Saturday, August 1, 2015

Art Institute: Madness & Anna Freud!

The Art Institute at Chicago had a number of Van Goghs. 

Vincent van Gogh

The Bedroom, 1889
Art Institute Chicago
Vincent van Gogh
Weeping Woman, 1883

This Van Gogh reminds me of an earlier blog about madness.

In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.
It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?

It was no coincidence that right next to the Madness and Modernity exhibition is the show of 
Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.

Bobby Baker Wellcome Trust

Bobby Baker is a successful performance artist who had suffered acute psychiatric problems including self harming, which she captured over a period of 10 years in hundreds of 'diary drawings'. These paintings (158 drawings, selected from a total of 711) and commentaries demonstrated her anger with the mental health service and any viewer thinking of entering psychiatry might be put off forever.

Bobby was told by the first psychiatrist she saw that she suffered from 
borderline personality disorder. (Time article link)
As her story unfolded in her drawings, one gets an uncomfortable feeling about the state of our psychiatric service and wonders if we are even at the 50th step. She has triumphed over some of life’s most frightening experiences despite all.
Bobby Baker Wellcome Collection

Let us look at Van Gogh's self portrait:

“As my ability to function improved, hell became more firmly encased in my skull. I’ve formed the opinion…..that psychosis is a metaphor for extreme suffering. My delusions led to paranoia that a network of professionals was constantly searching for evidence that I was wicked. …….Medication didn’t help – it just made me fatter and fatter.” Bobby Baker Wellcome Collection Exhibition pamphlet.
As a psychiatrist, I could not help being curious about the lack of an early history, having just come from a room showing a replica of Freud’s couch. According to Freud most mental disturbances have roots in one’s early childhood. 
The puzzle was solved when I read in the Observer of an interview with her:

“I don't know how but I must ask about her father next - the classic therapist's question is, in her case, inescapable. Again, a picture speaks first. In Telling Keith, she is weeping, her tears bizarrely swirling upwards. Her mouth is open and a sea floods out - in the middle is a tiny, drowning figure. ‘That's my father,’ Baker says. ‘I know,’ I say. I know because, in her autobiographical show Box Story she told audiences about a summer holiday in Brancaster, Norfolk when she was 15 and had just received her surprisingly good O-level results. Telling her father her news was 'the best moment in my life' and he gave her the happiest of hugs. She asked whether he was coming to lunch? Not straight away, he replied. He would have a dip first. A bit later, they heard a woman's voice shouting, ‘Help! Help! Help! A man's been washed out to sea.’ Her mother leapt to her feet shouting, ‘My husband! My husband!’”
Kate Kellaway Observer, Sunday 28 June, 2009.

Like my own patient, Bobby Baker suffered from bereavement.

You won’t be able to see the Madness and Modernity as it has finished, but the Bobby Baker drawings are on show at the Wellcome until the 2nd of August. Those running our psychiatric services should perhaps have a good look as they may well be featuring in a future Wellcome Exhibition. 

Anna Freud and Common Sense

I wrote in my book:
“……But Miss Horowitz you cannot fault. Her father was a famous child psychiatrist and she was really an Anna Freudian. Not so much of the penis envy or bad breast good breast stuff that Gail kept talking about……”
Miss Horowitz was my psychotherapy supervisor. We spent an hour and a half every week talking about my patients. It was years later when I realised the essence of her approach and therefore that of Anna Freud’s is the naturalness.
Much has been written about Sigmund Freud as a person with what looked like unresolved personal problems. He had without doubt influenced our thinking for at least thirty years as the Nobel Laureate Kandel conceded. He provided a framework for our further understanding of the working of the human psyche. Much as physical medicine is being continually updated by newer findings based on new scientific discoveries, later psychiatrists have been able to modify and improve upon Freud’s original ideas. I always view with suspicion the rigid adherence to classical ways in matters of the mind.
At the time when I was working at the Tavistock, Anna Freud (December 3, 1895 - October 9, 1982, sixth and last child of Sigmund and Martha Freud) continued to give seminars on Wednesdays at lunch time at her home opposite the Hampstead Clinic. This is now the Freud Museum. Anna Freud herself would already have been seated even if you made special effort to arrive early in order to have a seat. She would invariably be knitting and the few times I was there she seemed to be knitting this enormous scarf or even blanket. It spread over her knees and the floor in front of her as if to say “This is my space.”
Arthur Couch, who had 6 ½ years of psychoanalysis with Anna Freud, wrote a paper to try to give a picture of Anna Freud's views about adult psychoanalytic technique. The following excerpts gave particular insight:
“……She seemed not to know the orthodox 'Freudian' rules of technique about such restrictions. At times she even expressed her own opinions on certain realistic issues I was talking about. I recall telling her I was surprised that she should say such things; she answered : ‘Why are you surprised?’ …… I came to realize that I had previously assumed something too rigidly limited about Freudian clinical principles…….”

