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The wisdom of Paulo Coelho:

“One always has to know when a stage comes to an end. If we insist on staying longer than the necessary time, we lose the happiness and the meaning of the other stages we have to go through.
Closing cycles, shutting doors, ending chapters – whatever name we give it, what matters is to leave in the past the moments of life that have finished.

Did you lose your job? Has a loving relationship come to an end? Did you leave your parents’ house? Gone to live abroad? Has a long-lasting friendship ended all of a sudden?
You can spend a long time wondering why this has happened.

You can tell yourself you won’t take another step until you find out why certain things that were so important and so solid in your life have turned into dust, just like that.
But such an attitude will be awfully stressing for everyone involved: your parents, your husband or wife, your friends, your children, your sister.
Everyone is finishing chapters, turning over new leaves, getting on with life, and they will all feel bad seeing you at a standstill.

Things pass, and the best we can do is to let them really go away.
That is why it is so important (however painful it may be!) to destroy souvenirs, move, give lots of things away to orphanages, sell or donate the books you have at home.

Everything in this visible world is a manifestation of the invisible world, of what is going on in our hearts – and getting rid of certain memories also means making some room for other memories to take their place.
Let things go. Release them. Detach yourself from them.

Nobody plays this life with marked cards, so sometimes we win and sometimes we lose.
Do not expect anything in return, do not expect your efforts to be appreciated, your genius to be discovered, your love to be understood.

Stop turning on your emotional television to watch the same program over and over again, the one that shows how much you suffered from a certain loss: that is only poisoning you, nothing else.

Nothing is more dangerous than not accepting love relationships that are broken off, work that is promised but there is no starting date, decisions that are always put off waiting for the “ideal moment.”

Before a new chapter is begun, the old one has to be finished: tell yourself that what has passed will never come back.
Remember that there was a time when you could live without that thing or that person – nothing is irreplaceable, a habit is not a need.
This may sound so obvious, it may even be difficult, but it is very important.

Closing cycles. Not because of pride, incapacity or arrogance, but simply because that no longer fits your life.

Shut the door, change the record, clean the house, shake off the dust.
Stop being who you were, and change into who you are.”

It’s become a ‘thing’.

For a thousand days I wrote every day. It wasn’t a ‘thing’. That’s just what I did. I didn’t worry about who read it and why. It didn’t matter how good or bad it was. I just did it. Then I slowed down to writing roughly once a week.

Now, I think about writing. I talk about writing. I look up ‘writing’ on the internet. I consider on-line courses. I buy books on writing. I worry about writing well. I listen to podcasts of interviews with famous writers. I am on the lookout for writing tips in newspapers and magazines. I wonder what it must feel like to write properly every day. I envy those who can. What I do very little of, is write. I believe I repeat myself endlessly. I say the same things again and again. I forget things that are important. I hardly know any juicy big words. Why would anyone be interested in what I have to say? English is my second language and I can’t fully express myself in it anyway. My imagination is limited. I haven’t read enough books. I have no writing qualifications. Ms Confidence has evaporated and Mr Self Doubt has surreptitiously crept into her space in the vacant apartment of my psyche.

One ‘expert’ on you-tube suggested the way forward is to just write 3 full A4 sheets every day. She said,”… best not to think too much. Just put down on paper whatever comes to mind”. She called it a ‘brain dump’. She promised that over time it would start to make sense. It would become a story in your voice.

Maybe it’s time to go back to writing everyday. Maybe it’s time to start  my “big fat” book 🙂

PS: My favourite book on writing is ‘On Writing Well‘ by William Zinsser.

 

Confidentiality versus Life

Three years back I joined a club no one wants to be a member of. I became a parent who lost their beautiful child to suicide. He was 20. I didn’t think it was possible. I trusted his doctors to take good care of him. I trusted they would tell me if there was a real risk of him dying, given I am his mother and was his prime carer. I thought they had the expertise to identify and address ‘crisis’ when they saw it. Suicide was not in the script. It was not supposed to happen. I turn the fact of his sudden traumatic death over and over in my head and it makes no sense.

There are hundreds of distraught and bewildered members of this club. Common themes emerge from their stories. The commonest one is:

“They knew our child wanted to end his/her life but they didn’t tell us anything about it.”

Who are they?
Decision makers – Medics. Universities.

Why?
Because he/she is over 18, hence, technically an adult.
Their ‘confidentiality’ is paramount.

