In Limbo
Harrison Ford is sitting in front of me in his pyjamas. A small trace of dried spittle runs down his unshaven chin from the left corner of his mouth, bisecting his jaw like the joint of a ventriloquist’s dummy. There are some crumbs of breakfast peppering his pyjama jacket. He seems to have put on weight; the waistband of his pyjamas is now completely concealed beneath a roll of fat, and I’m estimating his breasts to be a B-cup. To be frank, I’ve seen him looking better.
Harrison sits looking down at his fat fingers, which lie moribund in his lap, like sausages displayed in a butcher’s window. He’s withdrawing.
“Good morning, Harrison,” I start. “How are you today?”
Harrison looks up, startled.
“Do you know why you’re here this morning, Harrison?” I ask. Another blank look.
I turn to the young woman sitting next to me.
“Dr Pasquale, we’re here this morning because we want to help Harrison to manage his mental health issues. We’re have these meetings once a week. It’s an opportunity for Harrison to tell us how he is, and for the two of us... the three of us... to discuss ways in which we might move forwards.”
The wording is all chosen deliberately, as is the setting. I do not see patients in the ward, in their beds. The bed is where we see patients who are sick, who need to be cured. The office is where we see patients who have issues, that need to be managed. Of course it’s all bollocks, but the latest NHS diktat, Mental Illness: A Framework for Change, insists on it, and it’s easier to placate the bean counters by playing along with their silly games than it is to fight them. And so we arrange meetings, not consultations, with patients like Harrison, and we pretend to be bank managers discussing overdraft arrangements, except that unlike at the Natwest our customers come in wearing their pyjamas and their breakfast, and smelling of piss.
“Dr Pasquale is our new psychiatric registrar, Harrison,” I say. “Won’t you say hello?”
Harrison looks at Dr Pasquale.
“Yesterday, I woke up...” he begins, in his unmistakably Yorkshire tone, and then stops. He leans forwards towards Dr Pasquale, and with an emphatic nod, says: “...sucking a lemon.” For a moment his eyes bore into her, and then they are gone, back down to the sausages.
Dr Pasquale echoes as she writes: “...sucking a lemon.”
Oh god, I think, she’s one of those.
My suspicions are confirmed later in the day, as we discuss the morning’s case load over a coffee in the doctor’s lounge.
“Harrison Ford... it’s not his real name?” asks Dr Pasquale.
“No, of course not. He just assumed the name, some years ago. He’s obsessed with the real Harrison Ford. His social worker says his flat is plastered with pictures and press clippings of the actor in a variety of roles. During his more florid periods, he’ll even tell you about the time he shagged Carrie Fisher. It’s quite amusing, if you have the time.”
I can tell she doesn’t share my detached enjoyment of the mentally ill.
“Interesting, what he said.” She retrieves her notebook from her pocket. “‘Yesterday I woke up sucking a lemon’. What do you suppose it means?”
“It doesn’t mean anything. He’s a schizophrenic with severe delusions and disturbance of thought. Trying to divine meaning from his random effusions is like trying to read futures from tea leaves, or trying to discover the meaning of life in a cat’s turd. It doesn’t mean anything at all, it’s jibberish. Please don’t fall into that trap of believing we can find a solution through dialogue, as if he’s bloody Northern Ireland. We find a solution through risperidone, increased by a milligram a week until he stops talking bollocks. Then we send him home.”
“Yes, but... a lemon,” she insists. “It’s just so evocative.”
Oh Jesus. She’s been here a week and I hate her already. Her rotation lasts a year at least, how the hell am I going to last? This is the problem with psychiatry; there are those of us who treat it the way it should be treated, as a scientific discipline like any other branch of medicine, and there are those who see it as their calling to save the world through compassion and understanding, one soggy tissue at a time. Sadly, they’re the sort who get on in this job; the monied patrons of private practice are fickle and prefer to be pampered. People who can afford their own consultant psychiatrist don’t want to be told “your head’s wired backwards, take these and come back to see me when the voices stop”, they want to have some emollient quack like Dr Pasquale tell them they’re confused because they caught their dad wanking when they were five, and that they can help.
“Yes, but you see, it isn’t, Dr Pasquale. It might just as easily have been a currant bun, or a dandelion. It means nothing. For god’s sake put the notebook away. You’re a psychiatrist, not a bloody psychology student.”
She folds her book closed with an injured look, and leaves the lounge.
The following week, another Tuesday morning, another meeting with Harrison Ford. This time he’s dressed in baggy grey jogging bottoms and a t-shirt tight enough to make him look like the Michelin Man. Again, he sits and stares at his fat fingers, although today I notice a mild tremor in his hands, and so I write in his notes:
Query iatrogenic parkinsonism? Review meds.
