Colletion Tragedies

                                    Sadness

 

 

 

                          And your experience makes you sad:

                      I had rather have a fool to make me merry

                             than experience to make me sad…..

 

            As You Like It - Act II, Scene 7

                                                                              William Shakespeare

 

 

 

 

With so many quotable quotes from As You Like It you may wonder why I would chose to pick this one.          

Perhaps it is a warning to young doctors to enjoy the blessings of inexperience. Luckily for me sadness brought about by experience from my clinical work is mercifully little but I would be either dishonest or heartless to say that there has been none.

As You Like It happens to be one of the few popular plays of Shakespeare that are often performed in schools, maybe apart from Dreams, and for most it is basically a comedy with a happy ending.

My wife and I went to a recent production at BAM (Brooklyn Academy of Music) by none other than Peter Hall[1] with his daughter playing Rosalind – their New York debut.  Few would imagine Sir Peter picking Brooklyn for his debut.  In the end it was a great experience. The New York Times said that it was more reviving than spending a week in the Caribbean. Having been an accidental resident in the Caribbean for two years I would dispute the comparison but totally agreed with the sentiments expressed.

At the BAM, it was like walking into a renovation site and in many ways I hope they leave it that way as it was rather charming. It was a most fitting setting for Shakespeare. I accept that they have to make sure it is safe.

It was at the start of my psychiatric training in England when I asked one of my gurus about reading matter.  Apart from Shakespeare, he recommended Ibsen.  I have since read most of Ibsen's plays but I still come back to Shakespeare, who seemed to be able to pick up so many strands of human experience.

 

My ideal Shakespeare is indeed one that can be performed on a bed sheet with a few broomsticks for prop and without wanting to sound derogatory, I would say that this was exactly the approach adopted by this production.

Much was left to the imagination and it worked.

 

Mrs Coleman

Now and again in our work we get an indescribably sad case.  Sometimes what started out as a rather straightforward case might begin to roll downhill so fast that we would be forever taking deep breaths thinking: can it get any worse?  We would question if what we were doing was making any difference at all to what seemed like a predetermined course where no intervention would be able to make any impact on the final outcome. 

One thing is for sure, real life is not like a play – you have only one chance to perform it and often not everything is clear.

Mrs Coleman came to see me about her daughter within months of my appointment as a consultant.  With my new job came advantages and disadvantages.  I used to be able to ask my seniors about cases, especially the difficult ones.  Suddenly I am supposed to know it all.  I used to have a big team working on a case, to the point that when the patient came to me there was hardly anything left for me to discover.  Single-handed consultants are “on their own”.  They are lucky to have a social worker and perhaps a psychologist.  I had both but the psychologist was not really part of our team – she happened to be sharing the same building.  She belonged to the old school, which meant she knew her field and she did not try to be a social worker or indeed a psychiatrist.  For a while it became fashionable to blame everything on background and upbringing. Any disturbed child not performing well at school had nothing to do with teaching methods or intelligence but everything to do with social background.  What were the implications for the social background of bright high achieving children?

There was some excitement in the clinic when it was known that a shepherd’s family had been referred.

Shepherds?  "As You Like It" sprang into my mind.

We have lambs so we must have shepherds – so I thought.  It is true that we seldom had referrals from the farming community. I can only remember one other case and that was when I was a trainee. Shepherds also conjure up scenes of nativity and there is a sort of biblical romantic feel to it.

What we did have was something quite different. As it was unfortunately the lambing season, the shepherd Mr Coleman, though making a valiant appearance, was as good as asleep during most of the session.  Mrs Coleman talked through the session with her rather charming old Sussex accent.

Mrs Coleman at the time had two children but it was the older daughter Laura of nine with whom she was having trouble.   Tom, some eighteen months younger, was a happy-go-lucky sort of boy. Laura had a whole range of behavioural problems.  She had recently taken to soiling in her pants.

