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Reliability
  1. Gillie Bolton
  1. Medicine and the Arts
 King’s College London University
 Department of English
 Strand, London WC2R 2LS, UK
  1. gillie.bolton{at}kcl.ac.uk
  1. Chris Woods
  1. General Practitioner at the Halliwell Surgery
 Lindfield Drive
 Bolton, BL1 3RG, UK
    1. Marion Cushine1
    1. Counsellor at The Rood Centre
 Arlington House
 4 North Bailey
 Durham DH1 3ET, UK
      1. Tom Heller
      1. General Practitioner and Senior Lecturer at the Open University
 School of Health and Social Welfare
 Open University, Walton Hall
 Milton Keynes, MK7 6AA
        1. Cecil Helman
        1. General Practitioner and Senior Lecturer in Primary Care and Associate Professor of Medical Anthropology, Department of Primary Care & Population Sciences, Royal Free & University College Medical School, Holborn Union Building
 Highgate Hill, London N19 5LW, UK
          1. Seth Jenkinson
          1. GP, retired and adventuring

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            Reading literature can provide aesthetic distance from one’s everyday need to evaluate actions, events, feelings, and thoughts, in moral and ethical terms. The reader trusts the writer to take them into other lives in which moral and ethical values are very different, or even seemingly non-existent. In reading they act and go where they know they would never allow themselves to go—or simply could not go—outside the pages of the book. The reader is therefore enabled to experiment with sets of values very different from the ones they are used to inhabiting. Having become involved during reading in this way, the reader is then free afterwards to ponder their response in their own time, and according to their own principles. Literature often does not offer answers or judgments, but presents situations which inevitably pose a series of questions.

            This is at its most pronounced perhaps when the narrator of a story or poem is unreliable—a liar, or untrustworthy in some other way. This character might well be the sort of person we’d never consort with outside the pages of a story. On reading literature, we tend to do more than consort with the main character; in some way we become him or her for the duration of the reading. This can be uncomfortable as the writer pushes us to empathise with the character, yet we pull away from him or her, struggling with our habitual moral and ethical judgments and feelings.

            I recently presented a group of bachelor’s in medical science (BmedSci) students with Rebecca Ship’s Dracula1 which is written in the voice of a self mutilator and drinker of blood. One of the students was angry: ‘Why have you given us this horrid thing to read?’ She didn’t want to try to explore the experience of such a person, despite knowing there are psychiatric patients who slice themselves, and lust after the blood of lovely girls. She did not want to accept the aesthetic distance offered by literature. I could have asked her similarly to share the horror of Orestes killing his mother,2 murder and thieve around Brooklyn with Lionel,3 or empathise with the child Zelda as she cruelly torments a boy.4 The only way to continue reading as if I am Zelda (the novel is couched in the first person singular) when what she does is so horrific, is to allow the Zelda in me a bit of freedom and temporarily escape my habitual values and judgments.

            As I read I can sense the continuity of experience between me the reader outside the book, and the me who becomes the Dracula psychiatric patient, or Zelda. The psychiatric patient is not a different order of being from me (even if he is fictionally given Dracula like qualities): there’s a Dracula in me, ordinary respectable wife and mother of two that I am. Reading about such characters offers the opportunity to explore that side of myself, deepen empathy and understanding, and develop workable and humane ethical values.

            I would like to challenge readers to write their own story with an unreliable narrator—a narrator we cannot trust or believe and moreover would not want to. It could be a narrator who undertakes immoral or unethical actions, like Zelda, Lionel, and Dracula, or one who thinks and fantasises as them—perhaps written from the point of view of a patient or some other character (colleague?). I don’t think writers present us with characters like this in order to make their readers think hard, though that’s one outcome, but rather in order fruitfully and graphically to think and feel through the issues themselves. Send them to me please at the address shown.

            All the narrators in the pieces below are utterly reliable. Marion Cushnie in her story Yvonne, below, demonstrates learning to communicate with a seriously mentally ill patient. The reader is led to imagine allowing herself to do daft things like dance to no music, and leap about over furniture. In such a non-verbal way might communication develop, as it did for Marion and Yvonne. Tom Heller shows us a picture of empathy and insight into patient needs and understandings, frustratingly at odds with the expectations and assumptions of his colleagues. Cecil Helman’s autobiographical stories deal with the odd human situations doctors find themselves in. The two stories are in counterpoint: in one the intervention is completely pointless; in the other it’s only too worryingly weighty. Seth Jenkinson’s is a cameo of insight and care; and Chris Woods draws us into the healing nature of aloneness.