“……As I recounted these various failed attempts each day, Anna Freud seemed to increase the intensity of her knitting, which she did most of the time so silently that I hardly noticed it. Finally, in one session, she began to speak about the issue of my soft-spoken patient. I expected her to give a very important interpretation about my difficult situation. But what Anna Freud simply said was: Tell her to speak up.’ This I did, and it solved that particular problem for the rest of a long analysis……”

“………Erikson's wife was pregnant, and he was spending many sessions talking about his worries about her pregnancy and what having a baby meant to him. Being very involved with this topic and wanting his analyst's full attention and concern, Erikson expressed his irritation to her that she was not speaking about it, but Anna Freud just kept knitting with increasing intensity while remaining silent……. when Erikson came into his session and announced that his new baby son had been born, Anna Freud gave him a blanket she had been knitting all along for his baby……”

Anna Freud once said: “The trouble with common sense is that it is so uncommon.”

Interesting Anna Freud link: The Independent

Slide Show: Guardian.

Can They Draw: From Picasso to Matisse 
Picasso, Medicine and Lloyds 
Picasso and Tradition
“Wake-up Call” to British Psychiatry 

Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?

Tuesday, July 28, 2015

Mahler & Wine: Sadness & Pleasure Principle

Pleasure Principle:

Sigmund Freud’s Pleasure Principle is well known, but his other small “contribution” to mankind, i.e. his unofficial discovery of Cocaine, is probably less so. He in fact became quite an enthusiastic user of cocaine, in addition to smoking a large quantity of cigars, up to 20 a day. He developed jaw cancer and had to endure 33 operations and eventually died of it. 
I am not here to encourage the use of cocaine or cigars (as if people who used them needed encouragement). 
Instead I am going to talk about some of my pleasure pursuits. I have from an early age been interested in music though I have never played any instrument except the “gramophone” if you can call it an instrument. It can also be said that I play these instruments by “proxy” through my children. I have always had a multitude of hobbies: photography, electronics (I built my own radios and valve amplifiers), and snorkeling to name a few. Arriving in London in the early 70s allowed for easy access to Franceand French wine and food remains one of my most pleasurable pursuits, though my interest in wines has now been extended to Port and other non-French wines. 


In life one goes through difficult times and we Chinese are fairly philosophical about it – unhappiness is often viewed as something secondary to external circumstances such as loss and bereavement, political injustice (which has afflicted most of our families) and other life events that are beyond our control. Our classical poets wrote about such sadness and generally accepted what life befell them. 

When life events do not go our way, some turn to religion, although more and more people nowadays turn to the “happy pill” (drugs). One can also seek comfort in Music, Poetry, Photography, Writing (and blogging), Painting, Fishing, Knitting, Travel and of course Food and Wine. 

In an age when people sought happiness in all ways possible we need to remind ourselves that sadness has been the driving force behind many writers and composers.

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.

Farewell                      Wang Wei (701-761)
Dismounting, let me share your farewell wine  
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest
Enquire no more when I am gone 
Till the end of clouds, endless white clouds!

Mahler died on May 18th 1911 in Vienna.

"I think it is probably the most personal composition I have created thus far."    Gustav Mahler

The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death. 

Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."

My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.


The benefits of moderate consumption of wine have been well documented by scientific papers and the popular press. However, the pleasure of visiting vineyards and tasting local wine and local produce and the regional cuisine is way beyond health pursuit. Given current concerns over the effects of a number of psychiatric drugs, we may have to have a fresh look at the meaning of sadness and happiness in one’s life.

