The Devil You Know

by Gwen Adshead

  I was able to witness the consequences of some of my colleagues’ developmental struggles early on in my career. Soon after qualifying in forensic psychiatry, in the mid-1990s, I did assessments for the UK’s medical licensing and regulatory body, the GMC, and sat for a time on their Fitness to Practice panel. The GMC has the power to suspend doctors from working or have them ‘struck off’ – the rather brutal phrase used to describe revoking their licence. During this period I was fortunate to get a scholarship to travel to the US and study at first hand the therapies our American colleagues were developing to help medical professionals. The groups I observed on my trip were made up primarily of practitioners who had lost their licences and needed to remedy this by completing treatment programmes. I remember being astonished at the thousands of dollars they had to pay so that they could return to practice; back then, as now, there was some free psychiatric support within the NHS for medical practitioners, although not the long-term therapy that some require. Most of all, I recall that across many different backgrounds and specialities, there was one common thread: they never wanted to ask for help until it was too late. For some doctors (and I think I may have been one of them once), choosing to study medicine in the first place seemed to be a way to avoid vulnerability, as if somehow being a doctor and a patient were mutually exclusive.

  There is also a practical reason for doctors not to seek help with their mental health: it can impact on their licence to practice. These days the GMC is primarily an agent of public protection and is highly reactive to any suggestion that a doctor might not be ‘a safe pair of hands’. This shift in emphasis was driven partly by the case of Dr Harold Shipman, who in 2000 was convicted of killing fifteen of his elderly patients. His case drew huge international attention, especially as it closely resembled a similar case in the US from around that time, involving physician Michael Swango. Both men were dubbed ‘Dr Death’ by their national media. In the UK, a high-profile public inquiry would go on to find Shipman responsible for over two hundred murders. History shows us again and again how black swan events can lead to disproportionate fear, and after Shipman there was a significant backlash against doctors.

  With all of these stumbling blocks, it is small wonder that many doctors won’t raise their hand for assistance. But in this case, David had gone to his GP and asked to be referred to a therapist; not just any therapist, but one he’d decided was suitable for him, for whatever reasons. Having made it this far, here he was telling me that he was just tired, not depressed. His manner was upbeat, his presentation calm. Since he was denying any illness, I thought we would need to get out of the medical narrative and into his experience as a person. I fell back on my favourite question: ‘If this was a story, where would it start?’

  David sighed and glanced at his watch, as if wondering if he really had time for all this. It seemed important to me to let the pause extend into a silence that he would have to break. After a minute or two, he began by explaining how, two years earlier, his long marriage had ended. When his wife left him, he began to have dreadful nightmares, which became worse over time, until he was getting only a few hours of sleep a night, at best. ‘No rest,’ he said, shaking his head, ‘no rest.’ He admitted this had made him ‘a little short-tempered’ at work. ‘You know how that goes, everything grates on you. And our wretched admin woman, Helen, she’s always on at me, asking me for my paperwork and all that admin rubbish …’ He appealed to me as a colleague. ‘Don’t you just hate it?’ I didn’t reply, although I do dislike paperwork as much as anyone else. ‘Then, you know, one thing led to another.’ He didn’t elaborate, leaving me to wonder what constituted ‘one thing’ and if his troubles at work were limited to a single female colleague.

  I was curious, too, about how much she and others might have put up with from David before they complained; the esprit de corps among medical professionals means it can take a while to use up good will. It crossed my mind that his patients may have begun making complaints as well, and perhaps the therapy wasn’t David’s choice after all. I asked him directly if that was the case. He insisted it wasn’t. He had come to see me because he knew he had to get over the end of his marriage, he said, and get rid of the damned nightmares, which were surely connected. ‘Oh? Can you tell me what they’re about?’ I asked. He parried. ‘Never remember them. I couldn’t say. Sorry to disappoint you, Doctor.’ People’s memories of dreams are variable, and as I noted in Tony’s case, the interpretation of them associated with traditional psychoanalysis is rarely part of my work. I was more interested in the fact that David ‘couldn’t say’. What was muting him? I made a note, then asked what he did when he couldn’t sleep or woke from a nightmare. ‘I just try to shake it off, as you do. Get up, get myself a drink, go online – wait for the dawn.’