Is it?
Is it more important than helping them stay alive?

The Hippocratic oath states:
“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

According to experts[1], these are the essential components of an effective suicide prevention safety plan:

  1. Discussing the reasons for living
  2. Safe environment
  3. Identify distress triggers
  4. Removing ways to harm yourself
  5. Activities to calm/lift mood or distract
  6. Contacts for general support
  7. Specific suicide prevention support
  8. Professional support
  9. Emergency contact details
  10. Personal commitment to follow safety plan

Most of the above cannot be implemented without the help of carers and families if the person in question is seriously unwell. This has been recognised by the Department of Health, Royal Colleges of Psychiatrists, GPs and Nursing along with The British Association of Social Workers and The British Psychological Society. Together they published a consensus statement entitled[2] “Information Sharing and Suicide Prevention” in 2014, the same year that my son, Saagar Naresh[3] passed away. It clearly states that practitioners should disclose information to an appropriate person or authority if this is necessary to protect a child or young person from risk of death or serious harm.

“If the purpose of the disclosure is to prevent a person who lacks capacity from serious harm, there is an expectation that practitioners will disclose relevant confidential information, if it is considered to be in the person’s best interest to do so.”

This is still not being practised. The world of medicine is a conservative and defensive one. Until the regulatory bodies, NHS Trusts and the Government come forward to reassure practitioners that their decision to share information appropriately will be supported by them, nothing will change.

While the world carries on, innocent youngsters die from lack of support and understanding from the very people who are best placed to help them. PAPYRUS, a UK charity dedicated to prevention of young suicides[4] demands that information be appropriately shared with carers and families by all who take care of vulnerable young people at risk of suicide.

Confidentiality versus Life. It’s a no-brainer.

References:

[1] https://www.healthcareconferencesuk.co.uk/news/newsfiles/alys-cole-king_1219.pdf

[2] https://www.bl.uk/britishlibrary/~/media/bl/global/social-welfare/pdfs/non-secure/i/n/f/information-sharing-and-suicide-prevention-consensus-statement.pdf

[3] www.kidsaregifts.org

[4] PAPYRUS (https://www.papyrus-uk.org/)

Treatment versus Care

In her entry to this year’s BMA News Writing Competition, a consultant psychiatrist relates the experience of her postpartum psychosis and explains that, although grateful for her treatment, something was missing from the care she received.

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The Human Factor

I am a consultant psychiatrist. Two years ago, I had a taste of my own medicine.

Three sleepless nights after the birth of my daughter, I became acutely ill. I slowly realised I couldn’t sleep — something strange was happening. Within six hours, I was experiencing a kaleidoscope of symptoms — elation, fear, heightened senses, delusions. I wanted to kill myself and my daughter.

Postpartum psychosis is a medical emergency and a consultant perinatal psychiatrist was at my house within the hour. I literally ran to her ward in my socks, my mum running behind, having forgotten her shoes too.

My first night was terrifying, but the staff were fantastic. As I rode an emotional rollercoaster, they reassured me, calmed me, gave me the sedation I desperately needed. Soon, I settled into a mild mania. Though at times it was very scary, I was fascinated. I noted with curiosity how my brain behaved. I felt great love for my daughter, and beneficence for my fellow man. I enjoyed all the activities the ward had to offer.

Five weeks later I was happily home. But what goes up, must come down. Gradually, I became unsettled, filled with self-doubt. I became convinced my baby was autistic. The anxiety became intense, and I considered suicide. My consultant coaxed me into hospital again. ‘It will only be two weeks,’ she promised. ‘I think you need to start lithium.’

You cannot breastfeed on lithium. One day I was connected with my baby, the next she fed from a bottle. My heart broke as my breasts filled to burst. It was a symbolic change, from wonderful to awful. She smelled wrong, artificial. I began a tiresome regimen of sterilising, preparing and cooling bottles, when all the while my baby yelled, to my great shame. As if in protest, she vomited spectacularly after every feed.

This time, the ward seemed an unfriendly place; swelteringly hot, noisy, tedious, excessively rule-bound. The other patients seemed uninteresting and depressing. My eldest son was bewildered: he wasn’t allowed on the ward. Why wasn’t mummy coming home? He became rejecting and oppositional. My heart broke some more.

