‘The American Diagnostic and Statistical Manual.’ He laughed slightly. ‘We call it the bible.’
‘Does he need to be involuntary?’
‘Absolutely. He’d walk out otherwise.’
‘So you’ll put him before the Tribunal? He wants me to hire him a barrister.’
‘He can be represented at the Tribunal by a Legal Aid lawyer for free. And they are better than outside barristers as they know all the ins and outs. But the hearing won’t be till Friday, so you can decide over the next few days.’
‘And his medication?’
Fielding maintained his gentle tone. ‘The antipsychotic will be pushed to settle the psychosis down. I’m sure it’s still there but he’s being canny and denying everything. And as I said to him, the lithium will speed the process up and will be needed in the future. We’ll do a lithium level on Tuesday and then adjust the dose up until it’s in the therapeutic range.’
‘And you have no doubt about the diagnosis? Not just stress? Not the bipolar two type I keep hearing about?’
‘No, it’s pretty straightforward. Bipolar two people are never psychotic and he is, I’m afraid.’
‘And he’s shaking and sweating.’
‘He has no temperature. Shock at coming into the ward and lithium, I believe.’
‘Thanks for everything you’re doing. I’ll go back and spend some time with him.’
SEEDS OF DOUBT
Sarah rang Dave when she got home.
‘It’s all a bit difficult, Dave. Martin is incredibly angry with everyone, including me. You know that he’s forbidden you to visit. He told me to leave twice. I feel so funny when I’m with him. It’s as if I’m with someone else. It’s not Martin.’
‘Have they come to a diagnosis?’
‘The consultant is convinced he has a bipolar one condition and is currently manic.’
‘And how are they treating him?’
‘Olanzapine and lithium.’
‘That’s reasonable enough.’
‘But he has quite a lot of side-effects.’
‘The staff will manage them, Sarah.’
‘Will I get him back, Dave?’
‘What do you mean by that?’
‘I guess I don’t know much about bipolar and he’s such a stranger to me. If he stays like that, it would be so difficult.’ Sarah did not wish to provide details, to state that she could not imagine holding, kissing, and especially sleeping in the same bed with someone so alien. But, most importantly, what if he was not the old Martin but remained someone different? A couple of Geraldine Brooks’ lines came into her mind: the greatest cruelty of madness is it’s power to blot out a person, and after a man goes mad, you struggle to remember him sane.
‘I want him back. I want to see his sunny face again. Hear his carefree laughter.’
‘He’s manic, Sarah, and out of touch with reality. The good thing about having a bipolar condition is that the mania can be treated and controlled. You will get him back.’ Dave paused briefly, his last few words somewhat tremulous, before continuing firmly. ‘We all want him back to his old uncomplicated self, Sarah. Martin is very special.’
A MIND ON THE MEND
By the Tuesday, Martin was more cooperative when he was reviewed by his registrar.
‘How is it all going, Martin?’ Hilary asked.
‘Going implies direction. My life is stationary. There is nothing for me to do here. It’s totally boring.’
‘I notice that you’re speaking more slowly. Less pressured.’
‘You’ve got me zonked out on the meds.’
‘I think it’s more than that.’
‘More zonked?’
‘I mean that I think things are improving.’
‘Things? That’s a generalisation.’
‘Could I ask you about your mother then?’
Hilary observed tears in Martin’s eyes. ‘She’s dead.’
‘So I understand. But how about your thoughts of communicating with her?’
‘She did communicate with me. Always ready to help me. The night I came to this ward I was sitting in the dining room and she shouted urgently at me. To duck my head immediately. I did and seconds later a toaster crashed into the wall in front of me. Thrown by that big bloke who had just been let out of Seclusion.’
‘Yes, that was very disturbing…’
‘But you miss the point. She was looking after me. If I hadn’t ducked I could have had quite a nasty injury.’
‘And now?’
‘She’s stopped talking to me.’
‘How do you explain that?’
Martin made a wry grimace. ‘God moves in mysterious ways.’
