Moving on to my next post on a psychiatric training rotation some years ago I met Mr L in my first outpatient clinic. He had a huge file and had been in follow up for 20 years. As he came through the door he announced, “That drug therapy the last doctor prescribed isn't working, you know doctor.” Then he sat down and, far from being jaded by the repeated re-telling, launched into a sparkling resumé of his chronic symptoms and worries. My first reaction (a little naive) was to marvel at the renewability of long-standing neurotic illness—the way it could be poured out at any time as if freshly minted.
However, my second reflection was that the institutionally minded field of psychiatry was as much the author of the shape and substance of Mr L's psychiatric career as he was. Every six months for 20 years a new registrar on rotation had listened to his ailments and tinkered with his medication, but little more. I, registrar number 41, resolved to try to shift the paradigm away from psychiatric patienthood and its dependence on doctor legitimated inability to cope towards recovery of functioning and autonomy as an ordinary citizen. Before long he seemed to respond to this new music, and he began to mention the pills less (I wanted to phase these out) and to talk the language of social rehabilitation. Encouraged by this, when the time came for me to move on to my next post I suggested that he continue with me for sessions of reducing frequency (aiming for discharge). He agreed. He saw me twice after I moved, but then he dropped out. I don't doubt that he returned to the old set up and was taken back.
Mr L's opening salvo may be seen as putting the new doctor on his mettle. With hindsight, what might be discerned from our subsequent interactions was an impulse to keep the doctor interested and even a modest optimism that the new doctor might achieve something where a lengthening list of predecessors had failed. He picked up what I wanted to hear and for a while he gave it to me (for a while he may have also have believed some of it himself). But it is hard to give up a way of being embedded over many years, and in the end he decided that the old music, and old dance routines and partners, were better. And thus I imagine that as he came through the door to see registrar number 42 for the first time he announced, “That anti-sick role therapy the last doctor prescribed isn't working, you know doctor.”