The Shinty Ball

Published by The Missouri Review. Shortlisted for the Perkoff Prize. Descriptions have been altered to ensure no patient is identifiable.

The first person I saw in a psychiatric outpatient clinic had a shinty ball in his hand. His GP believed he was paranoid, perhaps psychotic. The knuckles of his left hand were clenched white. The shinty ball: stitched leather enveloping cork.

I asked him why he carried it. He told me about the place he lived, a deprived area north of the river. His days saw dangerous neighbours, frightening dogs, a pervasive sense of dread. He was always on edge. His friend suggested a stress ball, which he’d bought and squeezed until it was taken from his pocket at the pub. He replaced it with a tennis ball, which was eaten by a dog. One day he found a shinty ball, which he now carried with him and which, although it was unyieldingly firm, he continued to squeeze.

He struck me as neither paranoid nor psychotic nor depressed. There was little I could add of value to his life but to listen to his story. The shinty ball stuck with me, a reminder of the particular ways we all must find to settle ourselves. And a reminder that my job was not simply to apply labels but to do a more difficult thing: to see people as they are.

*

“Right arm.” Nod. “Left arm.” Nod.
“And the legs.” Two nods. “Mind the head.” All nod.
“Last time he accepted oral medication, then spat it out and punched the nurse. So watch out.”
The nurses huddle together, nine of them. Light blue polo shirts. Watchful, focused, poised.
The leader speaks. “Are we ready? Let’s go.”
Unlock doors: one, two, three, four sets. Sucking thud of the air lock.

Where there is an immediate risk of harm to others from an aggressive or disturbed psychiatric inpatient, that person may be kept under supervision in solitary confinement. The practice is provided for in law by the United Nations and in England by the Mental Health Act 1983.

Legitimacy rests on providing a safe environment and on making efforts to maximise the person’s liberty during a period of isolation of the shortest possible duration. There’s little evidence that the practice improves symptoms of aggression long term, and seclusion is often experienced as coercive and punitive.

The room is a white bare rectangle. There is a single large window through which the patient is observed. Secluded patients are most frequently young people with schizophrenia, bipolar affective disorder, or personality disorder.

The man before me fits this profile. We have a short conversation in which he tells me that he is fine: he does not have a mental illness, and he wishes to leave the room.

I remind myself that he is on a treatment section of the Mental Health Act, although I don’t know his case well. I apologise. I cannot do as he wants and ask if the nurses may check his vital signs. He agrees. A nurse comes forward with the pulse oximeter, blood pressure cuff, and a small cup containing his prescribed antipsychotics. He becomes silent, his jaw clenches, his fists curl. I step back. He lashes out. They rush him.

I spot a postcard on the wall: I want to live, not just to survive.

In the on-call room, I turn the lock and slide the second bolt. There is a single hard bed, a blue cotton blanket, an NHS towel, and a swivel chair. The Trust provides us with an encrypted laptop, which is excruciatingly slow but can, with great patience, be booted up via a VPN while on house calls. The model of working is called “Agile”— which I like because it makes me sound like a ninja, when in fact I’m just a person without a regular desk.

Attempting to respond to a page from Green ward on the phone, I’m told their lines are down. When I arrive on foot, the issue becomes apparent: four computer monitors and two phone lines have been ripped off the wall and are arranged in a heap in the centre of the nurses station. Things got out of hand last night.

This can happen quickly. Psychiatric hospitals can be uncontained, frightening places—for staff and patients. I recently spent an hour holed up in the admission ward nurse’s station as a patient tried to break through the door after I’d placed him under section. Eventually he was lured away for a cup of tea and I escaped.

I thought of my last set of nights. Thirty-five-year-old woman: violent gash interior right forearm, forty-eight paracetamol ingested. Police found that she’d been molesting her twelve-year-old son. Died. Fourteen-year-old Eritrean girl groomed by paedophiles through Snapchat. Attempted to hurl herself from a bridge. Caught. Fifteen-year-old feeling suicidal again. Her mum’s tears behind her mask. Discharged. Seventy-two year-old woman starved for two weeks. Declined psychiatric help. Sixteen-year-old in violent mood after her father stole her Xanax while she slept. Watching EastEnders on her phone. Discharged. Fourteen-year-old swallowed AAA battery. Learning disability. Copying others who had that week swallowed screws, glass, and a hearing aid. Off to A&E. Forty-two-year-old man unhappy with his council flat. Keen to immolate town hall and himself. Day team to decide on.