“So, Harrison,” I begin brightly, “how are you feeling today?”
This time there’s nothing. No response at all, he just sits there with his chin resting on the roll of neck-flab, considering his fingers with detachment.
Dr Pasquale is sitting next to me, and she’s got her notebook out. I can tell that she’s dying to ask about the lemons, but we haven’t spoken much since the discussion in the doctor’s lounge and she hasn’t been here long enough to feel that she can flex her muscle by asking him just yet. She’s waiting for me to turn and nod my permission for her to lead. I don’t.
“Harrison?” I say. “How are you feeling?”
Still nothing, although his lips start to move, he’s muttering to himself but so quietly that even in the still of the consulting room I can’t make out a word.
“You’ll have to speak up, Harrison. Dr Pasquale and I can’t hear what you’re saying.”
He shows no sign of having heard me, but slowly his voice gets louder until finally we can make out what he’s saying.
“I’m not here. This isn’t happening. I’m not here. I’m not here.”
He sits and repeats this, over and over. To my left, the sound of a pencil scratching on paper sets my teeth on edge. After fifteen minutes I call time and he shuffles back to the ward.
At our next meeting, Harrison Ford’s tremor is noticeably worse, and yet his thoughts appear no more organised, his eyes no less vacant. We sit, Dr Pasquale and I, observing Harrison with frustration. I am frustrated because the risperidone doesn’t seem to be having any effect besides the drug-induced parkinsonism that is causing the tremor, and the next logical step will be to transfer him to clozapine, the wonder drug with such pernicious side effects that the patient has to submit to regular blood tests to ensure that the drug that’s saving him isn’t killing him at the same time. Needless to say, patient compliance is a big issue with clozapine. I’m not hopeful for Harrison’s future on it.
Dr Pasquale on the other hand is frustrated by what she sees as my refusal to treat Harrison as a human being, when in fact she is just misinterpreting my ability to maintain professional objectivity at all times for something more insidious. This rotation is going to be a long one.
“Harrison, we’re struggling to find a dose of risperidone that suits you. I’d like to move to a newer drug called clozapine. We’ve found it very effective in a number of cases like yours... cases where patients have not responded well to more conventional medicines. How do you feel about that?”
Harrison looks at me. His face is a mask, drained of expression by the side effects he’s suffering.
“You can try the best you can,” he responds, in a monotone that enhances the sense of stoicism.
“Yes,” I reply.
“If you try the best you can, the best you can is good enough,” he says.
“Well, I’m glad you feel that way Harrison. I can assure you that we are trying our very best for you.”
He looks at me, and I can tell from the slight turn of his lips that he’s trying to smile.
Here, sitting in front of me, is a perfect personification of the cruel paradox of modern psychopharmacology. Harrison has a mental illness that places him right on the fringes of acceptable human behaviour, and thus renders him highly stigmatised. His best hope of a cure is through anti-psychotic drugs, all of which to a greater or lesser extent cause this drug-induced parkinsonism, characterised most commonly by a gross paucity of motor control, coupled with localised tremor. In other words, you shuffle along like a zombie, face robbed of its expression, hands trembling, your voice a flat impression of itself. In overcoming your mental illness the drugs have turned you into a classic stereotype of what Joe Public would think of as a textbook nutter. And so the stigma remains, and you’re pushed out and stared at in either case.
After Harrison has left the room, Dr Pasquale sits down and types at the computer for a few moments. Then she turns and takes out her notebook. She has the air about her of someone who has resolved to move past a sticking point, and I suspect that we are about to talk citrus.
“You have to admit, he has a turn of phrase that sets him apart from most of the patients here,” she says. “He doesn’t say a lot, but what he does say... it’s almost like poetry.”
“Well, give enough monkeys enough typewriters...” I say, trying to disguise my irritation as distraction.
“I mean, it’s almost too poetic. Don’t you think?” she persists.
“What are you getting at?” I ask. There’s something in her voice that hints at an impending revelation.
“I was talking to my boyfriend a couple of nights ago, and I mentioned that we had a patient whose ramblings were at times quite striking. I gave an example: ‘Yesterday I woke up...’, and he completed it for me. He said ‘sucking a lemon’.” She lets this hang for a moment, like a schoolboy flourishing a chicken’s foot in assembly, waiting for the reaction.
“Does he have mental health issues, your boyfriend?” I ask, pointedly. “Perhaps they’ve done time together?”
