Dr Grumble recently described young women who turned up in casualty after taking an impulsive overdose as “silly girls”. There was a predictable volley of screeching from the politically challenged, but Dr No was and is with Dr Grumble on this one. They are silly girls, and to call them otherwise is not only silly, but also downright dangerous.
The gist of the screechers’ argument was that Pappa Grumble, in calling these distressed womenfolk silly girls, was acting in an insensitive, patronising and dismissive manner. He was insensitive in not appreciating their distress, patronising in calling them girls, and dismissive in describing them as silly.
What these distressed womenfolk needed, said the screechers, most of whom clearly wore their heart on their sleeve, was sympathy and help in their hour of need. There was further right-on screeching about the need for care, respect, empathy and a patient-centered approach. It’s a wonder there wasn’t yet more screeching about ethnicity and diversity.
Now, this kind of self-important sanctimonious twaddle may go down well at Euston Towers, but for Dr No, it doesn’t wash.
It doesn’t wash because, in their zeal to be not only right-on, but to be seen to be right-on, the screechers have lost the plot. In their enthusiasm to be seen as caring, empathetic, patient-centered helpers, they are allowing their own self-interest, in wishing to be seen as such, to interfere with that which is really important – the best interests of the patient. They are as much treating their own need to feel caring as they are caring for their patient. That is why it gets dangerous.
Let us return to the girl on the trolley in casualty. Let’s make her 19 years of age. She has no history of mental illness. She’s pretty (doctors notice these things as much as anyone else), and can usually wrap her boy friends round her little finger. Only, last night she couldn’t. She got dumped. She got drunk and do what girls do when they get dumped and drunk. She took an impulsive overdose of paracetamol – enough, as it happens, to cause liver damage and so possible death. Her mother finds her, and takes her to casualty.
At casualty, she declines treatment. Pappa Grumble thinks “silly girl” and imposes treatment. Luckily she got to casualty in time, and she recovers. The acute medical crisis is over.
The crucial question is what happens next. Although she has no history of mental illness, the fact she has taken an overdose raises the possibility that she might in fact have one. And so, almost certainly, she will undergo a psychiatric assessment, and it is in this assessment that her future will hang in the balance.
Given the importance of getting this assessment right, it should rightly be done by an experienced doctor who will probably (no one is infallible) get it right. Unfortunately, in practice these assessments are more often done by very junior doctors, or, even worse, noctors. Noctors who are not only lacking in diagnostic skill, but also prone to wear their heart on their sleeve, to be caring, empathetic, patient-centered helpers who – even worse – like to practise “on the safe side”. Noctors who, when they are not noctoring, will most likely spend their time posting anonymous screeching comments on Pappa Grumble’s blog.
Noctors are usually rather keen on clipboards, a legacy from their nursing days, when the clipboard hung on the end of their patient’s bed, and recorded the patient’s vital signs. Today’s clipboard is somewhat different. There is no TPR chart. Instead, there is a 22 page Assessment Form. There are a lot of boxes to be filled in and ticked off, and ratings to be made.
Now, the combination of a nursing background and a protocol driven assessment is flawed. It is flawed because it is weighted towards caring, rather than diagnosis. And that is dangerous, because what this young woman who has recovered from her overdose needs is not care, but diagnosis. An expert diagnosis. There needs to be a decision as to whether she has an illness, and if she does, what it is. The care, if it is needed, comes after the diagnosis.
Unfortunately all too often the flawed assessment leads to a woolly view that the patient (for she has now become one) needs help. No one really knows what the diagnosis is, but the noctor thinks the patient needs help. The noctor, remember, needs to feel caring. So she offers an outpatient appointment, or, even, God forbid, an admission. At a stroke, the patient becomes a patient with a psychiatric history – something that is not, as many will tell you, a very helpful history to have. But hey, it’s OK, because the noctor feels good, because she has been caring. She’s offered help, just to be on the safe side.
The trouble with all this well-intentioned interference is that all to often it turns non-psychiatric problem (an impulsive overdose taken for personal reasons) into a psychiatric one, and an individual into a patient, with a history he or she does not need, and which will do nothing but harm.
What this unfortunate girl does need is not care, but a confident medical diagnosis – that she does not have a mental illness. She is instead a silly girl who has taken an overdose that might have killed her but thankfully did not. She is freed to get on with the rest of her life, without the encumbrance of an unnecessary psychiatric history.