It was often our practice for the social worker to do a preliminary home visit, and my social worker told me that she was most impressed with their home when she visited.  They lived in a tied cottage on the farm.  The children’s grandfather was a shepherd and he had two sons, the older one working on the dairy side.  There was also a daughter, the children’s aunt, and her husband was the local milkman.  The aunt had children similar in age to Laura and Tom.  She worked part time in the local greengrocer’s and between her and Laura’s mother they split the fetching from school and childcare.  The aunt unfortunately was recently diagnosed with breast cancer and was having different kinds of treatment at the local hospital.  Luckily her husband was a milkman and could take over the afternoon part of the childcare arrangement whenever necessary.  Mrs Coleman took the children to school on the days when the aunt had to go to hospital.

The aunt was a strong lady, Mrs Coleman told me, and she was sure she would outlive her.

It was an old cottage they lived in and my social worker told me that Mrs Coleman kept the place clean and tidy. It was therefore most upsetting to her when her nine year old daughter started soiling herself.

It was mostly in the afternoon but not everyday.

As my social worker had just started her training at the Tavistock Clinic on child therapy it was a good chance for her to take the girl on for some individual therapy sessions.  Like my old consultant did when I was in training, it was now my turn to see mother.

This seemed to be a simple enough family and I did wonder at the beginning if there was much to unfold.

I was proved wrong.

Within two to three weeks of Laura starting therapy, Tom the younger brother refused to go to school. It was natural for everybody to think that there was some jealousy involved. So I arranged for mother to bring him to see me. It was rather obvious from the start that he was not very bright and that his not going to school had little or nothing to do with Laura but more to do with the fact that he could not keep up with the work and was being teased at school very badly. He tried to hit back at one particular boy and was told off by one of the teachers on duty at play-time. He did not want to go back. I arranged for the psychologist to assess him.          

Yes, he was functioning at a much younger age and yes, he needed to go to a special school. In those days it was called an ESN school – school for the Educationally Subnormal.  The SSN school was for the Severely Subnormal.  In the 90s, it was deemed more polite to call the subnormal children “special”.        

Both schools were local and extremely well run. Tom was transferred and seemed to have settled down well there.

Not bad. I congratulated myself.

Laura was getting on well with her new therapist. She was attending without any problem and was doing nice drawings, according to my social worker.

Mrs Coleman was grateful that I sorted out her son.  Tom, who had always been a Daddy’s boy, had upset father very much with his escapade but as he had now settled in his new school father was rather pleased. He in fact went to the same school so he made it a point to turn up to thank me once everything settled.

Mmmm, perhaps we are not escaping the genetics theory.

As a precaution, we also tested Laura but she turned out to be rather bright.

Genetics, you are wrong.

Not so, Mrs Colman must have thought. She was rather perturbed when I told her.  She started crying and pleaded with me to keep the secret she was about to tell me.

Her husband was not Laura’s father.

Mrs Coleman had worked at the local butcher’s since she left school and he was always all over her.  Before long he was having intercourse with her at the back of the shop.  He always gave her extra for that part of the service and she was happy with the extra bit of money.  The butcher’s wife had a stroke a few years back and had been bed ridden.

“It was not the money,” Mrs Coleman assured me. She did not want me to think of her as a slut.

None of the mothers I saw wanted me to think badly of them and it often took a while before they would reveal their secrets.

Mrs Coleman had also been seeing the shepherd but never gave him much thought as she felt he was rather stupid. The butcher was much brighter.       

Then one day some accident happened and she found herself pregnant. But the butcher was not going to divorce his wife. She was the one with the money.

She decided that the next best thing was to let the shepherd sleep with her as long as he married her. He was so pleased with himself and they had a big white wedding in the local church. 

So Laura was the butcher’s daughter and not her husband’s. Now that I had proved Laura was clever, she was afraid I might ask awkward questions although she doubted if her husband would ever really work it out for himself.

Once a parent realised that you had ways to get to the truth, they often started revealing things that you wished they never did.

The butcher had some idea that Laura was his and had been slipping even more extra money for mother to buy her things. He never had any other children.

I never broke my promise and to this day I do not think that her husband ever knew.

What was to unfold was what caused most sadness.

I attended some special seminar on sexual abuse and at the time some rather ugly looking anatomical dolls were produced for the sole purpose of diagnosing Sexual Abuse.  They were anatomical in that a whole family set including parents and grandparents, children and adolescent all had what was described as anatomically correct parts - females with breasts, nipples, vagina and anus; and males with penis and anus; and all the orifices were so to speak fully functional.  These dolls all had proper clothes on and yet all the clothes could come off.

