Some while ago we met Carly. I speculated that her recent cutting behaviour represented one end of a spectrum, where the "self harm" was an act of frustration taken out in the infliction of a little pain with ony minor and quickly repaired damage to the self. Yesterday I was called on to visit Ed in the local psychiatric hospital. Ed is right at the other end of that spectrum.
Ed first became ill around ten years ago in his late teens. He became withdrawn, quiet, and a bit "Goth". Then he sarted not wanting to go out at all. He kept looking behind him on those rare occasions when he could be persuaded out of the house. Then he stopped eating out. Then he stopped eating. The other lads on his estate were "picking on him". They looked at him "funny". They were "trying to kill" him. So was his mum.
He got very scared and took some pills and ended up in hospital. A psychiatrist was called and he was relieved. He took some meds and got a bit better and went home. Where he stopped the meds, began withdrawing again, got ill again and needed admitting back to the psychiatric hospital again, this time under the compulsion of a "Section", that part of the Mental Health Act that can require patients to be detained in hospital to be assessed and/or treated.
Being obviously paranoid he was assumed to be schizophrenic and treated as such. He got better again. Better at covering up his symptoms enough to be let home again anyway. As I said, this all began about ten years ago. In the interim he has had two longish spells of regular antipsychotic medication. He put on lots of weight, felt very dopey, even became diabetic as a result. But he stayed "better". Except that his fixed fears about the kids he had grown up with, and even his own mum conspiring against him never went away. And the "medicines" he was being given were making him ill. Small wonder he continues to think we are trying to poison him.
Since his paranoia stubbornly refused to lift along with his other symptoms the psychiatrists began to question their diagnosis / management earlier this year, and I was called on to examine Ed with a view to him being detained in hospital whilst his medication was stopped (something of a first for both of us). In the end it became apparent that he was not willing to go in to hospital voluntarily and we had little option but to section him again. His meds were stopped. He realpsed. He went back on medication and shortly after went back home, exactly the same as he had been.
Until last month.
He cut his left wrist. As in, cut it down to the bone, taking out a couple of flexor tendons along the way. He was admitted to the general hospital, but declined repair surgery. He was re-sectioned and admitted to the psych ward. A couple of weeks later he absconded and went out to play with the traffic. The traffic won and he went back in to hospital with a couple of broken bones. Now he's back on the psych ward and today I had to visit him there to apply Section 3 of the Mental Health Act 1983. This requires him to remain in hospital, and to receive treatment, for up to six months. He and I have done this little dance a time or two now, and we both know the likely outcome even as we sit down for the interview that will "decide" the matter. This time he tells me he was distracted and didn't see the cars. And the cutting? Well that was ages ago and he'll get the tendons fixed when he's back home, no problem.
Problem is, like a latter day Yossarian, if he saw the cars he was trying to kill himself and needs sectioning for his own protection. If he was so distracted he didn't see them his illness caused an accident and he needs sectioning for the protection of others. The outcome was never really in doubt. I think he accepts this. But on the way out of the interview room he asked me to assure him that he will be allowed to see the medication he is to be given before they inject him with it, so he can know just what he is being given. It is the only thing I can do for him before I sign my copy of the section paper and I do it with a heavy heart. The problem is I know he will continue to believe the nurses are poisoning him, and in a sense he is right. We can argue it's for his own good, we can argue it is for the good of others, but it remains the only, utterly imperfect, option we have.
I stand there state appointed judge, jury and executioner, depriving a man of his liberty with a stroke of a pen. This is a far from arbitrary act, and it is entirely necessary, but these are decisions I continue to loose sleep over. And then, just to rub it in, on my way out the door to the ward is locked and the nice lady on reception is away from her post, so I buzz in vain to be let out.
For a few short minutes I get a glimpse of Ed's world for the next six months. Then it's back to the car and on to the next visit...