This silly girl may or may not take another overdose. Whether she does, and what happens subsequently, will be influenced by her assessment outcome this time round. But that is another story, for another day.
>> “In their enthusiasm to be seen as caring, empathetic, patient-centered helpers, they are allowing their own self-interest, in wishing to be seen as such, to interfere with that which is really important”
The “my concern is greater than yours” behaviour that you refer to is is something that I come across far too much as a white, middle class, middle aged, male. It is often self defeating and incompetent. At my wife’s clinic – which doubles up as a reception area for assylum seekers – staff have for many years sent each other christmas cards. 2 years ago they decided it would be a good idea to stop this as they can speak to each other to pass on christmas greetings and instead use the money saved to contribute to a local charity. It worked well – for one year! The next year the local management decided that the money would go to the local charity supporting assylum seekers. Result -> no money .. for any local charity, no cards and miserable staff.
Why do well meaning but confused meddlers act in this way and impose their “moral” judgement on others?
I think it is because such people are comfortable but feel guilty. They are part of what Galbraith termed the “culture of contentment” and have an inner realisation that others suffer for their contentment. Some turn to religion to assuage this guilt, some (and sometimes the same people for a double dose of protection it seems)adopt this “right on” expression of concern you mention.
I think we need to come up with a deprecating acronym for such people – the best I can come up with is MCISSMo (My Concern Is So Much More).
Thanks for your interesting comment, PoH, which touches on one of the underlying themes to this post – why we become helpers, therapists and doctors, and what our real motives are. It touches on that thorny question: who needs the other the more: the patient, or the helper? But the top level theme is: don’t medicalise non-medical problems! It does no good at all, in fact it does harm, to give a silly girl a psychiatric label when she doesn’t have a mental illness.
A very interesting comment, PoH.
I often say, when people who ask what it is really about, that psychiatry starts off with deciding whether someone is mad (psychotic), bad (criminal) or sad (neurotic, as in having an affective disorder); or none of these (or even more than one of these – they are not mutually exclusive). The process of making that distinction is, in a medical context, making a diagnosis. Even Szasz did it.
Categorising, labelling, stereotyping, call it what you will, is a fundamental part of how we interact with the world. We get to know that a simple metal frame with two wheels will behave differently to a metal box with four wheels – and we shape our behaviour accordingly. We also give those two objects names – labels – and those labels can carry stigma and prejudice (road hogging cyclists; or motorists, depending on how many wheels you have). If we didn’t stereotype, if we approached every situation we encountered anew, we would go into an information processing overload.
Szasz also embodies the paradox of being both strongly anti-psychiatry (his two best known books being The Myth of Mental Illness and The Manufacture of Madness) and yet a practising psychiatrist – and one who used diagnosis too! And he made use of more than the prescription pad, as you note. One thing I often say to patients is one good friend is worth a thousand pills. We’re too quick to pop pills these days, and in so doing forget things that have stood the test of time, that work, and are generally side effect free.
And before anyone jumps down my throat – I know perfectly well there are toxic friends out there – and effective pills. It is a generalisation, but none the worse for being one.
Thank you for your post which illuminates just how badly the medical profession deal with such situations. Calling someone a ‘silly girl’ is in itself a stigmatising ‘diagnosis’.
It is a variation on the diagnosis of hysteria, borderline personality, histrionic personality etc which are imposed of ‘distressed womenfolk’ by unpleasant and often criminal ‘mental health professionals’.
I have recently explained to my GP that there is a consistent pattern running through my medical records from 1982 onwards of kind decent GPs who had my best interests at heart and abusive ‘mental health professionals’. I asked him to write to our MP though it took waving internal records at him to do this.
I find your confidence that it possible to accurately diagnose whether someone has a ‘mental illness’ or not rather naive. There is no objective evidence that ‘mental illness’ exists. If you have been on the receiving end of these idiots who call themselves ‘doctors’ and who destroy people’s lives then you would know that they cannot do this.
Unfortunately, I have met quite a few ‘psychiatists’ and the majority are the dregs of the medical community. They have no respect for the law or medical ethics. They experiment on people and make their lives a living death. That is what they have done to me and many others.
