Chapter 5 - Losing the Plot

One day in late 1983, I was sitting in a room in Rubery Hill Hospital, a former asylum in Birmingham, just up the road from the old British Leyland car plant. I was undergoing the clinical examination for membership of the Royal College of Psychiatrists. The man seated opposite me had just told me how he'd been arrested for 'stealing body shells'. Of course, I didn't know what a body shell was and it took me a while to realise that it was something to do with manufacturing a car rather than connected to science fiction.

'I can't help you any more, doctor,' he said through his nose in a thick Brummie accent.

One part of me felt inclined to tell him that he could not have been of any less help even if he had tried, but I didn't want to appear churlish. He had volunteered to take part in the clinical examination, and perhaps he really didn't have a clue why he had been admitted to this desolate and dreary place.

Then there was a knock on the door and somebody shouted, 'Time's up.'

I followed the young man up the corridor to a dusty room lit obliquely from a high window, and furnished only with a table and two hardback chairs, like those rooms used for prison visits that you see in films. Outside, the sun was struggling to escape from the clouds. The light illuminated a shard of dust suspended in the air above us. I tried to convince myself that my companion had a sympathetic expression on his face, but all I could see in his eyes was pity as he took in my bright, red wool crepe suit. I had bought it on impulse in the sale at Kendal's department store in Manchester two years before, in one of those rare moments when red seems like a good idea. It was the only suit I owned and it felt completely wrong. I knew I should have really worn black; not only did I always feel more comfortable in black, but it would have been better suited to my funereal mood.

'You have fifteen minutes to prepare yourself and then we'll call you in.' He stepped out then put his head back around the door. 'They are running on time.'

Just 15 minutes to summarise my notes and put together my formulation of the case. Differential diagnosis (a discussion of all the possible conditions this might be), musings on 'aetiology' (causes of the condition), any investigations I thought were required, a comprehensive management plan (immediate, short-term and long-term; psychological, physical and social aspects of treatment) and not forgetting the likely prognosis.

After what seemed like a very short time later, I entered the examiners' room. Two square-shouldered and suited middle-aged men, seated behind a table, were chatting to each other but fell into silence as I slumped into the chair opposite. I did not recognise either of them and they did not introduce themselves. They wore the universal uniform of British male hospital consultants: pin-striped suits and sensible ties. Not a hint of red. I presented the case to them, going through my formulation, and they both looked at me with quizzical expressions which suggested that they thought I was really making it all up as I went along. This was strange, as I proposed to them that the patient I had interviewed might have been fabricating too. I muttered something about the Ganser syndrome, a state in which people give 'approximate' or nonsensical answers to questions in order to appear to be mad.

Ganser, a German psychiatrist, first described it while working at a prison where he came across three men apparently pretending to be psychotic, probably in order to avoid taking responsibility for their crimes. Classically, the patient replies with answers which indicate that they have indeed understood the question and wilfully misunderstood it in giving their answer. The example I always remember goes something like:

Question: 'How many legs does a sheep have?'

Answer: 'Three, doctor.'

Meanwhile, I was providing my own version of approximate answers.

'Are you quite certain this is your preferred diagnosis?' the examiners asked.

They exchanged knowing glances.

Whatever I was doing or saying was clearly not what they wanted to hear. There was a pregnant pause, after which they both turned to face me and one of them opened his mouth to speak – and my heart stopped beating.

'Well, thank you very much, doctor. You can go now.'

And then it was over. I knew I had failed the Membership Examination of the Royal College of Psychiatrists as clearly as if I had walked out of a written exam after handing in a blank sheet of paper.

We drove back up to Manchester in the fading daylight along the M6. Winter was approaching fast. It was rush hour and the traffic dragged around Spaghetti Junction like red blood cells congealing in a hardened artery. Catherine, my colleague who had also taken the examination, chattered away while she was driving, as though she really believed I was listening. And I was, in a manner of speaking, but the negative voices in my own head were far more compelling than usual.

This is it. You've done it now.

What? What have I done?

You've proved yourself.

How have I proved myself when I know I've failed?

Who said you had to succeed! No, you've proved you really don't have what it takes to do it. You've been found out. It's only a matter of time now.

Perhaps this was really as far as I was going to go in my career in psychiatry. I had only achieved what I had so far under false pretences, by pretending to be competent.

I had been feeling increasingly anxious for some time. Three months before I took the examination in Birmingham, in the autumn of 1983, I had been promoted to senior registrar on the Professorial Unit at Withington Hospital. I was given a new job after employment as a junior doctor for three years without yet passing the required test, although I was expected to do so very soon and psychiatry isn't a subject which fits well into the simplicity of modern examination methods. I could write an erudite essay discussing the possible causes of depression, detailing the conflicting evidence from different sources, but I found it much harder to deal with multiplechoice questions that demanded I understood the received wisdom about subtle differences in frequency implied by imprecise terms such as 'commonly', 'often' and 'seldom'.

