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Thursday, April 13, 2017

Making of a Child Psychiatrist: (70) The General Practitioner (15); A bit more Child Psychiatry +

In supervision Ken opened up the idea of whether I should consider child psychiatry as a career. There was no pressure; just a collegiate discussion. He was aware I had only done one year of fulltime psychiatry, and therefore could not take the exams for the newly chartered Royal College of Psychiatrists, the former Royal Medico-Psychological Association (for which I was already an associate). That would take a further year of full time work in psychiatry to meet the basic requirement. But he thought it might be worthwhile taking the Diploma in Psychological Medicine examination for the Royal College of Physicians, which only required one year of full time work (already completed at King’s). He saw it as useful for the future if I ever decided to change career direction. I assured him I was happy in General Practice (which I was).
But some weeks later he asked if I might be interested in going up to London with him to a weekend of updates in clinical child psychiatry. Technically it was for consultants, but he was certain it would be fine for me to attend. I think he thought I might be company on the drive up and back, but now know he was being somewhat devious (bless him).  I was intrigued and excited, if a bit nervous. Once again I was conflicted, taking time away from the family to follow my personal interests. But Jan was excited for me, and fully supportive (as always), encouraging me to go. I had no details, and had no idea what to expect.
The meeting was at the Maudsley, just across the road from King’s. It was a surprisingly small group of people, with 15 of us packed into a seminar room. In my naïve state, I was taken round and introduced to all these people whose names meant little to me at the time – including Michael Rutter, Christopher Dare and Bill Yule, as well as Philip Graham (I believe). All four presented recent research and provoked lively discussion about the implications. I had never heard of the Isle of Wight studies, but they were to become highly influential over the years, as was so much other work done by Michael Rutter. Bill Yule talked about the use of various forms of behaviour therapy with children, and I found this refreshing and clear. I really liked the man and his approach, and (even though I was no longer in the UK by that time), I was suitably impressed many years later when it was he in charge of the psychological work after the cross channel ferry disaster. Chris Dare was also impressive, even though at that stage he was a registrar (I believe); enthusiastic and engaging he talked about some approaches to working with families, perhaps presaging his later seminal work with family therapy and young people with Anorexia.
What intrigued me as much as anything was the free and inclusive discussion after papers, and clearly these soon to be eminent professionals welcomed feedback, even from a total unknown. It was heady and, with the benefit of hindsight, it clearly turned my head.
I ended up determined to follow Ken’s suggestion of completing my DPM. So I set about investigating processes, dates and possible content and put in the application. In the meantime I found a brief 2 day registrar workshop on General Psychiatry, which aimed to be a final tune up for College exams. It was a great weekend covering a wide range of topics, even if I was totally out of my depth. There was a multiple choice exam at the end of the weekend - which was totally novel! I had never come across such a thing. In addition to having to face this, rather weirdly the scoring system did not just give marks for correct responses, but took off marks for incorrect answers. I scored some idiotic number like 9 out of a possible 114! Perhaps I should have taken this as one of several omens that perhaps my future career would not be as plain sailing as it might have been. But what I did was to take every available minute to study across the whole age range of psychiatry, and build up to the exam later that year.
I caught the train into London and went back to Queen’s Square to take the papers. Nowhere near as anxious as for my various final exams in medicine, I came out feeling I had done fairly well. Luckily there was no multiple choice…
An odd thing happened on my way home. I had bought a cheap day return ticket and arrived too late; the rush hour had just begun, and on that ticket I would not have been allowed to travel until about 7pm (without paying a premium). I was listening to the news in a café and heard the breaking news of two bombs that had gone off near railway stations in London. I was worn out by the travel and the exams, and did not need the anxiety of sitting around waiting for the IRA to practice killing people. From a public phone box I phoned Jan to tell her the story. Despite our slightly struggling finances she agreed it would be best to pay the excess and catch the next available train – which I did. It's a funny old world.
I later I completed the clinical and viva. The DPM would not get me consultant status anywhere, which was good because I had far too little experience as yet. But it was a sign that I was committed to trying to understand mental health and illness; and maybe that I was on a pathway out of general practice.