You will find on my blog an article written by Hamish Rattray, who was ‘diagnosed’ with ‘manic depression’ and given nothing but ECT and drugs. When I met him he was dribbing and twitching like a stereotypical ‘mental patient’ with an overdose of lithium.
Hamish was coached for Oxford by Andrew Motion and is very talented. He has himself written to Radley College, which he has termed ‘Auschwitz with Latin and Rugby’, saying that whilst his condition is believed to be partly genetic in origin, it can also be influenced by environment and he believes his situation was partly caused by the environment in which he spent his youth.
He told me that he had written that letter on May 6th 2004 just after I had asked a GP why it was acceptable to assault me at the age of 13 when the same act counted as torture in Iraq. She said it was rape (inaccurately) and then I told her that when I was seventeen I had been sent to a psychiatist for help by a GP who subsequently assaulted me and I tried to commit suicide afterwards. She said this was an ‘unbeliveable trauma’ and offered to get me expert help though expressing concern because it was to do with my work. I said to go ahead and do it anyway.
I then went to the pub to celebrate the fact that a doctor had finally admitted that there was something wrong with what had happened to me. Hamish then explained that he had mentioned in his letter that he knew someone who had been ‘raped by the son of a senior public servant’. I laughed and said it wasn’t quite right, there were several of them and asked what response he got.
He said they sent him a letter saying they had taken his comments into account and an Old Radleian’s tie.
I laughed (a little hysterically) and asked whether he thought they would send me a tie if I wrote them a letter. Then I added ..but what would I do with a tie?
Hamish said, ‘they do scarves, Kate’.
It therefore became a matter of principle to acquire an Old Radleian’s scarf on November 5th 2007, the twenty fifth anniversary tour of ‘Auschwitz with food’. Hamish was responsible for that. I needed to return to the scene of a crime which has affected my entire adult life and which I reported immediately afterwards and regularly to the medical profession ever since. The first opportunity to really explain what had happened was in a witness statement to CID twenty five years later. Here is the Institution where the crime was committed:
http://www.radley.org.uk/
On November 5th 1982, I sat in my study at Radley and wrote a letter to my mother explaining that I had told my housemaster he was petty pathetic and ludicrous and the next day he gave a social[house] prayers on the necessity of rules and why Anarchy wouldn’t work.
You will note the ‘insensitive, patronising and dismissive’ reference to the ‘female I mentioned in the last letter playing up in the way that adolescent girls tend to’. After re-reading the letter in 2004, I had a flashback of thinking I needed to start acting like a spy in order to carry out my plan to finish my A levels and escape to university away from Radley and my extremely abusive parents.
The ‘silly girls’ reference was designed to throw the wool over my parents eyes as to the true nature of my situation and I remember giggling when I wrote it:
http://katemiddleton-lsu.blogspot.com/2009/08/guy-fawkes.html
On 14th November, I walked out of Radley after a confrontation with my housemaster during which I told him I had been sexually assaulted by a bunch of boys and then got very upset and hysterical. Somewhat ironic.
On 15th November, I was referred to the Warneford by Dr Thorne who said I was ‘rather upset and vulnerable’ and had been cutting myself with broken glass. He was told by the college chaplain who had known exactly what the situation was since I was thirteen that I was a ‘complete loner’ with ‘no friends’. A blatant lie. I told Dr Thorne that I was ‘absolutely hardened’ and nothing could affect me.
On 17th November I had my first encounter with Deenesh Khoosal in the Warneford. Internal notes retrieved during the police ‘investigation’ show that by his own assessment I was ‘a pretty seventeen year old student’ completely sane and asking to be referred to a specialist. He then engaged in horrific bullying in a attempt to extract the details of my sex life, masturbation habits and sexual fantasies by force. He wouldn’t accept that I had none so I eventually told him that I thought about being a lesbian or being made love to by a man. He then wrote to the GP giving details of extremely personal matters on 18th November and making allegations that I was ‘confused’.
I told him that my ‘main problem was being in the wrong body’. That was my main problem. I had a cross-wired central nervous system and had been aware of this before puberty.
Letters in the file show that he had written to Dr Anthony Storr and Dr Keith Hawton saying he had ‘no personal experience’.