I begged for leave but developed extreme insomnia and could not get well. I remember one night getting up, sitting down, and getting up again for seven hours, unable to decide whether to wake my baby for a change. A burly nurse was recruited to force me unceremoniously to move to a room near the nurses. I was told I would be sectioned if I tried to leave. An informal patient, I was allowed out for only half an hour each day.

I told my consultant I wasn’t depressed, her ward was the problem. ‘You’re depressed’ she repeated, implacably, and brought in a second-opinion doctor. I was desperate to leave as soon as I arrived, yet those two weeks became two months.

Having a mental illness is one of the most disturbing and frightening experiences one can ever have. The rug is truly pulled out from under your feet. Suddenly you are somehow lesser, rendered powerless. I was one of the lucky ones. I knew what was happening, and was more able than most to speak up for myself. I got treated very quickly. Many don’t.

My consultant was a former colleague of mine, a peer. She was kind but paternalistic, and my care became a battle of wills. She believed her plan was faultless and that her ward was entirely beneficial. She conducted her ward rounds like job interviews and treated me like an adolescent. I watched helplessly as she pathologised my normal behaviour and denied promises to get me to comply.

We were fragile mothers, but were often shamed like naughty children for not ‘doing the right thing’, sometimes berated across the ward for all to hear by opinionated nursery nurses with little sensitivity to our mental state. Mothering a screaming baby during an intense crisis of confidence was a tortuous task, yet it was rarely considered that our babies were exacerbating the problem. Scared and disturbed women were managed by intimidating rapid response teams.

I lost trust in them, I hid symptoms. One night I nearly killed myself but never told.

I now can understand how my patients feel when they say they no longer want to go back to ‘that place’. How lack of insight guides them away from reminders of restraint, coercion, scrutiny and endless questions. How it is difficult to trust people who don’t treat you as fully human.

Despite all the positives and the expertise in my care, an important element was missing. Care needs to be more than medication, therapies and keeping people safe. Now I’ve had a taste of my own medicine, I always ask: ‘What is this like for you, what do you really need to help you get well?’

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A life sentence.

The best part of being human is to be able to feel stuff. All kinds of stuff. The world seems to be forever in pursuit of happiness in more money, more holidays, more clothes, more children and so on. The elusive ‘happiness’ is put on hold until the ‘more’ arrives, soon to be followed by more ‘more’.

In a week, it will be 3 years since Saagar died. For days I have been feeling this day approaching like a huge oil tanker which is going to squash my dinky little boat. This inauspicious day should be removed from all calendars everywhere for all the years ahead. It should be obliterated, erased, deleted and destroyed.

I think back on this time three years ago, trying to understand how Saagar must have felt. I try to find words for the thoughts and feeling that he could not verbalise. I lament the fact that no one could read his body language. I admire him for coping with his state of mind with patience and dignity. I look at his face-book post from this night. It was a full moon. He said ‘big ass moooooon innit”. I marvel at his ability to appreciate beauty. I remember how funny he was. I get a smile on my face. I promise myself never to take one moment of those 20 years for granted. Each of them was a blessing. Yes. It’s true that this feels like a life-sentence sometimes. Yet, I know I am blessed.

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“The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.”
― David Foster Wallace

 

If all the world’s a stage…it has props.

downloadIn the background stands a majestic Palladian structure in brick red. It’s nearly 400 years old. The artistic roof displays beautiful finials, turrets and cupolas. It’s easy to imagine the large atria and sweeping staircases on the inside. It appears as if this building emerges from an expansive lush green sea.

The cricket nets are placed to the right of this building. Many hours have been spent here, laughing, picnicking, practising, talking, spectating and playing. Multiple recordings of his bowling action have been made here, each scrutinised to the nth degree by him. Each one distinct to his discerning eyes but all identical, to my lay ones.

In the fore-ground sits a TV screen with ‘Friends’ playing. He likes Rachel. I think she plays the role of who she is in real life. Not much acting ability required for that. He doesn’t understand that. He thinks I don’t like her. I like Phoebe. We both love ‘Smelly cat’. He watches it when he is down. I see why. However feeble, it always brings a smile to his face as it does to mine now. However predictable, it doesn’t fail to amuse, to lighten the heart. The impression of a head is clearly formed on the red velvet cushion resting at the corner of a black leather sofa.