Dr Pasquale ignores my cheap dig. “When I asked him how he knew, he laughed his head off. Said he didn’t know, it was just the first thing that popped into his head. It was a song lyric, he thought. After a few minutes he picked up the tune, and started wandering around the flat trying to identify it. ‘Yesterday I woke up sucking a le-mon, yesterday I woke up sucking a le-mon... it’s Radiohead!... everything... everything... that’s it! It’s Everything In It’s Right Place, by Radiohead.’
“We looked it up, and he was right. So the last time we saw Harrison, I made a note of what he said that time too. Do you remember what it was?”
“No, I don’t,” I say, resignedly. An apology looms.
She consults her notes. “Harrison repeated over and over: ‘I’m not here. This isn’t happening. I’m not here. I’m not here.’ It’s a line from How To Disappear Completely, by...?”
“Radiohead?” I ask, miserably.
“Correct!” she says. “Same album as the other one, Kid A.”
“And today’s utterings?” I ask.
“I just looked them up,” she says, indicating the computer. “I put ‘Radiohead lyrics the best you can is good enough’ into Google. It’s Optimistic, by Radiohead. Also from Kid A.”
I breath a heavy sigh. “For fuck’s sake.”
Twenty minutes later, after further discussion and a little more Googling, we enter the ward and find Harrison sitting motionless in front of the TV.
“Where’d you park the car?” I ask him.
He turns to look at me, and even through the risperidone mask I can tell he knows he’s been found out.
“Where’d you park the car?” I repeat. And with that, he stands and shuffles to his bed.
He leaves the hospital later that day, with no medication.
“My first Munchausen’s!” says Dr Pasquale, with some degree of pleasure.
“Fascinating, isn’t it?” I ask. “And Harrison’s a textbook case; he’s been coming here on and off for years, and all this time...” I trail off, before I incriminate myself any further.
“He needs psychiatric attention though?” she asks.
“Undoubtedly. But he doesn’t need risperidone and he doesn’t need a hospital bed.”
“No, I don’t suppose he does.”
“You know, there’s plenty of literature out there; look up Sherringham and Tweed on Medline if you’re interested, they’ve done plenty of work on Munchausen’s. They feign any kind of illness, but you have to admit there’s something elegantly reflective to a Munchausens patient feigning a mental illness.”
She nods her agreement, then adds, “I wonder if one could feign Munchausen’s? How would you unravel that? Might it recurse endlessly?”
“Dr Pasquale, you’re a psychiatrist, not a bloody philosopher,” I remind her, and her smile indicates that she gets the reference.
“Good catch,” I say, as I leave.
Harrison sits looking down at his fat fingers, which lie moribund in his lap, like sausages displayed in a butcher’s window. He’s withdrawing.
“Good morning, Harrison,” I start. “How are you today?”
Harrison looks up, startled.
“Do you know why you’re here this morning, Harrison?” I ask. Another blank look.
I turn to the young woman sitting next to me.
“Dr Pasquale, we’re here this morning because we want to help Harrison to manage his mental health issues. We’re have these meetings once a week. It’s an opportunity for Harrison to tell us how he is, and for the two of us... the three of us... to discuss ways in which we might move forwards.”
The wording is all chosen deliberately, as is the setting. I do not see patients in the ward, in their beds. The bed is where we see patients who are sick, who need to be cured. The office is where we see patients who have issues, that need to be managed. Of course it’s all bollocks, but the latest NHS diktat, Mental Illness: A Framework for Change, insists on it, and it’s easier to placate the bean counters by playing along with their silly games than it is to fight them. And so we arrange meetings, not consultations, with patients like Harrison, and we pretend to be bank managers discussing overdraft arrangements, except that unlike at the Natwest our customers come in wearing their pyjamas and their breakfast, and smelling of piss.
“Dr Pasquale is our new psychiatric registrar, Harrison,” I say. “Won’t you say hello?”
Harrison looks at Dr Pasquale.
“Yesterday, I woke up...” he begins, in his unmistakably Yorkshire tone, and then stops. He leans forwards towards Dr Pasquale, and with an emphatic nod, says: “...sucking a lemon.” For a moment his eyes bore into her, and then they are gone, back down to the sausages.
Dr Pasquale echoes as she writes: “...sucking a lemon.”
Oh god, I think, she’s one of those.
My suspicions are confirmed later in the day, as we discuss the morning’s case load over a coffee in the doctor’s lounge.
“Harrison Ford... it’s not his real name?” asks Dr Pasquale.
“No, of course not. He just assumed the name, some years ago. He’s obsessed with the real Harrison Ford. His social worker says his flat is plastered with pictures and press clippings of the actor in a variety of roles. During his more florid periods, he’ll even tell you about the time he shagged Carrie Fisher. It’s quite amusing, if you have the time.”