‘I do think you are better.’
‘I don’t feel it. I’m agitated and still have the headache. In fact, it’s worse. My bowel movements are just fluid and I’ve got no energy.’
‘They are side-effects of your medications and they should settle soon.’
‘Has my wife organised the barrister?’
‘We haven’t heard. The Legal Aid solicitor will be coming to see you this afternoon.’
‘Tell me about the Tribunal.’
‘There will be three people on it. A lawyer, a psychiatrist and a community representative. I’ll present the reasons as to why we think you should be held in hospital. You’ll see them on a television screen…’
Martin smiled wryly. ‘So if they ask me if the television is communicating with me, how do I answer that without being locked up for a year?’
Hilary sought to deprive his sarcasm of oxygen. ‘They will want to hear what you think about things and your response to my evidence. And then your lawyer will argue your case.’
‘My case is to get out of hospital as soon as possible.’
‘Then that is how you should instruct him.’
Hilary knew that her suggestion was a good sign-off line and excused herself. Martin dropped his head as she walked away.
Wednesday afternoon was Fielding’s official Ward Round, when he assessed and reviewed his allocated patients. Before meeting with Martin, he had a briefing from Hilary and from Martin’s allocated nurse in the nurses station.
‘And how’s Martin going, Hilary?’
‘Really well. I’m a bit flabbergasted in fact as he’s improved so much. He’s still a bit irritable to talk to but not pressured, and no evidence of delusions or hallucinations. His lithium level is nought point four on four fifty so I was thinking of nudging it up a bit. Creatinine and thyroid are fine by the way. He’s been getting two point five of olanzapine in the morning and twenty at night.’
Fielding turned to the nurse. ‘And Bob. Your observations?’
‘He’s definitely improved. As Hilary said, less pressured, and he’s less obnoxious. Less of the “it’s all about me” stuff. But he’s still high. While he spends a lot of time in his room, when he comes out he can be too busy, too much in everyone’s face, still a bit pressured. But no psychotic stuff observed over the last day. As Hilary said, quite a dramatic improvement.’
Fielding smiled. ‘Excellent. Well let’s see him then.’
The three joined Martin in the airing court, each taking a seat on the bench facing him.
‘How are you feeling, Martin?’
‘Better. I remember your name as Fielding.’
‘Please call me Don. So how do you define “better”?’
‘I only have one parameter. Better enough to go home.’
‘You were keen to go back to work?’
‘I’m still keen but I’ve got so many physical symptoms, I wouldn’t be able to do so.’
‘Those side-effects will eventually settle. We’ll also halve the olanzapine soon, possibly even tonight.’
‘And the lithium?’
‘You are going to need to take it or some other mood stabiliser for quite a period.’
Martin chose to be philosophical, aware that his pressuring of the staff had been counterproductive. ‘It is what it is, I g
uess.’
Fielding was struck by Martin’s improvement. He was far less abrasive and provocative. Managing doctors as patients was usually difficult as they tended to have a higher rate of complications. He reciprocated with his key card of magnanimity.
‘Martin, you have improved so much that I don’t think we need to put you before the Tribunal on Friday. If you are OK tomorrow we’ll change your status to voluntary and, if there is a bed on the general ward, we’ll move you there. It’s a little less turbulent.’
Martin smiled wanly. ‘Sounds good. And discharge?’
‘Depends how you go there. Perhaps by the weekend.’
The staff moved away and reviewed their assessment in the station.
Fielding spoke first. ‘I agree, Hilary. A dramatic improvement.’
She responded with respect but with some evident doubt. ‘Perhaps too fast?’
‘Mania usually takes a couple of weeks at best to settle to that degree but I have seen rapid remissions. However, they’re the ones who can drop back into a nasty depression fast.’
Hilary returned to her concern. ‘If not mania, could it be something else?’
‘Well, I did raise the possibility of a psychogenic psychosis when he was admitted, meaning that the psychosis could be a reaction to the extreme stress of his mother’s death. And we’ve excluded a drug-induced psychosis.’ Fielding was comfortable about her challenge. She was a junior trainee. He did not judge it as personal.