I had a history with examinations. My colleagues and seniors didn't know about this. They didn't know how my hands used to sweat and shake before my piano examinations as a child. How I could be so paralysed by the fear of knowing I could destroy my chances of passing in the next moment that it would actually seem easier just to accept I had failed, turn in a rushed and careless performance, and get out of the room as quickly as possible.

The new job was tough. I was expected to oversee the inpatient care of a diverse and complex group of people, including a few 'celebrity' patients and relatives of important doctors who had developed their mental illness while at university in Manchester.

Daniel was an inpatient in the Professorial Unit. His father was a professor of medicine at a university in the south of England. He too had been studying medicine in Manchester, but had realised it was not his chosen career. Shortly before his finals he had dropped out and continued the heavy drinking that he had started as a student. He was now in his late twenties and, I began to suspect, was going to die young. We had admitted him after another serious suicide attempt.

'That's what my father always says to me: "You've lost the plot, Daniel",' he laughed as he mimicked his father's arrogant tone of voice. I recognised it from his telephone calls to the ward, demanding information about his son that I was unwilling to provide. Daniel was an adult and details about his care were confidential. I can understand how this often antagonises family members and carers, but Daniel's father did not need to know the information he was asking for, and his son denied permission for us to meet as a family. Unless there was an imminent risk of Daniel leaving hospital again, there was no reason to share information, and Daniel's father had refused to discuss his concerns with our social worker, insisting that he wanted me to answer his questions. Professional people who should know better are sometimes poor at respecting such boundaries where their own family are concerned.

Daniel started to weep, collapsed against the wall and slithered to the floor. I could smell strong spirits on his breath. His skin was sallow and the whites of his eyes looked even yellower than usual. I knew our ward sister would want to discharge him for returning to the ward under the influence of alcohol, which was against the rules, but I also suspected there was something more going on that I needed to find out about. Eventually, he told me.

I called in one of the nurses and we got him on to the bed. He wasn't fit to go anywhere for the moment, if at all. I could see that Daniel thought his life was over. The problem was that he felt he had never been allowed to decide what to do with his life because the script had been written for him by his parents. Although that was how it seemed to him, he had still tried to please them – and failed. The challenge was to try to help him to discover how he wanted to spend his life, however long was left of it. My fear was that he would avoid this challenge by continuing to poison himself with alcohol simply to hasten the end.

Later that night Daniel was admitted to a medical ward. I called his father to let him know and he seemed to me to be rather more disappointed for himself than concerned about his son's health. It was not, however, only the patients that I needed to worry about. In this new job I also supervised junior staff for the first time: young doctors who were eager to please and reluctant to ask for help when they had strayed beyond their capabilities.

'You'll have to speak to her. She can't talk to my staff like that,' Jennifer said. She was a nurse for whom I had a good deal of respect and she had taken a dislike to Judith, our new registrar.

'What's the matter?'

'Who does she think she is, coming in here and telling me what she wants doing?'

Judith was outwardly confident but when I sat next to her in the Admissions and Discharges meeting every Thursday morning at 8.30 sharp, I could almost smell her fear of failure. Professor Davies liked to play complicated mind games with the young female doctors he selected for his unit. I had been one once, and knew all the verbal garden paths and logical culde-sacs along which his searching questions could misdirect you. The task was to defend, word by word, what you had written in the brief summaries produced each week for all the cases that had been either admitted or discharged.

'So tell me, doctor, what does it mean… the patient's insight was "good"? How did you assess it? Perhaps you can enlighten me? So what if I'm willing to take the treatment, does it follow my insight is "good"? Might it still be possible I don't believe myself to be ill? What do you say? Would my insight still be "good" then? Come on tell me! If my insight was "good" then why did I come to the hospital seeking help when I believed I was being pursued by the KGB? Why didn't I go to the police station and ask for protection? Why on earth did I come to see you? Explain to me what you have written.'

In psychiatry, like any other branch of medicine, the junior doctors survived the working week on a combustible fuel of fear, caffeine, alcohol and occasional tears.

If anxiety is the manifestation of the fear that something will happen, depression occurs when fear becomes reality.

'What's up?' asked Lee, my colleague at the weekly psychotherapy supervision group that by then I struggled to attend.

Lee was older than most of us, having come to psychiatry as a second medical career after starting out in obstetrics and gynaecology. There was something very grown-up and wise about her.

'What do you do when you think you probably feel worse than some of your patients?'

'Leave it to me,' she said. 'I'll organise something.'

