Home Page    David Zigmond Home Page


(True) Parables from the frontline of the NHS


 Dr David Zigmond

Introduction and summary

The massive expansion of the NHS has led to a burgeoning of organisational and procedural changes deriving from mass-production industries and corporate capitalism. This ‘industrialisation’ of Health-Care is likely to confer clearest and greatest benefit when dealing with well-defined bodily complaints, ‘physical pathology’. When dealing with the evanescence and complexity of human unhappiness or mere dis-equilibrium, ‘functional pathology’, considerably more difficulties are encountered and generated.

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.

1. Imagination

You can’t depend on your judgement when your imagination is out of focus.

Mark Twain

Notebook (1935)

‘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:

‘You like all the difficult ones,’ his jest seems half-tribute, half-consolation, ‘I just think some people are impossible’.

– – 0 – –

2. Belonging

Every exit is an entry somewhere else

Tom Stoppard

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.

*           *           *           *           *           *

The consultant in charge of the populous but constantly changing Community Mental Health Team, Dr Q, thinks more management is called for. He writes: ‘We need to rationalise and unify this woman’s care. It is clearly not in the interests of the patient or the Service for her care to be fragmented. For this reason, I have asked the patient to continue her attendance to this department and arrange cessation of her sessions with you…’

I telephone Dr Q in an attempt to widen our understanding of this alluringly haunted young woman. He is more interested in speaking as Commanding Officer: Karen’s care would now be systematically planned, coordinated and monitored by his Multidisciplinary Team at HQ. With well-manicured authority he instructs me about the incipient New Order. Dialogue is skilfully bypassed. I am aware of holding my breath; I feel I, too, am being processed.

Karen’s compliance to such prescription is fragile: she meets with the many mental health professionals assigned to her, but is progressively confused and wearied by their complex and rigid protocols, their unpredictable impermanence. She describes it later: ‘They were all different, of course … A few I thought I could really trust and talk to, but twice they suddenly disappeared – gone for another job or training, or something. It hurts and I don’t feel safe … my barriers go up again …’ Karen’s offerings there turn shell-like: she yields only what she must.

She seeks connection and asylum where she feels less diminished and defined: she is discretely resolute in her regular contact with myself, and thus Dorothy. I have some unease about colluding with her unusual dissent. Dorothy and I are now as Foster Parents to this grown woman, with the added illicitness of an extra-marital affair. I convolute my mind with a cabal of dark interpretations: Freudian Triangles, Deposed Fathers, vengefully reprised children. I do not exonerate myself from these constructions: I can locate enough of my residual developmental sediment to secure my place. I have training and imagination enough to ascribe a variety of such roles to each of us. It is all plausible. It is, professionally, the safest thing to do.

I take the riskier course: I follow Karen’s thoughtful dissent, sensing that she has an instinct now to create new and positive patterns. I remember a harsh and pithy judgement of a non-medical friend: ‘The problem with most psychiatry is that, at best, it can stop some “bad” things happening … but it doesn’t usually help people heal and grow …’. I had ruefully agreed, hoping I might be an exception, at least sometimes.

*           *           *           *           *           *

The months that follow bring a seemingly impossible mix of alarming headlines and growing peace. The first headlines shock with a precipitous, ill-judged but highly-charged affair. She embarks on this with an impecunious, unrooted, political Balkan refugee. Unwary, he enters a Lioness’s Den of erotic attachment. With dismayed foreboding, I see her demeanour transform from a soft mist of adoration and total trust, to a terrifying furnace of raging accusation, incandescent disillusion, Total War. I see him briefly at this time: he is emotionally stunned, lost and inchoate – signs of Emotional Blast Concussion.

Amidst these emotional explosions she announces her pregnancy, her first. This news invokes waves of alarmed consternation across professional networks. How will this demonstrably unstable woman deal with the inexorable changes and responsibilities? Professional anxiety and vigilance increases. ‘Risk-Management’ becomes the gravitational nucleus round which their many activities orbit.

*           *           *           *           *           *

Karen then confounds and disarms us with her peace: a rapid crystallisation of structure and stability in her life. Faster than we are able to comprehend, she ceases her many ways of imperilling, alarming or punishing herself. Increasingly her emotional intelligence turns from hurt wariness to a capacity for reflective receptivity.

‘I’m a mother now … I have to make sure I don’t pass on my mess to the next generation,’ she says, patting a ripely-pregnant belly. The sagacity here is fresh and self-realised: the integrity of such self-regeneration rapidly renders obsolete the hundreds of pages of specialist, ‘expert’ communications in her thick folder. In this forest of technically-dense, bureaucratically-moulded prose, it is difficult to discern much of this woman’s unique bondage, suffering, struggle and quest for suffrage in her own life. Seeing her now tenderly touching her belly, and uttering such protective and far-foresighted intentions toward her ‘accidentally’ conceived foetus, I am suddenly and rapidly connected to her in my understanding.

*           *           *           *           *           *

Two years later I am talking with Karen of ordinary but crucial problems: of the difficulty of being a single mother, of being receptive to her toddler-son when fatigued and already multitasking, of finding a pragmatic, appreciative semi-detachment from her son’s father, her ex-lover. I have been close to formative events; she is relieved by the common understanding we create without lengthy explanation. Since motherhood, her female demeanour has changed from alluring siren to fecund and earthed mother. Sean, her delightful wide and sparkle-eyed son babbles happily in playful exchange with Dorothy, who welcomes this heart-warming, brief transformation of her office into a crèche.