Hilary mused. ‘If he’s not got a bipolar one condition then he may not need lithium in the future.’
‘True.’ He thought for a few seconds. ‘Let’s get a second opinion from the prof. Otherwise we stick to the plan. Review tomorrow and, if he’s still in good shape, we’ll transfer him to general and consider discharge in the next few days, either to a private hospital or to home. And Hilary, could you ring his wife and brief her?’
PROFESSING TOO MUCH
The ‘prof’, Professor Saxon Marshall, had a reputation. Several, in fact. At the personal level, he was held in high regard by many, including himself. Other academic colleagues viewed him as arrogant, intimidating and intolerant. Some criticised him as a sermoniser. This reflected his stated commitment to persuade his colleagues that bipolar disorder was a far more common disorder than they acknowledged, was commonly misdiagnosed, even more commonly undiagnosed, and commonly poorly managed. Many argued that he, in turn, over-diagnosed bipolar disorder. ‘What is the definition of a unipolar disorder?’ one professor had asked at a clinical meeting with his eyes glinting. He had waited five seconds to create a sense of expectancy before laughing as he answered himself. ‘A patient who has never been interviewed by Marshall.’
Marshall stated that he would interview Martin in the ward at two p.m. on Thursday afternoon. And that he would like Martin’s wife to be available to assist with any collaborative information.
THE WRITING ON THE WALL
After finishing work on the Wednesday, Sarah had visited Martin at the hospital and she was struck by his improvement. He smiled weakly at her when she walked into his room – a thin remnant of the smile that so defined him – and tentatively hugged her.
‘Thanks for coming, Sar. You’re my only visitor, you know.’
She rubbed his back and then stepped away, to sit on the only seat, after removing his wet towel. She still felt uncomfortable about physical contact with Martin, unsure as to whether he was still occupying a psychotic domain. And there was a second level of discomfort. This man who she had always trusted had betrayed her trust. She had boiled with anger for days about his infidelity but was aware that there was no point expressing it to him at this time. And so she adopted a visitor’s protocol.
‘Dave is keen to visit. You might enjoy seeing him.’
Martin shook his head. ‘No, I don’t want to see Dave.’
Sarah waited for a reason but none was forthcoming.
‘How are you feeling?’ The formal tone would not have escaped Martin.
He shrugged his shoulders. ‘Still crap.’
‘Is there anything I can bring you? Something to read perhaps?’
‘I can’t read, Sar. Eyes are blurry and I can’t concentrate.’
She decided not to run through other options. He would reject any suggestion. ‘The doctors think you have improved a lot.’
Martin simply nodded, offering no judgment. Perhaps a marker of how helpless he felt.
Sarah was not sure why he was so preoccupied. Had he gone back into depression? Was it because he felt so physically unwell? Or perhaps he was experiencing guilt or shame? Feeling uncomfortable, she chose to make it a brief visit.
‘Well, I’ll be here for the interview tomorrow.’ She stood up, and hung his towel on the back of the chair. She gave him a brief and tentative hug and judged that it felt like hugging a bean bag, as Martin simply accepted the hug before falling back onto his bed. He was either still very ill or perhaps trying to elicit her sympathy.
As she drove home she rang Dave on her mobile phone.
‘Dave. The doctors say Martin is improving rapidly.’
‘Excellent news, Sarah. How did you find him?’
‘Well I didn’t think he was that good but…’
‘Don’t read too much into that, Sarah. He’s probably mortified about what has occurred. Trust the doctor’s judgment.’ His voice became brusque. ‘When do you expect to get home?’
‘I’ll be there in a quarter of an hour.’
‘Can I drop by in an hour?’
‘Of course. Is there something wrong?’
‘It’s a practice issue I need to discuss with you.’
‘Oh, OK.’
