An open letter to Mental Health Services Director
Dr David Zigmond
My experience with an urgent psychiatric problem: an instructive example of current institutional complexity, rigidity and unresponsiveness. Bureaucratyrannohypoxia
In a recent phone call, I described briefly a fresh episode to you. It seemed (to me) a good example of the rising tide of depersonalised, procedural complexity. This burgeoning is burdensome: obstructive to sensible, sensitive, attachment-respectful care. It is often confusing, frustrating and disheartening for professionals, patients and possibly (even) managers. It is very expensive.
Before time submerges memory, I want to record this episode, and some of my thoughts about it. The episode is one of many: I choose just one, for focus and dissection.
My detail is very deliberate: please take your time.
1. The Prelude
Early one afternoon (in June 2010) I am telephoned by the mother of a 39-year-old woman. The mother herself is clearly fearful and distressed by convergent difficulties gathering around her daughter: "Ellie is crying all the time ... she won't eat and yesterday got drunk (again) ... she was doing so well until she foolishly and briefly tried to get back together with Omar (ex-partner) ... Just one night, but she accidentally got pregnant ... She was shocked and realised it was a terrible mistake. She had a Termination, but when Omar found out, he 'went mental' with rage and broke her arm so badly she had to have complicated operations, and now cannot use it ... She can't look after her little boy (Sam, age 4), so my sister is looking after him ... Ellie says her life is so useless and painful, she'd rather not have it ... I've got a disabled husband: I can't stay with her ... She doesn't want to go into hospital, she's had bad experiences there ... Can you help us, Doctor? ..."
* * * * * * * * * *
Ellie joined my GP list three months ago. I had seen her twice for routine appointments. She told me she was a 'refugee' from an acrimoniously broken relationship with Omar, and had moved across London to create both distance and defensible space. My more psychiatric questions clarified a pattern of several years' fluctuating Reactive Depression and spasmodic alcoholic consolation. She told me of her failed attempts to make a durable, loving bond with a man. Each ended with a variety of hurt, abuse, betrayal and derogation. It needed little prompting for her to talk of the developmental roots of this: her descriptions of a charismatic, powerful but sarcastic and alcoholically violent father; a cravenly collusive and melancholically abstracted mother. Her manner was naïve, warm, submissively apologetic, distressed and affecting. She was tearfully and copiously grateful for my interest in her current dilemma and its history, both recent and ancient. I realised how important quality and continuity of personal care would be for her. While re-prescribing her established anti-depressants, I communicated this to her: as her GP I offered her both periodic anchorage and guided-support across her Sea of Troubles. I talked with her of possible help from longer-term Counselling and Alcohol Services. We conjured and glimpsed future possible scenarios from a rebuilt life. She left me, both times, with a moist-eyed smile and a proffered, warm, firm handshake.
* * * * * * * * * *
My urgent visit to her revealed rapid disintegration. Having retreated into her bed and nightclothes, her chaotic and spasmodic speech was rent further by anguished sobbing. Her physical needs and safety were provided by her mother, now buckling under the heavy contagion of distress. Despite the intense level of emotional disturbance, I was able to establish sufficient recognition, communication and alliance with Ellie to calm and contain them both. I held her hand, to gently push out a fragile bridge to the small island in Ellie that could think and speak clearly. We established that she was so overwhelmed by her life-events, and her distress, that she could no longer competently care for herself and would need supervised care, until recovery. I told them I would try to arrange this for her, at home. I then returned to my surgery, to record a diagnostic formulation that would be required from the Mental Health Team(s).
That would do.
2 Complex Times: The Institutional Response 2010
On arriving back at my surgery I ring my Community Mental Health Team for contact details and procedural advice. I am given these, and contact the Crisis Team Manager, after much delay, via a Paging Service. The eventual telephone contact is one of a unilateral pro-forma interrogation (of me), rather than any kind of colleagueial dialogue. Her questions are formulaic, and I have the sense that the questioner is guided more by institutional rules than relevant experience. At the end of her questions she tells me that a member of her Team would be able to visit at an unspecified time within the next four hours and that it is essential that I am present, for the safety of her staff. I tell her that Ellie is forlorn and passively imploded: she is a possible hazard only to herself, not imminently and only indirectly. Also this institutional safeguard takes no account of my other work: I have a busy Practice to run.
The young manager is curt and adamant: Team Policy is not negotiable. We are at an impasse: it is impossible for me to comply. I now fractiously ask if she has any ideas as to how I may get Ellie urgently cared for, at home. She brightens with a nascent possibility: if I send Ellie to St Thomas' A&E Department after 6 pm, she will be seen by the OOH Emergency Psychiatric Team there, and they will assess her, and my suggestion.