Recently I had the opportunity to drive from the south of France back to London with my family. We decided to revisit some of our favourite vineyards and restaurants on the way. The great thing about France is the country’s ability to preserve regional styles both in wine making and cooking.

Our first stop was Rhone. Twenty years ago I visited Rhone and Maison Paul Jaboulet Aîné was my favourite vineyard. One could get a bottle of their La Chapelle Hermitage for a very reasonable price then. It was a fantastic wine and Hugh Johnson in his pocket guide described it as a match for any wine on earth. How true it was and its current price also reflects that. Now I have to settle forCrozes Hermitage. This wine fortunately needs less cellar time and the sunshine and soil imparts a flinty and peppery flavour that is so typical of the region. It has that elusive softness on the palate.

It was just as well I did not go for the top price wine. Afterwards I was told by a good friend of mine that since the death of the old man Gérard Jaboulet in 1997, La Chapelle Hermitage has not really been the same. The last great vintage was 1996. Nowhere is tradition more important than in some of the top vineyards in the world. Chateau d’Yquem hopefully will never give up their traditional method.

The white we chose from Jaboulet was Pararelle 45, the name taken from its cellar’s latitude position. It is a white wine with 20%Viognier, a grape variety that gives white wines in the area its long and lingering after-taste. It will be great with many Chinese dishes and of course sea food and will hold its own even with fairly spicy seasoning.

The next stop was in Burgundy, arguably one of the two best wine districts in France. I was once told by someone whose father was from Bordeaux and mother from Burgundy that Champagne is that place in between that produces a fizzy drink. Well, that is French for you.

Now when in Burgundy, there really is no point thinking cheap and with my daughter’s rather well trained palate we headed to Puligny Montrachet. It was vintage time and the chardonnay grapes were coming in. It was a moving sight and with the glorious autumn sun just setting we tasted some of the finest that this area has to offer. Not the most expensive, as Le Montrachet will set you back quite a bit. I tasted some grapes and even two or three were enough to convince me that everything was working for this region. You could taste just about everything even in a few grapes. Some of you would have seen the photo of the reds in one of my previous postings. It was a bit of tongue in cheek putting up glorious burgundies for cooking, but it is what they do in the region when preparing the fabulous local dishes of Boeuf Bourguignon and Coq Au Vin.

The Puligny Montrachet we chose was from Henri Moroni (so were the reds). Their tasting room was rustic and not pretentious.

We spit our wines, not because they were bad, but it was the only way not to be intoxicated. It felt like such a waste but Madame even insisted that we should. We tasted Chassagne Montrachet some years back and they were great wines too. This time we decided to have a slightly different experience. I was surprised at how different it was. This wine has a superb vanilla, almond and citrus nose that is so assertive that just smelling it is enough to convince you that it is a must have. The colour is a brilliant light gold with that very typical green tinge, exactly the colour of those tiny grapes we tasted outside. Unlike some lesser wines, the nose converts to even greater flavour on the palate.

This is a pedigree wine at a fairly reasonable price, by that I mean much more reasonable than Le Montrachet.
What is to go with this wine? I have often felt that some of these great white burgundy wines are best enjoyed on their own. However, it will be perfect with Turbot, Halibut, Scallop and Bresse Chicken, one of the first French produce to have an AOC. (In The Cockroach Catcher, the child psychiatrist lamented that the excellent free range chicken that he tasted in his childhood days could no longer be found.) I recommend most of the seafood (if very fresh) dishes to be cooked simply steamed or seared with minimal seasoning like a touch of sea salt, fresh ginger and coriander. Similarly the best chicken can be just rubbed with sea salt, steamed and served with a delicate spring onion and ginger sauce in its own juice. In my view, food and wine should complement each other but the very best wines simply enhance the dishes. 

Wine Posts:

Saturday, July 25, 2015

Art Institute & Mondrian:Thumb Sucking & Winnicott.

It was such a pleasure to encounter Mondrian at the Chicago Art Institute that I am reprinting my blog from earlier days.

