Women, interrupted

views & REVIEWS Living in the moment PERSONAL VIEW L V Campbell “E yes closed everyone. Just of everything be in the moment. No that mattered in extraneous thoughts at all, her life. Some only your own sensations. have described Stay completely in the dementia as moment . . . totally relaxed. Soon you will be being like able to do this anywhere, any time, without slipping back into even closing your eyes.” the dependency The soothing voice flowed over the group of childhood—but of overstressed health professionals, who were facing only further straining to absorb the latest and the best undignified decline, not in stress management. Doctors, nurses, and ascent as a child does. dietitians were trying hard to capture a feeling One night I told my mother normally foreign to health workers: total of the death of a lifelong friend of submission to their immediate sensations. hers who had had a major stroke. Having But the simple instructions proved difficult watched my mother become unable to for people coiled as tightly as springs, always recognise even well loved faces or names, ready to face the next challenge or assault. I had considered not mentioning the death Our enthusiastic young physiotherapist tutor at all. She often forgets that her friends are looked disappointed and decided to call it a dead and is surprised and upset with each day earlier than expected. As we filed out he reminder. So I wrote a couple of bland, handed out printed summaries for us to study meaningless lines in my mother’s name on a later. suitable condolence card and put it before my As we emerged from the dim interior the her, merely hoping she would sign it legibly. issues of the day descended on us like a toxic She spent some time writing clumsily and cloud, filling our thoughts. Although we knew then laid the pen aside. Later, when I put the that most of the problems we wrestle with letter in the envelope I had prepared, my eyes each day are forgotten in a year, swamped by filled with tears as I read the words she had even greater challenges, crises, and threats, written in a relatively clear hand: “Mollie was the adrenaline flowed into our veins on cue. my dear friend for many years. We wrote to Trying to empty my mind had merely opened one another often over the years. I will think a set of floodgates through which barely of her with love, till I too follow her.” suppressed deadlines and imminent disasters I expected so little of her, yet she wrote flowed unchecked. something simple and Perhaps most doctors During the session I beautiful. I have copied it had left one eye half open nowadays are doomed to live an and left it on my desk, to overcommitted, fretful life until remind me for ever (till I to see whether the others the inevitable degenerative were doing any better; a myself follow them both) few did seem to be in a that we never really know processes empty our minds calmer place. However, everything that lies in any I felt that my burden was greater than theirs, human mind. We feel important in our busy for my domestic demands included caring for jobs but may still estimate poorly what is in my elderly mother, herself once an extremely the mind of someone with “limited cognitive clever and devoted physician. In advanced abilities.” Some of my “retarded” patients age she had progressive memory loss, with are the emotional heart of their family: all that accompanies it. It is not necessary in one girl with Down’s syndrome provides a medical journal to describe the profound piercing insights into the psychodynamics indignities of the ageing process itself, but the of her family. As the child of a psychiatrist I final affront had been her loss of the memory spent many childhood years living in mental 560 hospitals, where I often attended Christmas parties with the long stay patients. It was a life full of delightful experiences for a child with no preconceptions as to who or what is regarded as “normal.” Contributions from mentally “impaired” people can far exceed our limited expectations of them and give unexpected insights into the brain’s plasticity. I followed my mother onto the balcony. She had wandered out there and sat gazing into the trees and garden as she often does now, watching—and yet not watching—the birds and butterflies darting among the flowers. She spoke little, just following the beauty of a bird soaring down to drink from the fountain or the panther-like progress of our cats through the undergrowth. I followed her gaze and realised that she was “in the moment” in a way I had found impossible at the previous day’s session. It was soon time for me to begin my frenetic working day. I left my mother in the early sunlight, quietly absorbing the sounds of the morning. She, who had once been as anxious, harrowed, and busy a medical professional as any of us, had acquired the elusive art of relaxation very late in life. Perhaps most doctors nowadays are doomed to live an overcommitted, fretful life until the inevitable degenerative processes empty our minds of all thought and we discover a similar enforced type of peace. We must accept that our vulnerability is the same as that of our patients and that we all huddle together under the inevitable blows of fate and time. With the great privilege in medicine of sharing our patients’ journeys, we doctors should learn to live more fully the moments remaining to us. Professor L V Campbell is director of the Diabetes Centre, St Vincent’s Hospital, Darlinghurst, Sydney, Australia [email protected] BMJ | 8 march 2008 | Volume 336 VIEWS & REVIEWS Liam Donaldson’s medical classic, p 563 review of the week Women, interrupted Women have been the focus of more psychiatric attention than men over the past 200 years. A new book reviewed by