I can tell she doesn’t share my detached enjoyment of the mentally ill.
“Interesting, what he said.” She retrieves her notebook from her pocket. “‘Yesterday I woke up sucking a lemon’. What do you suppose it means?”
“It doesn’t mean anything. He’s a schizophrenic with severe delusions and disturbance of thought. Trying to divine meaning from his random effusions is like trying to read futures from tea leaves, or trying to discover the meaning of life in a cat’s turd. It doesn’t mean anything at all, it’s jibberish. Please don’t fall into that trap of believing we can find a solution through dialogue, as if he’s bloody Northern Ireland. We find a solution through risperidone, increased by a milligram a week until he stops talking bollocks. Then we send him home.”
“Yes, but... a lemon,” she insists. “It’s just so evocative.”
Oh Jesus. She’s been here a week and I hate her already. Her rotation lasts a year at least, how the hell am I going to last? This is the problem with psychiatry; there are those of us who treat it the way it should be treated, as a scientific discipline like any other branch of medicine, and there are those who see it as their calling to save the world through compassion and understanding, one soggy tissue at a time. Sadly, they’re the sort who get on in this job; the monied patrons of private practice are fickle and prefer to be pampered. People who can afford their own consultant psychiatrist don’t want to be told “your head’s wired backwards, take these and come back to see me when the voices stop”, they want to have some emollient quack like Dr Pasquale tell them they’re confused because they caught their dad wanking when they were five, and that they can help.
“Yes, but you see, it isn’t, Dr Pasquale. It might just as easily have been a currant bun, or a dandelion. It means nothing. For god’s sake put the notebook away. You’re a psychiatrist, not a bloody psychology student.”
She folds her book closed with an injured look, and leaves the lounge.
The following week, another Tuesday morning, another meeting with Harrison Ford. This time he’s dressed in baggy grey jogging bottoms and a t-shirt tight enough to make him look like the Michelin Man. Again, he sits and stares at his fat fingers, although today I notice a mild tremor in his hands, and so I write in his notes:
Query iatrogenic parkinsonism? Review meds.
“So, Harrison,” I begin brightly, “how are you feeling today?”
This time there’s nothing. No response at all, he just sits there with his chin resting on the roll of neck-flab, considering his fingers with detachment.
Dr Pasquale is sitting next to me, and she’s got her notebook out. I can tell that she’s dying to ask about the lemons, but we haven’t spoken much since the discussion in the doctor’s lounge and she hasn’t been here long enough to feel that she can flex her muscle by asking him just yet. She’s waiting for me to turn and nod my permission for her to lead. I don’t.
“Harrison?” I say. “How are you feeling?”
Still nothing, although his lips start to move, he’s muttering to himself but so quietly that even in the still of the consulting room I can’t make out a word.
“You’ll have to speak up, Harrison. Dr Pasquale and I can’t hear what you’re saying.”
He shows no sign of having heard me, but slowly his voice gets louder until finally we can make out what he’s saying.
“I’m not here. This isn’t happening. I’m not here. I’m not here.”
He sits and repeats this, over and over. To my left, the sound of a pencil scratching on paper sets my teeth on edge. After fifteen minutes I call time and he shuffles back to the ward.
At our next meeting, Harrison Ford’s tremor is noticeably worse, and yet his thoughts appear no more organised, his eyes no less vacant. We sit, Dr Pasquale and I, observing Harrison with frustration. I am frustrated because the risperidone doesn’t seem to be having any effect besides the drug-induced parkinsonism that is causing the tremor, and the next logical step will be to transfer him to clozapine, the wonder drug with such pernicious side effects that the patient has to submit to regular blood tests to ensure that the drug that’s saving him isn’t killing him at the same time. Needless to say, patient compliance is a big issue with clozapine. I’m not hopeful for Harrison’s future on it.
Dr Pasquale on the other hand is frustrated by what she sees as my refusal to treat Harrison as a human being, when in fact she is just misinterpreting my ability to maintain professional objectivity at all times for something more insidious. This rotation is going to be a long one.
“Harrison, we’re struggling to find a dose of risperidone that suits you. I’d like to move to a newer drug called clozapine. We’ve found it very effective in a number of cases like yours... cases where patients have not responded well to more conventional medicines. How do you feel about that?”
Harrison looks at me. His face is a mask, drained of expression by the side effects he’s suffering.
“You can try the best you can,” he responds, in a monotone that enhances the sense of stoicism.
“Yes,” I reply.
