Thumb Sucking & Nightmares: Winnicott & Mondrian

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.

Composition with Yellow, Blue and Red (currently on display at Tate Liverpool)

This is how the scene was described in the book:

“……..“Mondrian.”
“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

I

n 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 Royal College 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 Square, London.  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.

         

Mondrian

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?”

         “Mondrian.”

         “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.”

        

Winnicott

         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.

         

Nightmare

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 China man?”

         “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 field...in 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

http://www.freud.org.uk/fmanna.htm

[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.

http://query.nytimes.com/gst/fullpage.html?res=9E0CEEDD153FF937A15756C0A964958260

NHS: A Closer Look!

A closer look as it may not be there:

©Am Ang Zhang 2005

I wrote a while back about: ?A National Car Service.

NCS (National Car Service)?

Imagine a society where you take your beloved car to a Private Garage for some repair work and it turns out that the Private Garage did a very bad job and did serious damage to the engine, transmission and other unknown bits. Now imagine that there is a State run National Car Service that will put right everything and at no cost to you and no charge to the Private Garage that did the damage in the first place.

Would it not be wonderful?

The Telegraph:

Doctors continued operating on Kelly McLure, 31, after she suffered her cardiac arrest at the private Belvedere Hospital, in Kent, it was claimed.

Southwark Coroner’s Court was told paramedics were kept waiting for 45 minutes despite insisting on taking her straight to A&E.

Instead Dr Edward Latimer-Sayer, her surgeon and Dr Ahmed el Sayed Moustafa, the anaesthetist, continued with the routine nose and chin procedure after stabilising her.

Mrs McLure, known as Kat, suffered brain damage during the operation on November 22, 2005. She died six months later.

The Herald Scotland:

In 2002, Denise checked into a private clinic for what should have been a straightforward procedure to remove fat from her stomach. Afterwards she spent six weeks in intensive care (in NHS hospital), the surgeon having repeatedly punctured her bowel.

In the next seven years (again under the NHS) she endured more than 20 operations to repair the damage before succumbing to meningitis in 2009. She was 43.                             

                                                                                                  

Read all about it here>>>>

The surgery was performed by Dr Gustaf Aniansson (from Sweden), at the private Broughton ParkHospital near Preston, Lancashire. Dr Gustaf Aniansson took himself off the GMC register so that he could not be struck off and it was believed he continues to practice in Sweden.

In the new world order of our NHS, private provider (AQW)for commercial reasons need not let the public have access to information about their activities etc, and even the doctors they provide. As they say, be very afraid.

Dr Phil Yerboot is very direct:
In  Boob Jobs and One Night Stands

The PIP breast implant scandal rumbles on with a seeming stand-off between the Minister of Health and the principal users of these implants, Transform and The Harley Medical Group.

Transform has nothing on its website (that I could find) to inform patients about the PIP implant issue. The Harley Medical Group does so here, but feels that this is a problem that it wishes to lay on the MRHA for licensing the PIP implants. Both are interesting organisations, with peripheral clinics where early consultations with Nurse specialists are followed by surgery at a few central hospitals. The Transform group lists its Surgical staff here. I could not find similar information on the Harley Group website, though they do state that their surgeons are on the UK Specialist Register as Plastic Surgeons, this may well be because of recognition in another EU state. Several on the Transform website seem to have only Specialist Training as General Surgeons.  The Transform Surgeons have mostly trained overseas and are not rooted in the UK medical culture in the same way as most BAAPS members, most of whom have past or present substantive NHS Consultant posts.               

It is my understanding that if there is just one fully registered surgeon prepared to be clinically responsible, ANYTHING GOES.  For all we know, it could be someone from Sweden and that someone could at short notice resign from the GMC.

Perhaps SoS will have to set up an NBS, National Breast Service soon.

Right now, we still have the NHS, the National Health Service. It is free even if the damage was done by a private doctor and treatment will be for as long as it takes. The private doctor will not be charged any fee and some even continues to practice here or in other countries.

Soon, such a National Health Service may not be there! That is how the government is going to save money.

First appeared in Jan 13 2012.

NHS Reform & Hospital Consultants ...

Private & NHS: Choice & Consultants

NHS Reform: The Plot Against Consultants!

NHS: A Hospital Based Service?

Simplicity?