The letter from the College arrived two months after I took the examination, in mid-December. I finished on the ward early, as it was the staff Christmas dinner. I usually didn't get away until after 7 p.m., but I knew the envelope was waiting for me. The others who took the examination with me had found out their results already.

Catherine had called me, announcing, 'I've passed! I can't believe it! You know I really thought I had failed.'

'That's great.' It didn't feel great but what can you say when you know, really know, you will not be celebrating?

'I'm really pleased for you.' I tried to say it with conviction, but it was very difficult. As I rapidly scanned the piece of paper and extracted the information, my heart seemed to stop beating. We are sorry to inform you that you have failed to reach the required standard… to satisfy the examiners… failed the multiple-choice paper and the clinical examination.

Professor Davies collected me from home to take me to the restaurant where we were to meet up with the rest of the clinical team for our Christmas party that very evening. As we drove there, a painful and frightening idea kept intruding. I could hear a voice speaking in my head. It sounded like my own.

Open the car door and jump out. Wait until it picks up speed on the motorway and then do it. Go on… It will be easy. Go on… now!

But I didn't. I resisted. I tried to distract myself by watching the headlights of oncoming cars as they flashed by and pretending that this moment, of being lulled into an oddly comforting trance by the rhythm of the city, would go on for ever and we would never arrive.

But the desire to escape from my life – perhaps even to end it, if I allowed myself to listen to that inner voice – was stronger than I had ever felt before. I had not told anyone how bad I was feeling, particularly not Professor Davies; I had a feeling that he disapproved of people who chose suicide. I had seen evidence of this when Catherine and I had been with him one day in the staff common room, where he held court every lunchtime. He expressed his anger at the poet Sylvia Plath for having killed herself and left her children without a mother. He knew Plath's GP in London who had been trying, in vain, to treat her depression before she died.

'It's a very selfish act,' he said.

'But if it seems like the only way out…' I argued. I couldn't blame someone for feeling like this. When you are so depressed, you cannot think of the consequences for others. You think only of yourself and you cannot believe it is ever possible to feel differently. 'She might have thought the children were better off without her.'

'But could you forgive someone for killing themselves? That's the question.'

'Could you?' I retorted.

He didn't reply, but instead smiled enigmatically. He didn't have to provide us with answers.

The car pulled up at the restaurant and I realised the professor was talking to me.

'How can we make things easier for you?' he asked.

'I need time to study.'

He looked at me with knowing eyes. I didn't need to say more. 'You feel ashamed about failing?'

'You needn't, you know. There are a lot more important and terrible things a human being can feel ashamed of than failing an examination.'

He was right, of course. Not about there being many worse things than failure, or so it seemed to me at that moment, but about the terrible sense of shame and humiliation which made it painful to sit and eat with my colleagues, aware as I was that they knew but would not be talking about it.

'And are you getting some help?' he enquired.

By then, I had started seeing a psychotherapist who I shall call simply E, arranged through the referral that Lee had made for me.

'I am.' I smiled through the tears.

'We won't stay long, and I'll look after you.'

I struggled through the next few weeks in a state of unreality, managing the ward from day to day, still working but not seeing my own psychotherapy patients. There was nothing of myself left to give them, and I could not work with them without giving something of me. The vital energy I drew on in those intense moments in therapy, when it felt like I could connect with another person in order to help them to change or grow, seemed to have all drained away from me.

Then I fell acutely ill with a salmonella infection. It took a physical disease to get me away from work because a part of me did not accept that my mental ill health was a reason to stop working. Work had almost become my only reason for living and my relationship with psychiatry had become the single most important dimension of my life, far more important to me than my marriage or my friendships. This was why, I realise now, failure in the examination shook my sense of identity so profoundly. It had resonated with my own particular vulnerability: a style of coping with the stresses and demands of the world through immersion in my work that I had learned in childhood. If all of this bothered Jim, he didn't say, but I knew he cared for me and tolerated my moods. However, it was as though I was there in our relationship in body only and even then, hardly at all.

Soon after I returned to work, a stone-and-a-half lighter, one of my patients with a diagnosis of schizophrenia (in which a person usually not only experiences hallucinations and delusions, but also difficulty in thinking and changes in behaviour) told me that she had recently met an old friend of mine who had encouraged her to try to manage without her medication. I was intrigued and asked her if she would tell this person how to get in touch with me.

It turned out to be Jane, my best friend from medical school. She was in Manchester and living in a basement flat in Didsbury, not far from the hospital where I was working. Jane and I had often talked about dropping out of our medical training. In some ways she seemed less comfortable a student than I did, as though she had simply drifted into medicine with her straight As, unlike me who hadn't quite made the grades demanded but had been accepted anyway. It was only when we had started our psychiatry attachments that she really began to show enthusiasm for a medical career, or more specifically, a psychiatric one. So we were all amazed when, in our fourth year, Jane suddenly announced that she was going to give it all up and leave medicine.