On 22 november my housemaster wrote to my father saying I was in a terrible state and the ‘doctor’ I had seen was ‘concerned’ about me. He kept this up for weeks whildst abusing me in private.
On 25 November Khoosal assaulted me without consent as described to the police twenty five years later. There is a description of my genitals in the notes and no record of seeking consent. When arrested on September 4th 2008 by Angie Murray, a child abuse officer from Thames Valley his excuse was that he wanted to look at my body. She did not read the notes before the interview or have the training or knowledge of the law to conduct such an interview. Assault of a child is not a normal part of counselling.
In law any unconsented touching is an assault and it is recognised that it can lead to psychological/psychiatric injury. Bullying leads to post traumatic stress disorder and eventually suicide. The Royal College of Shrinkage have a factsheet on the emotional effects of sexual abuse on children which includes taking overdoses. I wonder if Khoosal wrote it. He should know:
http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthandgrowingup/childabuseandneglect.aspx
In the aftermath of Khoosal’s brutal and coercive invasion of my privacy, he ordered me to write a diary which I did whilst listening to the new Dire Straits album, Love over Gold.
You will note the reference to the song ‘Private Investigations’ in the diary.
http://www.youtube.com/watch?v=SGB3KyyTxP0
‘confidential information …it’s in a diary this is my investigation… not a public enquiry …treachery and treason ..there’s always an excuse for it…and when I find the reason I still can’t get used to it.’
You will also note that after telling my housemaster I had come closer to slashing my wrists than that afternoon and wanted to leave he accused me of making a ‘silly show of myself’. I have a letter written by my ‘mother’ just after my first attempt to leave on 14th November in which my housemaster said I was ‘trying to draw attention to myself’ and my ‘mother’ comments ‘Oh dear! how silly!’
The word ‘silly’ therefore has a personal significance. I don’t think protesting about a criminal sexual assault at the age of 13 is all ‘silly’. I don’t think raising the matter of a criminal attack by a thoroughly dishonest sub-literate ‘doctor’ who was telling my housemaster through this period that he was a specialist, that I was obviously ‘v disturbed’ and needed psychiatric help with the GMC and police is silly either. Here is the diary:
http://katemiddleton-lsu.blogspot.com/2009/08/suicide-diary-in-instalments.html
On 3/12/82, I went back to Dr Thorne to ask to be removed from the situation once again and he prescribed me a large supply of Valium. He also wrote a letter to my mother saying that in his opinion my problem was deepseated and serious and that she would need to find an alternative place of education for me.
That afternoon I saw Khoosal and told him that I had told my housemaster I felt like slashing my wrists and wanted to be taken seriously. He has written in the notes: ‘expectation – wants me to listen’. and ie ‘about being a girl’.
Three days later I made my first attempt at suicide on the evening of 6/12.82. He then libelled me by making allegations that I was mentally ill ie ‘obviously v disturbed’ to the school whilst making defamatory allegations to Dt Thorne that I has ensured I was expelled for school. Nobody seems to think I am entitled to an explanation as how it could be that I was completely sane and asking for a referral before he got his sticky paws on me.
On 7th December I was ‘assessed’ by Dr Anthony Storr. He was sent the diary by Khoosal for his ‘perusal’ but ignored it. If he had not been an ignorant aggressive bully I would told him what had happened. Instead, he gave me a barrage of aggressive questions and I had to calm him down. He has written in the notes that he asked me ‘Do you want help? practical guidance about getting sex change etc’. He recommended Jan Morris’s Conundrum. Shame I did not read the letter for a further 22 years.
Storr then wrote to Dr Thorne saying he was ‘not quite sure’ why my rebellion ‘against the authorities started’ but at any rate he thought my histrionic behaviour was designed to get me expelled from school and did not think I was currently suicidal.
Storr then forced me to write a letter apologising to a criminal who had just ruined my planned career and health. Hamish Aird at Radley said, ‘you mean the famous Oxford professor?’ in connection with Storr. He was utterly incompetent and extremely unpleasant. I told a Dr McDonald in 1985 that I had the impression that Storr had made up his mind before meeting me what the problem was and I was right.