  Our time was nearly up, and David wanted to know where we would go from there. I suggested we meet for six sessions over the following six weeks and then review. We set up a regular day and time to meet, then he stood to leave, thanking me for my time. ‘In your expert hands, I’m sure I’ll make great progress.’ Did I detect a hint of sarcasm? He was on his way out before I could respond. I glanced at the clock and saw that he had effectively terminated the session a few minutes before time. I had a feeling of being dismissed like a junior cadet by a superior officer.

  *

  The following week he did not appear at the appointed hour. I waited in my office and even went to the window to watch for his arrival, but there was no sign of him. ‘He rang and said something came up,’ our receptionist reported. That was interesting. I thought he wasn’t working at present – ‘on leave’, according to the referral note – so it wouldn’t be a medical emergency. It was more likely that having begun the process, some reluctance had arisen about engaging with the work of therapy. But he was right on time for the next session, even a few minutes early, breezing in with smiling apologies and an explanation for why he’d been absent. He was a keen golfer, and just as he’d been leaving the club last week to meet with me, he’d run into our local MP, an acquaintance of his, who had asked him to join his table. The MP was having coffee with – and here David dropped his voice and almost mouthed the name – the deputy PM of the day. I think I was meant to be impressed. ‘I couldn’t very well beg off, could I? “Terribly sorry, chaps, must go see my therapist.” Anyway, I’m here now. What’s the plan, Doctor?’ I think I had the passing impression that he was a little too hearty, as if he’d been drinking, but he was so lucid I didn’t pursue it.

  I suggested we might use this session to talk about his life history. I wanted to know about his childhood, his growing-up story, but instead he responded by starting in the recent past, at his silver wedding anniversary. He described throwing a lavish party (‘Cost an arm and two legs, let me tell you’) at the golf club’s smart restaurant, with dinner and dancing – ‘Black tie, the works.’ He mentioned two grown-up children, who came for the event with their young families. There was a daughter who lived in Wales and a son up from Cornwall, but he revealed nothing more about them or the grandchildren, not even giving me their names. He did comment in passing that ‘they adore Connie’, his wife. I thought I detected a note of sadness there, something of Twelfth Night’s Sir Andrew Aguecheek and his wistful ‘I was adored once too’.

  David described in detail the elaborate party arrangements, the speeches, the fine French wine that he’d ordered and the Tiffany necklace he had presented to his wife in front of the crowd. ‘It all seemed, you know, tickety-boo. Happy families. Then … boom.’ A few weeks later, Connie packed her bags and went. He snapped his fingers: ‘Just like that.’ ‘I’m sorry – do you mean she left you without explanation?’ He looked away, then shrugged, telling me his wife had just suddenly announced one day that she wanted to go and live in Cardiff with their daughter, to be with the grandchildren. ‘It was fine,’ he said. ‘Fine,’ I reflected back to him, unconvinced by this innocuous little word that so deftly closes down emotional conversation. �
�Look, there wasn’t anyone else, if that’s what you’re thinking. On either side. Nothing like that. We’d grown apart, probably.’ I just nodded, waiting for more. He stared at me, somehow conveying anger that I wasn’t responding. Then he shifted position, clasping his hands behind his head, extending his legs and looking up at the ceiling. ‘What else can I tell you?’ Now he sounded rather bored. I asked if he wanted to say a little more about his children – what did they make of the split? ‘I couldn’t say.’ That phrasing again. What was preventing him from saying more? Did he know?

  There was something worrying about the picture that was emerging. A man in his late fifties who is approaching retirement is already statistically within a higher risk group for suicide, whether or not they admit to depression. Some doctors become so identified with their work that retirement is tricky; it can seem like not just the end of a career, but the death of a part of their self, which is possibly why so many carry on well past the normal pension age. It was important to be forewarned and stay mindful of what a loss of identity might feel like. Good mental health also depends on community, and David sounded socially adrift in the wake of his divorce. His club might be a convivial setting, but golf isn’t a team sport, and he appeared to have no relationship with his children or their families and may have alienated at least some of his work colleagues.

