DAVID ZIGMOND, MB ChB MRCGP DPM
Department of Psychological Medicine, Hammersmith Hospital, Du Cane Road,
London W12 OHS
Saint-Exupery, Flight to Arras (1942)
Proud, elderly and sprightly, Mrs Gladys Parlett does not betray her inner burdens and chasms openly. Slightly tinted, sharply coiffed hair surrounds an alert, kindly, discreetly rouged face. Freshly pressed and quietly co-ordinated clothes accompany a manner that seems merely consonant and pleasant to the unwatchful. Those more canny might become aware of more disquieting signs; her tinted spectacles both frame and conceal restless and sorrowfully glistening eyes, white knuckles keep a grip on her handbag with primitive tenacity, her ankles lock together as if to prevent impulsive and involuntary movement.
Until her beloved George’s death, Dr L's dealings with her had been infrequent, simple and matter-of-fact. To the doctor they had been undemanding, courteous and easy people, and his pragmatic contact with them reflected a cordial and uncluttered alacrity. Her bereavement, though, soon heralded an unprecedented change. She came to him frequently, and with numerous and protean complaints; a previously dormant stratum of self now erupting with a lava of fermenting and inexorable dis-ease. Dr L, a busy practitioner, but not illiterate in the task of reading what is not directly conveyed, at first responded with familiar precedent, sympathetically and symptomatically. Her collage of headaches, giddiness, respiratory infections, arthritic pains and nausea received the kind of specific remedies that keep Dr L in respectable, if undistinguished, company.
Recognizing that he was dealing with a woman, for all her years, unused to verbalizing her pain and conflict, he was patient and delicate in making deeper contact. She needed, he thought, much encouragement and support in clarifying and validating her underlying turbulence and sense of injury. He supposed, or hoped, that exposure and apposition, to himself, of her internal wound might guide her capacity for restoration. Exploring discreetly beneath her sense of physical peril and instability, he suggested she take him into her gallery of memories; cherished sepia-like episodes and life-fragments, some idealized, many bitter-sweet, receding back to a post-Edwardian childhood.
Gladys, a middle child amongst many in a poor Methodist docker's family, perceived her world then as loving but harsh. She had few doubts regarding her place and role amongst others, but the conditions demanded of her for such kinship were strict and uncompromising. She grew shyly and demurely into a womanhood of loyal but limited bonds. She met George, a young docker, also in his early twenties, at a local wedding. He was then, and remained for nearly 50 years, with few deviations, a sensitive and steadfast companion. More socially confident than she, he provided, through their long interdependence, both a bridge to, and a buttress against, the outside world’s demands, vicissitudes and opportunities. By nature a retiring and retroflective person, she had, nevertheless, for several decades, a milieu in which she had an unquestioned, largely unconscious, sense of purpose and attachment.
No inconvenience to others
What is conveyed to the doctor now, though, are memories and vestigial fragments of Gladys's previous ecology. Her two sons, currently married, middle-aged and with their own families, have enacted with great success the aspirations of their prudent, once poor and conscientious parents: propelling themselves upward and outward in a society increasingly occupationally and socially mobile, they now occupy homes and work-roles beyond any experience or familiarity of their parents. Pursuing better employment opportunities, both sons have settled far from the declining and ghost-like community of the old docks. They are dutiful and attentive sons, reliable in maintaining contact by telephone, and driving the many miles from the salubrious suburbs to visit her. Sometimes from concern, sometimes through guilt, they wonder whether their stoic but hurting mother should live with one of them, but this possibility is fraught with practical difficulties — neither can offer a home capacious enough to provide Gladys with her own bedroom, without depriving one of their children of their’s; an arrangement they perceive as erosive to their own family's ecology. Gladys, in any case, overtly and overly proud and self-sufficient, has pre-emptively parried, in many utterances, any arrangement where she feels she may be, as she puts it, 'a burden' or 'inconvenience' to others.
In Gladys's childhood it had been quite different, she remembers, for her own grandmother, Milly. That old lady, like Gladys, had lost her husband 15 years before her own death. But there were important differences. Milly remained very much at the centre of a large family which, through hardship, poverty and social inertia, had little opportunity for mobility, change and, therefore, disintegration. The old lady, the senior matriarch, living in cold, crowded conditions in the family home amongst three generations, was the repository of female know-how, oral family history and tradition, and, often with mollification, sometimes with contention, of counsel, judgement and verdict. Increasingly disabled with arthritis and lingering pulmonary consumption, Milly nevertheless lived out a frail but powerful widowhood of central importance to those around her until her eighty-eighth year. Consulted for her experience of the tangible tasks of recipes or the management of childhood ailments, or the more intangible problems of how to find happiness, or at least peace, amongst others, Milly had little reason to think of herself as her granddaughter does; 'a burden' or 'inconvenience' to others.