It was McDonald who was one of the doctors directly responsible for my second serious attempt at committing suicide because although he openly admitted knowing nothing about my problem he was determined to stop me getting specialist help until I was very much older. So in the end on December 23rd 1987, I drank a bottle of Gordons and set myself up for a hanging. In the event, it was easier to cut my wrists in a blood bath. It was while having an interesting experience of going into the white light that a ray of hope appeared and I decided to have one last try at getting to a specialist.
In the emergency room the blood sprayed all over the doctor’s face and she paniced and ran out of the room. It was not pleasant for anyone. Dr Pencheen ‘assessed’ me the following morning as completely sane and needing specialist help. By that time I had already found a way of a private appointment. On Christmas day, a friend was told ‘people like that are a waste of time’ by a nurse. In 1983, I had specifically asked a GP called AP Bennett to be referred to a female psychologist. The letter he wrote refers to actually asking for an appointments as a ‘waste of time’.
After I had got the life saving treatment from Russell Reid my life was made absolute hell by my family. I have supplied the authorities with hundreds of documents going back thirty years and about the abuse in the family. Everyone knew about it, nobody told me what was going on or did anything about it.
All the shrinks just wrote to the GP to tell them the ‘prognosis was pessimistic’ in view of my ‘rather arrogant’, ‘hostile’, ‘aggressive’, ‘dominant’, ‘bully’ of a father and ‘cold’ mother. That was not my psychiatric problem, it was their problem and my mother was told to get help by Jeremy Christie Brown in 1991 and never done so. As my brother has said this year, neither of them have much insight into the effect they have on other people.
All the medical profession just joined in with the abuse.
‘They murmured as thay took their fees/there is no cure for this disease’.
I have just uncovered correspondence from 1989 between Dr Russell Reid and my mother which shows that he has no insight into the minds of people like her. ‘We do not regard ourselves as ‘threatening’, ‘selfish’ or ‘aggressive’…before going on to make a series of threats and an amateur diagnosis of mental instability. I was twenty four years old and writing letters asking to be left alone. I now find that Reid was writing letters undermining me behind my back and behaving like a complete idiot.
Twenty years later, the situation is unchanged and I had an email from the creature I call ‘Killer Mummy’ alleging that I need psychiatric help. No professional supports this view. They did not unfortunately force this very dangerous creature into psychiatric torture. I have had my health ruined instead.
The negligence and stupidity of the authorities when dealing with ‘silly girls’ who take overdoses and cut themselves brings shame on society. The real issue is violence against women and girls in this society. The best book on this subject is Professor Judith Lewis Herman’s Trauma and Recovery. Others think so too.
http://www.traumatised.org/Essays.htm
One of Herman’s chief points is respecting the survivor’s autonomy and the vital importance of allowing her to manage her own recovery. This is precisely the opposite of what the mental health system does to people. That unfortunate woman who was allowed to die is undoubtedly a victim of this lack of provision.
Your scenario of the ‘silly girl’ taking an overdose and maybe doing it again depends on what happens next. If she is just ‘assessed’ and sent home without the problems being addressed then she will probably do it again. A stigmatising psychiatric label will only be damaging. There needs to be a change of attitude towards this kind of problem. It is not a ‘mental illness’ or a ‘personality problem’ but a problem in living. I have read the multitude of assessments of me which are inaccurate, patronising and never dealt with the abuse problem. That is still the case today.
I am now 44 with a first class degree which it took me twenty years to achieve because of abuse from all sides. Can you imagine how it feels to have discovered that medical profession have known about the abuse since 1983? That needs to change so that if a doctor knows someone is being abused they report it to the correct authorities and the abuse is stopped. The average male doctor has no idea what is like to be on the receiving end of ‘Don’t listen to her, she’s just hysterical’.
Thank you for your kind remarks regarding my comment on ‘The Gathering Storm’ when you announced your intention to do a post on ‘silly girls’. I mentioned my meeting with Peter Redgrove who a Gruaniad critic once suggested was sometimes ‘unfairly seen as a shaman, an old warlock going crazily on about menstruation’.
In 2007, I pointed out to John Kingston QC at the GMC that Redgrove’s Wife is now writing books of poetry with that title …
Look what happened to Sylia Plath and Aurelia Hughes who were married to his friend Ted Hughes. One does not want to be judgmental but…
Everyone should read this book. Particularly doctors with an obsession with an obsession with ‘diagnosing’ and ‘assessing’ people. It is not a legitimate medical speciality.