A very odd thing happened about two months later. I received a package through the post. The postman was unsure what it had in it, and there was a note in out letterbox to say he had left it on our concrete coal bin. It was padded, but within you could feel various shapes both hard and soft that made no sense. There were what appeared to be wires. I was slightly freaked, in part because of my crazy Victoria station experience. I called our local police, apologising for being a nuisance. A panda car came round to the house with two grinning officers. Both felt the package, and not very convincingly said they thought it was nothing serious. We scattered up the drive while one of them got out a penknife and, holding the package at arms length, carefully slit down one edge. Gingerly he pulled out the weirdest collection of ‘stuff’; a bottle top, half a torn playing card, bits of unfinished poetry in a hand I did not recognise, a used match and odd bits of disconnected wire. There was a tiny noose made out of cotton. There was nothing coherent. The police left, having smilingly patted me on the back; joking between themselves about the story they had to tell. I was embarrassed, relieved, curious and perplexed. My best bet, maybe surmised from a couple of bits of the handwriting, was that Jenni had sent me a message. What it meant, I could not work out; perhaps a mix of old anger and jettisoned bits of a despairing past. Unfortunately we were never to meet again; follow up in those days was a bit limited given the small numbers of child psychiatry professionals. Some years later I did find out, in a roundabout way, that Jenni had completed her nursing training, and had moved on to midwifery. I hope she had a good life.

Sunday, April 2, 2017

Making of a Child Psychiatrist: (69) The General Practitioner (14); A bit more Child Psychiatry +

At my third weekly visit, a young woman of 15 called Jenni was discussed in the team meeting. She had attempted suicide at home following recurrent arguments with her mother and was thought to be in serious danger. She had only been in a couple of days, but no-one felt they had made any headway in developing a relationship. She refused to talk, was sullen and resentful and refused to leave her room even for meals, which were barely touched even when brought to her room by a nurse prepared to sit with her.  Night staff had reported she prowled around the unit at night and they thought she was investigating avenues for escape. The unit had always been secure with windows that had limited ability to open, and access to the two lifts only available by key. These were worn on a lanyard around the neck of staff members. To date I had not yet been trusted with my own key and always had to ask a staff member to escort me into the lift and down to the ground floor. There were external emergency stairs, but the door was always locked, keys were kept in the charge nurse’s office, and I am not sure that Fire Drills had ever been thought about.
At the end of the meeting the charge nurse said that Dr. Fraser had suggested to her it might be a good idea for me to attempt some sort of therapy for Jenni; she did not look convinced. I simply said I would be delighted to see her. I read through the referral letter, some comments by Ken Fraser, and the daily nursing notes. There was a hint of angry trouble between Jenni and her mother’s boyfriend, the father having left the family home some years prior and not in contact.
I knocked on Jenni’s door, taking over the chair of a nurse who had been sitting with her. I explained who I was and how I thought I might be able to help. I told her that I had read through the notes, but people seemed to be perplexed about what had led to her trying to take her mother’s tablets. No comment or response. No eye contact. Not even a flicker of a reaction to anything I said. Just a dead look straight ahead. We sat in not very companionable silence, with me trying various speculations about what might have happened, and how I imagined she may have felt. No response. The chair was by a window, so I was able to look at treetops and distant roofs while trying to find another avenue. After nearly an hour of trying I explained that I had to leave, but that I would return the following week. In the meantime, I hoped she would get lots of rest, and perhaps get to know one or more of the nurses. No response.
I reported back to the charge nurse, and detected a hint of amused satisfaction. Perhaps I made that up.