  I imagined him at home after Connie departed, a lonely man with a pressured job coming in late, knocking back a few stiff drinks in the hope that they might help him to sleep, then drifting around the echoing rooms looking at framed photos of a life lost to him, before a slow climb up the staircase to bed and a struggle for respite, only to be plagued by indescribable nightmares: a dark and pitiful nightly sequence, repeating on a loop. Sometimes I have had to stop myself from filling in gaps like this, even though such images occur to me quite naturally. I have learned that picturing a life that is not my own, although a component part of empathy, can also stop me from hearing or noticing what is real. But if I never did it at all, that might be worrying too. How does one step into someone else’s shoes and not imagine where they walk?

  I thought I’d better ask David for the name of someone close to him that I could speak to if necessary – a trusted friend perhaps. This isn’t an unusual request to make in cases involving depression, and it only happens with the patient’s permission. He brushed me off, but he knew my professional duty, so when I pressed him gently, he grudgingly agreed that I could speak to his GP and practice manager if it came to it, ‘which it won’t’. He couldn’t even muster the name of a close friend. It was an emotionally bleak landscape, and I had the sense of some deeply buried distress. But as our session ended, David assured me that he was ‘in fine fettle’, urging me ‘not to worry, my dear’. He left the room with a cheery ‘See you next week,’ and I could have sworn he winked at me.

  The next time we met he appeared dressed in casual gear, face flushed, sporting a polo shirt with the collar up, very pleased with his golf game that morning. His ebullience subsided when I asked if we could go further back in his history, to his early childhood. ‘Ah, we’re into Freud territory now, are we?’ Making exaggerated air quotes, he gave me what I imagined were the only lines of Larkin’s poetry that he (and many others) knew by heart: ‘“They fuck you up, your mum and dad …”’3 He broke off, grinning, as if expecting a gold star from the teacher. I said nothing. ‘Freud, Jung … it’s not real science, is it, Dr Adshead?’ I wondered why he wanted to belittle the profession. I know there are some doctors who still view psychiatry as a Cinderella speciality, but it is unusual in a GP since their work is so entwined with mental health. I decided to treat his comment as banter and allowed myself an eye-roll, as if pretending to be insulted on behalf of all psychiatry. ‘Tell me about your parents,’ I prompted. He threw up his hands in mock-surrender and began.

  His narrative was brief and to the point, more professional bio or newspaper profile than memoir in style. He was named for his father, who was also a GP. His mother was a nurse. ‘Usual thing. Runs in families, doesn’t it? Same for you?’ I noted how he felt an immediate need to change course and start a different conversation, something more mutual and less like doctor and patient. Mildly, I reminded him that we were there to talk about him, not me. For a second, I felt a pull to use his first name and was aware of something maternal in that urge. It’s always an interesting moment when therapist and patient move to the use of first names, if that happens. We weren’t there yet; in fact, he continued to address me as ‘Doctor’ to the end, although it always had a mocking quality, I thought, in line with his snarky attitude to psychiatry.

  David went on, describing how his father had set up his consulting room downstairs in their family home. He recalled how the children had to tiptoe around and be quiet during surgery hours: ‘Seen and not heard.’ Technically, his father was always at home, but … And there David halted, unable to articulate something. ‘He was … there and not there, you know?’ It was the first time I thought he’d said something with some personal truth to it. I recorded those words on my notepad, sensing they had an emotional complexity which would only later be revealed. David raised his eyebrows when he saw me taking notes but made no comment.

