Interview with dr. Ferdinand Jónsson, an Icelandic psychiatrist and well-known poet.
Páll Matthíasson: You have practiced psychiatry as a consultant Psychiatrist in a busy sector team in East-London for the last 17 years. Can you tell me a bit about your service and catchment area?
Ferdinand Jónsson: I work in Tower Hamlets in the Bethnal Green Neighborhood mental health team. Tower Hamlets is an inner-city London borough. Mental health services are provided by the East London Foundation Trust. This is a borough with much poverty and densely populated. In my opinion Britain aspires to be a highly civilized society, trying their best to look well after the most vulnerable members of the population. Most of which are people suffering severe mental illness. I have been blessed by working with people from all over the world, patients, their families, and the people, like me who offer a service to them.
In Tower Hamlets we run the Continued Care model. Meaning you work closely with GP practices. We follow patients through outpatient clinics, with the most unwell patients under the neighborhood mental health teams. You also work with these patients in our inpatient services at Mile End Hospital. You liaise closely with the general practitioners and consult with them when patients who are doing well are discharged back to primary care. One of these GP surgeries was Health E1, the homeless medical center on Brick Lane. So, you see all sorts of things in your work and you meet and form relationships with many amazing people. Working with patients and their families through different stages of service is a great fountain of hope for us who work with these patients.
As a psychiatrist, it is a sad fact of life that some patients end up succumbing to their illnesses. I know that you have in the past criticized how suicides are handled by the authorities, with inquests being held, almost like it´s a blame game. Can you give me your thoughts on this?
Suicide is deeply disturbing and there is nothing one can say to change this fact. We know how difficult this is for families and their loved ones. The pain does not leave. It magnifies with this act and gets dispersed to other people in the patients’ lives. And we know sadly it often sits there firmly.
Families and loved ones are the true victims of suicide.
These issues are also extremely difficult for the staff. We form strong relationships, with our patients. This is very rewarding but makes you at the same time vulnerable when things go wrong. You rely on staff being professional, kind and going the extra mile. Kind staff are also exceptionally good at blaming themselves.
I believe the fact of the matter is that when it comes to exceptional staff who work in mental health, they often have a deep experience of the effect of these serious conditions in their own lives.
There is also an unhealthy division between how mental and physical health is viewed. Many people in management, service providers, politicians and members of the public believe that we should always be able to stop these terribly painful events.
It is important to remember that we are highly effective in helping people. We literarily keep death away. But death is a part of life. We cannot do this all the time. No other health service is expected to aim for a Zero Death. If that were the case it would mean the most seriously ill people were not being seen! The people we work with are often highly risky. There are also other factors that contribute to the suicide that are outside our control .
We should try to accept the fact that sometimes the prognostic factors are very difficult. Death should be at the front row in the hall where we practice our work. We need to support our great colleagues and stick to the truth of our human existence.
For if we do not, we will lose the staff our patients and families need the most.
I have seen this happening all too often. I see part of my job as speaking out against any misconceptions of mental health being able to stop all suicides. I try to be honest about investigations into serious incidents. I feel these are often over simplifications of the complexities of the human condition and the multi-factorial nature of serious mental illness.
I know that you have in your work twice had the difficult experience that patients under your care have killed other people. That must be a truly harrowing experience. Can you tell us about that?
Well, these are some of the worst. The worst for me was when a patient killed another patient on one of the wards I worked on. Then you seriously think about changing into another career. To get work anywhere, as far away from these horrors as possible.
I guess it helped me to have a long experience and being fearless of expressing my feelings. Also, when the second homicide happened, I demanded support and help. I sent all the senior managers an email saying that I normally loved my job. But since this had happened, I was feeling physically sick. I received a response within minutes and support from most of my colleges, with very few exceptions.
I was lucky in having a good relationship with some amazing colleagues and I had their help through all these sad experiences. A small number of the mentally ill can be highly dangerous, so treat these conditions firmly and work with people you trust. And most importantly, seek advice from your colleagues in the teams. Make sure they are empowered and able to speak their mind and bring their brains and wisdom to complex risky problems.
What sort of feelings and thoughts does going through something like this awaken in a clinician?
A sense of grief and failure. With all its emotions, including anger. A sense of having not done your best. But also, sometimes a sense of a sad blessing having been given a chance to work with great people. Also, an expression of the complexities of life and the sense of the basic fact that you can never stop something that is a normal part of our existence. These experiences of death, can cause practitioners to become very defensive in their practice. Staff becomes scared of being real and our patients will ultimately suffer.
So, form safe relationships at work so this can be expressed and somehow worked through. I also recommend a close, safe relationship with other medics outside mental health. My brother is a surgeon. They often have a much healthier relationship with death than we have. With me it feels like trauma and I try to use that pain and anger to defend myself and those who work these difficult jobs with me. However, one has to be careful here. Of not being too defensive. Hard times are often the best opportunities for growth and learning.
If our job was easy, everyone would be doing it.
Any advice to other psychiatrists, if they find themselves in such circumstances?
Try to be kind to yourself and others. Try the impossible, of looking after oneself in a holistic way. Meaning physically, emotionally, intellectually, and spiritually. Remember spirituality is not solely for the religious. We all need this. Spirituality is for example in art and nature. The great views of our little worlds.
Defend your good staff and respect them. Celebrate their unique skills and journeys that has led them to excel at their work.
But whatever you do, never throw your colleague under the bus. Everyone is accountable for their work. Never escape your threatening fears by blaming your colleagues!
We had a sad death on one of our wards. I was on call that Saturday, so was able to manage a very difficult situation. Including supporting staff and patients. What stood out for me, was pointing out to the patients, in a group setting, the fact that although we are nurses, doctors, managers and staff members, we are also human beings. And as such greatly affected by this tragic death. The outpouring of support, kindness, and gratitude from all the patients, directed at staff, moved me to tears.
Foster some reflective, kind, supportive friends.
Meet the family, with staff and seniors that can chair that meeting, if necessary. But only do so if the reaction of the family is within the limits of normal grief. Meaning - do not see families who have threatened you or your staff with physical violence.
Try to stick to the basic principles of our work. The pain of our patients’ life does not belong to us. It belongs to them and their loved ones.
It has also been helpful for me to hold two positions in my mind as a psychiatrist. We fight serious incidences every day of our work. In most cases, we are successful. So, the main stance is to fight ill health and death.
However, there must be another stance when death has happened. We need to remember the enormous pain and difficulties patients with mental illness face.
Be humble. We will never know how it is to be in their shoes. Remember we do not read minds. Respect our patients and the decisions they have taken in their difficulties. Wish them peace.
Thank you, Ferdinand, for your thoughtful reflections! □