Lozenge Composition with Yellow,Black, Blue, Red, and Gray1921
Art Institute Chicago 

In my book The Cockroach Catcher I described how I was suddenly confronted with a piece of work by Mondrian. I have to confess it was not an artist I have heard of at the time. I did not think it was a favourite for most others at the clinic. In a sense I inherited it by accident. Having stared at it for the better part of two and a half years and then spending the next thirty plus years comparing it with other modern art in museums round the world, I have come to appreciate it more and more.

This is how the scene was described in the book:
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?In any case the Mondrian would be fine on its own.
Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso………”
The Tate now of course has several Mondrian works.

Now you can read the whole chapter here:

Chapter 10  First Encounter

In the winter of 1972, something happened that sealed my fate to stay in England forever.  I was appointed Registrar to a world famous clinic.
         By then I already had one of my higher qualifications (D.P.M. – Diploma in Psychological Medicine) and was in the process of sitting the first ever examination of the Royal College of Psychiatrists. At last we could achieve the same standing as colleagues in most other disciplines - a membership, not just a diploma.  I had moved to London to take the examination for this most prestigious psychiatry qualification. My wife had accompanied me for what we thought was a year abroad.
         On a cold October morning I made my way to one of these old mental hospitals which was running the first ever training course for the RoyalCollege Membership examination. It would be foolish not to be there as most of those who ran the new College were on the teaching panel.
         As you drove into the main gate of this rather imposing Victorian beauty or monstrosity, you got the same feel as in most mental hospitals of the same era. There was the odd one working the kerbs and gardens. A small group might be shepherded by a nurse to cross a road on their way to their morning’s appointment. Many had the typical shuffling gaits from the antipsychotics they were on.
         The last of the summer’s Hydrangea flowers still tried to hang on. They looked tired and ugly. I would never have hydrangea in my garden.
         The Post-grad place was easy enough to find as you just followed the majority of the cars.  Wow, with half an hour to go, the car park was already nearly full.  I suppose we all wanted to have a nearby spot to park on such a chilly morning.
         I liked to be nearer the front as chances of falling asleep would be much reduced. I spotted a gap, made my way in and before I could sit down, someone offered me a hand.

Gail: Thumb Sucking

 “I am Gail. I am from the Tavistock.”
         The Tavistock?  Many others would think this was the place they had pop concerts, and doctors would know that the British Medical Association was at Tavistock SquareLondon.  But I knew. I was too astonished. I did not know what to say. Then I managed to utter my name and said that I would be going to the Tavistock, and that I had just been appointed a Registrar there.
         Where I came from no longer seemed so important.
         Synchronicity[1], you see. Gail put her thumb in her mouth and started sucking it vigorously.
         “Sorry, my mother’s fault and she has already paid for my analysis for the last three years. Between you and me, I preferred my thumb. Who is your analyst?”
         “Haven’t got one.”
         “Oh, yes. Dr Collinwood is the odd one out. Her registrar does not need to be in analysis.  However, one good thing the thumb sucking did was to get me my job at the Tavi. I was already in analysis.”
         Analysis for thumb sucking? I thought to myself. Never! Whatever next? And a sought after job in London?
         What did I do wrong, or right to get my job?
         “Ah, you see you are Chinese. You don’t need analysis. Your predecessor was Greek. She had the collective culture of the Ancient Greeks.”
         Perhaps her next registrar would be Egyptian.
         Over the next six hours or so, I began to understand the scale of her problem. It was really like having sex in public and she could be so engrossed in it. It would be wrong to suggest that she tried to reach orgasm but sometimes from the sound she was producing it was not far off. Now and again she noticed that I was paying more attention to the thumb sucking than to the lectures. She stopped and apologised.
         It would be odd to have gone through years of training at a place where the perceived wisdom was that all problems big and small could be traced back to our childhood and more particularly to our sexual development that I should write about my work without any reference to these aspects.  It would also be peculiar if I, having been brought up in a Psychoanalytic Centre of world class reputation, could pretend that sex did not play a significant part in human psychopathology.
         My first encounter with my future colleague certainly shocked me. What was I getting myself into? Was I going to see even crazier people?
         The staff, not the patients.
         My start at the Tavistock was straightforward enough. They had a good introductory pack. I was first briefed by Miss Frys the social work team leader. She was the nicest person one could meet and work with. Warm, kind and she listened carefully. She looked normal enough. I found out later that she was a Quaker and she came from a family where every female member lived to over a hundred. She looked like she was heading that way too.
         She told me Dr Collinwood was very fond of her previous registrar who was a Greek girl.  She was going back to Greece to have her first child before starting a Child Psychiatric clinic there.
         “We are rather fond of Greeks here right now, as there are two others whom you will meet probably at lunch.”
         One later on became a Health Minister in charge of Psychiatry and the other started the Athens Psychoanalytic Society. I too became very fond of both of them and continued to meet them occasionally at international congresses.

