Wednesday, October 26, 2016

Paradoxical Approach & Anorexia Nervosa!

©2016 Am Ang Zhang 

We sometimes tread a very dangerous path in our dealings in Child Psychiatry and nothing is more so than in Anorexia Nervosa! Thank you Jay Haley for your inspirations!

The Cockroach Catcher.

         "This is the Captain again. I hope you have enjoyed the view of St. Lucia. It is unusual to have so little cloud.  Anyway, in seven minutes we shall be able to come into view of Barbados.  We should be coming in from the north side where you will be able to see Port St Charles. Then we shall go round the west coast. With any luck you will be able to see Sandy Lane, the best hotel in the world. So, in seven minutes. Barbados. The temperature in Barbados: 83 degrees Fahrenheit, with scattered clouds.

         In seven minutes I would start my life of leisure in this Paradise Island in the sun.

         Seven minutes.

         Seven minute cure.  My famous seven minute cure. It was the making of me at the Adolescent Inpatient Unit. It was the pinnacle of my career. The most defining seven minutes in my career. 

         And Candy really helped me launch myself into it.

         “It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”

         Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine.  Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.[1]

         Candy was just two days free of tube-feeding, which apparently was the only way to get her weight to a less frightening level.

         Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night.  Some would argue: since we as a state hospital would not be getting the money, why should we take the risk?  After all, the consultant in charge would be in the dock if the patient did die.  Nowadays, patients and their families are trigger happy and complain even if the patient becomes better. God help us if they die. 

         I argued the case in the opposite fashion. We shall help the authorities without precondition and who knows, I may be able to get them to give us something when the time is right. 

         Cynics at the unit looked at me as if I had just dropped off another planet. Get something out of the Health Authority? When were you born?

         A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Clinics are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments.

         The poor nurse did not realise what hit her. That was my first week. I am never threatened. I like the challenge of difficult cases and definitive statements like – the patient will die.  I like to prove it otherwise.

         The nurse concerned was not naïve either. Far from it. She based her judgement not on what she knew about me. It was only my first week after all. 

         No, she based her judgement on her knowledge of the unit, as she used to work here. She was once its lead nurse. Alas, poor pay and bad conditions coupled with the deteriorating consultant leadership prompted her to jump ship. I could not blame her for that. 

         The unit went through a difficult phase until the last consultant was finally suspended. Even before that, other consultants started refusing to refer patients here, and the two main Health Authorities that the clinic served had to fund ECRs (Extra Contractual Referrals in the then re-organised Health Service lingo) to mainly private hospitals.

         Then the unit had a locum and the operation was scaled down drastically. Bed availability dropped to less than half the normal capacity and the waiting list for admission grew. Unlike elective surgery, some patients in psychiatry cannot wait. Beds had to be found and often they were placed with adult psychiatric patients. It was not ideal even for the psychotics and certainly inappropriate for Anorexia Nervosa. Private Hospitals had to be used.

         My first task as the new consultant in charge was to ask the Charge Nurse what would limit our ability to admit to full capacity.

         “Your time,” was his reply.

         So we aimed to move to full capacity, not overnight but within the following three months. The shock on the faces of the managers as this was announced at a meeting gave me such an adrenaline rush.  

         Or, did they think, “What a fool!”

         Fool or no fool, one needs to enjoy one’s work, even in the NHS.

         This perhaps is one thing that the government has conveniently forgotten. Many of us do what we do because we enjoy it. Otherwise why should anyone want to teach in universities when they can earn ten or twenty times more in industry? We may also decide to dedicate more time to work for personal pride and satisfaction. During the few years I worked at the inpatient units I spent in excess of a hundred hours a week there, one man doing the job of at least two.  In addition to that, I was still looking after two outpatient clinics. 

         With increased capacity, we were ready to take on transfers. At that time the Health Authorities still had decent managers not yet blinded by directives and performance targets. For a start these managers did not interfere with clinical matters. For our part we were free to exercise our clinical judgment.  Unfortunately many consultants abuse this privilege of clinical independence, often making excessive demands for treatments and investigations, and managers have learnt to ignore them.  Worse the government set up this organisation called NICE (National Institute for Health and Clinical Excellence) to try to deal with such behaviour.  

         “It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”  

         The nurse was probably unwise to make such a declaration, as my mind was already made up to take on Candy regardless. 