  He went on to talk about his mother working shifts at a nearby hospital and how the children were cared for by a succession of nannies. What were they like? ‘Super,’ said David, adding that he felt ‘lucky to be looked after by such gorgeous young creatures’. I mindfully suppressed a wince. He was the eldest; the four children were each separated by a year or so – ‘Close in age, if not in life, I’d say.’ Again, this had a more personal ring to it and that rueful sort of Aguecheek tone I’d noticed earlier. He described being sent off to his father’s Catholic boarding school at eleven, where he did well in his studies and excelled at tennis, becoming captain of the team, just as David Sr had been in his youth. I commented that it sounded as if his mother and father were somewhat absent from his childhood, but he baulked at this, insisting that they were excellent parents, ‘top notch’. He added that his father had coached him at tennis and golf in the school holidays (neither of them team sports, I noticed), and there was a family holiday to St Ives each summer. Picture perfect. I imagined David Jr all those years ago, coming home during school breaks to find the nanny busy with the little ones, having to rummage around in the kitchen for a cold supper, padding about in his socks so as not to disturb the patients below and staying up late to study ‘real science’ at his desk in order to become a true replica of his father. How else would he get parental attention, between the younger children and the stream of needy sick people downstairs?

  I was thinking how familiar his story was. In the 1970s, American research into vulnerable doctors found that the majority tended to be first-born children who had complex relationships with their parents.4 I had seen this in other doctors who had come to me, and there was always that same emphasis on strength and normality, on achievement and action. I thought David’s whole presentation had a contemporary, almost millennial twang, carefully curated, ideal for Facebook and Instagram. Here’s David in school uniform, and there he is holding a tennis trophy, his proud dad’s arm round his shoulders, and that’s him with his adorable younger siblings, all arrayed in stairstep formation, squinting into the sun on the beach in Cornwall. Happy families. It was not that I thought he was lying, but rather that this was a kind of cover story culled of any blurry, painful or unflattering moments.

  He continued with a similarly jolly account of medical school in London, giving no sense of the usual messiness or uncertainty of student life. He had met and married Connie, who was training to be a nurse. He described her as ‘a looker, back in the day’, adding that she was ‘a good girl’ and ‘did what she was told’. He seemed oblivious to how derogatory that sounded. I made notes as he went on to talk about the births of his son Tom and daughter Lucy. ‘How were they, growing up?’ I asked. He said something vague about how they’d been ‘fine’ an
d had ‘done well enough in life’.

  Group animals, like humans, need to be able to read the feelings of their fellows, that process of ‘mentalising’ another person. David seemed to have little capacity to think about others’ emotional experience, and once again I marvelled that he was a GP, given their need to be particularly thoughtful about human relationships. As he presented this restricted and rather offhand view of his marriage and family, I remembered how he had also dismissed a (female) work colleague and how he had been making those little digs about my work ever since we met. If he minimised the feelings, beliefs and experiences of others so easily, he might also be doing the same with his own. Given his other risk factors for suicide, that worried me. Moreover, if he couldn’t allow himself to be vulnerable, to make that shift from doctor to patient, I doubted if I could help him.

  *

  At our six-week review, we agreed to continue our sessions. I wouldn’t normally have done this – as I have said, I tend to limit my private sessions. But I felt we hadn’t really begun, as if he’d been treading water thus far. When asked how he was doing with his sleep, he shook his head, repeating his original complaint – ‘no rest’ – as if that was a final verdict. I again tried to draw him out on the reason for his lack of rest, asking him about his nightmares, but he changed the subject, veering off to talk about work and how he planned to go back soon after his ‘little break’ to ‘serve out my time’. To my ears, that casual use of the idea of a prison sentence was particularly intriguing, but he didn’t mention it again.

  Our weekly discussion consisted mostly of him telling me about his thoughts (though less about his feelings), always peppered with little jibes about therapy clichés and comments about how ‘you shrinks do go on about the past’. I thought wistfully of my work in places like Broadmoor with patients who, for the most part, recognise that they need help and are willing to put the work in. I never thought David’s resistance to therapy was personal; on the contrary, I had no sense of an attachment to me – or to anyone else. At times I found him both wearing and unpleasant, and as always, I had to note that as interesting and move on.