Tag Archives: mental-health

We need to talk about co-dependency

My name is Alice Kumari, I am a 49-year-old GP who works in West London. The following is an account of a day at work at the end of November 2023.

I arrived at work shortly after 6.30am, unlocked the practice and put on the coffee, before Anu, our head receptionist arrived a few minutes later. By 7, my first coffee was on my desk, and I was working through the results that had come in over the weekend. I checked the ‘Global Tasks’ to see which results had come in for other doctors – Dr Overton had 149 results in his inbox, results he was sitting on, unable or unwilling to do anything about them. I wasn’t sure if it was burnout, or the fact that he was nearing retirement or both. I really ought to speak to him I thought. As senior partner, this kind of thing usually came down to me, even though I suppose now at least, that it ought to have been a partnership issue. I cleared other doctors’ inboxes too, because we were under huge pressure as a practice, and I’d had two doctors in my room crying on Friday and a trainee had complained to her supervisor about the workload. After going through the results, I signed off the prescriptions and worked through most of the documents. Before starting on my emails, I got another cup of coffee and said hello to reception team and Dr Jain. “You’re early again, I thought I’d be the first one here!” he said cheerfully. He was due to go away on leave and had come in early to make sure his admin was clear before he left. “I’ve cleared your results and scripts for you, so it’s just the documents” I said. “You’re so kind Alice, I would have done it”. Yes, he would have done, but it was easy enough when I was on a roll. I noticed that my coffee cup was nearly empty, and hesitated wondering if it was too soon for more.

Sophie, my first patient arrived 30 minutes before my surgery was due to start. She was very anxious and was trying to escape an abusive relationship. She didn’t want her husband to know that she was coming to see me, so she would come in on her way to work, and I would let her in before the practice opened for appointments. Sometimes I would see her after my evening clinic or fit her in at lunchtimes. We had known each other for nearly twenty-four years, and I had even looked after her mother when she was pregnant with Sophie.  Not long before I started work, GPs would deliver their patients babies at home, and sometimes I wondered what it would have been like if I’d delivered Sophie too. I don’t remember her smelling of alcohol. I’d gone out of the room to get a third cup of coffee but when I came back, Charlie my trainee was waiting to start his tutorial and said that my room smelled like an espresso-martini. “Well, it  wasn’t me!” I exclaimed, perhaps a little too urgently and earnestly. Charlie, embarrassed apologised and I apologised for embarrassing him. I explained about Sophie and then used her story to illustrate the role of trauma and adverse childhood experiences in attachment difficulties and the recreation of violent relationships in adulthood. I realised suddenly that I had meant to have a formal case-based discussion for his educational portfolio and stopped myself just in time. “I don’t know how you do it” he said at the end of the tutorial, “I can’t believe you were here at six thirty and you’re going to do evening surgery as well today”. “Actually,” I said, smiling, “I’m finishing early today because it’s my 25^th wedding anniversary and Stuart is taking me out for dinner”. My heart skipped a beat as I checked to make sure that my evening clinic had been moved – it had. Dinner was on.

As far as I can remember it was a typical Monday morning. In other words, Hellish. There must have been at least 200 patients on the triage list for me to work through, trying to allocate them to about 30 GP appointments on the day, perhaps as many somewhere in the coming weeks, and a scattering of nursing, trainee, student, physiotherapist, pharmacist and other options for allocation. It’s like Whack-a-mole. As fast as you allocate one patient, another two are added to the list. By 9.30 there were already a hundred. My future appointments were all booked up so any patients on the list that were mine, I added a note underneath to say I would call them later. I did two visits and skipped lunch and postponed (again) a meeting with the accountants and then debriefed Charlie before starting afternoon surgery. I’d added several extra patients from the morning’s duty, but today I felt relatively relaxed about it. Stuart hadn’t booked the table until 9 and I was planning to go straight from work anyway, so I’d have time. I messaged my mum about half-way through the afternoon surgery, “Are you still OK to baby-sit the girls this evening?” I didn’t hear back immediately which put me into a mild panic so the next couple of patients were a bit of blur. I called her and it went straight to answerphone. I tried to hide the worry / irritation behind my cheery, “Hi mum! Just me, just checking” message. One effect of our total triage system was that every obviously straightforward patient is filtered off to a student, a trainee, a nurse or someone/ anyone other than their usual GP. The only patients that can get through to us have reached a point of crisis or complexity that the person in charge of triage on the day they call has made the decision that only the patient’s usual doctor can deal with it. Our clinics are busier, more complex and more emotionally fraught than ever before. It’s important to say that when it goes well, as it quite often does (or rather, did), you feel like you’re doing the best job in the world, working at the top of your grade, using all your skills and experience to help people that really need you.  On other days, it sucks everything out of you and your family are left with an irritable husk of a human being. In the weeks running up to this day, most days seemed like that. It was easy to blame it on external factors – winter pressures, work being dumped from hospitals and every other public service you can think of. Everything seemed to end up ‘Back to GP and ‘Get al Letter from your GP’ seemed to be the answer to every problem humanity faced.

