David Zigmond, GP

Published in JHH12.3 – Beyond Peak Medicine

I have worked for 45 years as a frontline NHS doctor, as both a small practice GP and large hospital psychiatrist and psychotherapist.The last two decades have burgeoned NHS systems of management and computerised informatics. Few predicted the wider costs: for as our investment in such packaging and control has risen, so our capacity for personal engagement and understanding has declined. My response? To convert my angered fear and sorrow into wider analysis and debate.

A system is nothing more than the subordination of all aspects of the universe to any one such aspect.

Jorges Luis Borges, Labyrinths (1962)

Rick: chaos in vivo

‘My mum suggested I come to see you. She hasn’t been living around here for years, but I’m still here and she thinks you may be able to help me…’ Rick’s self-introduction is determined, pushing through his anxiety. I sense quickly the importance of his risk.

Well, I hope so… Of course, I’ll mainly want to know about you. But tell me first: who is your mother?’

Rick, vulnerable but trusting, names his mother – Angela – and continues: ‘she’s now not in a good state – has a terrible chest from all that smoking – and now she’s lost her spirit and confidence: all the things that happened to her … she hardly goes out now. But she says you really helped her, all those years ago…’ A slight brief shrug displaces a longer, engaging smile: he signals both the abject and the fraternal.

Angela’s name rapidly unspools many flashbacks from my years of engagement with her. I recall an attractive but haunted woman, a vortex of symptoms and distress, and then the many interweaving life dramas that both precipitated and made some sense of her cacophonous dis-ease. Beneath that I discerned her tragic ‘choices’ in love: dangerously charismatic men whose sexual allure was somehow generated by their capacity to control, wound and humiliate. The rest followed from this: eruptions of jealous rage and beatings, sullen and tense suspicion, abject pleas for reparation, alcohol and drugs to find palliation and peace, ‘anxiety’ and ‘depression’.

By the time I first met Angela, I thought the roots of her self-damage were too deep for any insighted reversal or reclamation. While hoping I might just help her change her fate, I recognised that improbability. But then I could, at least, comfort, contain and bear witness.

Her children, then, had already been taken into care and I did not know them. Her Tree of Life seemed blighted: I hoped its unseen fruit would fare better.

So, Rick, what is it that’s not right for you…?’

Rick looks down and purses his lips. I sense him searching intelligently. He looks up: ‘I don’t seem to be able to keep a job or a girlfriend for more than a month. It’s something to do with trust…’

Of course, I knew your mother a little… but tell me, from your point of view, what happened to you – when you were small – with the people you needed to trust?’

The earlier part of Rick’s answer I had imagined: his mother’s warmth but unaccountable (to him) lability, the alpha-males’ glowering explosions and furies, the home like a flimsy boat in a perilous storm.

His time in care I had neither known nor imagined. With affecting directness he now describes a startling variety of foster parents: some kindly, patient and wise, but others exacting a perverse revenge for some (presumably) hidden and ancient grievance of their own. Frightening and unpredictable beatings, then being forced into a locked cupboard: these are among the dark and destructive memories he now retrieves for me.

As he leads me through his survival story of this dismal human hinterland I am buoyed up by something I had not expected, and cannot explain: his resilience and spirit. His eyes flash and glow with animated intelligence, and a wide range of recognised feeling. He auras an inclusive warmth

We humans are so paradoxical in our vulnerability and resilience.

I cast a baited long line; I think he will understand: ‘In the middle of the last century there was a French philosopher called Jean Paul Sartre. He said something very interesting and simple that’s very important for us all: “Freedom is what we do with what has been done to us.”’

Rick’s apprehension and engagement are rapid. He looks up and away to make sure he has understood, and to make it his own. He blows softly through his teeth, an exhalation of relief and recognition. His look to me is canny and wise far beyond his youth.

I risk more, a variation: ‘Here’s another good one, especially for you – with all the adults who let you down in your childhood. It’s from about the same period – Eleanor Roosevelt, the American President’s wife: “Learn from other people’s mistakes: you won’t have time to make them all yourself.”’

Wow! That’s wonderful. It’s so funny, but so true. Well, I’ve certainly had a lot of people showing me what not to do … And now you’ve given me so much to think about…’

I offer Rick some more encouraging notions, as a bridge, before suggesting he contacts a local young person’s counselling centre.

I’ll offer what I can to guide you in all this,’ I say. ‘Come back and see me in two weeks.’

He leans forward to shake my hand and then stands and turns. His short walk to the door now has a confident stride.

Humankind’s vulnerability is often complexly obscure and intractable, but now, with Rick, I feel both clarity and connectedness: we are close to the source of both his pain and his self-healing capacities.

As he leaves I feel hopeful.

Ajita: order in vitro

At the end of my working day Ajita is sitting with me. She has been in post for a year, yet already the mounting stress and weariness are evident. I think this is both because, and in spite of, her diplomatic skills. Her designation is ‘Mental Health Commissioner’: her job is to define the mental health needs of a large city area, then design remedial systems and then negotiate with various ‘providers’ about their tenders: contents, packaging, timing and price.

