Saturday, October 8, 2016
Making of a Child Psychiatrist: (48) Training in Psychiatry (1)
I was based on the psychiatry ward at King’s from October 1968, and gained part ownership of a small consulting room that had a collection of well-used textbooks and some newer paperbacks, a desk with two upright chairs, two comfortable chairs and a couch! More importantly, and unlike the experiences of my previous eighteen months, there were opportunities in the day to read bits of text. The job entailed clerking in new patients, getting to know them, completing a physical examination, discussions with nursing staff, writing up the notes and making sure they had medications from before admission written up and prescribed. Of course, these changed as stories unfolded or new understandings emerged. Ward rounds were taken at a much slower pace than I had experienced before, with consultants and registrars trying to get a grip on the biological, psychological and family factors that might have contributed, and willing to hear out even the lowliest of nurses and I. Discussions around treatment were more coherent and even at times collegiate, which gave the ward a sense of being a team working together on the same problems, and in the same direction. I was home.
The casework was not easy. This was a Professorial Unit, but King’s was an acute hospital serving the South London area, and this was shared with the Maudsley Hospital directly across the road. In the Maudsley there were many wards, and more patients with very severe illnesses like psychosis; much more in the way of chronic illness. King’s consultants had the luxury of accepting cases from across London if they fitted specific professional interests. Even so, the inpatient unit was semi-acute and short term. The objective was to sort out diagnostic issues, and reset medications. There was time for some short-term psychotherapy, but it was recognised this was brief, targeted, and tailored to enable a local psychiatrist or psychotherapist elsewhere to take on the case.
The unit had a reputation for managing patients with Anorexia Nervosa, an interest of Donald Liddell the Professor, director and senior psychiatrist. But what that meant in practice was that we assessed and tried to manage people who had been to several prior services and had been unable to manage the treatment offered, or had frankly rejected it. There is no clinical case harder than someone with Anorexia who has gained experience from previous admissions to hospital, and honed a bunch of strategies with which to test clinical staff. And yet we had successes, and I put this down to the collaborative teamwork, and the sense of working together that seemed to become engendered in patients and their families.
Strictly speaking, family therapy as such had not been conceptualised, and yet I was encouraged to work with our families and try to understand the unresolved issues that might appear to be blocking progress. Even the re-feeding program was more collaborative than rigid and combative, even if optimum weight targets were set and rarely gained. I guess looking back the underpinnings were more psychoanalytic, trying to match the internal working model of their family life with the reality, or at least the reality we could discern on the ward. This may well, in part, have been influenced by Irving Kreeger, a psychiatrist with the unit who was primarily a psychoanalyst, but also held a part time teaching position at The Maudsley.
We had weekly small group case-based seminars with Dr. Kreeger, a gentle thoughtful man who seemed to respect us as people, but always appeared slightly amused by us - as if he knew some secret (he probably did!). Irving was the first teacher I had who shared his well-honed views about assessment of the suicidal patient, a special interest about which he had published a thoughtful clinical paper on the role of the psychiatrist in 1966. Considering how scary it can be as a junior doctor to have to assess a suicidal patient in Casualty, and make coherent and safe plans for follow-up, I guess he sowed a number of seeds for my future. Through that whole year, I never missed one of his seminars.
I probably would not have known this at the time, but there was also another piece of teaching which left its mark on me. There was considerable excitement about, and repeated reference to, the work of the Social Psychiatry Unit over the road at the Maudsley, which had focused on people with schizophrenia and their social lives and recovery. In 1962 George Brown, a psychologist, and his colleagues (Elizabeth Monk, a research psychologist, George Carstairs and John Wing, both psychiatrists) had published a paper about the year following discharge for 128 men with schizophrenia. This was one of those pieces of research that would change and challenge psychiatry for years to come. In simple terms it reported that if your family were controlling and hostile, and likely to express their emotion (now reduced to ‘Expressed Emotion’ or EE), then you were more likely to deteriorate and be re-admitted during the subsequent year. This essential message that family dynamics were crucial to recovery had filtered over the road, and been influential in our work with people with a while range of diagnoses. This included our work with young people with Anorexia and their families.
So without much experience, and minimal skill as yet, I often found myself with one of the ward nurses sitting with a family exploring the way they understood the anorexia, the impact on their lives, and what they had found helpful or not. I did not have a plan, nor did I set out to intervene; rather I was just trying to understand. To be truthful, at that stage I did not even have a framework for therapeutic intervention. But a potted version of the session would find its way into the notes. Occasionally, bits would emerge during informal discussions with nursing staff, although more often than not I was just a sounding board for their thoughts (given they were often vastly more experienced than I). As with my experience in Casualty, I seemed to learn a lot about psychiatry from nursing staff who had spent so many years in their role they had absorbed therapeutic skill and were the backbone of the inpatient unit, even if their work was not often openly acknowledged.
One of the other psychiatrists admitting patients to the ward, but with a contrasting approach, was Dr. Anthony Hordern, who in 1965 had published a book on depression (‘Depressive states: a pharmacotherapeutic study’). Dr. Hordern was a very different character to Donald Liddell or Irving Kreeger. He was precise, obsessive and had high expectations, but did not want his patients to have psychotherapy from a junior doctor. Ward rounds began and finished on time, and Tony was focused on the symptomatic presentation and the clinical picture as presented by the patient. He appeared to have little interest in family dynamics, and was quickly dismissive of speculative ramblings. He was involved with Dr. Harvey Syme doing research into a new drug called clomipramine (Anafranil), so any patients who were part of the study were expected to follow the protocols. Questionnaires like the Hamilton Depression Rating Scale and others were expected to be completed. I can now understand this having myself been involved in research over the last 30 years but at the time it was all very irritating, and feedback was sparse.
Tony and Harvey were specifically involved in breaking new ground with clomipramine, using it in an intravenous infusion form. I was impressed by the suggestions about its potential, listened avidly to discussions, and was impressed that research was being done on ‘our’ unit, even if I had had no training in or experience of intervention research.
Given the strict criteria for inclusion, most of the patients with depression were not involved in clomipramine trial, but were treated in a more standard way, with medications in the form of tablets, or with electroconvulsive therapy (ECT). So I was trained in the application of ECT, mostly by watching the registrar who explained about the dose, the time, the position of the electrodes on both temples, and a number of precautions that had to be in place before pressing the button. There was always an anaesthetist present. They gave the intravenous Thiopentone, and monitored airways and recovery. Although unilateral ECT was later to gain ground on the basis of fewer side effects – particularly reduced loss of memory – I do not remember us using it. The ECT was mainly given in an outpatient clinic, with about 20 trolleys lined up side by side. On occasion there would be someone from the inpatient ward beginning a course, but mostly they came in from the community for their treatment, resting afterward for a couple of hours to ensure recovery from both the treatment and the anaesthetic, and then going home with a relative.
Over my year, I grew to loathe those mornings when I had to attend the ECT clinic. I knew very few of the patients, was unable to develop a relationship, hated the mechanistic and (what appeared to be a) brutal process. From some of the stories, I began to hate the fact we might be damaging personal memories. The registrars just seemed to accept the treatment prescribed by their consultants. So who was I to know anything? I did what I was told, and had no-one I could debrief with or to whom I could grumble. But I have to say that in the few patients I got to know over time, there was a genuine lifting of mood and an acceptance that ECT worked to get them back into life. I just wished I could have avoided being part of the process.