A child told me, “When I was in that hospital there was blood running, police dragging someone to their room, people banging their head against the wall. I saw that and thought maybe I should do it.”
We learn so much from the company we keep.

I thought of the act of reducing misery to a list like this. As though it were clean and tidy and took no toll.

I head to A&E to see Cole, a twenty-five-year-old man with no known mental health history. I’m told he’s come in with police and presents as paranoid and delusional. He believes himself to be well. What do I think?

Cole is slim. A Black man in a neat shirt and scuffed cargo trousers. His mum next to him. He’s alert. Calm on the surface but holding his body tense, as though the impression is costing an effort to preserve. He speaks a little slowly and in a roundabout way. It takes time to tell his story.

Cole was in a relationship with Lucy. There was strain. They bicker. She belittles him. He has trouble knowing when to leave her alone. There is an air of dependency. He feels stigmatised and embarrassed when they are out together, and Lucy becomes angry and hits him. Lucy is white; Cole is Black. He feels others are quick to see him as a threat. It upsets him that Lucy will not say he is her boyfriend when they argue in public.

This morning, Cole was feeling sad waiting for her call. The call never came. He went to Lucy’s house, where they had another argument. Lucy said, “I don’t want to be with you, it’s done.”

Distressed, Cole called his mum. When she arrived, they pulled away in the car, but then Cole opened the door and stepped out. Five miles an hour. He fell but was unhurt. Mum, terrified, put him back in the car and, driving past police engaged in a separate altercation, stopped and explained that she didn’t know what to do. They brought him to A&E.

This is Cole’s first relationship. He’s sleeping OK and his appetite’s normal. He denies thoughts of suicide or self-harm or thoughts of violence toward anyone else. He doesn’t believe he has a mental illness and wishes to go home. He appears to have a fair degree of insight.

Rendering an accurate, atheoretical account of the mental state of another human being is the fundamental skill of the psychiatrist. I sit with Cole and listen, nodding at times, asking occasional questions, testing hypotheses and pressing links in thought where these seem strained or strange. Try to feel my way into his internal world. In this case, it is not difficult—heartache being nearly universal.

Cole has had a bad day. His girlfriend has broken up with him and he stepped rashly out of a moving vehicle. He has since calmed down. It is conceivable that he may act recklessly in future, although this does not seem to be a feature of the way he copes. His mum is keen for him to go with her to the countryside for a while. I attest to the wisdom of mothers. Scrawl a list of options should he need someone to talk to: his GP, a self-referral psychotherapy service, the Samaritans. He asks if he should try to go back to Lucy. I tell him it’s not my business but that there seem to be some unhealthy dynamics at play in their relationship, and that in any case it is sometimes a part of love to let go. I turn away and wince: both at the cliché and at my own catastrophic failure to heed that advice.

Cole is discharged from A&E. He explains he’d called NHS 111 once before. “It was a mistake,” he said, “I needed someone to talk to and all they wanted to do was ask me if I was hurting myself.”

I stop for a packet of fruit gums to savour on the way home. Chew the first—it tastes like soap. Check the packet—best before a year ago. Many bodies on the train. A man with a lit cigarette in his mouth and fresh blood on his shoe. Another in sandals with a hundred leeks poking from a carrier bag. A twenty-something-year-old sucking a pacifier.

I pick up my phone.

The way Facebook lines it up is strange.
“I wanted to write down and share with you what Zoë meant to me. . .”
Scroll.
Post from her fiancé.
“My partner has been missing since last night. She left the house on foot at 8 pm and didn’t return . . .”
Scroll.
Her best friend.
“There are no words that can explain how incredible she was and how much she meant to me. I know I wouldn’t have made it through the last year without her.”
Scroll.
Fifty comments.
“. . . too much of this.”
We’d been at medical school together. I see her red hair flash and dance on a badminton court. Her kind smile. Jokes shared at parties. They are only flickers—lightning under clouds.

My head lolls forward. Eyes close. One thing about wearing a mask— when your face is ashen and you are biting tears, you draw little attention.

I think of what it entails. Each day, lives fold out before you like an old map. You listen, follow the tracery, try to understand. Seek an accurate impression, form a plan, act it out. Sometimes it helps. Crises pass. There can be change or acceptance. Other times you are but ears amid the flood. Eyes surveying the wreckage. You fail or are not sought. Such an extraordinary and unfathomable and joyful and miserable and terribly strange vale.