The idea was that normal children played with them as normal dolls but abused children would perform with the anatomical parts.

I had a full set ordered, having spent sometime persuading the managers that others had labs and X-rays and so on, but these were the only tools we required for the specific job.

Laura was the first to discover them and before my social worker’s eyes one of the male figure’s penis was in the girl’s mouth. She told my social worker that was what Uncle Tom liked.

What followed were special “disclosure” interviews conducted under camera. Uncle Tom was the milkman. It happened to both girls. When the boys were in the kitchen playing computer games on the TV, slowly the girls were made to suck him.  That was when Laura started soiling.

           

Mrs Coleman went berserk. Arrangements had to be made for alternative child care which really meant she had to cut short her hours at the butcher’s.  Uncle Tom moved to his mother’s as a temporary measure pending Social Service investigation and Police enquiry.

Mrs Coleman could not sleep at night and called her GP. He asked her to pray with him as she had to be forgiving.  She was so angry and when she was cleaning around the house she managed to get some caustic liquid all over herself and had to be admitted to hospital.  She was also referred to the adult psychiatric department.         She started attending an anger management group at the hospital.  It was thought to be the best way to help her deal with recent events. 

One day when I went in to work, my social worker was already there and in tears.  Mrs Coleman had just taken a massive overdose of Paracetamol and her liver was thought to be too far gone to survive.  She died a rather painful death and we were all deeply saddened.

Could we have done any better?  Was the truth too much for Mrs Coleman to bear?  Would she still be alive if we had not discovered the sex abuse?  We would never know. We might have rescued Laura from sex abuse but now she had lost her mother. Mrs Coleman was right about one thing though, her sister-in-law did outlive her.

           

As Shakespeare said,

“….And your experience makes you sad….”

           

I wanted to hide the dolls.

                                     Collection Tragedies

                                 Manic-Depressive Suicide

 

 

 

We found them! We found them! There was great excitement in the police car as the news broke through the radio.

“Are they all right?” Mr. Tanner shouted from the back of the police car.

“Just checking. They are not moving….. Yes there is a pulse. Yes, older girl too. … mmmm mother. Yes! They are all alive. We are getting them on the helicopter.”

The high drama occurred on a Sussex beauty spot that is riddled with legend and stories of ghosts and the devil.

Chanctonbury Ring  was a truly man-made landmark.  In 1760, a crown of beech trees were planted on top by a young man named Charles Goring, who lived to eighty five and saw his trees grow to maturity.

Unfortunately it is also a spot where legend has it that you can trade your soul with the devil.  Mr Tanner was a very successful businessman who ran a number of very successful stores in the south of England. I was called to see his eldest daughter Tara following a massive overdose of painkillers. She survived because she took Aspirin instead of Paracetamol. There was perhaps some advantage in not being streetwise, namely not knowing which drug to take.   Or perhaps she did not really want to die.  It was not easy to tell after the event, as there is always an emotional rebound after an act like that.  The lack of a suicide note was a positive indication and in truth, young people often want to draw attention to something going terribly wrong by attempting suicide.

I realised straight away that this was different to the kind of overdoses that we saw two or three times a week on the wards. She had not been involved in drugs, alcohol or boyfriends. She was not really worried about her exams. She was not at the top but within the top few percentages. No. She said it was not her exams that worried her.

But she would not tell me what her fears were.

The meeting with both parents did not throw any light on the situation.

It was one of those meetings where you found yourself not being able to get anywhere inside the family.  Everybody was well spoken, courteous and indeed unemotional.  Mother was extremely pleasant and told her daughter that she would take her and the rest of the family on a Caribbean cruise after the exams.  Tara was quite happy to stay on at the hospital despite mother’s request for her to be discharged.

After the meeting, one of the nurses whispered to me that she knew the mother as she had seen her before on the adult ward when she worked nights there.  Our nurses often worked nights or weekends in order to earn extra money.  She went on to tell me that she in fact tried to jump onto the rail track a little while back but was somehow stopped.  She also told me that the father was a very successful and wealthy man.  She wondered why Tara was not in a private hospital.

