Gene and punishment

Hail, And as soon as I start blogging, something happens at work I am legally not allowed to talk about. Seriously - people are dead, and arrested, and so forth. A body has been found, and someone stabbed, and someone else is in custody. It's all been grim.

In other news, I have had to send one of my patients to Sarah.

The reasons for this are as follows: Erica was one of the patients I inherited when I took over this practice from Doctor No about three years ago. Doctor No was a woman of Asian descent who brought a strong, Confucian work ethic to the practice, but whose attitude towards clients was possibly more influenced by Han Fei Tzu than anyone else. Han Fei Tzu was, as those of us who read a few too many "Master of Kung Fu"comics back in the seventies know, of course, the author of the Han Fei Zi, the Fifty Five Chapters.

This rather dispiriting text explains that the ruler maintains discipline via three attributes: (his) position of power (勢, Shi); certain techniques (術, Shu), and laws (法, Fa), and that this power is maintained over an essentially evil and lawless people only through instantaneous and unflinching application of force.

The "certain techniques" in this case seemed to consist of kicking people off the methadone programme, but I digress.

Erica had come to me with a job, a boyfriend, a decent bank balance and a very occasional "habit" of smoking heroin. Three years later, under my care, she was unemployed, penniless, anxious, openly depressed and deeply in debt. She had been an administrative officer with a local bank - now she was working doing sex toy parties (a difficult thing for a woman who wasn't really comfortable doing that kind of thing). Her parents had found her medication, there had been a disagreement, she had come to the clinic with a black eye that she didn't want to talk about. Every month now for the last six months her address had changed, she was couch-surfing amongst a dwindling number of family and friends.

Things were bad.

And they were, if anything, more frustratingly bad for all concerned because she was one of the few who had deteriorated fairly dramatically under my care.

And there were other things, too. She failed to attend appointments, she forgot or didn't like medications, she was unable to attend counselling, or psychiatrist appointments, or meetings with the housing trust - but she was always early to see me. She was always what the textbooks say "cleanly and appropriately dressed".

A few months back she emailed me, on my work email address, which she'd found. That's not in any way illegal or immoral or anything, it's a free country, but it was somewhat alarming, mainly because it was unusual. And also, it does open up the whole "emailing to each other" can of worms. Not that worms in a can email each other, but if they did, it would be, you know, awkward.

I suspect some of you may already be thinking "get over yourself, mate, it's only a freakin' email", but there are things that can go wrong here.
Anyhow - rather than email back I sloughed the letter to Cerridwen, one of our nurses, and asked her to fix the problem. And then next appointment, which was last Thursday, she told me how she felt. Well, not first off, and not verbally.

First she told me how things were going. Things were uniformly dire. She could not go on like this. She didn't know why she was sabotaging herself, why she made so many bad decisions. There was so much going on, emotionally, so many things. She didn't know what to do.

And she reached into her handbag and pulled out a couple of sheets of paper, covered with hand-written notes. "Here," she said. "This will explain how I feel."And she left.

I didn't open the note, I just sat there for a moment.

Then I called Cerridwen and we went and saw Ernie, our senior nurse, and there was a fifteen minute monversation (I think he managed to get a syllable in every few minutes or so) where I told him how all this, well, stuff was going on.

"Stuff..." said Ernie.

"You know," and I waved my hands ineffectually. "It's all look at my terrible emotional trauma, see how nothing can be done, doesn't it make you need to love me, please rescue me," kind of stuff."

There was a long silence. Cerridwen opened the note.

"I have so much love to give and no-one to give it to," she said.

I looked at her, irritably.

"Can it wait?" I said. "We're working."

"Not me, you clown" she said. "Look."

And she handed over the note.

"The only man I have feelings for is married," I read. After that was three or four lines of text, scribbled out and illegible.

"Checkmate" said Ernie.

Now, this should be the end of the matter. Boundaries have been crossed. There is a set protocol here. I have referred her to the Eastern service, where the two doctors are Dr Hahn, a vastly experienced and maternal woman with a long history in the mental health services (on the side where you lock people up, not the side where you get locked up), and Sarah. I don't know that there are a lot of options at the moment.

But there's more to it than that. There is a way in which things for her have altered. There is an aspect of punishment, of rejection, or abandonment to this.

She has become, in some way it's hard to articulate, a "bad patient".

Someone is sick, and they come to us, and we treat them, as long as she is not too sick, or as long as she is only sick in particular, prescribed ways.
The thing is, you look at borderline personality disorder, you look at it as a disease, and there are certain alterations in the brain. Prefrontal cortical control over the amygdala, the bit of your brain that recognises emotions in others, is weak. The amgdala is hyper-reactive, it over-reacts to certain facial expressions. It interprets both negative and neutral facial expressions as threatening.

This is at least partially under genetic control - to an extent, you are born with the tendency to see frightening or enraging things when other people do not. These "heritable risk factors" create difficulties in normal attachment - the emotional instability means fractured, fluctuating relationships that bafflingly, terrifyingly career out of control, that creates further emotional instability, and so on.

Erica - heavily mascara'd, wearing her best clothes, always on time - is going to experience this as rejection. She will experience this as rejection, I think it is possible to see her point of view with this.

So, she is being rejected.

She is being punished.

Generally, you're punished when you've done something wrong.

Generally, it's wrong when it's not your fault.

The closest I ever came to hearing wisdom in my few brief months in the psych training programme was someone saying that pathological personality structures (borderline personality disorder, antisocial personality disorder, etc.) were not things designed to piss the treating doctor off, they were instead structures that the patient had constructed to protect him or herself from the world. Less spite and malice than psychic scar tissue and reflex movements, ways of getting by.

Anyway. I have a patient waiting. I am out of practice with this - the computer ate my last three posts.

Please be patient.

Thanks for listening,
John