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