Karen tells me of growing good contacts she has with other professionals: a Health Visitor, the new Clinical Psychologist, a Community Support Worker. She talks of them with growing trust and faith. Without deliberate design she has assembled around herself a kind of extended family. I reflect on this a while, and lightly contrast her flowering conviviality with our previous shared era, a tangled and dangerous time, when any dependent relationship was likely to carry an explosive charge. For several years, she had managed, time and again, but without any conscious intent, to replay myriad variations of her painful childhood dramas. As we sample these shared historical events, we contrast our different recollections and perspective. We talk of the inevitability of Personal Relativity, and the importance of creating Common Language, the most reliable balm for humankind’s painful awareness of our individual separateness and mortality.

Equally surprising, to Karen and myself, is the redemption and resumption of her parents’ relationship, both with Karen and one another. After many painful years without contact, her mother and father are back in her life, but dramatically transformed. They visit and welcome as calm, kindly, ageing parents and doting grandparents. Karen learns of the paradoxes behind the transformation: her parents are living separately, but close. After decades of internecine marital strife, they have found affectionate and loving peace in separation.

I marvel at the mystery of unseen and insensible matrices that guide such parallel events.

*           *           *           *           *           *

‘A good Clinical Outcome, then?’ Keith gently teases me with mock managerial formality and falsely dry tone. Another veteran practitioner, he, too, struggles to maintain his Élan Vital amidst the increasing constriction of institutional rules, diktats and deadlines; the rhetorical boa of planners and politicians.

‘Seriously, though, what do you think most helped Karen’s transformation?’

*           *           *           *           *           *

I ask Karen.

She looks down for a few seconds. I imagine she is rapidly respooling the last five years. Her answer is scattered, but thoughtful:

‘You gave me time and space, faith and guidance …’ She hesitates, checking for my understanding. I believe I do, but I prompt her elaboration.

‘Well, you’ve always been here for me, and for a very long time … You helped me find my voice and rediscover a self I’d been running away from … If you ever offered me guidance or suggestions, I’ve always thought it’s from a real and growing knowledge of me, not some theory, or book or plan about The Mentally Ill … I’m not mentally ill, I was very disturbed: it’s very different…’

This notion is expressed with a brief burn of sardonic anger. This yields to a smile of recognition between us. I raise an eyebrow; my curiosity about her distinction.

‘What I mean is … Yes, I was like a person blinded with fear and confusion, and like a dumb person in not being able to talk about it. But I was never deaf: through talking with me, you guided me back to my voice and my vision. Then I could get my life back and start to make it really my own. Can a seriously mentally ill person do that?’

Her question is genuine. I delight in her simultaneous ingenuousness and sophistication. I wish often that my colleagues would ask such trenchant but unaffected questions. I inhibit my urge to now explore this question, a favourite haunt of mine. She goes on, to talk of Dorothy and our small department.

‘Dorothy has been great … always helpful and interested, but never bossy. A lot of the psychiatrists have wanted to control me, without understanding very much at all. Some have talked to me as if they know everything already. I felt very diminished: “shrunk to fit” their professional theories and procedures.

‘Coming up these stairs to be greeted by Dorothy’s friendly manner, sitting in this cared-for space, surrounded by growing plants and homely, colourful prints, has somehow given me the same kind of messages that I’ve talked about with you: that I can heal and grow …’

She becomes quietly thoughtful, and I enquire about why she thought she had received these vital messages so rarely.

‘Well, a lot of doctors don’t seem to think like that, but even if they do I’ve got to have a good relationship for it to mean anything … It’s like talking about love.’

This last utterance was a short circuit I had not expected. The shock enlivens and awakens me. In unmanaged and unengineered contact, human electricity can flow in unexpected ways.

*           *           *           *           *           *

Keith talks of the death of a neighbour. She had lived many years in the large multi-occupancy house next door. He has only just heard of her death, three months after the event. He is disturbed by his remoteness from someone so close. We discuss the broader theme of how new technologies lead us to live such lives: where we communicate electronically-mediated words and images instantaneously to the other side of the world, but are insentient of our surrounding environment, oblivious of our neighbours.

My mind returns to an event Karen described three years ago, shortly after one of her turbulent stays in Dr Q’s unit. She had resisted a brain imaging scan, feeling both repelled and afraid of the formidable machinery. The young doctor, she said, was curt, prescriptive and didactic: it was ‘imperative to exclude significant pathology’ (such was most unlikely, and thus hardly ‘imperative’). Karen submitted to the scan, but never trusted them with much of her story.

This brief tale can be readily dismissed by more common or cursory analyses: the doctor was inexperienced, busy, unimaginative; or Karen is oppositional, oversensitive, paranoid. Much more interesting is this account as a microcosm, cultural metaphor, Zeitgeist. We are constructing a world of sharp new paradoxes and polarities. We have grown used to, expect, rapid and precise information and images: we are impatient and intolerant of the indistinct, the ambiguous, the slow. We pour massive resources into machinery to provide us with such unprecendently detailed and accurate images, but hardly notice that our own subjective image-making, our imagination, is atrophying. Karen is more easily electromagnetically scanned than imaginatively heard. Keith e-mails unknown people with effortless regularity across continents, unaware of his long-term neighbour’s slow death, fifteen yards away. We increasingly delegate our tasks and responsibilities to inventions which save us time and effort but, with cruel inversity, we observe our lives as incrementally more rushed and less savoured. The mostly inexplicable, but thriving, new syndrome of children with Hyperactivity/Attention Deficit Disorder may serve as a pathological index of our accelerating, kinetic and rootless lives. To belong, we have also to be-long; we have to stay, be still and receptive. Long enough to relate and to bond.

– – 0 – –

Contents Copyright ©; Dr David Zigmond 2007

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

David Zigmond would be pleased to receive your FEEDBACK

Version: 2nd May 2012

Home Page    David Zigmond Home Page