“If you try the best you can, the best you can is good enough,” he says.
“Well, I’m glad you feel that way Harrison. I can assure you that we are trying our very best for you.”
He looks at me, and I can tell from the slight turn of his lips that he’s trying to smile.
Here, sitting in front of me, is a perfect personification of the cruel paradox of modern psychopharmacology. Harrison has a mental illness that places him right on the fringes of acceptable human behaviour, and thus renders him highly stigmatised. His best hope of a cure is through anti-psychotic drugs, all of which to a greater or lesser extent cause this drug-induced parkinsonism, characterised most commonly by a gross paucity of motor control, coupled with localised tremor. In other words, you shuffle along like a zombie, face robbed of its expression, hands trembling, your voice a flat impression of itself. In overcoming your mental illness the drugs have turned you into a classic stereotype of what Joe Public would think of as a textbook nutter. And so the stigma remains, and you’re pushed out and stared at in either case.
After Harrison has left the room, Dr Pasquale sits down and types at the computer for a few moments. Then she turns and takes out her notebook. She has the air about her of someone who has resolved to move past a sticking point, and I suspect that we are about to talk citrus.
“You have to admit, he has a turn of phrase that sets him apart from most of the patients here,” she says. “He doesn’t say a lot, but what he does say... it’s almost like poetry.”
“Well, give enough monkeys enough typewriters...” I say, trying to disguise my irritation as distraction.
“I mean, it’s almost too poetic. Don’t you think?” she persists.
“What are you getting at?” I ask. There’s something in her voice that hints at an impending revelation.
“I was talking to my boyfriend a couple of nights ago, and I mentioned that we had a patient whose ramblings were at times quite striking. I gave an example: ‘Yesterday I woke up...’, and he completed it for me. He said ‘sucking a lemon’.” She lets this hang for a moment, like a schoolboy flourishing a chicken’s foot in assembly, waiting for the reaction.
“Does he have mental health issues, your boyfriend?” I ask, pointedly. “Perhaps they’ve done time together?”
Dr Pasquale ignores my cheap dig. “When I asked him how he knew, he laughed his head off. Said he didn’t know, it was just the first thing that popped into his head. It was a song lyric, he thought. After a few minutes he picked up the tune, and started wandering around the flat trying to identify it. ‘Yesterday I woke up sucking a le-mon, yesterday I woke up sucking a le-mon... it’s Radiohead!... everything... everything... that’s it! It’s Everything In It’s Right Place, by Radiohead.’
“We looked it up, and he was right. So the last time we saw Harrison, I made a note of what he said that time too. Do you remember what it was?”
“No, I don’t,” I say, resignedly. An apology looms.
She consults her notes. “Harrison repeated over and over: ‘I’m not here. This isn’t happening. I’m not here. I’m not here.’ It’s a line from How To Disappear Completely, by...?”
“Radiohead?” I ask, miserably.
“Correct!” she says. “Same album as the other one, Kid A.”
“And today’s utterings?” I ask.
“I just looked them up,” she says, indicating the computer. “I put ‘Radiohead lyrics the best you can is good enough’ into Google. It’s Optimistic, by Radiohead. Also from Kid A.”
I breath a heavy sigh. “For fuck’s sake.”
Twenty minutes later, after further discussion and a little more Googling, we enter the ward and find Harrison sitting motionless in front of the TV.
“Where’d you park the car?” I ask him.
He turns to look at me, and even through the risperidone mask I can tell he knows he’s been found out.
“Where’d you park the car?” I repeat. And with that, he stands and shuffles to his bed.
He leaves the hospital later that day, with no medication.
“My first Munchausen’s!” says Dr Pasquale, with some degree of pleasure.
“Fascinating, isn’t it?” I ask. “And Harrison’s a textbook case; he’s been coming here on and off for years, and all this time...” I trail off, before I incriminate myself any further.
“He needs psychiatric attention though?” she asks.
“Undoubtedly. But he doesn’t need risperidone and he doesn’t need a hospital bed.”
“No, I don’t suppose he does.”
“You know, there’s plenty of literature out there; look up Sherringham and Tweed on Medline if you’re interested, they’ve done plenty of work on Munchausen’s. They feign any kind of illness, but you have to admit there’s something elegantly reflective to a Munchausens patient feigning a mental illness.”
She nods her agreement, then adds, “I wonder if one could feign Munchausen’s? How would you unravel that? Might it recurse endlessly?”
“Dr Pasquale, you’re a psychiatrist, not a bloody philosopher,” I remind her, and her smile indicates that she gets the reference.
“Good catch,” I say, as I leave.
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