Gwen Adshead considers why this is still the case Mad, Bad and Sad: The History of Women and the Mind Doctors from 1800 to the Present Lisa Appignanesi Virago, £20, pp 540 ISBN 978 1 84408 233 9 Rating: **** Some people seem unfairly talented, and Professor Appignanesi is one of them. She is both a historian of ideas and novelist and, together with John Forrester, previously wrote a book entitled Freud’s Women, about the important female figures in the history of psychoanalysis. Here she returns to the themes of psychiatry, history, and gender, but in a broader context and with a bolder aim: to examine how and why women seem to have been the focus of so much psychiatric attention over the past 200 years and why this is still the case today. This hugely readable book provides an overview of the historical development of ideas in psychiatry, without superficiality or glib generalisations. The contents include not only remarkable case histories but also discussion of different topics that have generated psychiatric debate in the past, such as sleep, sex, mother-child relationships, and child abuse as a cause of disorder. Many of the case histories are forensic in nature, which made me realise afresh how the history of psychiatry is closely tied to the philosophy and psychology of rule breaking in general, especially in the context of bizarre and violent crime that demands an explanation. Like all good books this one made me think and want to ask more and related questions. Firstly, it still seems difficult for any type of psychiatric discourse to take male distress seriously: femininity and associated mental problems as alienism have clearly preoccuBMJ | 8 March 2008 | Volume 336 pied psychiatry since its inception, but masculinity and its attendant problems (violence and addiction to name but two) seem to slither away from the medical gaze and retain a dreadful normality. Secondly, I was struck by how many of the women in the case histories had been exposed to sudden bereavement and losses of important figures, either in childhood or adulthood. The power of grief to disorganise the mind and give rise to pretty much every psychiatric symptom known to classification seems hardly to have been acknowledged by the mind doctors of each time period who dealt with these women. Yet the 19th century had Robert Burton’s classic account of melancholy; the 20th had access to the research of John Bowlby and Colin Murray Parkes; and the 21st has Allan Schore’s work, setting out exactly how grief, and the loss of attachments, drives people mad. This work may be especially relevant to the question of why women are over-represented in psychiatric populations. If women’s autonomy is in some part relational, not indexical—that is, some aspects of their identity are located in external relationships and roles—then (to paraphrase Donne) any person’s death diminishes and disorganises some woman’s identity. Lastly, I found myself maddened by the persistent tendency of any psychiatric discourse to embrace reductionist and essentialist theories of how humans work. Time and again psychiatrists claim to have the found “the” cause of mental distress (especially in women), and this “cause” lies in the uterus, the teeth, the colon, the diet, the unconscious wish to sleep with your father, the conscious wish to be educated or have the vote. All of these at one time or another have been seen as the sole explanation Psychiatrists seem to be drawn to simplistic accounts of experience like extremely dim moths to an artificial light for female psychological distress and the basis for often quite inhuman interventions called ­“treatment.” The human mind is arguably the most extraordinary, unusual, and glorious manifestation of organic life on this planet, and yet we still take ordinary mental functioning for granted. Like spoilt children we do not realise what an extraordinary thing mental health is. Equally, we still do not treat mental illness as being a disorder of the most complex biological system: a system that manages to integrate internally and externally generated experience into a consistent whole that is unique to each person. The scale of the complexity is staggering—as is the scale of the disaster when things go wrong. Yet psychiatrists seem to be drawn to simplistic accounts of experience like extremely dim moths to an artificial light. Appignanesi says something very important at the start of the book. She says that as a historian she is sceptical of present certainties. This seemed to me to be an important message for scientific researchers and therapeutic practitioners in the field of mental distress. It is not likely that there will be one solution to human distress, any more than there is one source of human creativity and joy. Therefore dichotomies such as nature or nurture and genes or environment are not only silly, they are as mad as the pathology they seek to explain. Equally, there is unlikely to be one treatment that suits all, as we will no doubt discover when the money for the “cognitive behaviour therapy for everyone” programme runs out. Taking uncertainty and complexity seriously is something that the human mind is good at; it is only psychiatry that seems sometimes to have been a little reluctant to be this human. Gwen Adshead is a forensic psychotherapist, Broadmoor Hospital, Berkshire [email protected] 561 VIEWS & REVIEWS Bitter sweets FROM THE FRONTLINE Des Spence We clinicians have a stereotyped view of university academics: bearded cyclists, with sandals and odd terry socks, writing books that no one will read. But our academic comrades can enjoy a moment in the sun. Splashed across the media, a recent meta-analysis of antidepressants concluded, after a reanalysis of unpublished data released