            Hut

            Breathe space and woodscent,
 count the emptiness
 in and out.
 Held by walls
 and light through windows
 and darkness and stars and mist only.
 Free to leave and come back.
 Free to laugh—
 tongue in cheek and groove.
 Safe inside and alone.
 Not trying to be something else.
 Not trying to be a hut and a half.
 Wild flowers will be seas
 and moors will break
 into a surf of cotton grass
 and flowers will bloom
 and the world will fit together
 as simply as the hut itself.

            AFTERWORD

            Hut felt as though it wrote itself, which is always exciting. Reading it now is a bit like an adventure. Not sure what you will find or where you will end up. The poem feels like a meditation with the hut a place of stillness and sanctuary. There is freedom and lightness of spirit and no pretence in this place. Things are simple, the space is empty, yet in this unaccommodated state there is change, peace, and understanding. There is sense of unity.

            Yvonne

            Yvonne was 16 years old when she was admitted to our ward. I was 24 years old and very new to working with people who were mentally ill. I found myself powerfully drawn to this young person. Yvonne was very beautiful but very ill. She would sit alone entirely preoccupied with her own inner process. Sometimes she would laugh and chuckle, but more often weep, racked by sobs and she could not be comforted. Sometimes she would dance for long periods—graceful and slender, her movements following some inner music. She had no interest in food or drink and she never had any visitors.

            As a fairly new student of psychiatric nursing, her medical history was explained to me. As the importance of making some sort of contact with this young person was impressed upon me, I was given the task of beginning to make some sort of connection with her. So I observed her and sat close beside her and talked to her, but for a long time she did not see me and she did not hear—but she would allow me to hold her when she was weeping. There was no language to our communication for many days.

            Then one day when I was with her and I was once again overcome by the unbearable poignancy of her demeanour and her utter isolation, I was struck by something strange. I thought how I had been expecting Yvonne to join me in my world—that perhaps in order to achieve this I should first of all endeavour to join her in her world—perhaps then she would be reached.

            So, without realising, I began to demonstrate a very basic mirroring practice. I decided that so far as I was able I would do what ever she did. When Yvonne danced, I danced; when she sang, I sang—when she arranged the furniture, I helped her; when she jumped over a footstool, so did I. When she was still, I was still also.

            Eventually I saw that she was becoming aware of me—on a couple of occasions I felt she was testing me. Eventually she allowed me to help her drink some water and we shared a sandwich. After many days, when I asked her once again who I was, what was my name, she named me. I have never forgotten Yvonne and think of her frequently in my work both as nurse and counsellor.

            I remember what she taught me of how to be with another when that “other” to all intents and purposes is lost and inaccessible. I recall the profound absorption as I worked with her and the growing awareness that I was where I was meant to be.

            I remember the grief and sense of loss in acknowledging that all care I offered, and my intense desire to nurture and rescue her, was to no avail. Her illness could not be conquered or vanquished but continued to rage through her psyche. I remember this beautiful, young fresh 16 year old girl, standing alone in a room moving and dancing and weeping and singing, and who called me by name. Then, I remember too, the slow and bloated young woman who no longer recognised me when I visited her, but who greeted me anyway and who showed me her new handbag.

            AFTERWORD

            Working with Yvonne confirmed to me that I was doing something I cared passionately about and which I found deeply satisfying and rewarding. All of these certainly, but also challenging, moving, and often painful. Writing about Yvonne leaves me wishing for better skills and gifts to convey the richness of my experience with her. I learnt a great deal which I have never forgotten and which has informed my work to date.

            It is 30 years since I last saw Yvonne. No, I do not remember her just as she was when last I saw her. Although I do find myself wondering how different the outcome may have been, had she been able to benefit from some of the newer medications now available for her type of serious mental illness? I like to think there are fewer people who suffer as Yvonne did, who benefit today from the right psychological support and care, plus the appropriate medication.

            I choose to remember her dancing and singing, her tremendous energy, and quicksilver thoughts. And, most precious of all, the occasion, as we stood in a queue at a shop, when she turned to me and said: “I love you Marion”. I love you, too Yvonne, I will always be glad that I met you.