At centre-stage, a pink and silver drum-kit sits atop a hand woven black and white Moroccan rug.  2 goblet drums wait in the wings – a Djembe and a Darbuka. A set of initialled drum-sticks read ‘SN’. Big round black bags lean against the wall. They weigh half a tonne. They encase special cymbals – presently silent but given half a chance, fully capable to raising the roof of not just our house but also that of the neighbours.

A fake snake coils on the study table with its tail realistically hanging off the edge. It has been used successfully to blow the living day-lights out of people of all ages, shapes and forms, on many occasions. It took me 2 years to immunise myself against it.

An unwieldy ragged cricket bag with wheels at one end lazes against the wall. One entire shelf in the cup-board is dedicated to cricket gloves, balls and other paraphernalia.

The sun streams in from 2 big sky-lights and the space is lit like a sanctuary. A silver Apple Mac laptop lies gaping on the study table with funny cat-videos playing. It’s connected to the dome of Harman Kardon speakers which hide under the table.  An assortment of coins, head-phones and keys splash across the dark wood table top. A few coffee mugs are scattered around the room with various shades and degrees of dry brown coffee lining the insides.

Behind the door is an overflowing willow laundry basket. A pair of union-jack boxer shorts shine through. The space smells of an unkempt temple with a male caretaker –  hints of incense, musk and testosterone. From the door hook hangs a towelled maroon dressing gown.

All the props are here, tell-tale signs of a life. Where’s the main man? At a subtle level, his absence is only physical. His essence is present.

It’s in all the props, in the air around them, in the luminosity of the room, in everyone he touched, made jokes with, played music with, was kind to and loved. In the glow in my eyes, the light in my heart. In me.

His essence is here. I only need to close my eyes. This must be immortality.

“Do you not know that a man is not dead while his name is still spoken?”                              – Terry Pratchett

(Ref: A fully referenced, peer reviewed article published in an educational, medical  journal for GPs; a case study of a young man called SN to demonstrate the importance of Suicide prevention training and the role of human factors in patient safety: http://journals.sagepub.com/doi/full/10.1177/1755738017724183.)

Non-writer’s Block

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Brindisa, a Spanish Tapas Bar sits at one corner of Borough Market. I sit at the window at one corner of Brindisa, sipping hot chocolate after a long day at work. A wee treat. It’s raining just short of cats and dogs. Umbrellas are out in all their colours and varying degrees of wind-induced angular crookedness. Hoods are up and hair flying off scalps at funky angles. Some walk hunched and shrunk, others wear big smiles, facing the sky. Many pairs of crisp city shoes step off the kerb and dunk straight into puddles. Squelch. Squelch. Squelch.

The last few weeks of writing less traverse my mind. In the first week, that vacant hour seemed contrived – like a designer hole in the evening. I strapped myself in a brace of immobility, letting it pass, pretending I wasn’t watching. On a couple of occasions I was desperate enough to turn to the TV for help. It felt unnatural and abrupt to break the rhythm of writing every day. I had a non-writer’s block. I knew it was coming but it was more unwelcome than I thought it would be. It made me feel like I was being denied the sweets I loved. I felt redundant. I thought of Saagar and missed him more than normal, if that’s possible.

The second week was a week of late nights – emergency surgeries at work, friends visiting from abroad, reading an ‘unputdownable’ book. Sleep and energy deficit was huge. There was no time to think or write. An e-mail came as a reminder that the last of 36 instalments towards the payment for my bike had been made. Yes. I got it in July that year. Saagar helped me with setting the height of the seat, inflating the tyres and oiling the chain. He worried about me cycling on London roads. He was an avid cyclist. Once a female driver of a car nearly hit him because she was on her mobile phone. She apologised to him. He used to answer my phone when I drove. He also used to answer my text messages. He felt strongly about mobile phone use by drivers. He hated that we lived on a hill. The last bit of the bike ride home was hard for him, as it is for me but I am getting used to it. One e-mail and a barrage of memories!

The third week was quiet. Cats. Music. Food. Candles adorning Saagar’s picture. Time to record a podcast with an eminent Consultant Psychiatrist, Dr Dele Olajide. Lots of cycling. Sleeping. Si and I pottering around the kitchen. I wash the spinach and he wilts it. He clears up the sink, I put the dishes away. Si boils the kettle, I prepare the mint for the tea. We dance our culinary waltz and Milkshake sits as a spectator on the upper stall of the kitchen island. In the pauses between ‘doings’ we dance. We rejoice, we dance, we create new memories. 

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