         What if the private hospital did not exist?  It would have been down to us then. So to me that was no big deal. After all, most private hospitals are notorious for transferring their dying patients to NHS hospitals so as not to mess up their pristine mortality figures. What was so different here?

         “Shall we meet the family?” I said, trying to break the ice.

         There had of course been a pre-visit by our Charge Nurse and his team.

          “This one is difficult and I think you may have a problem with father.”

         Candy led the three-some. She gave me such a look as if to say, “Wait till I give you all the trouble.”  She looked out of the window for the rest of the time. Mother was warm but worn. Eighteen months had taken its toll and she was gracious enough to be pleased to meet me. Father on the other hand seemed to show some anxiety. In fact, he was a quite a powerful negotiator, and had managed to persuade the insurers to agree to extend the private medical care for another six weeks on a shared cost basis, either with the parents or with the Health Authority.  He was still quite keen on the private treatment, and was half hoping that I would refuse to take Candy on clinical grounds and then the Health Authority would pick up the bill from then on.

         To be fair, eighteen months was a long time even for Anorexia Nervosa.  Perhaps someone else should have a go.  NICE had not yet come up with a standard treatment and I certainly would challenge them to do so. Tube feed everybody?  That would be the day.

         Mother was more intuitive and I think she got the measure of me very quickly. “Darling, perhaps we should give Candy a new start. The new doctor might work in a different way.”

         “It is the nurses that did most of the work.” A final and desperate attempt by the nurse from the private hospital to set the record straight was missed by the nervous family. The rest of the world still looked up to the consultant, perhaps not for much longer but until Armageddon, I was going to enjoy it.

         “I will give it my best shot.”

         So on a rather unusually beautiful sunny Tuesday morning, we received a soon to be dead Anorexia Nervosa patient who had been abandoned by her insurer to the unsafe NHS. 

         What a challenge! Some of those at the meeting must have considered that I was delusional.   

         I believed that money should not be part of the consideration for the best health care and I was determined to make sure that my delusions should remain true for me.  I had to maintain a good service in my little corner of the NHS.

         Perhaps I was able to capture mother’s heart and gain her confidence through mine. She decided that they should give us a try.

         Do I tube feed her straightaway or do I wait?

         I am no coward. So let us wait.

         Adolescent units are notorious for making life difficult for authority figures. This is perhaps due to severe professional rivalry. To most of the nursing staff, the only difference between the psychiatrist and them is that the psychiatrist is licensed to prescribe. If a patient is not on medication a psychiatrist would barely be needed. Over time various mechanisms have been introduced to minimize the input of the psychiatrist even when he is supposed to be in charge. Many psychiatrists gave up the fight a long time ago just to survive. A patient’s stay in hospital involves a large number of multidisciplinary meetings that often lead to half-baked treatment plans that have little hope of success.  Surprises are unwelcome and generally discouraged. 

         I have found this kind of “consensus” approach a serious problem.  It is simply not my style.  Perhaps one of the reasons I stayed as an outpatient consultant all these years was to continue to enjoy the independence from such approach.

         Now all eyes were on me. 

         On that Tuesday I felt as though the whole unit was putting me through a trial. It was like living through a reality show. Everybody was watching me, and I would have to deliver or perish.  My reputation, the reputation of an alien psychiatrist, was at stake. I needed to act fast and I did not have eighteen months. Otherwise I would be packing and leaving this jungle, house or whatever reality show I was in. 

         Apart from true madness, Anorexia is the only condition where one can use the Mental Health Act to detain and if necessary force feed against the patient’s wishes, although little is known about how effective this aspect of our law is. There is still a rather high mortality rate, even in acknowledged centres of excellence like the Maudsley[2]. Tube feeding does not seem to be saving lives.  It also hurts our pride if we have to succumb to tube-feeding.  It means that we have failed as psychiatrists.

         Then I remembered my own golden rule about parenting. When all else fails, try bribery.  And that is what I did, but not with Candy.

         Any nurse that could get Candy to start eating would get three bottles of nice wine or two cases of beer.  It might not be strictly against the rule, but I am sure a few eyebrows were raised.  Candy refused to eat or even drink.

         I had to be in London for a Royal College meeting that Friday.  My mobile rang. Day 4: Candy was still refusing to eat or drink. 