Dr L, in his surgery and home-visits, spends much of his time attempting to decode, if possible detoxify, the somaticized distress of his many elderly patients. It was not always so. A young man when he first entered practice, intellectually crisp and eager to apply, directly and succinctly, the concise medical notions and tools he had imbibed assiduously in his hospital training, he found himself responding with a polite, brisk veneer which masked an intense irritation when he encountered those, like Gladys Parlett, who somehow defied his efficient and medically rigorous ministrations. Like a sheep-dog he would, with energy and vigilance, attempt to round them into his pen of medical diagnoses and managements only to find, repeatedly, that his 'good work' was to no avail. Many of them, with apparent obstinacy or perversity, didn't follow his instructions, developed side-effects to his prescriptions, wouldn't give up the medley of their complaints and symptoms. `If it weren't for these damn patients, I could be a good doctor', retorted a wry and weary older partner when the young Dr L sought commiseration and advice for his increasingly chronic sense of frustration and impotence. `Frankly, when I see them coming through the door, the question I ask myself is "How can I get them out as soon as possible?"', was his senior colleague's acid and nihilistic counsel.
It was some years before Dr L could understand and make creative use of these feelings of redundancy and defeat, to realize that this somehow mirrored his patients' experiences of decline, abandonment and nullification. He had, first, to face his own losses, witness his parents become elderly, and sniff his own mortality and transience. Dr L's private struggles and dilemmas in this arena have slowly transformed his way of understanding and responding to these refractory and disequilibrated people. He sees now that this public role as a family doctor has a symbolic significance for them, far more subtle and demanding than the problem-solving, technically-based functions in which he had previously immured himself. From a world rotating and changing increasingly rapidly around a technological axis, those at the periphery, particularly the elderly, unplaced and unable to contribute, are thrown off by a kind of social centrifugal force to become society's 'loose- bodies', disconnected and disinherited.
Gladys's grandmother, Milly, was part of the Stream of Life until her own death. Gladys, in contrast, must face her involution and ending, unaccompanied by the evidence of fresh life, the tending of which is one of the few things to make approaching death meaningful and bearable. Human contact and nourishment, having a social role in which we find meaning and which is valued by others, are the social prerequisites for inner and outer peace.
Gladys, and so many of Dr L's elderly ‘regular attenders', have little such social role, contact and nutrient to sustain them. Their dis-ease, for them often ineffable and intense, finds inchoate articulation in their bodies. Sometimes, with encouragement from Dr. L, there can be a translation into words. At other times this seems pointless and unnecessary, and a tacit understanding grows implicitly. Dr L has come to recognize the symbolic, perhaps unconscious, investment that is made in him and his surgery-environment. The waiting area is often a kind of village square where the elderly and isolated are, for a while, part of the milling of a local community; familiar faces encountered, fragments of gossip exchanged, babies paraded, admired and envied, older children reprimanded and humoured. The doctor's room becomes a sanctum or retreat where secrets, pains and private burdens may be, if only briefly, unloaded, alluded to and shared.
Dr L's physical presence, reassuring in its familiarity and constancy, has great importance for those whose personal landmarks have gone, receded or become rare and ritualistic. For those seldom touched, the physical examination becomes imbued with potent ingredients of care and recognition, something that eluded his earlier judgement when such activities were determined more rigidly by 'clinical indications'. Any medicines he may prescribe, too, have meaning and functions he would have overlooked before he came to understand the anguish that can he born of aloneness. The bottle of medicine or tube of cream becomes a kind of talisman or reminder of the doctor's continuing existence when he is absent.
A waiting room for death
Gladys Parlett's anguish and sense of desolation have been intense and profound and, at times, beyond the reach or influence of Dr L's empathic interest or rationalized medications. One week she sat, almost immobile and mask-like, and talked obliquely, with a darkly-veiled foreboding, of ending her life. Managing for the first time to persuade her to see a psychiatrist, he arranged an appointment for her to see a consultant known to him as an approachable, sympathetic and psychologically skilled practitioner. This initiative was curtly and bureaucratically rebuffed. A phone call from the outpatient secretary indicated that all patients of her age had to be seen in the Psychogeriatric Unit; no exceptions could be made. Dr L balked, complied and acted accordingly.