'I can't tell you what's going on. It's too difficult to explain,' was all she had said to justify her reasons for changing to Philosophy and then, a few months later, dropping out altogether.

'It's just… Well, everything's changed. I just see things really differently.'

Her down-to-earth room-mate had a pretty clear idea: 'She told me she was hearing voices.'

I understood why Jane was not inclined to share these experiences with me, realising, as we both did, the potential significance of such an admission.

If you tell a doctor, and particularly a psychiatrist, that you are hearing voices, chances are they will suspect you may be suffering from some kind of psychotic illness and are really experiencing hallucinations, although many illicit drugs can also cause this to happen. Nowadays we also know that many people hear 'voices' at some point during their lives, particularly when they are under stress, and it does not necessarily mean that they are 'going mad'. Sometimes people hear their own thoughts, as I had done, apparently spoken aloud but inside their heads. Other times they hear people speaking to them – and they hear these voices as clearly as they hear other people talking – from outside their head. All of these experiences can occur in severe depression, but Jane had not seemed depressed – quite the opposite, as she had been almost euphoric at times.

Jane was working in a bookshop and when we met, she told me that she had been to India and was now a devotee of Raja yoga, which demanded not only a strict regime of meditation, but dietary restrictions too.

'How are you?' I asked her.

'Oh I'm fine. You have to believe me; I'm really, really well!' She laughed, the same old raucous laugh, at my apparent disbelief that she could be happy with her lot. She looked physically well but I could detect the same troubling sense of total self-absorption with her inner world and the same inexplicable quiet euphoria about her that had been evident at the time she dropped out of medicine. It was as though she had discovered the meaning of life and was bursting to tell me about it but couldn't, because I would not have believed her. And yet, in a strange way, I found myself envying her. She was living the life of her own choosing. Perhaps she had discovered a secret worth having? Or was this, as the professional part of my psyche whispered to me, quite simply a terrible tragedy and a wasted life, which might have resulted in so much more? Had she, in losing one set of hopes for life, stumbled upon something more meaningful to sustain her?

But she had a curious, almost transcendent detachment from the world; she was familiar, yet no longer the same. I could not work out if she was possessed or simply and truly self-possessed. I missed her habits and mannerisms so much, yet the part of her who had been my friend was no longer to be found. There was no connection between us, and I felt the sharp sense of loss all over again for the person who had been my closest friend and confidante during those strange, rich times we had shared as students in Edinburgh.

Daniel died a few weeks after he was moved from our unit. His liver function had deteriorated, and at that time, unlike today, it was not usual for people with alcoholic liver disease to be offered liver transplants. I wish he had been given another chance at life, but there would still have been a great deal of work to do together in disentangling his depressed mood from his dependence on alcohol. Some people drink because they are depressed; sometimes drink can make you depressed. It can be difficult to work out what came first, and it's very hard to treat depression with either drugs or therapy if a person is still drinking.

After a few months working in therapy with E, my mood had gradually improved, and I regained enough confidence to try the examination again, although I was still very apprehensive. I re-sat it at Northwick Park Hospital, in Harrow, just north of London, six months after my first attempt. I did not wear the red suit. My patient provided me with a clear and concise history. This time I passed. I was relieved I seemed to be back on track and settling back into the apparent safety of the narrative I had mapped out for my life a few years before: marriage, medicine and becoming a consultant.

I have seen many people in my career who almost believe it is really possible to magically plan out how your life will turn out, and they try to plan their children's lives too. Sometimes it seems as though they can, because nothing terrible has ever happened to them in their lives thus far; everything has gone as expected. Then they experience a loss, and the closer this loss relates to their sense of who they are, and where they see their lives going, the greater the difficulty will be in coming to terms with it. In failing the exam I had temporarily lost the plot I thought I had safely sketched out for the story of the rest of my life. No one else created this plan. I was quite sure it was mine alone. I disregarded any thought that I, too, like Daniel, might have been still trying to please my father in some way, even though my father was dead and gone. I realise now that I was effectively papering over the cracks which had threatened to appear after my father's death. At the time it merely seemed as though I had temporarily lost my way and then found it again, but I failed to understand that coming off the pre-ordained track of my life might have been what I really needed. I have learned that sometimes those moments of chaos, when life careers off the rails, hold important messages about things we need to change in our existence – and the rigid expectations that we, and others, have of us that we need to challenge – before it is too late. If we address these, we can start to move forward once more, towards achieving our own goals. If we choose the goals ourselves, we have a better chance of success.