The Clonazepam Curtain

Hail,
Today we learnt about the psychiatric interview.

We have our teaching sessions in Mulberry House, the oldest psychiatric hospital in the state. Mulberry House is on several acres of prime land just north of the city, land gazed upon enviously by banks and lawyers' firms. Mulberry trees - smooth, pale bark, pale green leaves that the sun shines through - cluster around the buildings, and a river runs through it. In the old days there were peacocks.

In the old days, of course, there was an art school, and pottery, and dance, and long sessions of therapy - and seclusion in windowless rooms, and camphor induced seizures, and occasionally lobotomy. Nowadays, things are different. More on this later.

What this means for us every Wednesday is four hours of lectures. The first few were on the history of psychiatry, at the moment we're looking at how to interview (nine or ten hours) and then there are the introductions to the common illnesses and the common therapies.

So - today was four hours talking about talking. Dr Lung spoke at length on where to sit when speaking to a patient - never stand above them, don't isolate yourself at one end of the room, never ever sit within arm's length (and here he illustrated this by extending one brawny hand and making a grabbing motion). Chairs themselves should be comfortable, should make the patient feel valued (not those orange plastic ones you get in schools) and not intimidating, but not difficult to get out of quickly and not of a weight likely to be used as a weapon.

And what about doors? Doors that open out are an occupational health and safety hazard - people walking down the corridor can get struck by them if you have to exit in a hurry. However, doors opening in can prevent you exiting in that same hurry. Sliding doors are unreliable - if you're thrown against them you can actually jamb them shut. Ideally, multiple doors into (and out of) every room can be arranged, so that both you and the patient can leave at any time, but obviously this is not always possible.

I don't know what that leaves us with - trapdoors, foundling wheels and firemen's poles were not specifically excluded - but I will be on the lookout for those bead curtains (see above) that seemed to be popular in the seventies, in fims where people lounged in pools and smoked opium and had orgies.

Anyhow. We also discussed silence, how to respond to silence, what the patient's silence can mean, what your silence may mean to the patient. Silence, said Dr Lung, can be used almost as a diagnostic tool, an instrument -

And isn't that a remarkable mental image, silence as a diagnostic tool? Using silence and quiet like we use light and steel and radiation. In the same way that you had to keep photographic plates in a lead-lined safe, or the faintest nebula can be seen on the darkest nights, some ideas can only come out in quiet.

Haing said that, I think others may have a more extreme view of this than I do. Dr Lung spoke of a particularly challenging psychotherapy patient his professor had had in the US a few decades ago. His professor had been seeing this patient for intensive private psychotherapy, and had been sitting with him for five one hour sessions a week for eighteen months, often emerging looking tense and drained, and retiring to his room to write copious (but private) clinical notes. Eventually he emerged from one session jubilant. A major breakthrough, he announced, had been made.

"What happened?" asked young Lung.

"He spoke," said the professor. "For the first time in eighteen months."

I don't know what the patient said. It may have been to enquire who was paying for this.

Anyway.

We discussed (briefly) the idea that having had mental illness makes you a better doctor. My opinion on this is changing. I have previously been of the opinion that it does not - if you look at mental illness purely through the lens of the medical model, when you have a heart attack, you don't go to the bloke who's had five heart attacks, you go to the guy who got into cardiology. By that measure, the same thing should apply to psych.

But I don't know - I am changing my opinion, and weirdly enough, it is not my own experiences on the other side of what I once heard referred to as the Clonazepam Curtain that are changing my mind, but things with Sarah. At the risk of embarrassing her, her pain is considerable, and along with chronic pain comes many of the cardinal signs of depression - disturbed sleep, altered appetite, emotional lability*. It's not something I feel like discussing here, but if there is any good to come out of her suffering - and I would do anything to change this - seeing her like this has made me a better doctor.

Anyway. I have resolved to make this a cheerier blog, and I shall end with two short stories from those "how I made a clown of myself" pages in the medical journals. One concerns a doctor who was at the time the night med reg at Royal North Shore or some prestigious hospital on the East Coast. It was his job to go around in the evening, close the curtains, make sure the patients were okay, and in the morning open them up again (it's true - this actually happened, and to an extent still happens. I will leave this for another blog entry). He went to ward 5C, closed the curtains and turned to Mr Saxon.

"And how are you today, Mr Saxon?"

"Terrible, doctor, terrible. All day long they've been keeping me awake."

"They?"

"The elephants. With their trumpeting and screaming. Constantly, never stop, never heard such a racket."

It is not recorded if the remainder of the standard psychiatric interview was carried out - is it one or several elephants? Are they talking about you, perhaps in a derogatory way? Do they issue commands? Are these elephants known to you, family, friends, famous elephants? - before our hero performed the standard tired med reg intervention - ten milligrams of haloperidol and two of clonazepam in the thigh.

In the morning he saw Mr Saxon sleeping the sleep of the cortically sedated, smiled and opened the curtains - and stared aghast at the circus that had set up on the grounds outside.

Luckily, due to Mr Saxon's relatively advanced chronic renal failure, it was a long time before he awoke, and by this time the circus had moved on.

Another mentions how he had been called out to see a child, whom I will name Blayde Spleenrenden, who had apparently taken a (small) overdose of carbemazepine, an anti-epileptic medication**, and was acting drowsy. He rushed over to the house. Inside were two women, one pregnant.

"Did you see any kids playing in the street on the way over here?" asked the pregnant one.

"No..."

"Oh - it's just that Blayde's gone down to Maccas and we haven't seen him."

"I was told he was only four..."

"Yeah, well, his sister had to take him down there to calm him down."

"I thought he was very drowsy."

"Well, he woke up and he started screaming," said the non-pregnant one. "What do you think is wrong?"

"It's pretty hard to diagnose without actually seeing him," said the doctor.

The pregnant woman paused for a second and pointed to a picture on the wall. "Well, there's a photograph, him and his sister in the bath when he was two. Is that any good?"

Anyway. I haven't actually gone on about my mood yet, that can be tomorrow.
Thanks for listening,
John


*There is actually a term called "emotional incontinence" where you blurt things out uncontrollably in a way that causes considerable embarrassment. Before blogging this was actually a disorder.

** This is why I won't do that job. Ambulance, ambulance, ambulance.