I arranged to see father.  In a one-to-one situation, he was a good deal more lucid and forthcoming.

Tara’s mother came from a wealthy family and her own father was extremely successful.  She was very pretty when he married her, although recently she had put on quite a bit of weight. She had a rather tragic family history.  Her grandmother was in and out of a private psychiatric hospital where she eventually hanged herself.  Her mother was diagnosed with manic-depressive disorder and killed herself by jumping onto a railway track.  He felt that neither had the best treatment from the private hospitals.

His wife’s first breakdown was shortly after the second daughter’s birth.  There was only a year’s difference between the girls.  She did get into a short funny phase after Tara’s birth but she became pregnant again and the pregnancy seemed to settle her.  He said it was not the blues but that she was more manic.  She spent a lot of money on redecorating the whole house, decided she did not like the results and started all over again.  Then she stopped sleeping at night. He realised that something was wrong and went to the doctor.  She was admitted but was well after she was put on Lithium.  She did well for quite a while and he thought his nightmares were at last over.  She decided she was well enough and decided to try for boys.  Unfortunately the next baby was still a girl, followed by another baby girl a year later.  She was very upset and stopped her medication.  Not long after that she vanished from home and was seen to be behaving strangely at the local railway station.  She had seldom used the trains and when questioned by the railway police could not give a good answer.  She was brought home and he took her to the hospital where she confessed that she was going to kill herself.  She was put on some new medication that had just come onto the market and that seemed to have worked well, except that made her put on a lot of weight.

They always had a nanny since the eldest was born and with the arrival of the younger girls they increased the staff to two nannies and a house-keeper.  He admitted he was wealthy but he did not want to use private healthcare because he felt his in-laws were badly treated.  He thought his wife had been well cared for in the last ten years or so.

I am a traditionalist who believes that Lithium is still the drug of choice for Manic-Depressive Disorder.  Tara’s mother was well for ten years.  She was taking only Lithium and no other medication.

Father was now extremely worried that Tara either had the same condition or was heading that way.  He said he would have no problem with any treatment that I cared to recommend. He also told me that both his older daughters had phenomenal mood swings at the best of times and if they wanted something done it had to be done “now”.  He always thought that they were perhaps a bit spoiled and did not think much of it.  They were both like their mother.  He said he only mentioned to his wife that perhaps they could take the family on a Caribbean cruise and the next day she booked the cruise.  Now he was wondering whether he might have to cancel it.

In the last three to four years it seemed to have become fashionable and even desirable for somebody to have Bipolar Disorder (Manic-Depressive Disorder).

There was a touch of glamour to Bipolar Disorder too, as so many historical figures and modern day celebrities had been diagnosed either contemporaneously or posthumously with Bipolar Disorder.  A “coming out” of sorts. Many parents now are no longer satisfied with ADHD. They want Bipolar. It is helpful to de-stigmatise mental illness, but not so helpful that so many want to “catch” it.          

These parents seem not to be aware that there is a serious downside to Bipolar Disorder: a very high mortality rate mainly from suicide.

Father however was right.  Based on family history and current presentation, there was little doubt in my mind that Tara also suffered from Bipolar Disorder.  Convincing the nursing staff was perhaps more difficult. Luckily the nurse that knew mother helped.  Otherwise Tara would just have been branded a very spoiled child – spoiled seventeen year old and why, with such privilege, should she want to take her own life?

I started her on Lithium and within four weeks she was quite a different person.  She had another four weeks before her first examination and we started trying her for some week-ends at home.

It was during one of these week-ends when mother asked Tara if she would go shopping with her.  Tara declined as she was busy with her studies.  Mother decided to take the younger two. For a long time father had not allowed mother to go out without one of the nannies.  Somehow they were busy with other things and Tara was not really aware of the rule.  Mother put the little ones in her new SUV.

When father came home, he threw a fit.  Mother had been gone for three hours and was not answering her mobile.  Tara told me that she realised later when mother said goodbye to her it was like a final farewell.  She felt a bit strange but because of her exams she did not think twice about it.

They called the police and the Helicopter was summoned. Thanks to modern technology they were able to narrow the car down through the mobile phone signal transmission.