through freedom of information legislation, that they are no better than placebo in all but severe cases of depression (BMJ 2008;336:466). The study seems to vindicate the position, held by many, that antidepressants are overprescribed. However, this isn’t a time to say “we told you so” but an opportunity to reflect. Leaving aside the merits (or lack thereof) of the study, why weren’t these conclusions available a decade ago? Private companies own the data from trials and have enormous vested interests in controlling access. Therefore, passive suppression of unfavourable results by not publishing them is a legal and legitimate business. Throw in commissioning bias, positive publication bias, and the lack of adequate trial registration and it is hardly surprising that the body of “available evidence” strongly supported antidepressants. Luckily, our researchers are wising up. But how could “available evidence” translate into 16.2 million prescriptions for selective serotonin reuptake inhibitors (SSRIs) each year? Launched in the early 1990s, SSRIs were widely promoted. The “defeat depression” media campaign ran in the UK from 1992 to 1997, a joint venture of the royal colleges but bankrolled by SSRI manufacturers. GPs were told that “depression is common (one in four patients), recognisable, and treatable.” The subtext was that depression was under-recognised and untreated: we were failing patients. Although prescribing antidepressants seemed counterintuitive, we did as we were told. And so began the medicalisation of mood, an unforeseen adverse reaction of evidence based medicine. How much harm have we done? Plenty. We have accepted under-reported but common withdrawal syndromes and possible dependence issues. But worst of all we have neutered a generation of patients, making them doctor dependent, denying them the opportunity to develop coping strategies, and eroding their self esteem. What does the future hold? It will give us time to demand full access to all trial data published and unpublished. Respect to the socks and sandals. Des Spence is a general practitioner, Glasgow [email protected] See EDITORIAL, p 516, and FEATURE, p 532 Life at the sharp end Starting out Kinesh Patel 562 Just as we’ve got used to excuses about the wrong types of leaves on the line and even the wrong type of snow when we wait for a train, we’ve also now become so accustomed to the wrong type of bureaucracy in the NHS that almost any form of management is resented. Take venous cannulas, for example—a deeply unglamorous topic, admittedly, and the bane of many junior doctors’ lives. A new batch arrived on our ward a couple of months ago, a special safety model that looked pretty much the same as any other cannula. However, when the needle was retracted from the plastic cannula, a metal device clipped over the end to prevent needlestick injuries. The inherent cynic in me then made me try to stab myself with the needle repeatedly, and then I tried to prise off the safety device with an old biro, all to no avail. Wonderful, I thought. A genuine leap forward, with the potential to abolish instantly all cannula needlestick injuries. Everyone has attended cardiac arrests or trauma calls where needles are left scattered all over the patient at the end. Who hasn’t had a friend or themselves injured by a stray needle? So, it was with some dismay when I noticed a few weeks later that the old type of cannulas were back. I spoke to the ward sister about this and was met with the response: “Too expensive.” And that was the end of the conversation. About 100 000 needlestick injuries occur in the NHS each year, more than 250 a day. If 100 000 patients (rather than staff) each year were being exposed to other people’s blood, how long would it take before this sort of recklessness was remedied? Unfortunately, even though we have a National Patient Safety Agency—issuing directives such as that advising that covering patients in paraffin may make them prone to immolation—the prospect of a similar scheme for staff seems far off. Would British Telecom or ICI try to economise for the sake of a few pennies when the real potential consequences include contracting fatal illnesses? This is a prime example of the need for a bureaucracy—where people in power make important decisions affecting the entire organisation in days not years. The reality is that the ward sister has to pay for important safety equipment out of a fixed budget and is castigated for overspending. Of course, any adverse events (“claim sensitive” events in management speak) come out of a separate budget so don’t affect those spending the money in the first place. What will it take for this to change? A scandal more profound than that of healthcare professionals contracting hepatitis C or HIV? Until then, I suppose we just have to be as careful as we can. Because, as we all know, tomorrow it really could be you. Kinesh Patel is a junior doctor in London [email protected] BMJ | 8 march 2008 | Volume 336 VIEWS & REVIEWS The plague’s the thing Of all the epidemic disletter would have BETWEEN eases, plague is by far reached Friar LauTHE LINES the most literary—or rence, and Romeo perhaps I should say would have got his Theodore Dalrymple has inspired the most girl. And the most literature, from Bocromantic love story caccio to Camus. The would have ended inspiration of literawith Juliet pregnant ture was not the only and Romeo desertbeneficial effect of ing her, claiming the disease, however: to need his space the Plague Orders because the relaof Elizabethan Engtionship just wasn’t land forbade Sunday going anywhere. indulgence in tipIt is difficult not to pling, gaming, and believe that Shaketobacco taking but, speare’s descripmost important of all, tion of the state If, in Romeo