(True) Parables from the frontline of the NHS
Dr David Zigmond
Introduction and summary
Such disorders as those of behaviour, appetite, mood or impulse (‘BAMI’) introduce innumerable human variables, and from all participants involved. Measurement, standardisation and technical language all become highly problematic, if not contentious. Ensuing operational difficulties are inevitable. For those interested in ethics and epistemology, important questions arise. This presents a vast and ambiguous area, particularly in General Medical Practice and Psychiatry. Inadvertent damage may result from indiscriminate and automatic use of mass-production protocols. The cost, in both human and economic terms, is probably enormous, but receives little attention.
In all human life inevitable compromises have to be made: between structure and flexibility, control and creativity, Group conformity and individual integrity. Such dilemmas have a universal span from the lives of individuals to the largest groups.
From the basis of current NHS events, these and related themes are illustrated. The narrative and dialogues are authentic. Only peripheral descriptive detail is changed to guard anonymity. Although the personal nature of the recording may be uncommon, the dilemmas they describe are not.
‘This one’s going to be trouble …’
Sophie approaches my desk with officious pleasure, a privileged messenger of bad news. As senior receptionist she opens ands pre-digests much of my post, both to prime and protect me. Or so she supposes.
‘You’ve been assigned this man, Stefan M, because he was extremely rude, and threatened violence against Dr K … Dr K had no option but to remove him from his list … Dr K’s surgery had to call the police … I hope you won’t keep him longer than you have to …’
I sense in Sophie not just concern, but a hidden, elliptical gratification, an anticipation of righteous vindication. Her expression carries gravitas skewed by a faint twist of a smile.
* * * * * *
Stefan M’s self-introduction to me, the next morning, disturbs me with the unexpected. His proffered handshake is warm and firm; receptive but not at all overpowering. Watching him walk across the room, I am reminded of an ageing, wounded male lion – previously a powerful predator but now incrementally vulnerable and unable to hunt. He meets my gaze with subtle and kaleidoscopic complexity: pride, hurt, defiance, pleading, enquiry. His intelligence is sharp, sprung, mobile.
The answers to my opening salvo of routine medical questions further alerts me to the breadth, depth and weight of this man’s troubles. Among my notes I write:
Medical: Age 38. Heart attack last year. Lassitude and weakness since. Says he can’t work because of this (never previously ‘off sick’). Smokes 40/day for 15 yrs. Sister died aged 39, two years ago, amidst political asylum litigation (in Scandinavia). Psych/social: From previous African conflict zone. He and (now deceased) sister fled to different European countries as racial minority persecution mounted in danger and savagery. Both he and sister fought hard for political asylum, in different countries. He succeeded. His sister’s case became impacted as a ‘cause célèbre’, when she died suddenly. Plight of his remaining, once-hunted family members unknown: presumed dead. Since in UK (10 yrs) worked 16 hrs/day as advocate/spokesman for his much-mauled national group. Deeply disturbed by sister’s death, but worked harder and smoked more to obscure grief. Collapse of relationship with girlfriend after heart attack: says sexual potency problems (1st time) then. ?Blocked grief etc. ?Medication effect ?Smoking/vascular. Enquiries re: depression: explicitly denies this. (Tightens his jaw and hands and says: “What good would that do … who could care for me now?” His eyes moisten, but he rapidly dabs them. He looks away – ?hoping I will, too.) Imp: ?Masked Depression ++.
I ponder this Psychiatric term, now little used: an explanation, a description, a hypothesis spawning its own questions about the masker and the maskee, the relationship of the ‘ghost’ to the ‘machine’.
Stefan M’s cumulative life-traumas seem enormous, matched almost by his formidable courage, resolve and wilful integrity. Almost, but not quite. It is the ‘not quite’, I suspect, that has led to his incapacitation. Fighting against such mountainous adversity for so long, he has attempted an indefatigability of the superhuman. Only his body can stop him.
* * * * * *
Only later, when Stefan has mapped me as a Safe-Haven, do I enquire about how his (mis)communications with Dr K had become so conflagratory.
‘He told me that, from the information he had received from the cardiologist, there was no reason for me to stay off work … he asked me psychiatric-type questions, which I felt patronised by … When I tried to discuss this with him, he turned away from me toward the computer where he was consulting investigations and some kind of recommendations. I said I just can’t work with this weakness I have. He said that, from the information he had, he couldn’t help me further. While still looking at the computer he asked me to leave.’
I asked Stefan if Dr K had known much, or anything, of his story.