The following week I had mulled over a number of approaches, and thought it might be best to do some speculation based on my limited experiences with suicidal people, bits and pieces I had read, and what little I knew of adolescents. If I said something wrong she might correct me, and at least that would be a response. If I challenged her, it might provoke her into arguing; most adolescents seemed able to do that. Opening of a dialogue was the critical issue. I have no idea where these ideas had come from given my limited experience with psychiatric patients; perhaps it came from all the televised dramas I had watched when I was an adolescent, or more likely from one of the nursing staff during my year in psychiatry.
But there had been high drama at Lanthorne. Jenni had apparently dressed in street clothes, taken her suitcase, and casually joined some parents of another child as they left the unit after a visit one lunchtime. They were busy with their own discussion, and apparently did not give her a second thought. Jenni had headed for the local cliffs where she sat for a while ‘thinking about her life’ (she was to tell me later). This was to be the lifesaver, given it took time for her to be missed, her escape reported to the police, and a hunt begun which included members of the Lanthorne staff. By the time people found her, she had already thrown her case of belongings over the cliff. Eventually one of our male nurses was able to talk her into staying, and returning to the unit. He deserved a medal.
After saying who I was and asking if it was OK to come in (no response), I said “I will take that for a ‘Yes’, and entered (no response, not even a look). I sat in the chair by the window, and started a one sided conversation. I slowly recounted what I had been told, (“I understand that…” - no response), said how glad I was that she ‘had decided not to jump’ (no response), and then quietly said: “I guess whatever has happened to you, it was bad enough to make you really want to die.” “Do you still feel a bit like that?” (no response). “I guess I will have to take that as a maybe…” There was no response and Jenni remained silent, sullen and withdrawn, as staff reported she had been all week. After a lengthy pause, I began to speculate. “My guess is that someone has forced you to do something against your will, and you hate them.” I sensed a subtle stiffening in Jenni’s posture, but she did not look up or answer me. There was no denial, no explosion at me, so I took that as meaning I might be on the right track. I let the silence lengthen. “My best guess is that it was someone you trusted” (no response) “someone who should have known better, perhaps” (no response) “someone you can’t talk about because if you did, it might upset someone else, and you don’t want that person to be hurt.” (the silence lengthened). “Some of my other patients have told me that the worst thing that can happen to you is to have a serious argument going on inside your head. One you just can’t sort out. And you know it will hurt you or someone else whatever you decide.” (no response)
I looked outside the window for a while, and then back at Jenni. There was nothing - not the flicker of an eyelid.
A change of tack… “Jenni, last time I was here you had a notebook open on your bedside table. And it was rude of me to notice, but I saw that you like to draw little diagrams and pictures. I’ve brought you some drawing paper, and some coloured art pencils I had not being used at home. I know it can be really hard to talk, especially to a man, so I thought you might like to draw instead.” I placed them on the very end of her bed, and said I would be back next week. “I apologise that it will be a whole week, but I am only able to come here once a week.”
I wrote up some notes, and checked in with the staff nurse, letting her know I had left some art pencils and paper with Jenni given she was finding it hard to talk. “I hope that is alright”. She smiled and suggested one of the teachers on the ward might be interested in helping.

I was on tenterhooks for the whole week. I did not ignore my other clinics or patients. Was Jenni still alive? Had I been too pushy in my approach? Could I have made things worse? Had she repeated the escape from the locked unit? Of course I was relieved when I attended the Canterbury clinic, and had 5 minutes to discuss her in supervision with Dr. Fraser. He asked where the idea of artwork had come from, and I told him that both my parents had been artists, and I had done some bits and pieces and some model-making as a youngster, and had found it peaceful. He nodded, and reassured me that Jenni had begun to take some part in ward activities, although she was still fairly mute.
That afternoon I drove to Lanthorne a bit less anxious than I had been. After the staff meeting where nurses echoed Ken’s comments, I knocked on the door, announced my presence and when there was no response, I went in. Jenni was sitting in the same position staring straight ahead as if she had been there all week. There was no acknowledgement or greeting. I said I hoped she had had a better week, and then sat quietly waiting. Nothing happened, so I asked if she had had a better week, or whether the ‘dark thoughts’ were still troubling her as much? (No response). Eventually she leaned into her bedside, and took out the drawing paper I had given her the previous week. She flung it onto the bed, and then what looked like a piece of cardboard on top of it. Not a word was spoken.
“May I take a look?” (no response). “OK, I will…”
The piece of 20 by 15 cm cardboard had originally been white, but had been painted black on one side. It had been carefully cut into to create a design showing a face with tears running down a cheek set into a spider’s web – not only evocative and dramatic, but very competently and carefully done. At its bottom right hand corner, was Jenni’s name carved into the design. The whole piece had been preserved by covering with a clear adhesive film.