Now in her late thirties, Ajita has spent several years working in mental health services coordination and management. Before that, at the beginning of her career, she used to work one-to-one with patients as a clinical psychologist. Her time is now spent with executive abstractions: largely looking at computer screened documents and data, or sitting in meetings trying to devise the best ‘system’ to suit the kind of people she used to know and tend as a therapist.

Her current task – to define, refine, purchase, package and pipe 290,000 cubic metres of cognitive behaviour therapy type help, equitably and appositely, to all the psychologically anguished sufferers in her city sector – is proving much harder than anyone had anticipated or can now understand.

To venture some leverage Ajita now focuses on one small part of the problem.

What’s wrong with the GPs? I don’t seem to be able to get them involved or interested. Am I flogging a dead horse?’

Not dead yet, but certainly dying.’ I offer a morsel of optimism.

She becomes more engaged with her own figure of speech: ‘What is it that is dying?’

This is a relished question.

Oh, Ajita. So much! Our art, our heart, our craft, our wit, our philosophy…’

Yes, yes. But how, why is this happening?’ She is impatiently searching for her understanding, not my sophistry.

‘Well, in my last two decades of work what I have seen is a progressive loss of personal work satisfaction and identification. We used to be nourished by vocational motivation, now we are controlled and (dis)incentivised by managed careers and systems. I used to feel part of a colleagueial family, now it’s more like a coercive healthcare factory.’

So, what has caused that?’

All sorts of things that are themselves related. At the centre is our wish to make things “efficient” by attempting to control everything by systems: standardisation, proceduralisation, increased division of labour, restriction and prescription of language…’

But if systems make things more efficient, how can that be a bad thing?’ Ajita is wanting more efficiency from my answers.

Because systems are by their nature limited and limiting. Systems deal only with specified designations of behaviour and events. Systems cannot engage with intelligent discrimination, with personal meaning, value, motivation or relationships.’

Meaning?’ I am unsure if this is stealthy irony from Ajita

Well, if we overinvest in systems, we first displace, then destroy, these things: our personal relationships and meaning – the very things that provide our gratification and motivation.’

Why is that so?’

Because systems can only deal with commonalities, not personal differences. Yet it is the differences that give us our identities. Knowing the commonalities is science: that’s the basis of our treatments. Our systems work well with these. But discerning and nourishing our difference is a very different territory: it’s the art in our practice – the basis of healing, growth and palliation. Systems are here mostly ineffective, often destructive.’

Because?’

Because our healing needs personal attachment, knowledge and attunement: only then can we reach our most imaginative and intelligent judgement. Mostly systems function by eliminating such human vagaries.’

So where does that leave us with mental health services?’

In a quagmire of paradoxes. Mental healthcare is fascinatingly humanly complex and thus relatively elusive to systems…’

Surely we just need better systems.’ Ajita sounds irascibly brisk and chiding.

No. Because – particularly in mental health – things are most often not what they seem. One thing is better understood in terms of something else, and that something else is individual and unpredictable. Systems do very poorly with such complex human processes; systems do much better with stable physical states.’

So, give me an example of how you can help people without such systems.’

I tell Ajita about my fertile and pluripotential encounter with Rick, just a few hours before. How the navigation and meaning of our meeting depended on the nature and quality of our contact, and then our ignited imagination. I explain to Ajita how I need not only the head-space and heart-space to improvise like this, but also the personal continuity of care to be able to synthesise from such wide sources – my much earlier personal knowledge of Angela enabled healing flashes of insight in her son a dozen years later. Such transactions exemplify the quintessence – the raison d’être – of the now almost extinct family doctor or general psychiatrist: they could quickly discern what ailed and what might heal a wellknown individual. How can institutionally managed systems – eventually distilled to “procedures” – get anywhere near the kind of understanding and influence that evolved rapidly between myself and Rick? What begin as transactions become transcendent through the transpersonal. This subtle cauldron of human influence needs little informatics but much individual intelligence; sparse systems but rich personal attachments.

I sense Ajita’s detachment from my portrayal of the importance of attachments. She glances furtively at her watch and then rubs her eyes: such metapsychology is wasting our time.

Look’, she says, ‘this isn’t helping very much. The way we all have to work now is with systems that are clearly and properly managed, where we all know what we’re doing and we can see, even measure, what our outcomes are. Apart from anything else that’s how we secure our funding and future. I really can’t see how all the things you’re talking about can fit in or be applied. It’s obviously very interesting to you, but seems too chaotic to be useful to me…’

Ajita leaves me with a discomfiting paradox: I may conjure healing sense with patients, but my contact with colleagues is increasingly glutinous with defensive anxiety and procedural pre-emption.

Ajita’s terra firma gives her back her path to a world of managed clarity, but its reassurance is specious – for it quickly loses sight of those subtle paths to how we might best understand and heal one another.

The enlivening and heartening exchange I had with Rick has been displaced – at the end of a very long working day – by something very different.

Originality is unexplored territory. You get there by carrying a canoe. You can’t take a taxi.

Alan Alda