         “No tube feeding, just check her blood chemistry” was what I decided should be done.  People do not die so easily even with committed fasting. We had got time, and nobody was going to get my wine or beer, I told myself.

         By Sunday, there was a major concern that Candy, having not eaten for five days, might be at some risk.  A quick electrolyte check showed normal sodium and potassium levels.  I left instructions again not to jump up and down and worry too much.  I was quite sure she must have been secretly drinking, perhaps not from her own jug. Often other patients would “help”, not quite comprehending how their “help” might indeed be a “hindrance”.  I have even seen nurses “helping” to dispose of patient’s food or even eat it. Anorexia stirs up funny emotions.

         By the time I got in on Monday, Sophie, Candy’s nurse said to me, “I think you had better see Candy. There has been no change at all.”  This was in some ways quite unusual as most of the time the consultant in charge only gets involved in family meetings and reviews that are pre-planned. Junior doctors deal with the day to day checking on patients.  Perhaps she was somehow hoping that I would give in and put Candy back on tube-feeding. 

         I think if there had been a NICE guideline[3], I might not have been given this chance.  Instead some on-call doctor over the weekend would have put her on tube-feeding as per protocol. After all, that had been her mode of feeding for weeks. 

         We would use the law if and when it became necessary.

         However, that would have defeated the whole point, as she would have been stuck with the old ways forever.  

         Stubborn patients deserve stubborn doctors.

         Candy came in.
         “Aren’t you going to tube feed me?”
         “Then I will die.”
         “So I will be very sad but we do not tube feed here.”  At least I don’t.
         “You can’t do that.  I want to be discharged.”
         These are more or less verbatim reports. My mind was racing fast trying to come up with an answer.
         “I want to be discharged!”
         “Candy, it is actually possible.”
         I can still remember the look of horror on Sophie’s face: “Is this doctor for real?”
         “You mean discharged today?”
         “Yes. I mean today.”
         I could see Sophie was in complete shock. “What planet did this consultant drop out of and how is he going to pull this one off?”
         “Well. If you start off by drinking one carton of Ensure Plus and some squash, then eat your lunch and have another Ensure Plus in the afternoon, you will be discharged home and you can come back daily.”

         When I used this case in my teaching sessions with junior doctors, they invariably showed incredulity that I offered this to Candy just like that, without consulting her parents or her nurse.  I knew that if there had been any discussion it would never have happened. There would have been objections from somewhere.  That is the trouble with consensus.

         But you see, it was important for Candy to know that I had authority. Many adolescent units have gone too far the other way, and they really are a reflection of dysfunctional families where the adolescent rules the roost.  A totally democratic approach will never produce the thunderbolt and deliver the sustainable therapeutic effect.

         A strange bond was developing between me and Candy. I gave her a way out and she would oblige.  I had no doubt at all she would be compliant.
         Sophie then went to fetch exactly what I told Candy she needed to 
consume. When Sophie came back, the drinks went down in seconds.  I could see the relief and disbelief in Sophie’s eyes.
         That took seven minutes.
         And now the real work began: the details.  I told Candy she would be discharged as an inpatient and would need to come in every day as a day-patient. A trick you might say.
         She did not object.
         She never expected to be discharged in her state. The important thing was that I took control. For her it was a relief. She never protested that I perhaps tricked her. It too was a relief for her to have something in her stomach.  What was more important was I saved her face and she, mine.
         I was to stay on in the show.
         How could I justify sending a fragile fasting patient home on the first day of resumption of eating?
         For five days we achieved nothing when she was in hospital.
         What about the parents?
         In fact I phoned mother in front of Candy straight away.  I played a trick on her. I just said, “Candy is coming home.” A long silence indicated how shocked she was. Then I told her of our seven minutes.
         “I knew you could do something.  That was what I told my husband, but I did not know it was going to be this quick. I did tell him you were OK.”
         You can wait for years for a case like this. It is like a hole-in-one. You just know the moment the ball leaves the tee. With one such case, I could now put up with anything anyone cared to throw at me. 
         At least for a while.
         To Candy, it was like a heart transplant. She had been stuck for too long and was probably pleased to get out. Hospital was not like home and she had not been home for a long long time. 
         So where is Candy now?
         She was eventually discharged to attend a state school but that did not work. She eventually went to an agricultural college where she worked mainly with horses and did extremely well. Her weight was well maintained. That took another fourteen months.
         But she remained a day patient throughout except for a long weekend when her parents went away for their anniversary. At Candy’s request, she stayed in the hospital that weekend.

