I
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t is not
easy to admit to failures and harder still for doctors to do so especially if
they did everything right and according to protocol.
Doing the “right” thing is not an
indication of success.
Hardly.
Yes. I am coming back to Anorexia
Nervosa again and I do not apologise for it. I am apologising for our failures
though.
When I took over the adolescent unit as its consultant in charge there were six
Anorexia Nervosa patients in varying stages of emaciation or weight gain
depending on from which side you want to look at it. It is not always wise to have so many
anorectic patients together as they do
share tricks with each other and it is often more difficult to customise
treatment.
What needed my urgent attention was of
course Sammy. Sammy had a very feminine name but preferred the nickname Sammy.
Sammy’s Section was due to expire in less
than 14 days and I had to compile a report for the Tribunal which would be
sitting to decide on her fate.
It was perhaps a sign of our failure as
psychiatrists to effectively treat Anorexia Nervosa that eventually case law
was established to regard food in Anorexia Nervosa as medicine. Therefore food may be used forcibly to treat
Anorexia Nervosa when the condition becomes life threatening.
The usual test of mental capacity no
longer applies. Instead the law is used forcibly to feed a generally bright and
intelligent person “over-doing” what most consider to be “good”. They try to eat less and eat healthily by
avoiding fat and the like and wham we
have the law on them.
I have to admit that I have not liked
this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of
tube fed patients.
On the other hand not everybody is able
to treat Anorexia Nervosa patients or, in reality, do battle with them. It
requires experience, energy, time, wit, charisma and often impeccable timing.
However, sometimes I do wonder if we are indeed doing a disservice when we take
things out of parents’ hands by agreeing to take over.
With hindsight and upon reflecting on a
number of cases I have dealt with, I often wonder: if hospitalisation had not been
an option at all, would improvement rate and, more importantly, mortality rate
have been any different.
We do not section people for smoking,
drinking, or doing drugs, which all endanger life. Nor do we stop people
running the Marathon or eating raw oysters
when these activities regularly lead to mortalities.
Society is coming round to do something
about over-eating in children but it will take some time before they apply the
Mental Health Acts.
To me, the moment a psychiatrist turns
to the law he is admitting that he has failed.
At least that is my view and if I
perpetuated the Compulsory Order with Sammy, I too would be part of that
failure.
There had been no weight gain in Sammy
despite the tube feeding and the debate was: shall we increase the feed or
shall we wait? Everybody just assumed that she would stay on as a compulsory
patient.
Despite bed rests and even more
embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not
to gain weight whatever we pumped into them. The balanced feeds were in fact
quite expensive. There was no secret that they were aware of the exercises they
could perform even on bed rest and the determination not to put on weight had
to be seen to be believed. If such determination was applied elsewhere I was
sure these young girls could be very successful.
I had to find an answer, an answer for
Sammy and an answer for myself.
Being forced to eat by the State
remained the treatment of choice for everybody except for one stubborn
consultant.
“At least we did all we could,” my
staff constantly reminded me.
“And she is the most determined of all
the Anorectics we have right now.”
More reason to show the others that
this new psychiatrist had some other means than brute force, I thought to
myself.
Yes, I could be as determined as they
were.
The hours of family therapy only brought about accusations and counter
accusations with hardly any resolution. Middle class families have certain ways
of dealing with things where some branches of family therapy are not
particularly good at all.
The modern trend is certainly moving
away from blaming families. Or that is
the rhetoric of most who write publicly about it.
Whatever the official line, families
cannot help feeling blamed.
“If we are not to blame, why do we need
family therapy?”
“There are so many other families like
ours. Why do they not have the same
problem?”
We may reassure them that there are and
that is the truth, but the truth is that there are also Anorexia-free families.
Yes, it might help if they do find a
gene like they did with obesity. Yet
that cannot explain why there are more extremely obese people in say the U.S.
which collects gene pools from across the globe.
So Sammy’s family had the full benefit
of eight sessions of family therapy by two very experienced therapists. In the
end, there was just a lot of recrimination between all parties including the
therapists and all agreed it would not be the way forward. That was when
tube-feeding started.
Minuchin[3] dealt with over-involvement,
over-protectiveness and conflict avoidance in these families with no special
apology on whether he blamed the family or not. He used to start with a meal
session with the family. His success, like many such methods, probably had more
to do with his charisma than his method and is thus difficult to replicate.
For Sammy and her family the message was
simple and clear enough, no matter how hard we lied.
The
family had failed and the hospital had to take over.
That was the blunt truth.
But the hospital had failed too and we
had to resort to the Mental Health Act on one of society’s most sensible and
decent and safest citizens.
I decided enough was enough. I could no
longer perpetuate the no-blame approach. I could no longer continue to hide
behind the power conferred onto me by the law.
In short, I had to reverse just
about everything that had gone on before, and more.
Just two weeks before the tribunal sat
we had the big review meeting. To most at the unit, the review was fairly
routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for
difficult to treat Schizophrenics and difficult to control Bipolars in the
acute manic phase. Sammy would be “detained
at Her Majesty’s pleasure”, and classed with the likes of the few psychotics
who had committed the most heinous murders. To save Sammy’s life, it would be
natural to continue with the Mental Health Act.
Yes there would be weeks of tube
feeding and bed rest, but the State had to take over the complete care of this
bright young thing for her own sake.