* * * * * * * * * *
After 6 pm I manage to contact the Duty Psychiatrist after much searching via the Hospital Switchboard. I tell him the outline of the current crisis and some selected antecedents. He is sympathetic in manner and pragmatic in plan. I do not tell him of my freshly-exited impasse with the Crisis Team, lest this somehow invalidates my request. He cordially suggests I send Ellie to A&E, where someone from the Emergency Team will assess her. A much briefer but much more dialogic and helpful phone call, this. I express my relief and gratitude.
* * * * * * * * * *
I now call Ellie: her mother answers, fatigued and expectant. I outline the plan. She responds with realistic despondency and deferral: "Ellie's now exhausted and asleep ... She's in no state to go to hospital and wait around for someone to ask her lots of questions. Can I take her tomorrow, after she's had a night's sleep?" This deferral makes sense to me, though I simultaneously sense my unfair frustration with their lack of 'compliance' to The System.
I call back the hospital Duty Psychiatrist and tell him of these developments. She will arrive the next morning at A&E. I will fax a letter with some helpful background and my reasons for recommending Home Treatment, by the Emergency Team who can assess her in A&E.
No, he says. Do not send a letter as this will be received within ordinary working hours, deemed a procedurally incorrect GP referral, returned to me with the instruction to re-contact the Crisis Team and start again. However, if I get the patient and mother to attend A&E, and make no mention of all our prior communications, it would be treated as a fresh self-referral and not sent back to me. As co-conspirator, he is inventive and supportive: he knows The System. Such stealth and deceit is essential to procure what I know is necessary for Ellie. And to return home that night. It has taken me 2½ hours.
The time later taken by Staff in A&E, and later by the Home Treatment Team, merely to assess and decide, would be much longer.
3. Simpler Times: The Institutional Response 1970s-80s
From the early 1970s I have had several decades working in, and then alongside, psychiatric services (the latter as a Principal GP). The response I now describe is drawn from many similar incidents in this earlier period, in which I was either active, or witness to. It is typical of the better practice of the time. The scenario is thus a fictitious graft of those old experiences onto my more recent problem with Ellie.
* * * * * * * * * *
After seeing Ellie at home, I immediately phone Dr G, the Consultant Psychiatrist at Highmount Mental Hospital. Dr G is aged about 50, and has been a consultant there for ten years. He has got to know many of the GPs on his patch and is interested in, and respectful of, the very different psychological qualities, styles and abilities that the different practitioners bring to the encounters with complex emotional distress. We have had warm and efficient problem-exchanges several times over five years. I sense he has a good sense of my human and professional strengths, deficits and (I secretly hope) vulnerabilities.
When I call Highmount I am initially put through to Linda, his secretary. She has a bright, alert and friendly manner and is clearly interested in her work. We immediately recognise the other's voice: we have a short bantering diversion, the kind of safe familiarity that keeps morale and relationships buoyant in turbulent waters. I tell Linda about my patient Ellie, in outline, and what I am hoping Dr G will arrange. She tells me that Dr G is busy on the Wards, and that he will call me in an hour.
Dr G calls me as arranged. It is calming and reassuring to hear his voice. Linda has briefly briefed him, and he invites me to tell him what else I think is most salient. His few questions are intelligently chosen, from long and wide experience. He understands a complex situation with graceful and subtle speed. My conversation with him has lasted only five minutes, but it is full and consummate.
He will get Ellie visited in the next couple of hours, he says. He's not sure who will go, either himself or his trusty, long-affiliated CPN, Patrick. Either Patrick or Dr G will call me the next morning and let me know what they have decided and implemented.
Dr G makes his expected second call to me. He had visited and spoken to Ellie and her mother for about half an hour: it was harrowing, affecting contact, and the time taken matched what he needed to know, as well as the sufferers' near-exhausted emotional resources. They had all agreed to try caring for her at home, unless she deteriorated. Patrick would visit daily, and would also liaise with Social Services. Dr G would revisit later in the week. The usual medications were specified and prescribed. Another short but full colleagueial dialogue: concise, companionable, accommodating, flexible and satisfying.
4 Comparisons, contrasts and comments
These different scenarios will be familiar to all older Practitioners who have retained memory and interest. Likewise, I believe, my frustrations and critique. The following brief comments are fairly random. Some problems I identify may have become insoluble: I hope I am wrong.
No easy answers to such questions, even if desired. No Reset button.
The work of all in Public Welfare has become increasingly in thrall to doctrines and mindsets from Health and Safety, corporate, competitive industry and policing. The resulting Bureaucratyrannohypoxia has coalesced to a Culture that ensnares and suffocates us all. The fragile but rich influences of healing, humanism and holism are now almost extinguished. Likewise the better kind of confederate socialism that used to contain the NHS. How can we resuscitate and rehabilitate these?
Such questions are crucial far beyond our local responsibilities or individual career spans. I hope this open letter will provide some spark and fuel for our further thought and discussion. I look forward to both.
With best wishes.
Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com
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