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The medicalisation of laughter

Examining humour and humanity in mental health

At a time when recruitment and retention of psychiatrists in the UK remains perilous- with recent figures indicating less than 3.6% of medical graduates are choosing the speciality, when at least twice that is needed for a population of our size- I am forced to consider my own reasons for choosing mental health. I am ashamed to say I recently spent an emotional few months wrestling with an overwhelming desire to leave it altogether.

Why? After 15 years of training, I was exhausted from apologising to patients for not being able to do the best for them due to factors outside my control, from not being able to offer timely follow up appointments due to lack of staff, to not being able to refer for social inclusion groups due to lack of funding. A story all those in the NHS will sadly be familiar with.

After a half-hearted stab at rational thinking (being a doctor is still a respected profession and stable occupation, I am only two years away from being a consultant, my parents would kill me if I ‘gave up’ now…) I wasn’t able to elucidate the real reason I decided to stick with it and continue my journey as a registrar in general adult psychiatry.

It was at this point, as I caught sight of the tube station across the street from my bedroom window, that I was reminded of a patient I had seen a community mental health clinic a few years ago. He had a background of schizophrenia with prolonged hospital admissions, usually after stopping his oral antipsychotic medication which had led to multiple relapses. In order to minimise future risk of hospitalisation, we had had a detailed discussion about having an injectable form of the same medication, known as a ‘depot’ given which would negate the need to take tablets daily. I remember drawing a diagram of the lower half of a body and showing him that the depot would be administered in the upper outer quadrant of his bottom. He seemed encouraged by this and agreed to consider it.

As is the folly of NHS job rotations for all junior doctors in training, by the time this chap had returned for his follow up appointment, my post in the community mental health team clinic had ended. I had moved on to a different hospital and I never saw him again.

Until one exceptionally busy Friday evening on the Piccadilly line, when I was in a rush to meet friends for dinner. Packed to capacity, this patient was standing at the other end of the carriage when he saw me squeeze into the other end.

‘Doctor!’ he shouted happily, in a voice designed to carry and waving his can of cider in my direction. ‘Look, it’s my doctor! Tell me, what is it you kept saying you wanted to do to my bum again?’

I remember freezing momentarily but when the entire carriage dissolved into a snort of confused giggles I laughed out loud. It was such a delightful moment.

That’s just it- there is a certain je ne sais quoi with psychiatry that despite all the worry, all the sleepless nights tormenting about the suicidal patient seen earlier in the day, all the unanswered questions in the complexity of an oft-faulty human mind, it offers a level of honesty and hilarity I have never experienced before. After all, I saw laughter as a loss of control- and if there was ever an occupation for which composure was a prerequisite, it would be a psychiatrist?

The overriding memory I therefore ascribe of my four years of being a psychiatrist so far is one of humour. It is one of laughs- outright, astonishing, endearing belly laughs. Moments that still have the power to weaken me with the hilarity even after years have passed. Why did they not teach us about this benefit at medical school? Why don’t more psychiatrists talk about the humour unique to our profession? Surely this is a USP- that a career in psychiatry could be good for your health? After all, the evidence connecting humour with physical health benefits such as improved immunity to infection is gaining traction daily. Perhaps we need to advocate humour as a therapeutic aspect of our clinical encounters?

In reporting examination findings of a patient’s mental state, the oft-used term ‘evidence of formal thought disorder’ is recorded. This is an umbrella term for a disturbance in thoughts that can be indicative of mental illness. It has always bemused me- what is formal about the patient who is unwaveringly convinced that Donald Trump and Beyoncé are indeed the same person, or the patient who is adamant flavoured custard pots ‘are out to get him’?

I believe that if there was even a hint of the simple, consistent and heartening laughs a career in psychiatry will reward you, more doctors may be attracted to the field. Certainly, feedback I have received from patients over the years indicates a strong preference for a grounded but light-hearted approach- with one comment made recently that they did not have the perception that psychiatrists ‘knew how to laugh at all’.

Maybe this can go some way to encouraging frank discussion about mental illness which can be tricky for many. Perhaps the next time we reach for a repeat prescription, we can think about the insouciance of laughter with our patients- after all, it is free and you can never have too much of it.

And in a field governed so heavily by risk, I believe humour another one worth taking. It is what keeps me going.

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