Mother had strapped the girls up, driven them up Chanctonbury Ring, attached a hose from the exhaust and put it through a narrow opening of one of the windows and left the car running.  She left a suicide note saying she was a burden and caused Tara to be ill with her own Bipolar. Worst, she could not give her husband his heir.  She took some gin and fell asleep at the back with the girls, who had probably been given drinks that were laced with gin as well.

Thank goodness for catalytic converters and mobile phones – they did not come to much harm.

Unfortunately, mother had to be admitted compulsorily to a secure mental hospital and it was likely she would be there for a long time. The cruise had to be cancelled.

Tara’s younger sister then took an overdose and she too was treated as a Bipolar Disorder patient. Tara managed to get the grades to get to the university she want.

I saw mother once walking in the garden of the secure wing of the hospital.  She thanked me for all that I had done for her family.

What a tragedy.  What a family tragedy!

 

 

 

                            Collection Tragedies

                                   Forgiveness

 

 

 

KING CLAUDIUS….My fault is past. But, O, what form of prayer

Can serve my turn? 'Forgive me my foul murder'?...

 

HAMLET  Now might I do it pat, now he is praying;

And now I'll do't. And so he goes to heaven;

 

Hamlet Act 3, Scene 3.

                                                               William Shakespeare

 

Sometimes we are reminded of our patients in the most unusual way.  One summer we had the opportunity to go on a Baltic Cruise which started and finished in Copenhagen. It is unavoidable on such tours to come across tragic stories in history.  The different Baltic countries had their fair share of wars, sieges, slaughters and some of the most macabre murders[1] in the history of mankind.

Our last stop was outside Elsinore and those of us who were interested were tendered to visit Kronborg Castle, the setting for Shakespeare’s Hamlet.   

Hamlet reminded me of Anita.   She refused to attend school because of Hamlet.  In my work I have come across many unusual patients but it has never occurred to me that someone would refuse school because of Hamlet.          

I can still remember being called to see her on a Domiciliary Visit as she had refused to come to the clinic.  The parents were not very forthcoming and felt that at seventeen, she should be able to talk to me herself.

She reluctantly agreed.  We then had a most interesting discussion about Hamlet.  She was upset because her English teacher did not like what she wrote about Hamlet.  The essay was about Hamlet and forgiveness.  She felt that Hamlet indeed should have been more “forgiving” and killed his uncle when he was praying.

           

“So what if the uncle goes to Heaven?  Big deal!”

“Instead,” she added, “he got himself killed as well.”

           

Our sweet prince was no hero to her and that upset her teacher. He really wanted the class to write about Hamlet and Laertes[2] exchanging forgiveness .

She then refused to return to school.  At least that was what appeared to be the problem.  I eventually got her back to school and persuaded her to see me at the clinic regularly for the next eight months or so.  She wrote a good deal and told me that she kept a diary that was kept under lock and key.  She said whatever happened she would never let anyone see it, not even her psychiatrist, as she would probably have to kill that person afterwards.  I did not ask to see it and told her that I had no intention of asking to see it in future.

Teenagers have their secrets and I certainly want to respect that, I thought.  She did show me some other writings and she had some very interesting and unusual things to say.

Looking back, I often wondered about the challenges we faced, having to base our diagnosis and treatment on some of the most subjective things related to us by our often very disturbed patients.  We could hardly expect to get any “truth” from them, and yet various psychiatric professional bodies seem to accept psychiatric diagnosis made in this way as infallible.  She probably did give me a clue but unfortunately I missed it.

One day she was very distressed, saying she thought she might have caught something from a Spanish Waiter that she slept with. I was a bit puzzled as she did not appear to be the promiscuous type and certainly not the type who would sleep with someone she hardly knew.

We had some discussion and I advised her to go to the Special STD  Clinic to have it seen to.

She never turned up again despite several reminders.

Then she came to the notice of the adult psychiatric department following a serious overdose.  This was on the day of her father’s death.  She saw a lady psychiatrist and disclosed to her that her father had been abusing her since she was eleven.  She never kept any follow-up appointments though and there had not been any further episodes of self harm.

Nearly a quarter of a century later we had four boys referred because of serious sleep disturbance.  One of my colleagues at the clinic made an initial home visit and afterwards asked to see me in a distressed state.