Miss Frys had some impressionist prints on the wall and they just seemed to match the colour of her hair. A peculiar picture with coloured squares was by the cupboard and was obviously not hers.
         “Ah, an imposition here. You see, our local library is very good. They have all these prints they lend out to clinics and public offices. This one seemed to be the one left when everybody else have had their pick. I thought, well it is not my type of picture, but it is mathematical and perhaps a Chinese would appreciate it.”
         There were not as many Chinese in the U.K. in those days, and multicultural understanding was almost non-existent.
         Well, it is not in my nature to speak my mind, not at a first meeting with someone who seemed to ooze wisdom and kindness. I took another look and asked, “Who is the artist?”
         “Very neat,” I said.
         “It is rather, I think you should have it in your room.” Miss Frys replied.
         “Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?  In any case the Mondrian would be fine on its own.
         Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso.
         Now I am going to be cultured as well.
         “Do you like music? The library has a superb collection of records and they get every thing new as well. I live very close to the Festival Hall. I must take you to a concert there some time unless you have been already.”
         I must confess that with all that studying and preparing for the arrival of our first baby, concerts seemed like a lot of trouble; but I would certainly try and get the records as I had a very good sound system.  Radios and electronics had been my hobby from the age of nine, and over the years I had built at least eight systems of my own, starting with a simple crystal radio set, then graduating to a triple valved receiver system and ultimately to a high fidelity amplification system with EL84[2], which remains the gold standard of the industry.
         It was not until some years after her retirement that I finally took up her offer and met up with her at the Royal Festival Hall. There is no better place to be in London on a late June evening when the light never seems to want to disappear.
         “So you are having a new baby in March. Dr Collinwood is very pleased because you will be able to observe your own baby’s development. It will save a lot of time. But I shall arrange for you to do your nursery observation about three streets away.
         “Now here is Dr Collinwood, I can hear her coming down clanging two cups. She had this kidney stone problem years ago, and her doctor advised her to drink lots. So she takes two cups of coffee instead of one. Oh, I see the coffee lady is bringing down two more. I presume one is for you and one for me.
         “We have this coffee lady who comes in at ten to make coffee. I do not think they pay her very much, but the clinic is thinking about instant coffee and tea-bags so that they can save some money. She has been here twenty two years, as long as I have been, and is part of the fixture. We are all writing letters.”

         I greeted Dr Collinwood, my consultant. She put the coffees down and shook my hand. She looked less scary than the first time I met her. There were now more smiles. What was she making of this young Chinese doctor from across the globe, I wondered.
         Her first concern was the baby. Well she was a real children’s doctor. I later found out that she had worked for years with Winnicott. Winnicott is someone I still have a lot of time for. He was really a paediatrician but his psychological understanding of children and mothers was nearer to my heart than many of the Viennese psychoanalysts such as Sigmund Freud, Anna Freud, and Melanie Klein etc.  Dr Collinwood continued to show great interest in both our children and after she retired the whole family had spent quite a number of summer holidays at her retreat in Suffolk. One time the grand parents came with us too.
         I knew straight away that I would be fine at the Tavistock.
         “There is this case I need to talk to you about.  We missed the last two case presentations (maternity leave and all that) and I promised that we would try and do one six to eight weeks after your arrival.
         “I do not normally give my new junior any old case to take over but this is a nice boy and you might get on with him. I shall continue to see his mother.”
         Meeting with the psychotherapist was another really nice experience. There was so much gesturing that I later discovered was a Jewish thing. But Miss Horowitz you cannot fault. Her father was a famous child psychiatrist and she was really an Anna Freudian[3]. Not so much of the penis envy or bad breast good breast stuff that Gail kept talking about.
         We had twelve cupboards all with individual keys.  Each therapy patient got assigned one and they could put their first name on it. There were packs of toys that the other psychotherapist sorted out and it included drawing material. Drawing paper was multicoloured and we tried not to let the children take their drawings home as a rule, as they were important material for analysis.