            Terry

            Terry gave me a rock. Well actually it’s a crystal. When you get close up to it you can see it’s beautiful. Look right into each little shaft and shard and facet and it glows pink. He said it’s a healing crystal. It works, it’s been charged. It certainly looks as if it should work.

            If only I could get everyone to slow down enough to look deep inside the thing—right in, right inside. It’s rough in the hand and it soon warms up. It gets the heat from my palm, but it seems warmer than that. Terry says he feels like I’ve got healing energy, and I thank him for that and for the crystal. He says that I’ve helped him—bless him—he’s so honest and open and addicted. He’s a naïve user, led down the path of opiates and needles because he believed the first person who said it would be good. Now he says he’ll reduce his prescribed opiates little by little—but he can’t manage. His face, tight by now, confesses to the “extras”, and he looks like a little boy at the nursery.

            Over the years he’s told me that he likes the open air and that he goes camping whenever he can. He has a dog on a string and hepatitis and solid veins and a liver like an old leather wine sack and a mother who weeps for him and a heart of pure . . . well I don’t know . . . it just seems as though he’s been misguided and needs some security, a rock from which to explore himself.

            I took the crystal rock to the doctors’ meeting, and they laughed—the bastards. They just couldn’t see the thing; they wouldn’t stop to look at the jagged bits or the smooth bits. They couldn’t see how pink the pink was, or feel the warmth, or love the human who brought me the thing. They said that I needed all the help I could get with healing people . . . ho! ho!

            And the rock suddenly felt cold and the pink drained away into my clenching fist.

            AFTERWORD

            So many things conspire to make professional health workers all the same, fit into the mould. Protocols, appraisals, pathways of care and targets, to mention but a few are (probably) necessary. But what happens to the creative parts of each human doctor? Our unique, distinguishing features are often well hidden below the surface, controlled, and defended.

            Two stories

            ONE

            With my small car skidding and sliding along the icy roads, I am thinking of those words of Arthur Conan Doyle, himself a doctor: “He goes from house to house”, he wrote, “and his step and his voice are loved and welcomed in each. What could a man ask more than that?”5

            That was in the days of horse and buggy, but today it is a particularly icy Boxing Day, and I am on call. They phone for a house call. Shivering and clutching my bag, I trip and slither up the frozen garden path, to the front door. Inside the house is hot, and filled with tobacco smoke. A fire burns in the grate. As the mist clears from my glasses, I can see a big Christmas tree in one corner, festooned with multicoloured lights and silver ornaments. Other silver ornaments and gold foil angels dangle from the ceiling. In another corner a high pile of opened presents and scrunched up balls of torn wrapping paper.

            The whole family—parents, three teenage children, a few aunties or and uncles—are gathered around the television set, holding cans of beer or bottles of Coke. For a moment they look up at me with puzzlement, then turn back to the game show on the telly. Someone on the show is about to win the Big Prize, but it’s certainly not me. For no one seems to be paying me any attention. “I’m the doctor”, I say, loudly, “You told the receptionist you needed an urgent house call. You said that your daughter was ill, that she couldn’t breathe properly. That’s why I’ve come.” The father drags his eyes slowly away from the screen, and shrugs. “Oh, that’s Mary here, she’s got a bad cold. Her nose blocked. She’s coughing a bit. Ain’t you, love?” Sitting beside him Mary, fifteen or so, shrugs. “Suppose so”, she says.

            I follow her to her bedroom, and examine her. The room is lined with posters of pop stars, and other celebrities. There is nothing to be found. Nothing wrong with her. A minor respiratory infection, that’s all. Outside, I can hear the snow still throwing itself violently against the window panes. I wonder if my car will start again, in this cold and damp. With difficulty, I only just manage to stop myself strangling her with my stethoscope. And then getting to work on her father. But I say nothing. We return to the lounge, and she resumes staring at the TV. Everyone ignores me. No one offers me coffee or a drink. In fact, no one says anything to me at all, as I stand awkwardly in the doorway.

            Right, I think. Still standing, I write out a prescription for cough medicine, paracetamol, and a decongestant. “I’m afraid you’ll just have to get them for her—” I say, “Today. As you say, she’s got a bad cold. As you say, she can’t breathe properly through her nose. That’s why you called me out, isn’t that so? Now look, there’s an emergency pharmacy in—I think it’s only about five or so miles from here. Not more than that.” They stare up at me from the settee. Their faces have turned white as the blizzard outside.

            “Merry Christmas!” I say and walk out, hunched against the driving snow.