“Wow!” was all I could think to say at first. “You really are quite some artist. You could not tell us any more clearly what it feels like to be you – trapped, and very distressed” I had to keep looking at it. She picked up the cartridge paper pad and pushed it towards me. There was only one complete painting, again very competently done. The lower part of a face stared directly out, the lips tied together by straps with buckles on both sides. “And you cannot or must not talk to anyone about whatever happened.” She tilted her head down, and there were tears. “I understand.” (and more than that I could feel her pain and confusion to the point of tears).

Saturday, April 1, 2017

Making of a Child Psychiatrist: (68) The General Practitioner (13); A bit more Child Psychiatry +

The following week in clinic, Ken asked me how I got on, and I simply reported that the system was all new and might take me some time to grasp, but I had sat in on a staff meeting, done the tour of the ward, met some of the children and parents and “hoped I might be useful”. He smiled and changed topic.
When I returned to Lanthorne, the first thing I noted as I came out of the lift was a pile of faeces against one wall of the corridor. I found a nurse who grumbled about ‘Peter doing his thing again’ and said she would deal with it. I joined the meeting. They had completed two case discussions despite the fact that I was not more than 5 minutes late after my diversion, and again I was sat on the last available chair at the back. I listened carefully to how the cases were handled and was impressed with some of the changes reported in a couple of children to whom I had been introduced the previous week. The teacher was particularly pleased with a sudden beginning of excitement to learn in one of the children.
When we got to Peter, the discussion seemed very limited; they had ‘a program’, and needed to keep it going. I felt obliged to briefly report what I had seen on leaving the lift to cries of “Oh, not again…” and a couple of smirks. One of the staff was clearly angry, and began with “That makes me really cross. I told him what…” cut off by the charge nurse. She turned to me asking whether I had had any experience with ‘encopretics’? I said I had two small boys at home and that Jan and I had had some fun with potty training, reading favourite books or playing favourite music and rewarding anything that looked like a success. But no, I had not yet had experience working with ‘encopretics’. She looked away saying “I think we just need to keep on with the program, but getting angry with him will not help!” It was not until the following week that one of the nurses let me know quietly that she had suggested to Peter that they could read a book together while he was on the toilet, and this had been ‘fun’. He had had two ‘successes’, and enjoyed a biscuit from the ward kitchen after each occasion. She had discussed this ‘new’ idea with the parents, and three weeks later they were keen to have him home after a successful weekend visit (and an admission of four months). I never did really find out what ‘the program’ had been.
One of the recurring problems discussed in meetings was how to gauge when a young person had recovered. Was there an optimum time that would give confidence that change had occurred? How many symptoms needed to improve before parents would accept that their child had made sustainable progress? Who would be the judge of any given behaviour? Did it have to be a consensus score? Clearly it was the nurses who spent most time with the patients, so it made sense for the score to be agreed amongst them. With the charge nurse’s permission, we began the idea of charting key behaviours once a week in the meeting with an agreed score for each of them from 0 to 10 on severity. The most severe behaviour would probably occur before or around admission (and could be scored 10), and (hopefully) become less severe or less frequent with therapy and as time drew near for discharge. There emerged a rule of thumb that once each of the behaviours were down to 3 or 4 out of 10, discharge could be discussed with parents. Very crude sort of measure, yet pragmatically useful, and it became part of the language of team meetings.