All that medical training and exams and so on had not prepared me for what I had to do. I had to start from scratch. I was not even going to take a history. The first session with Michael would be a play oh, sorry psychotherapy session.
         “You will be fine, although it would have been better to learn on a new case.”
         All the Nation’s pride and glory was up to me now. I could only succeed.
         Michael turned out to be a very nice boy as I was promised. He had two problems: nightmares and soiling.
         The nightmares annoyed mum but she really could not stand the soiling.
         “There must be something physical, Dr Collinwood. He has already seen the Greek doctor for six months and now you want him to see this Chinaman?”
         “Oh, very nice to meet you,” she said, putting her unlit cigarette back in her big handbag. She had a very Jewish look with a very Cockney accent. If I knew what I know now, she looked exactly like one of those handing out drinks in one of the New York Hassidic Jewish camera stores. The way her eyes were scanning she did not miss a thing.
         “I brought his pants from school.  He soiled it again.  I thought the doctor might want to see it.”
         I was beginning to “like” her.  Such consideration!
         “Sorry mummy.”
         “There is no need to show Dr Zhang. I hope with a few more sessions we may get to the bottom of the problem.”
         Dr Collinwood was confident. I was not sure if I was.  But my tough medical training saved me – the important rule of using long words and never expressing doubt.  I did not hesitate and said, “Sure we are going to.”
         Mrs Green was evacuated during the war. Dr Collinwood and Miss Frys were trying to put a series together on the effect of evacuation on problems for mothers with the next generation. It was quite unique in its way as hopefully there was not going to be another war and perhaps evacuation would not be used if there was one.
         Her husband was probably Jewish as well and was on Incapacity Benefit as a result of some illness or other.
         Michael soiled only at school and almost always just before going home or coming to the clinic. He often woke up screaming in the middle of the night and insisted that mother should go and see him. She now put him in bed with her to save getting up, she told Dr Collinwood. Mother cleaned for the school so Michael stayed at home with father.
         Mrs Green was so fed up that the previous week she took Michael up Archway Bridge ready to jump. She called Dr Collinwood instead.
         At least in those days we did not have tons of local authority social workers around you once something like that happened. Nowadays Michael would probably have been placed with another family at some point.
         Michael got into a routine pretty quickly. First, we played football - a soft ball. I kept goal three times and he three times. Then we wrote the score on the little black board. He wrote his name on the card provided for the cupboard but insisted on putting three black lines round it.  What would Miss Horowitz say? Then he played with the animals and then arranged the family dolls around the table. Mother, father and a little girl. A boy would probably be too close to home.
         Though he was eight, he was more like six in size and was very timid. He asked permission for just about everything.
         He would then finish with a game of draughts. I made the mistake of leaving the pieces as they were. He saw me three times a week, and he was my first and only patient then.  He asked if I saw anyone else. I quickly learned to put some names on the other cupboards and tidied up the draughts. An obstetrician delivering his first baby must not let the mother know it was his first.
         He soon started drawing. Mother, father, and a baby girl in the middle. We religiously put all these in his cupboard.
         “I like that drawing,” he pointed to the Mondrian, “So neat.” He was right.
         We saw mother and son separately at the same time for fifty minutes twice a week.   Mum always said goodbye to Michael outside my door, with a kiss and darling this and that.  One day after a few sessions, as she walked with Dr Collinwood to her consulting room, she said very loudly, “Is your new doctor any good?  He seemed quiet and sensible, but Michael tells me he only plays football and draughts with him.”
         It was much later that I realised that children are equipped with defences so varied that it sometimes takes one a while to understand what has happened. Michael was an intelligent boy. He had set up decoys. He had now established with mum that I only played football and draughts with him. No wonder we only ever played for a few minutes each time and no wonder it did not matter if the draughts game finished.
         Now instead of putting the girl in the family group, it was a boy, and he no longer drew a girl on his pictures. He drew a boy.
         He kept putting the father in the toilet in the doll’s house.
         One day Michael drew me a picture that I could no longer hold back from Dr Collinwood until supervision time. I intruded into her fluid loading time.
         Michael drew a naked mummy complete with big boobs and pubic hair. The boy in the middle was naked too and had a rather large tool on him. Father was in his pyjamas and Michael drew tears down his face.
         We made the case presentation. It was well attended by nearly everybody including those from the other teams. Word must have got out that Dr Collinwood had a case that had sex features.
         Father suffered from severe diabetes and had been impotent for years.  Mother had very bad abuse history from the evacuation days and had become rather needy of sexual gratification. In a desperate attempt to shame her husband she slept stark naked and put Michael in the middle. She would get Michael to have an erection and then say to her husband, even your eight year old can do better than that. She would not contemplate leaving him, as the benefits were good and she got to drive his car. Dr Collinwood did not mince words on erotic stimulation etc. etc.  All the way through, Gail never sucked her thumb. We passed around the drawings. Freudians made their bid with Oedipus and all that. Kleinians[4] insisted on bad breast. To me it was just an abused mum having a bad time and using the boy to get back at her husband.  But it was only my first case.
         Gail gave me a thumbs up (the other thumb) approvingly afterwards and said I passed the test. I told her that attending Dr Collinwood’s case meetings could save her lots of money. “It’s my mother’s anyway,” she said.
         Michael continued to see me for the best part of the rest of my stay at the Tavistock.  His nightmares disappeared and he stopped soiling.  Nobody knew if his mother stopped fiddling with his penis but to me it was an eye-opener. At least being Jewish she had no qualms about bringing Michael to the clinic three times a week for his therapy sessions. Since then, I have collected quite a few other similar cases, but I shall always remember Michael and Mondrian.