At around 6pm I got a screen message from reception, “Clarissa is on line 1, shall I put her through?” Clarissa is my mum, and there was a patient in the room with me, a young woman from Sierre Leone who was pregnant after being raped at home. She was living in a hostel, and I was speaking to her through a telephone interpreter. She was crying and the consultation was taking a long time, I messaged back, “Tell her I’ll call her back in 5”. I switched the screen off because I didn’t want to be interrupted any more or for my patient to think I wasn’t listening. But the truth was that after that I wasn’t really listening. I was worried about why my mum had called. I started catastrophising about her not being able to baby-sit and the possible reasons. It took a concerted effort to get back on track and the consultation drifted before I could reassemble a state of presence. My phone buzzed at least twice before the end of the consultation, and I checked it as soon as my patient’s back was turned to leave the room. My heart stopped. I knew it. I knew it! How could she?!

My mother is a (relatively) famous professor of public health. She rose to some fame during Covid with TV and radio interviews, but things really took off because at the same time she was diagnosed with breast cancer and then wrote a book about her experiences. It had just been published and she was going around doing events and interviews. She was messaging to say that celebrity / author/ podcaster GP Rangan Chatterjee was doing a live event in Cambridge this evening and at the last minute, possibly because someone else couldn’t make it, he had asked if he could interview her. I called her straight back. “Mum, seriously, not Rangan?” We had been at medical school together and had even dated briefly. I thought he was a dick, although I couldn’t quite discern my judgements from professional jealousy, the way he dumped me, his  constant virtue-signalling getting up at 4am to do naked yoga and meditate, self-care smugness’, fake vulnerability, trauma blah. And as for all the health product advertising crap. I fantasised about heckling him on stage in the middle of his interview with my mum. Neither of us were listening to each other. I didn’t care about Rangan, I didn’t give a damn about how much it mattered to her, I didn’t listen to her say she would pay for Stuart and me to go away for a weekend with her first royalty cheque. I wanted to argue with her when she said that it wasn’t as if we were doing anything that special by going to a local restaurant on a Monday night. Instead, I said, “Mum, seriously, that’s incredible, I don’t believe it, The. One. And. Only. Doctor Rangan Chatterjee. You’re basically up there with Bessel Van de Kolk and Gabor Mate now. Next thing you’ll be on the New York Times best seller list, and we’ll all be going to Dubai for Christmas!” We laughed at this because neither of us could imagine anything worse than Christmas in Dubai. “Seriously though, that’s fine. Really, you’re right, we weren’t doing anything all that special other than it being our 25th anniversary, but honestly, you’re probably doing us a favour, I’ll basically be completely shattered, and we’ll probably only talk about the kids and they’re probably at the age where we should be able to leave them alone anyway. You should go, it’ll be amazing, I’m so proud of you!”  I hung up a little too abruptly while she blathered on about how much she knew I’d understand and how much she loves me blah blah blah.  At least my patients give a shit I thought as I turned my screen back on and realised how late I was and what a selection of seriously troubled souls I’d lined up at the end of a long day.