‘No, he didn’t ask much, and I didn’t think he was the sort of person I could talk to … He seemed much more interested in what was on the computer. After he had glanced at me, I don’t think he could remember what I looked like …’
* * * * * *
Soon after, I attend a local medical meeting, a congregation that owes its longevity more, I suspect, to the reliably good curry served there (a silently appreciated bribe by International Pharmaceuticals), than to important shared concerns and commitments.
Dr K and I are long familiar cohorts. He is a ‘busy GP’ with a large practice and a bluff, no-nonsense, impatient amiability to help his long-term survival. Our affinity is stable and considerate, but not deep. In greeting he shakes my hand, a limp detached ritual as he looks away, toward the banqueted table, his gaze dully observant.
‘Bad luck! I hear you’ve been assigned that very rude and troublesome man Stefan M, ‘ he mocks, with the relief of the released.
Soon after, amidst the steaming fragrances of massed curries, I try, with lightness and diplomacy, to interest Dr K in how our own common aggravations may easily blind us to the exceptional tragedy of others. He glances at me briefly with a slight twitch of a shrug, while spooning another large self-serving of Chicken Dansak:
– – 0 – –
Every exit is an entry somewhere else
Rosencrantz and Guildenstern are dead (1967)
Karen greets me by her bed, B23, with the social facility of a TV chat-show hostess. Her hair is dark, wavy and lustrous; a generous and sensuous frame to a soft, cherubic face. In counterpoint, sharply mascaraed eyes warn me of other agendas, of danger. Given the seriousness of her overdose a day previously, this now silk-gowned young woman seems disarmingly urbane and insouciantly welcoming.
Behind the curtained screen Karen and I are now invisible to the gaze and traffic of the ward. This seems to free Karen to hesitantly disclose a little-known self, more usually obscured by her competent, voluptuous masks or painful shards of self-harm.
The brief, typed referral form had forewarned me of the latter: ‘3rd serious overdose, with alcohol binge, in recent months. Recent stresses: break-up with boyfriend and alleged rape (different relationships). Denies mental illness and wants to leave …’
The story Karen tells me is as perplexingly discrepant as her calm social persona and her juxtaposed, profoundly hazardous behaviour. Within the envelope of her salubrious suburban home, her publicly polished, professionally respected parents were locked in decades of a grimly hypnotic power struggle. Their two children became both weapons and casualties. Common emotional violence would erupt, often through a haze of alcohol, in periodic convulsions of physical violence. In her early teens, under cloaks of darkness and alcoholic amnesia, her father culminated the domestic damage in a sexually intrusive visit to her bedroom. Karen, with admirable but precocious resolve, left her parents and never returned.
* * * * * *
This first time I meet Karen she is entering the Eye of the Storm that will determine her mortal existence. In the months that follow, her life is like a narrow path skirting the edge of an abyss. Several times she lunges, with angry despair, both softened and fuelled by alcohol, to her own self-annihilation. The serial projects of foiling her self-killing are administered by teams of physicians and psychiatrists at various other inner city hospitals: the Blue-Light Ambulance disgorges this dangerous cargo with blind haste. Precedent is neither known nor important. The practitioners immediately charged with saving her life are similarly blinded by emergency: there is no place here for nuance or finer historical reference. Medication and the Mental Health Act will contain: if not, ‘Severe Borderline Personality Disorder’ will explain. Karen becomes both lost and lime-lit by the doctors’ (self?) defensive conferral of ‘dangerous mental illness’. She may be transiently contained, but she is not understood.
This follows a pattern where the (usually) young and inexperienced practitioners, fearing for both Karen’s life and their own professional career, act with zealous and crisp efficiency. In order to forestall disaster, Karen becomes crippled by pre-emptive strikes: Sectioned, medicated, monitored, ‘Specialed’. Karen is managed: dialogue is discarded.
Karen remembers the earlier exchanges she had with me and re-contacts my small department, a different venue and culture from the busy, bustling, prescriptive Community Mental Health Team now in charge. In this small, relatively quiet hospital department, there is great stability and accessibility for Karen. Over several years she keeps deliberate and regular contact with me via my long-serving secretary, Dorothy, a woman of unpretentious warmth and robust but respectful intelligence. Her considerable range and length of life experience may discretely illuminate, but will not dazzle. Dorothy and I are both gently silvering with age, a source of wistful banter between us.
* * * * * *
Contents Copyright ©; Dr David Zigmond 2007
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