There is, of course, nothing new in the world. Others had apparently devised a formal scale some years before (Honigfeld G, Gillis RD, Klett CJ. (1966). NOSIE-30: A treatment-sensitive ward behavior scale. Psychological Reports. 19, 180-182). This was a 30-item ‘Nurses Observation Scale for Inpatient Evaluation’ geared to measuring behaviours in adults with Schizophrenia. I do not believe I had heard about this formally or informally at any time prior. And in fact, given the content of items, the original scale would not have been of much use at Lanthorne. Our scale was developed for use with a wide array of children and their problems, was pragmatic, flexible, very brief, and focused on key behaviours (rather than symptoms of one disorder). It was also very much a consensus measure, and the process of scoring was as important as the ultimate total score. As befits the times, we would never have ever considered publishing such a thing.
At my third weekly visit, a young woman of 15 called Jenni was discussed in the team meeting. She had attempted suicide at home following recurrent arguments with her mother and was thought to be in serious danger. She had only been in a couple of days, but no-one felt they had made any headway in developing a relationship. She refused to talk, was sullen and resentful and refused to leave her room even for meals, which were barely touched even when brought to her room by a nurse prepared to sit with her.  Night staff had reported she prowled around the unit at night and they thought she was investigating avenues for escape. The unit had always been secure with windows that had limited ability to open, and access to the two lifts only available by key. These were worn on a lanyard around the neck of staff members. To date I had not yet been trusted with my own key and always had to ask a staff member to escort me into the lift and down to the ground floor. There were external emergency stairs, but the door was always locked, keys were kept in the charge nurse’s office, and I am not sure that Fire Drills had ever been thought about.
At the end of the meeting the charge nurse said that Dr. Fraser had suggested to her it might be a good idea for me to attempt some sort of therapy for Jenni; she did not look convinced. I simply said I would be delighted to see her. I read through the referral letter, some comments by Ken Fraser, and the daily nursing notes. There was a hint of angry trouble between Jenni and her mother’s boyfriend, the father having left the family home some years prior and not kept in contact.
I knocked on Jenni’s door, taking over the chair of a nurse who had been sitting with her. I explained who I was and how I thought I may be able to help. I told her that I had read through the notes, but people seemed to be perplexed about what had led to her trying to take her mother’s tablets. No comment or response. No eye contact. Not even a flicker of a reaction to anything I said. Just a dead look straight ahead. We sat in not very companionable silence, with me trying various speculations about what might have happened, and how I imagined she may have felt. No response. The chair was by a window, so I was able to look at treetops and distant roofs while trying to find another avenue. After nearly an hour of trying I explained that I had to leave, but that I would return the following week. In the meantime, I hoped she would get lots of rest, and perhaps get to know one or more of the nurses. No response.