I always teach students that patients like this are hidden in plain sight. They’re all around us, every second or third patient on a normal day of any GP in a deprived area. Survivor-victims hiding self-harm and suicidality, addiction, eating disorders, and more behind walls of shame and masks of coping. As a female GP working in the same practice for over 20 years, the walls were down and the masks were off as often as they were on and the trauma was not hidden, but plain to see and painfully apparent. Like Marley’s ghost in A Christmas Carol, Mankind was my business. And the more messed up they were, the more I drew them in. Finally at around 7.30, I got another sceen message from reception to say that Sophie wanted to see me. I went out to call her in, but she wasn’t there. I checked with the receptionists, but they said that they’d sent the message an hour ago, but Sophie said she couldn’t wait. The computers do that sometimes, losing or delaying messages at random. I vented at the software, the unaccountable ghost in the machine that disrupts my work innumerable times every day. “She looked really bad” the receptionist said, as I went back to my room. Suddenly I realised I’d forgotten to call Stuart to let him know that dinner was off. It was 7.45, not too late to cancel hopefully. Maybe I can call him after Sophie in that case, I thought. I called Sophie but her phone went straight to answerphone, and I left a voicemail. I sent a text in case that was easier for her, and then checked my admin – there was even more than there had been in the morning. I longed for a glass of wine. It was definitely wine-O-clock. No, I must finish this. So I got on with it. The next thing I knew my phone was ringing and it was 8.30 and Stuart was calling to say that he was just heading to the restaurant and would be a bit early if I wanted to join him for a cocktail. Oh no, no-no-no-no-no-no, Oh no-no-no-no, I don’t believe it. “Your mum said she be at ours by 9 and I left the girls finishing their homework, so they’ll be fine” he said cheerfully. It’s too awful to recall the rest of the conversation. It didn’t go well. I remember thinking I really, really need a glass of wine and then remembered that I actually had a bottle in my bottom drawer that a patient had given me the week before. Genius, you star.

Honestly I’d never done this before, even if I’d imagined it many times. I opened it and poured a little into my coffee mug to rinse it out. It would be a shame to waste it I thought and so drank it quicky before pouring a decent amount in and breathing a big sigh before turning back to my computer. Another screen message. “London Ambulance on line 1” “What?” I was incensed. I was just about to enjoy finishing my admin for the first time ever, it was 8.25 on a Monday evening, and I was the last doctor left in the practice, it was my wedding anniversary and I had wine. Why me, why now? Why is it always me? Why is it never in the middle of the day?” I picked up the phone. “Is that the GP of Sophie Wright?” “Yes”, I answered, ”Why, has something happened?”

I got home some time around 10pm. Somehow, I’d managed to finish the wine at work. I’d meant to tip the last mug-full down the sink, but disgusting though it was I couldn’t bare to waste it and I told myself that the only thing worse than a full bottle of wine in my work desk was half a bottle. Even without the wine, I was in a very ‘fuck-it’ frame of mind and so I drove home. Stuart was drunk when I got back watching Inside Out with the girls and half a bottle of whiskey in one hand. There were pizza boxes on the floor.  “Well, who’s this?” he said sarcastically when I walked in. “Aren’t we lucky?” I went straight to bed in the spare room, hissing at him to sort everything out, including himself. I got up at around 1.30 and went downstairs, Stuart was asleep on the sofa and the house was a mess. I tidied up in silence until I couldn’t keep my eyes open and then went back upstairs.

The next few weeks I described as my breakdown or n professional terms, burnout. I prefer not to think of them too much. Looking back, they were a tragic inevitability in a story that began long ago. My dad met my mum shortly after he came to London from Uganda, chased out by Idi Amin in 1974. He escaped after his family were murdered by soldiers, something I didn’t discover until very recently. I never knew him because he left us when we were very young. My mum bought my younger brother and me up with help from her mother, a severe Irish Catholic disciplinarian, and our childhood flipped between boarding school and home with my mother being mostly absent. Her work involved a lot of conferences and long working days, and she would always promise to make it up to us, but she never did, and we stopped believing she would to protect ourselves from the disappointment. They say that if you find a partner, chances are they’re as messed up as you are, and it was as true for my parents as it was for Stuart and me. In our 20s we felt invincible, and our lives revolved around parties and clubbing with the amazing powers of recovery that meant we could dance all night and study or work all day. It was ideal preparation for life as a junior doctor, and for Stuart who worked for City Bank. With time his work continued to encourage hedonism while mine required a calmer disposition and gradually our relationship, that was tied together with our states of mind, began to become more … difficult. Sorities paradox describes perfectly the impossibility of identifying when drinking alcohol becomes alcoholism. The myriad medical definitions of heavy/ hazardous/ problematic/ dependent alcohol use are of little use when the person you’re trying to apply them to is your partner. Like boiling a frog, you don’t notice until you’re out of your depth. Perhaps if I’d known that my own father who I never knew, was an alcoholic, or if I studied Greek tragedies alongside science, I would have been more alert to the possibility that subconsciously I’d find myself married to one.