[1] Synchronicity – In The Structure and Dynamics of the Psyche Jung describes how, during his research into the phenomenon of the collective unconscious, he began to observe coincidences that were connected in such a meaningful way that their occurrence seemed to defy the calculations of probability. Unfortunately it is often quoted as a scientific basis for astrology and other improbabilities.
[2] EL84 - a vacuum tube (a.k.a. valve) of the power pentode type. It has a 9 pin miniature base and is found mainly in the final output stages of amplification circuits, most commonly now in guitar amplifiers, but originally in radios and many other devices of the pre-transistor era.  However, even now, hi-fi connoisseurs still prefer sounds produced by valve amplifiers to digital transistor sound.

[3] Anna Freud - Anna Freud moved away from the classical position of her father, who was concentrating on the unconscious Id (a perspective she found to be restrictive) and instead emphasized the importance of the ego, the constant struggle and conflict it is experiencing by the need to answer contradicting wishes, desires, values and demands of reality. By this, she established the importance of the ego functions and the concept of defense mechanisms. Focusing on research, observation and treatment of children, Freud established a group of prominent child developmental analysts (which included Erik Erikson, Edith Jacobson and Margaret Mahler) who noticed that children's symptoms were ultimately analogue to personality disorders among adults and thus often related to developmental stages. At that time, these ideas were revolutionary and Anna provided us with a comprehensive developmental theory and the concept of developmental lines.
   As such, the formation of the fields of child psychoanalysis and child developmental psychology can be attributed to Anna Freud.
“……I think that a psychoanalyst should have...interests...beyond the limits of the medical facts that belong to sociology, religion, literature, ,[and] history,...[otherwise]his outlook on...his patient will remain too narrow. This point contains...the necessary preparations beyond the requirements made on candidates of psychoanalysis in the institutes. You ought to be a great reader and become acquainted with the literature of many countries and cultures. In the great literary figures you will find people who know at least as much of human nature as the psychiatrists and psychologists try to do.”        Anna Freud

[4] Melanie Klein - child psychoanalyst who worked in London (as the US required a MD degree to practise psychoanalysis) had a strong following and some severe critics too. Her theories – (as portrayed in Nicholas Wright’s 1988-Mrs Klein) include references to: "good breast" and "the bad breast"; "symbolic urine"; playing the violin as "a repressed masturbation fantasy"; automobiles  being penises and mountains being breasts.