I reported back to the charge nurse, and detected a hint of amused satisfaction. Perhaps I made that up.

Friday, March 31, 2017

Making of a Child Psychiatrist: (67) The General Practitioner (12); A bit more Child Psychiatry +

I would never say that general practice was onerous. Most of the time it was delightful to have responsibility for the care of my own ‘flock’. Much of it was very ordinary to my growing experience, even if frightening to some patients. It was a privilege to be able to relieve the anxieties with confidence.
Of course, Birchington was the kind of place where people had lived all their lives, or where they had retired from a lifetime of work in London 25 years ago and were now prone to the ravages of time and age. So, people had terminal cancers, or serious cerebrovascular accidents, or heart attacks, or their bodies just succumbed to old age. Part of the job was to be realistic, to work closely with our district nurses to ensure that our patients were as comfortable as possible in their last weeks and days. There was no place for hiding the truth, and often my patients were relieved to have the story explained to them in terms they could understand where they had been confused by others not so comfortable to discuss the issues. I guess I had learned powerful lessons from my Sri Lankan doctor friend’s dying during my second job at King’s, but also from being with my mother during her last weeks and days.
So much of what I did was to sit and ‘be with’ someone during the last stages, particularly when they had few relatives and supports but refused to be sent to a hospital or home. One of these was Elizabeth who came from a small family scattered across Southern England, had lost her parents during the blitz in London, but had been part of that generation of stoics who ‘soldiered on’. Elizabeth had secondaries from an ovarian cancer treated years before, and our local oncologist felt their service had reached the end of the line. Despite her chronic pain and discomfort, she did her weekly shopping, cooked for herself, and looked after herself as best she could, adamant she would not accept care. She had worked at the War Office and had a fund of stories about intrigues that had likely never been told and likely never would be. Given my own forces’ connections, I found it easy to listen, and she had the knack of making us both laugh long and loud.
In those days, diamorphine (heroin) was simply part of the doctor’s bag, and I had carried the same five ampoules around in the back of my car for at least two years. From time to time, Elizabeth would be in such pain that the nurses would resort to asking me to help; which I did on a couple of occasions. Such a useful analgesic with few side effects from a standard dose; you could see the relaxation of facial muscles as the pain disappeared and euphoria set in. And the stories got funnier. One of us stayed with Elizabeth for the hour or so after each injection. Nothing adverse ever happened, but the injection seemed to allow her to cope for the next couple of weeks on her oral medications. Elizabeth eventually died in her sleep one night some weeks later, as she had wanted.
I never felt the need to pop into the chemist and replenish my small supply, and was only ever to use one more ampoule of my five - with a patient in her mid eighties, dying from cardiac failure in her own home shared with a younger sister, also just in her eighties. It was in response to a heart-wrenching request from the sister, deeply saddened by watching her sister’s struggle: “Is there nothing you can do to ease her distress, doctor?” My patient died at home 48 hours later, and the sister came to the surgery a couple of days later to express her gratitude for ‘being so kind’.
I guess relieving pain is a major role in a doctor’s life. And relieving pain from psychological and interpersonal causes rather than physical was ultimately to become a major part of my life’s direction. And it began in a seemingly innocuous way.
Ken Fraser had overseen my work with a small number of children and families for about six months at the Canterbury clinic, when he did me the honour of asking if it would be possible for me to do another half-day session. The proposal was that I would visit Lanthorne House once a week, and provide some medical backup by phone if necessary when Ken was not available. Having again discussed it with Jan, and then with John, I agreed. I was excited and daunted, not sure what I would find or how I would manage.
With some trepidation I found my way to Broadstairs, and wandered into the ground floor of a three-storey building, asking for directions to the unit. “Upstairs”, they said, “Lift at the end of the corridor”. No enquiries or checking of identity. So I walked the length of the corridor sensing the atmosphere (echoing, dingy and empty with cries and whimpering off, and the smell of ancient dust and old faeces, barely concealed by disinfectant), and caught the lift to the top floor. Why would you organise an inpatient unit for young people with psychiatric problems on the top floor? Pragmatic reasons, I guess.

I asked for the charge nurse, and was shown into a cramped office where there was one of many case conferences going on between the many nurses, two psychologists, and an activity therapist. I was briefly introduced to the group, and invited to find a seat on the outer circle, where I listened for the next hour or so to the challenges of managing 25 inpatients of varying ages and with a myriad of problems. Fascinating. The charge nurse was clearly in charge, and stood no nonsense. At the end of the meeting, she asked me what I thought I might be able to contribute? Not aggressively, you understand, but clearly marking out her territory and ‘ownership’ of the ward, the staff and the patients. I stuttered a bit, and then took a one down position saying that I had had some minimal training in adult psychiatry and some therapies but had only recently started at the Canterbury clinic working with children and families. I was happy to do whatever I could to assist her in managing what were quite obviously a diverse and tough group of clinical problems; albeit I was only going to be available face to face one half day a week. I must have hit the right note, because she visibly relaxed and asked me to write up some medications for two of the youngsters who were being discharged and needed a supply before they were able to see their own doctor. Writing up medication was the classic role of the doctor, and safe ground, so I was happy to do that! Would I like to see round the unit? More safe ground, and I was happy to do that! She asked one of her junior nurses to escort me round and explain the daily routine. So, for the rest of the day I was introduced to a range of young people, two sets of visiting parents and several therapists who were not at that point deep in therapy. I asked about what types of therapy were available, whether groups were being run, whether excursions were possible within the budget, how many people were on night duty, and how emergencies were dealt with? By this I meant how an individual medical emergency might be handled at night, and was told that on occasion staff from the two lower floors could be called in to assist. After afternoon tea, I was trundled back to the charge nurse who asked if I had any questions? Skating on rather thin ice I asked how she might like to use me? Clearly all the cases were in the overall charge of Dr. Fraser, and she would have to discuss with him what I may be capable of doing. I said that would be fine, and that I looked forward to attending next week, and hoped I might be of use. My first three hour ‘session’ had been completed.