            TWO

            I am quite alone in the darkened room with the old woman, holding her hand, and she is dying. It won’t be long now. Some few hours, or perhaps days, at the very most. The family are standing outside the door. I can hear their harsh, whispering voices, for something fierce is going on out there, a major argument. The voices go to and fro, rising and falling, Two sons, a daughter, and some daughters in law. Suddenly, one of the sons opens the door, and motions to me.

            “My mother has agreed to certain changes in her will, Doctor. She decided on this earlier in the week, when we all met together, and just before she started going downhill. I wonder if you could just witness her signing the amended will. As an independent witness, as it were. It’s all quite straightforward.”

            I notice how he is staring straight past me, his voice hard but beginning to crumble at the edges. He carries the document into the stuffy room, folded so that I cannot see its contents—only the dotted lines where we will both sign: first her, then myself. I see that he has already written in today’s date. He looks towards the doorway.

            “We’ve discussed it in full with her, Doctor, I assure you. The three of us. She’s agreed to all the changes. Haven’t you, Mum?”

            I say: “I need to speak to her on her own. Completely on her own. To make quite sure that she does agree. That nothing’s being done against her wishes, if you see what I mean. I’m sure you understand.”

            I am surprised by the harshness of my voice. Slowly, reluctantly, the son leaves the room, closing the door heavily behind him. I can hear him, or the others, leaning right against the door, almost breathing through the keyhole. I lean over her frail form, speaking clearly into her tiny, withered ear.

            “Mrs Evans, your son says that you’ve agreed to certain changes in your will. Is that true? I don’t need to know what they are. Only that you’ve agreed to them, and that you know what you’ve agreed to. Do you understand? Please tell me. It’s very important that I’m sure that you know exactly what you’re signing. And of your own free will. Do you understand what I’m saying?”

            Outside the door, there is shuffling. A whispered argument has begun again, voices rising and falling. The old woman opens her eyes. Her voice is thin and faint. Like her body now, it is composed almost entirely of air. She nods, but there is the faintest trace of a smile on her toothless gums. “I agree with them, Doctor”, she says, “Yes, I agree with all the changes. Every one of them. Everything changes, isn’t that true? I know just what I’m doing. And why I’m—”her voice fades away, then she looks at me again in surprise—”Everything changes—”she says again.

            I sign and leave the room, avoiding looking directly at any of them, as they stand bunched around the doorway, staring in at the shadowy bed, and the document lying beside it.

            AFTERWORD

            To me these pieces, both based on real events, portray the most curious aspect of a doctor’s life: the way one dips in and out of thousands of human lives, and dramas, but without even knowing the whole story behind them. The work of a busy doctor often resembles that of an archaeologist, struggling to reconstruct a fuller picture of a particular human situation, from small shards or fragments of reality, glimpsed on a house call, in a ward, or in a busy clinic or surgery.

            The unequal struggle

            She sat day after day on her mattress, clothed in a tattered and dirty dress, giving me a shy smile as I did my rounds. She had been brought in from God knows what village or hovel. The hospital was full and she was accommodated on a mattress on the floor in the corridor. She couldn’t walk because she had a flaccid paralysis below the waist. There weren’t any relatives or visitors. She was about 14 years old.

            After a while it occurred to me that I could get her a fresh dress from the “calamidades”, the bales of clothes that came apparently from Scandinavia to our part of Mozambique. I saw people with Stockholm University on their chests. I saw Michael Jackson. I saw a gaunt, bony woman hoeing the dry dusty ground in an “Iron Maiden” T shirt.

            So I acquired a clean, fresh, bright print cotton frock of roughly the right size and took it to her in her corridor. When I held it up in front of her and she realised it was for her, she leaned forward and embraced the skirt of the frock, somewhere in front of my knees and laid her cheek on the material as if she were caressing a lover.

            AFTERWORD

            I wrote this as a recollection some 10 years after it happened. When we in the comfortable world hear the seemingly endless bad news from Africa, I am reminded of this incident. It exemplifies for me the type of human misfortune that lies behind statements like “Mozambique belongs to that group of countries known as Highly Indebted Poor Countries”. Those are people’s lives we are talking about, the only lives they have.

            REFERENCES

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            Footnotes

            • Opening the word hoard is edited by Gillie Bolton and items should be sent to her at the address given.

            Footnotes

            • 1 (pseudonym)

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