[1] Olanzapine – (Zyprexa-Lilly) Anti-psychotic drug. Eli Lilly agreed on Jan. 4, 2007 to pay up to $500 million to settle 18,000 lawsuits from people who claimed they had developed diabetes or other diseases after taking the drug. Lilly denied any wrongdoing. In its statement, Lilly said the settlement did not change its view that Zyprexa is a safe and effective treatment for mental illness.
   Lilly’s internal documents show that in Lilly's clinical trials, 16 percent of people taking Zyprexa gained more than 66 pounds after a year on the drug, a far higher figure than the company disclosed to doctors.
   Olanzapine-induced weight gain may be secondary to excessive ingestion of food due probably to an inability to increase plasma glucose and leptin following a glucose challenge.
   The F.D.A. added a warning in 2003 to the label of Zyprexa and other new antipsychotic drugs about their tendency to cause high blood sugar.  

[2] Anorexia mortality:
Anorexia nervosa is a mental disorder with a high long-term mortality. Detained patients gained as much weight during admission as voluntary patients, but took longer. More deaths among compulsory than voluntary patients (10/79 v. 2/78) were found 5.7 years (mean) after admission. CONCLUSIONS: Compulsory treatment is effective in the short term. The higher long-term mortality in the detained patients is due to selection factors associated with an intractable illness.
The British Journal of Psychiatry 175: 147-153 (1999)
© 1999 The Royal College of Psychiatrists.

[3] NICE guidelines for eating disorders were not issued until January 2004, some years after this case.

Monday, October 24, 2016

Chicago: From Magritte to Amanda

Could the Cockroach Catcher have missed this exhibition?

Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”

 “Magritte was an amazing artist who has much to offer us today,” said Stephanie D’Alessandro, the Gary C. and Frances Comer Curator of Modern Art at the Art Institute, who was instrumental in assembling this exhibition of nearly 80 paintings, plus collages, objects, photographs, periodicals and examples of the artist’s work in advertising.
“I think that living in an age of mobile phones, in which we are so used to acquiring all sorts of information with great speed — and assuming it is ‘correct’ — has resulted in a loss of the ability to let a picture really take us into its own world, with all its unique habits and customs. So working with installation designer, Robert Carson, I’ve tried to create a series of small, initially quite dark spaces that should help make the experience of each art work more intense and intimate, and will let your imagination tell you where you want to go.”
The Magritte show, awash in images at once grotesque and erotic, mundane and mysterious, unspools in more or less chronological order. It begins with the crucial body of work, both paintings and paper collages, that he created in 1926 and exhibited the following year in his first one-man show at the elegant Galerie Le Centaure in Brussels — a show greeted by mostly negative reviews. It moves on to his subsequent time in Paris, where he lived for three years, becoming part of the Surrealist circle led by the French poet and theorist, Andre Breton, and such artists as Salvador Dali and Joan Miro.

 Magritte reminds me of Amanda.

         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”
         “But only if she wants to.”
         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.

         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the René Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story.

It has taught me one thing: Anorexia Nervosa may be just a manifestation.

The Cockroach Catcher Chapter 33  The Peril of Diagnosis 

Tuesday, October 18, 2016

NHS: The Last Sunset & The Last Cook.

 As the sun sets on our beloved NHS:
                                                           ©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook

ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.
         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely.
         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
         You never know as people do not really research these things.
         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.
         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.
         But she had two lovely looking girls.
         We knew from the start there were handling issues and most likely diet ones too.
         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  
         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.
         We were at a loss as to what was going on.
         The girls would get worse over the week-end and soil. This went on for quite a while.
         Then one day the cook talked to me.
         “Sheena never stays Mondays,” she told me.
         I listened.
         “Have you noticed she is always in dark glasses on Mondays?”
         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
         Sheena was not a movie star.
         I arranged to see Sheena.
         She said, “You knew.”
         I nodded.

         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
         I suggested that I should speak to him but she looked terrified.
         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.
         Was it such a cop-out on my part?
         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 
         The unit had long since been closed.
         The last cook in the NHS retired .

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