal with this group in the hospital exclusively. The main HR unit of the hospital would no longer be overseeing HR concerns, complaints, etc with mental health employees. 

It is the responsibility of everyone to preserve and protect our core values by recognising what truth is and is not; what a fact is and is not; and begin by holding ourselves accountable to truthfulness and demand the pursuits of our future be genuine and fact-based — not based on wishful thinking, not hoped-for outcomes made in shallow promises, but with a clear-eyed view of the facts as they are, and guided by reality and the truth that will enable us to seek solutions to our most daunting challenges (Tillerson, 2018). 

The response to these observations will no doubt be fiercely denied. However, I am confident that my appraisal of this landscape is sound. In one of my professional mentorship supervision sessions, I was reflecting about these circumstances. My supervisor validated my observations by stating that he had multiple conversations with several different people this week — and they all were essentially the very same conversation that we just had. Perhaps the most profound mantra I took away from our time together before he departed was … “even though there is no mechanism in place to address these issues … it doesn’t mean you are wrong”.

Still others have suggested in one way or another to just relax … lower your standards … and look the other way and pretend like everyone else does. And to this I simply say: I fight every day to not give in to such collusion. In my mind, to do so would be to admit to being part of the sickness. And I am adamant that I am not sick. I might be an asshole, but I am not sick.

REFERENCES

  1. Skidmore, Mickey. “Train Wreck” 2020
  2. https://edition.cnn.com/2018/05/16/politics/tillerson-trump-truth/index.html