Sarah walked straight from the garage to the kitchen and poured herself a gin and tonic. Dave had sounded so serious. It would not be a trivial matter. When he arrived she offered him a drink, and he poured himself a large glass of red wine.
‘Thanks for calling about Martin, Sarah. It sounds good.’
‘Yes. A relief, even if a long way to go.’ She hesitated briefly. ‘There’s obviously something pressing, Dave.’
Dave stood up, put his glass on the divider and paced around. He spoke sombrely. ‘When the staff got to work today there was graffiti on the front wall and the reception door had been chiselled with the same words.’
‘And? What words?’
‘Martin Homer. MD. Manic depressive.’
‘Shit!’ exclaimed Sarah before bursting into tears. ‘That woman of course?’
‘I have no doubt. I’ve gone through the CCTV but can’t identify anyone.’
‘Is it still there?’
‘We had the wall cleaned and the door sanded back by mid-morning but, of course, the staff and a number of patients saw it.’
Sarah punched the lounge pillow. ‘Damn, damn, damn!’
Dave spoke slowly. ‘None of the patients raised it with us, so we haven’t needed to give any explanation to them. Some will be concerned and perplexed however and we’ll need to work out how to manage that later. I needed to respond to the staff’s concerns immediately as they were quite discombobulated.’
‘You didn’t tell them that Martin was in a psychiatric hospital?’
‘No.’
‘How did you explain he couldn’t work this week?’
‘Said he wanted to spend a day or two with you after you got back from overseas, and then he’d picked up the chest infection you’d caught on the flight back. That he didn’t want to return to work until he was no longer infectious.’
‘And how did you explain the graffiti to them?’
‘I simply stated that a patient with a personality disorder must have done it for some unclear reason. Essentially, I was stalling for time until we could discuss how to go forward. But then one of the receptionists asked me what manic depression was.’ Dave spread his hands, gesticulating what can I say.
Go forward, thought Sarah. Hackneyed but not inappropriate. If only they could go back. ‘I’ve no idea
what to do, Dave.’
‘It’s up to us, Sarah. We can’t bring Martin into the decision.’
‘Do you think we should tell the staff that he’s had a breakdown?’
‘No. Too many risks.’
‘Your thoughts?’
‘I’d like to paint a few walls after midnight tonight. That Jeff has schizophrenia, Claire has social phobia and I have PTSD. A distraction strategy. Make it look like a nutter has it in for all the doctors.’
‘But?’
‘It’s not fair to the others.’
‘So?’
‘I’ve absolutely no idea. If you have no solution, all we can do is continue to stall. Probably best though if you ring the manager and say Martin won’t be in for another week.’
‘I’ll think of some excuse.’ Sarah punched the cushion again. ‘That Bella woman! What a bitch!’
Dave nodded. ‘She’s a real piece of work.’
INSANITY, INSANITY, INSANITY; ALL IS INSANITY
On mid-morning of the Friday, Martin was transferred to the general ward. It was supposedly less restrictive and it did seem less threatening and dangerous. However, he was not allowed any leave from the ward, not even to have a coffee. He stayed in his bedroom for an hour and then went and sat in the dining room. The occupational therapy morning program had already finished and most of the patients sat where they had had breakfast, now waiting for lunch, boredom evident. A couple of other patients were agitated, with one clearly tortured by his demons, banging on the nurses station door and yelling through the porthole window at the several nurses on duty.
The thought I don’t belong here echoed and echoed in Martin’s head, almost in beat with the shake of his hands.
Martin went outside to the airing court where a few patients paced up and down, all preoccupied. In a gazebo, three men sat somewhat crouched and Martin could smell their cigarettes before they were quickly stubbed out when a nurse caught sight of the blue smoke. One patient quickly walked away, swearing loudly. As he passed, Martin saw amateur tattoos and suspected they had probably been made with potato cuttings when he was in jail. The ward was like any hospital unit with its ratio of ninety per cent boredom and ten per cent code red emergencies – but here the emergencies were due to bursts of violence and psychotic behaviour.
In Two Minds Page 18