I could not see any other way either.
Unless …….I could reverse everything
that had gone on before.
If our work is to be therapeutic then a
sort of therapeutic alliance is important, even if tentative. Some people do not realise that you can fight
with your patient and still have a sort of therapeutic alliance.
I had a plan.
These meetings were attended by just about
everybody who had anything to do with the patient. They were held at school times so that most
of the teaching staff could be present as well. These meetings also had a
tendency to drag on as everybody seemed to have a lot to say about very little,
a trait not just limited to psychiatrists but also seen in social workers,
therapists, nurses, junior grade doctors, teachers and visiting professionals.
People always seemed to have a lot to say on cases where there was the least
progress.
My personal view is that this was a
sure sign of anarchy which had unfortunately drifted into our Health Service,
encouraged in part by the numerous re-organisations that had gradually eroded
the authority of the doctor.
Saul Wurman[4], an architect by training but also an author of business and tour
books, famously wrote that meetings really do not always need to be an hour
long. Why can it not be ten or twenty minutes?
Could I achieve that?
After briefly explaining to all the
purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube
“Micropore’d[5]” securely and said, “What do you think?”
“It is so unfair. Now I shall not be able to go to Harvard.”
It is generally perceived as a given
that a U.K. citizen who has
been Sectioned will not be able to use the
Visa Waiver to visit the U.S.
If that person then has to apply for a Visa, having been detained under the
Mental Health Act must be a major hindrance, although I have never seen this
applied in practice. One of my patients did have to cancel a horse trial trip
to Kentucky
because she was sectioned at the height of a manic episode.
I did not know she had aspirations to
get to Harvard but I was not surprised given what I already knew about mother.
“Before I say anything else, can I ask
you a few things?”
“What? Sure!”
“Do you smoke, drink, take Ecstasy or
go out clubbing?”
“No.
Why?”
“Do you have piercings and tattoos on
you?”
“Tattoos—yuk! Yes, I having my ears pierced. That is all.”
“Do you like Pop music?”
“No way. I play the violin and I like
Bach and Bartok!”
Everybody was attentive now.
“Do you shoot heroin or smoke
Cannabis?”
“No way!”
She was getting annoyed.
“What about boys and sex?” I felt bad
even to ask especially in front of her mother, who I thought would faint if we
knew something she did not.
“How can you even ask and in front of
my parents? You know I don’t do things like that!”
I can remember my own adolescence. I
did not do any of those things either and I did not even have pierced ears.
I then turned to the parents. Mother was a history teacher at a famous
private school in one of England’s
most middle class town. She also spent a year at Harvard, hence Sammy’s
ambition to follow her. Father was a prominent city lawyer.
“You have always provided well for her,
a good education, European and U.S.
holidays, a comfortable home and expensive music lessons.”
“We are fortunate enough to be able to
do that. She is our only child.” Mother replied in a tone implying, “what’s wrong
with that?”
“And she has always been a bright
child, strong willed and single minded. She passed her Grade 8 violin with
distinction at 14 and could have become a musician. But she wanted to do
International Studies.” Mother added.
“So she always had her way.”
“She has always got on with everything,
studying and practising the violin. And she keeps a tidy bedroom!”
A tidy bedroom! My goodness, everything
was falling into place.
“Sammy……”
“Yes……”
“You know what? You are the first
adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do
not smoke and you do not do a load of other things I asked you about. You are
by modern standards a FAILED adolescent!”
Then I turned to the parents.
“And you, FAILED parents!”
“And we FAILED you. We failed you
because we had to hide behind the law and force fed you.”
Sammy said, “I can’t do all those
things even if you make me.”
Ah, the turning point.
“No, don’t get me wrong. I don’t want you
to either.”
I then told her that I would like to
take the tube off her despite lack of progress, or because of it.
It simply had not worked.
I wanted her to take over, do what she
needed to do and I would decide in about ten days if I had to extend the
Treatment Order.
Forty five minutes. The meeting took
forty five minutes as people had to present summaries of different reports, the
details of which were irrelevant here.
The battle was over. Sammy looked
relaxed. Nobody was fighting her now. She was back in control.
I took her off the Section as she started to put on weight and before
long she was discharged.
We forget how easy it is to entrench.
To entrench is a sure way to perpetuate a problem.
P.S. She got into King's College, Cambridge.
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Anonymous said...Did she get to Harvard/do something else she wanted to do? Do you get to find out what your patients do after you've sorted them/fattened them up or do you just have to imagine what happens to them afterwards?
I've had a whole series of psychiatrists over a space of half a century and most mean little or nothing to me, but there's one I'd love to track down and tell how much he helped me and how I'm getting on now, except that it might look a bit like obsessiveness or stalking or something so I don't.
Cockroach Catcher said...I have with my cases felt that my patients should not be fighting with me if they are fighting. A good therapeutic alliance could be formed in a number of ways and I am sure you will agree with me that Anorectics have much stronger will powers than most psychiatrists. Fattening was indeed not my aim but society is very strange in not sectioning people that over eat, or smoke or run the Marathon etc. etc.
I suppose it is not revealing too much to say she went to one of the two top Universities this side of the Atlantic.
I am very fond of my patients and I think they, me.
Thanks for writing.