The psychogeriatric young registrar pronounced the old lady 'significantly clinically depressed' while also surveying her isolation and 'vulnerable, insecure personality that has led to her notable lack of confidence and tendency to depressive illness since the loss of her husband . . .' A change of antidepressant medication and attendance at a Geriatric Day Centre 'for support and socialization' were recommended.
Much to Dr L's disappointment, but little to his surprise, Gladys developed intolerable 'side-effects' to both the chemical and social prescriptions and discontinued both. It was difficult to assess the possible physiological basis to her reaction to the drug, but her intense dislike of the old people's Day Centre was more easily understood: 'It's like a waiting room for death' she said with a stark, ruthless economy that arrested Dr L's breath for several seconds. 'They're very nice there, very kind, but I don't want to sit around with all those old people that I don't know, being "jollied along" . . . I know you don't have much time, doctor, but I'd rather come and talk to you, it's more natural, more like real life . . . I've known you and Sheila [the receptionist] for years, so it's like family, if you know what I mean. I hope you don't think I'm being difficult.’
Many might have done; Dr L did not, though the task of surrogate kinship, he reflected, was paradoxical in its ordinariness and complexity.
Separation from life's flow
For a profession currently festooning itself with variations on the themes of `holism' and 'community care', people like Gladys Parlett confront us with daunting and growing challenges. By well-rehearsed rote we are liable to ascribe her distress to some type of psychiatric phenomenology or psychopathology, thus deflecting from a perspective which sees her disintegration as an individualized microcosm of a dislocation and decay happening increasingly in our socially fragmented times. Gladys's symptoms can, perhaps, be most clearly understood in terms of her growing and profound alienation from those around her. She is deprived of social function, substrate and network.
Milly, through a long, often cruel and tragic life, never lost a sense of belonging and purpose amongst others. Gladys, by contrast, in a life increasingly free of the kind of violent vicissitudes, thraldom and injustices her grandmother was subject to, enters her last stretch without this essential raison d’être. Her life now lacks an 'existential holism'. Her anguish flows from not being part of the Whole. Dr L, whose waiting-room bustles with human traffic, whose familiarity brings continuity, whose words and touch imply knowledge and interest in her private world, provides a sadly sparse but cherished sense of contact and inclusion. Despite its assigned function, the Geriatric Day Centre was perceived by Gladys as being a form of caring which separated her from the rest of humankind.
There is a certain irony and paradox in treating Gladys Parlett within the special designation of `psychogeriatrics'. Certainly, her intense misery and despair warranted more time, attention and facilities than Dr L could muster but, as she made trenchantly clear, she could not tolerate this in a form which underlined her separation from life's flow. With the solid but spurious logic of our times, we assume that a growing problem must be given special and separate facilities, practitioners and premises. But if Gladys is to be reinstated into any Family of Man it makes little sense to attempt this in a manner which purports to create a 'community' comprised solely of the aged. The meaningful and healthy ecology of the aged cannot evolve from isolation. It must include the young.
Among the intriguing and tragic perversities of the human condition is the fact that the most enduring and certain of our bonds arise in the midst of hardship, adversity and common struggle. There were few lonely and alienated people in the last World War. When we are not engaged in the struggle to survive, we are occupied by the task of creating personal and social meaning. The burdens of (relative) peace, prosperity and proliferation of choice may be often unacknowledged, but are inescapable. In an age where it has become the desired norm to define and pursue our own modus vivendi, where technology both generates and catalyses social diffusion and mobility, it is difficult to keep crucial events of our life-cycle within a familiar and ecological human matrix. The hospitalization of birth, decline, grief and death are all, to some degree, indices of our failure to live 'holistically' with one another.
As our real community dwindles, and neighbours become strangers, family becomes (albeit loyally) nostalgic visitors, the church is vandalized and empty, and the corner-shop closes down, we create fictional or symbolic substitutes. Perhaps television's Eastenders and Crossroads and the doctors' new ideologies of Therapeutic Communities and Community Care are akin in their efforts to provide 'societal prostheses', devices that provide, by artifice or illusion, a sense of community when the natural community is perishing. Gladys's shrill protest about the Day Centre, a kind of phantom-limb pain, alerted Dr L to her defiance of the alien and the unnatural. Holism, he has come to recognize, extends tantalizingly and without limit, beyond the simple and tidy notions he had assembled and displayed, Lego-like, in order to become a doctor.
HOLISTIC MEDICINE, VOL. 3, 9-14 (1988)
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