 A few months later, thanks to support from my own GP and an excellent therapist, I found myself listening to an interview with Mellody Beattie, who described her marriage to an alcoholic who concealed his drinking until she discovered a bottle of vodka hidden in the toilet cistern the day her first child was born. Listening to the entire interview, I discovered for the first time, the concept of Co-dependency and I realised that it’s always been a defining feature of my life and the people around me. It took the pressures of work and marriage for co-dependency in my personal and professional relationships to reach breaking point, as it inevitably does. And like Rumpelstiltskin, I needed to name it to break its power over me. Co-dependency is a concept that originated in alcoholic treatment /AA communities where people realised that alcoholics were frequently in relationship with people who couldn’t find any reason to live beyond helping other people. Co-dependents become obsessed with or controlled by other people’s behaviour. Their Our identity becomes lost except in relation to the people with whom we are co-dependent, and we have no self-esteem except in taking care of others. We’re outwardly highly effective and popular because we’re always the first to volunteer, the first to arrive and the last to leave, we rarely ever say ‘no’, we’re extremely organised, and we’re outwardly cheerful and in control, but hide a seething resentment and perpetual anxiety.  Co-dependency begins in trauma, specifically in insecure attachment in childhood and is often intergenerational. I can see it all around me, especially because so many of my friends are other women who as children needed to care for parents or siblings because their own parents for whatever reason were unable to do it themselves. At work, we fall into the trap of believing that we’re the only one who can help the most vulnerable and needy patients and our boundaries, because we never learned about them when we were growing up, are all over the place. A good friend said, “we set fire to ourselves to keep our patients warm”.

I was out of work for nearly a year. I’m not ready to describe how bad things got during my absence, but it’s sobering to think how thin the veneer of coping was during the months before I had to stop. I recently started back at work, although strictly part time and I still see my therapist and my GP regularly. Stuart and I are both sober and we go to our own separate CoDA meetings. We went together very briefly, that was a bad decision. It’s not couples therapy.  We’ve introduced clinical supervision at work and every day we take turns to debrief, and we’ve invited a therapist to run monthly Balint groups. I still arrive early, run late, fit patients in all over the place, and specialise in looking after the people whose lives are full of intractable trauma. Actually, specialise is too grandiose a label, I don’t have any extra training or qualifications, I just see a lot of really damaged patients, but I do it with less resentment, more awareness, and more patience. I’m still a husk of a human being at the end of my long days, but they are only once or twice a week instead of every day. I’ve joined a bimonthly narrative supervision group, a gym and a book club. I wonder whether this is an excess of self-care and another aspect of co-dependency I need to work on, but it’s better than self-destruction. it seems normal among my friends. Perhaps we’re all a bit co-dependent. The Rumpelstiltskin effect didn’t break the spell, like in the fairy tale where naming him frees the princess. Knowing why you’re screwed up doesn’t stop you being screwed up, but it does help. I’m on my recovery journey and I want to say it feels good, but that’s hard. Honestly it feels precarious and provisional, and knowing how unwell I could become makes me apprehensive. Trauma and co-dependency are unavoidable aspects of being human, and this awareness enables empathy. Compassion for patients seems to come easily, but turning it inwards, that’s the hardest part.

References:

Mellody Beattie interview where she talks about her childhood and marriage

The Rumplestiltskin Effect

Co-dependency Anonymous

https://codauk.org/meetings/

The Balint Society

https://balintsociety.org.uk/balint-groups-and-balint-method

Further reading:

Mellody Beattie author of Beyond Co-dependency https://www.melodybeattie.com/

Pia Mellody author of Overcoming Co-dependency https://beyondtheorypodcast.com/pia-mellody-on-the-meadows-model/