Now …back to trying to sort out the mess the bastards made of my life . I want to get on with it at last….
http://www.amazon.co.uk/Wise-Wound-Menstruation-Everywoman/dp/0714530557
Kate – Thank you again for writing in such depth.
I do in fact agree with much of what you say about the medical profession and the harm it does, especially in psychiatry.
Where we might not agree is over what the medical profession should be doing.
I think one of the core functions of being a doctor is diagnosis – that is, identifying the causes of symptoms; which then points to treatment (and prognosis). Diagnosis is, at its heart, a process of pattern recognition, which then guides what you do next.
You say “Calling someone a ‘silly girl’ is in itself a stigmatising ‘diagnosis’. It is a variation on the diagnosis of hysteria, borderline personality, histrionic personality etc“. The whole point of this post – and I’m sorry that the title had personal resonance for you – is to highlight the importance of saying when someone is not mentally ill – with the express intents of (a) keeping from the hands of meddling incompetents and (b) allowing them to escape, so far as possible, with their self-esteem intact. It is to say that they do not have a diagnosis of hysteria, borderline personality, histrionic personality etc, and that instead their symptoms and behaviour can be explained by other means (silly behaviour) – and the help they need (if indeed it is needed – not all do need help – they just get over it) be provided outside the medical arena – by family (not your first choice, I know!) or friends, for example.
When I was younger, I lent towards the Szasz/Laing view of things but 25 years of doctoring has persuaded me that there are states which – for now – we call mental illness. I still think psychiatry has more holes in it than a Swiss cheese, but a good, principled psychiatrist can make good use of the medical model – even if it is a temporary, working model – interpreted widely to help patients. I’ve seen it done, just as I have seen some very horrible things done.
From what you say, many of your problems stem from over-diagnosis and over-interference (in all its meanings). You should be applauding my attempts to point out the importance of not stigmatising people by giving them a psychiatric diagnosis that doesn’t fit and doesn’t help!
I do appreciate that for you the word silly strikes a raw nerve. But the general point remains. It can be as harmful to say there is illness where there is none, as to miss it when it is there. Diagnosis is the process we docs use to make that distinction.
Interested in your reference to Szasz.
I was taught (briefly) by him during a short course at Cornell University and had the chance to dine with him when – as a layman – I was able to question his proposition that the practice of psychiatry was not always in the patient’s best interests.
I remember him agreeing that people who were disturbed and acting in an abnormal manner could be Mad,Bad or Sad. The problem was the correct allocation (diagnosis?) and the historic misapplication of “Mad” to people who were either Bad and incapable of rehabilitation (in which case they should be detained in prison) or Sad (in which case they might benefit more by what we would now call Cognitive Behaviour Therapy or being talked through their worries)
When I met with him (around 1987) long stay psychiatric hospitals were still full of people who were Sad and/or Bad but not Mad and of course with Goffman, Szasz worked hard to “release” such people from wrongful internment.
I remember distinctly his response to my question “Then why do you still practice Psychiatry”. He said he knew he was a good counselor and could help people this way. However he went on to say that I also might be as good councelor for all he knew and if so I should not need medical training to help people who were Sad or Bad if I could help them.
I never thought Szasz was anti psychiatry as such – just careful that those interventions which required medical training were only carried out on people who truly were in need and not applied inappropriately to people who were not.
I therefore think that the thrust of your post would have met very much with Szasz’s approval.
If you can bear the Sun’s lurid hamster-ate-my-wife style, there’s an interesting story here.
Putting aside the fact it is is The Sun, so it must be true, there are some points worth noting, all the more so because they are (apparently – we don’t know how much the Sun subbed the story) written by Melanie Miller, a close and long-time friend of KW. At one point she writes:
“You stupid girl,” I howled at her in the hospital.
Miller, remember, is a close and long-time friend of KW. She would not wish to be dismissive or patroninsing to a friend in distress. And yet she – the friend – uses the just the kind of language that the screechers tell is dismissive and patronising.
Of course, said with the wrong intent, it can be so, but here it is just being said as God’s honest truth; just as Dr Grumble used it. And Dr No would use it.
Miller also writes:
“You expect me to let you die?” I yelled.
and then, at the end of the piece, gracefully forgives her one time friend for taking her own life.