She said it was one of the worst cases she had ever come across and asked me to see the mother, who happened to be my patient twenty some years prior.

It was Anita.

She, who should be in her early 40s then, appeared worn and exhausted, and looked much older than her age.

When her father died it was all too much for her.  She said she was very confused by what happened to her.  She admitted that there never was a Spanish Waiter but she was hoping that I would enquire further.  She was desperate to understand what was going on then.

“The overdose woke me up,” she recalled, “I felt I had to forgive what my father did to me.”    

She decided to go into journalism. One of her assignments was to do an article on a notorious murderer.  For that, she had to interview that murderer in prison.

“That was the start of all my troubles.”

Fascinated by her first case experience, she became a voluntary prison visitor for those prisoners who did not have any visitor of their own.

“We live in a very forgiving society.”

Then she met this man that was to become her husband. He was serving time for murder.

“He killed his father who abused him for as long as he knew,” Anita recalled, “I could identify with him and I felt so sorry for him.”

Was it the process of reparation?  I too struggled to understand her.   

She found herself falling in love with him.

Prisons allowed conjugal visits and before long she had two boys by him. Because of her and the children the parole board soon granted him day release passes.

A murderer granted day release!  Not long after he was out on license.

We indeed do have a rather forgiving penal system.     

“But he never even knew his father, let alone killed him!”

By age nineteen he was doing time in a borstal and soon after his release he killed the landlord who took pity on him and gave him board and lodging.  The landlord was unfortunate enough to catch him trying to steal from him.

“I did not know until the trial.”  She meant the latest one.

It is amazing how protective we are of convicted criminals. I could never understand why the probation service did not warn her.

No wonder the public has little faith in our rather liberal judicial and parole system.   People sitting on parole boards seem to continue to fail to see into the darker side of the human psyche. Often those trained to understand the human mind also appear not to understand, or are they so driven by performance targets and results that they just want another successful treatment to add to their credit?

This man had “anger management” therapy when he was doing time.  The truth is a psychopathic personality is capable of adapting to suit his ulterior motives. We do have too many psychiatric casualties from such unfortunate releases from maximum security mental hospitals and I am not even referring to psychotic patients.

He could not hold his job as a security guard and started to do break-ins. He was open to his wife and she said she did not understand why she never informed his probation officer.

“Perhaps I was afraid of him but he convinced me that these people would get their money back from insurance and he was never going to hurt anyone as he loved her and the children and did not want to be locked up again.”

One cannot help wondering how much the wives of “famous” serial killers actually knew and to what extent they were convinced by the arguments put forward by their spouses.

She had two more boys.          

One day he decided that they could make more money if he set her up as a prostitute. He would stop the house break-ins as it was getting more dangerous with the alarms set up by people.

Surprisingly she went along.

“I had to do something to stop his burglary activities.  I did not want to lose him.”

“I was sick over the first client.  As it reminded me so much of what my father did, I told him I could not do it.”  The next day he said he was resuming his break-in business.

“The rest is in the papers.”

He came home when the children were having tea. He was covered in blood.

“The idiots tried to stop me!” he told her.

The children were screaming.  Suddenly she felt a strong repulsion and called the police.

Even the most forgiving philanthropist had her limits.

“I was thinking more of my children.  I was not going to be like my mother. I was sure she knew all along.”

I had to agree.

How could this ever have been allowed to happen?  What did her forgiveness do to her?  Could I have done anything?  He was tried for murder and sentenced to life imprisonment without parole.  What he did was much worse than what he told her on the day he came home covered in blood as he tried to rape a woman on the way back from one of his breakins, but that was by and by. Hopefully no one will think it unkind to lock him away forever. You never know.

Anita had to pick up the pieces of her life again, having had her long held belief in good human nature and forgiveness totally demolished.

It was probably destroyed a long time ago by someone she should have been able to trust.

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[1] https://www.ricksteves.com/watch-read-listen/read/articles/russia-revolution-st-petersburg

[2] LAERTES
           Exchange forgiveness with me, noble Hamlet:
           Mine and my father's death come not upon thee,
           Nor thine on me.

                              Hamlet, Act 5, Scene 2

 

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[1] http://levyarchive.bam.org/Detail/occurrences/2256