and Juliet, prohibited “the outraof Scotland under Friar John had not been geous play at the footMacbeth’s rule does confined in a house ball.” Who, observing not make use of the that was suspected of any modern English author’s experience harbouring the plague, football crowd, could of London during an the all important letter deny that this would epidemic: “Where would have reached Friar be a most excellent sighs, and groans, Laurence, and Romeo thing? and shrieks that rent would have got his girl Some scholars the air/Are made, maintain that the not mark’d: where plague reduced Shakespeare’s output violent sorrow seems/A modern extasy: and shortened his career. Elizabethan the dead man’s knell/Is there scarce ask’d playwrights were like journalists: they for who, and good men’s lives/Expire wrote only when there was an immediate before the flowers in their caps,/Dying, demand for their work. The playhouses or ere they sicken.” were closed frequently during the ElizaOddly enough, the constant death bethan and Jacobean period, once the knells got on people’s nerves. In Ben bills of mortality showed that more than Jonson’s play The Silent Woman, the char30 or 40 people had died of the plague acter Morose, a forerunner of Proust, was in the past week. so exercised by the “perpetuitie of ringOther scholars have suggested that the ing” that he was led to “devise a roome, quality of the drama fell with the decreaswith double walls, and treble seelings; ing frequency of the plague, for there is the windores close shut, and calk’d; and nothing like impending catastrophe to there he lives by candlelight.” focus your thoughts on what is imporOf course, our ancestors considered tant in life. (“Depend upon it, Sir,” said that the plague was God’s punishment for Doctor Johnson, “it concentrates a man’s their sins, provoked by the popular entermind wonderfully when he knows he is tainment of the day, the drama. “The to be hanged in a fortnight.”) Certainly, cause of plagues is sinne,” thundered one Shakespeare’s greatest plays were written clergyman, “if you looke to it well: and at a time when plague was at its most the cause of sinne are playes: therefore frequent, if not quite its most severe. the cause of plagues are playes.” It is hardly surprising that writers of Luckily, he was wrong. For if tele­ the time alluded often to a disease that, at vision (the “playes” of our time) caused regular intervals, killed a tenth to a fifth plagues, the bubonic and pneumonic of the capital’s population. If, in Romeo would not be epidemic, they would be and Juliet, Friar John had not been conpandemically endemic, or endemically fined in a house that was suspected of pandemic. harbouring the plague, the all important Theodore Dalrymple is a writer and retired doctor BMJ | 8 March 2008 | Volume 336 View publication stats Medical classics Profession of Medicine By Eliot Freidson First published 1970 The fundamental and consistent criterion that distinguishes a profession from other occupations is its autonomy, a condition that is not absolute but that depends for its existence on the tolerance and protection of the state. Eliot Freidson, a giant of medical sociology, drew this conclusion as the central theme of his comprehensive analysis of the nature of professions. For those who work regularly with medical professional bodies or with doctors in managed care environments, Freidson’s monograph, now nearly 40 years old, rings so many bells as to be positively deafening. Freidson argues that the special privilege of considerable freedom from the control of outsiders rests on three claims by professions. Firstly, that there is such an unusual degree of skill and knowledge involved in professional work that non-professionals are not equipped to evaluate it. Secondly, that professionals are responsible and may be trusted to work without supervision. Thirdly, that the profession can be relied on to deal itself with members who behave incompetently or unethically. Freidson sees medicine as the archetypal profession. He discusses other attributes of the profession and then moves on to its relevance to the sociology of illness. For, he argues, if a profession is entitled to have ultimate control over the content of its work, the medical profession has heavy influence over determining what illness is and in the creation of illness as a social state. Doctors unfamiliar with sociological thinking and analysis will find Freidson’s arguments very involved, requiring careful study rather than relaxed reading. Yet this is not a book purely for the student or those with an academic interest. Its power is in the ability to explain the culture, attitudes, and values of the medical profession but also to predict its behaviour. In particular, assessing actions that affect the profession (collectively or individually) and reacting to those actions make perfect sense when seen in terms of the potential threat to autonomy. Having said all this, the medical profession in Britain (and many other countries) has seen its autonomy constrained greatly over the last two decades: more rigorous standards of practice, a wider base of clinical skills, a broader ethical framework, and new responsibilities to corporate goals and targets in managed care environments. The medical profession has largely adopted and accepted these erosions of its traditional freedom from external control, but perhaps the very process of doing so has contributed to lower morale. It would be fascinating to debate this changed context with Freidson, but he is no more. His ideas, however, remain an inspiration, and they deserve a place in any debate about the medical profession’s future. Liam Donaldson, chief medical officer, Department of Health, London [email protected] 563