Just tell me when

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Lydia is an unemployed, single woman in her mid-thirties with a long history of psychiatric illness for which she has been prescribed a cocktail of tranquilisers and antidepressants. She has attempted suicide more than once in the past, been compulsorily hospitalised ('sectioned' in the UK) several times and regularly visits the hospital where she talks to a very experienced psychiatric social worker, Jeremy, whom she trusts and likes.

Jeremy sits in his small room in the hospital alone with his patient files. Before calling Lydia into the room he picks up a large folder containing her notes, sighs and says to himself: 'Ah, another case of 'Thick File Syndrome'. Between this visit and her last about 6 months previously, Jeremy has attended a course of Provocative Therapy (PT). Having always had a mischievous sense of humour, he enjoyed the course and was moved by the Golden Rule of PT: Affection in the Heart and a Twinkle in the eye. He goes into the corridor outside the room and cheerfully invites the sad-looking Lydia into the room. (Unlike the other cases here, this was not a scheduled session of PT which is why I've used the pseudonym, 'Jeremy' instead of 'Provocative Therapist'.


Jeremy: Hello Lydia. How are you?


Lydia: Very poorly. I just don't have anything to live for.


Jeremy: Mmmmm... Are you taking all your medication?


Lydia: Yes, but what's the point?


Jeremy: To feel a little better?


Lydia: I don't know. It's so up and down but mainly down, terribly down. You know I think I'm going to do it this time?


Jeremy: (inwardly sighing but trying to look composed) Do what?


Lydia: Do myself in.


Jeremy: (looking at her very kindly) We have been here before Lydia; it never ends well.


Lydia: Yes because I didn't do it right. This time I will.


Jeremy pauses and looks at her. In his mind he sees his version of the movie of her life, the suicidal attempts, the many threats to commit suicide, the sheer agony of existence for her. He knows that the correct thing to do is start the process of sectioning her. He just needs the signature of a psychiatrist. On paper it's an open and shut case. But something stops him from doing this. His conscience tells him that while this course might keep Lydia alive, it will do nothing to help her long term prognosis. Suddenly in the pregnant silence of the small room the smiling face of his Provocative Therapy teacher comes to his mind's eye: 'Affection in the heart and a twinkle in the eye'. He thinks wrily to himself: 'What have I got to lose? Besides my reputation and my job? But that's all about me...'


Lydia: Well?


Jeremy: (looking at her kindly) So you really want to do it this time?


Lydia: (nodding) Yes I do.


Jeremy: (nodding a bit more solemnly) I hear you. Lydia, I trust that we are all masters and mistresses (Lydia flinces slightly at the word 'mistresses') of our own destiny. I respect all your choices although I'd much rather you stayed alive because (picking up and showing her her thick file of notes) I've got to know you quite well over the years.


Lydia: So what? Nothing's really helped me.


Jeremy: That's true. But we have always got on well, haven't we Lydia.


Lydia: (nods) Yes, but ...


Jeremy: Yes, I know I've not been able to improve your life much, but may ask you something to tell you something that would help me?


Lydia: (a bemused look appears on her face) Yes, of course, Jeremy.


Jeremy: You plan to commit suicide?


Lydia: (nods)


Jeremy: Can you just tell me one thing? When exactly do you plan to do the deed?


Lydia: Why do you want to know that?


Jeremy: (Sighs and takes a deep breath. He knows he's going out on a limb but he is committed now. He picks up his appointment book and starts to flip the pages.)


Jeremy: You see, I'm a very busy man. I'm booked up four months in advance and several of those appointments are scheduled for you.


Lydia: (stares at him with a look of shock and disbelief on her face)


Jeremy: (looking at Lydia with immense kindness and smiling eyes) If you can tell me the exact date you plan to kill yourself, then I can free up several of your appointments for other people.


Lydia: (rising to her feet) Why you heartless bastard!! How dare you talk to me like that?


Jeremy notices that the energy in the room has risen dramatically. He is being criticised but concomitantly he knows something powerful is happening to Lydia. He has never seen her so animated, so confident, so angry. Something deep inside him tells him that this is the moment of the case. This is it!


Jeremy: No need to get annoyed, Lydia. I'm just doing my job. With cuts everywhere and low funding we have been encouraged to be as efficient as possible you know...


Lydia: And you still continue to joke! Maybe my miserable life is just one big jest to you.


Jeremy: No, I both laugh and cry when I think about your life.


Lydia: Okay, that's about all I can take!


Jeremy: But what about telling me the date!


Lydia leaves the room in a huff and Jeremy feels a mixture of being elated and a little fearful. Lydia seemed strangely energised by the conversation but who knows how she will feel in a few hour's time. Something tells him to just to wait and see.


FOLLOW UP:

The next time Jeremy sees Lydia, she is much better. There is no talk at all of suicide and she wants to discuss her medications. The improvement is noted by Jeremy on a weekly basis and he knows that his brief essaying of PT must have been the catalyst for this change. He never mentions that strange interaction again. However over the next three to four months the counselling is much more productive. Her improvement is monitored by her psychiatrist who reduces and then removes her medication. Eventually, at her own request she is discharged from the out patient unit of the hospital.

FIVE YEARS LATER

For the next 5 years, Jeremy doesn't hear a thing about her but every now and then wonders how she is. Then one afternoon her thick file appears on his desk. 'Uh-oh' he thinks to himself. 'Here we go again!' He calls Lydia into the room and notices that she has lost weight, is unusually well-groomed and looks more embarrassed than depressed.


Jeremy: Hello Lydia! Long time no see. What can I help you with today?


Lydia: Well I've been fine, Jeremy.


Jeremy: (looks her over in a comically exaggerated way and nods in agreement)


Lydia: I don't take any medication and my life is so much better. However I'm very nervous about taking the test for my driver's license and I thought that you would be the right person to help me with this.


Tears spring to Jeremy's eyes. He knew he had taken a huge chance on that fateful afternoon but was always aware at a profound level, that he was following his conscience - while still being aware of protocol and hospital guidelines. For a moment he is speechless then the usual mischievous smile returns to his face.


Jeremy: (picking up her thick file again and paging through it) Mmm... I'm not sure that someone with your psychiatric history should be allowed to drive...


They both burst out laughing.


ANALYSIS:

This case show that while caution is always important, sometimes courage is needed in counselling. Jeremy could have followed the letter of the psychiatric unit, but knew that it would have no effect on Lydia's revolving door relationship with the hospital and himself. When he saw her anger emerge, he knew something had happened and decided to wait and see. Lydia was outraged, but in her conscience she knew that Jeremy deeply cared for her. She knew that there was nothing at all callous about his outrageously 'rude' remarks. An intelligent woman, she may have known (even consciously) that he was taking a chance, even risking his reputation and disciplinary action. However behind all of this she had felt his care, love and powerful wish for her to change. It was possible that it was the realisation that someone had loved her enough to find in himself the courage to take such a personal risk on her behalf, that finally provoked her to change her life.