©2012 Am Ang Zhang

I have previously suggested that the new CCGs should buy up Hospitals as the current internal market system is having a very serious unhealthy load on the total cost of Health Care in this country.

Why not do the opposite, let the hospitals employ the GPs. In other words: integrate primary and secondary health care and be done with the internal market that is grossly skewing the way health care is funded.

With some of the “best” advisers available (costly as well), the only reason for recent governments to pursue the market driven idea can only mean one thing: the eventual privatisation of most providers of health care! 


But wait for this: only the profitable ones.


US Model:

One can assume that for a range of basic medical conditions, the NHS (by now a brand) will be free at the point of delivery. Private providers to the NHS will provide on a per case basis and we already have the best example of this is the US in the form of Medicare:

An estimated 77 million people born between 1946 and 1964, turn 65. This year, the first 3 million will reach that milestone, adding significantly to the 47.5 million patients covered by Medicare in 2010. That explosive growth will jeopardize the federal program’s ability to meet its obligations at the same time that it inundates physician practices and hospitals.

Largely left to their own devices in finding help with these problems, these patients have a habit of seeing several physicians, including specialists. No referrals are needed, and Medicare pays a fee to each doctor for every visit. That adds up to a situation in which not only are there no limits on how much is spent, but often there’s no one in charge to make sure patients don’t receive unnecessary or counterproductive treatments.

At UCLA:

It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.

“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 

US Health Insurers had a good deal, they do not need to deal with this group.

If one look closely at Hinchingbrooke: they will only have so called 48 hour in-patients, no neonatal, mental health (illness more like) and certainly no dialysis. So if all hospitals are to be run by Circle what will happen to the other patients.

The answer is simple: it will never happen and there is little doubt in my mind that Circle will provide good profit for its investors. These smart people do not throw away money unless they belong to others.

A Hospital based health service:

The Cockroach Catcher has many medical friends working in different health care systems and most of my friends find our GP system ‘unique’. They see that progress in medical science has meant that it is difficult for a generalist to be able to do everything. Many medical procedures require specialist training.

Growth in most other countries has been in the area of specialist doctors.

The UK is the only country in the Western Word that is defying the trend. The serious side effect is that soon we might be running out of specialists in this country: well trained specialists.


So, what would be so wrong with a Hospital based integrated NHS.


My suspicion is that it will happen but it would be the privateers that will be doing it to have full control of cost that would be escalating. 


It is already happening in the US and believe you me, it will here. By then it will be too late as the specialists would have left the state run NHS.

Biodiversity: Abalone & Nanotechnology

Recent medical blog posts by Dr No and The Witch Doctor coupled with the banking scandals would mean that aspiring Bright Young Things may indeed need to take The Cockroach Catcher’s advice and take up opera singing or biodiversity as alternatives. There is of course always archeology and anthropology. Looking at my friend’s children the last two were strictly for the Bright Young Things with super rich parents.

The Cockroach Catcher will now try to convince you that if you do not have the voice, then perhaps Biodiversity is for you.

Those that know what these shells are will know that they housed one of the most sought after sea food in the Far East.

 ©2012 Am Ang Zhang

Yes: Abalone.

But I am not going to give you a recipe but talk about the colour especially of the inside of the shell.

It has been widely known that colour on the whole is produced by the light it absorbs. That remained true for leaves, flowers and dyes etc., etc.

No so with Abalone.

No, instead there is a 2-3 layered nanoparticle/nanocrystal network that would affect the passage of light and the energy of light will be changed when it emits from the surface of the crystals.

Butterflies too use the same nanocrystals.

These indeed form the basis of modern day Nanotechnology.

Mother Nature should be ecstatic

Nature Posts:

It’s a Bird, a Reptile, a Mammal: It’s Platypus

ECOLOGY: First Bees, Now Bats. 

Paraguay: Technology Meets Ecology 

Hong Kong: Humpback Whale

Tasmania: Whales & Dolphins-Mother & Baby

Toucan: Darwin & Infra-red Technology

Family & Healing: School Phobia & Post Natal Depression

In an age when it has become more or less impossible to gear your intervention or non-intervention in the practice of Medicine, I remember this family fondly.

From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 1

T

he early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K.was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

Catherine

         Catherine, aged fourteen, had not attended school for some time and all attempts by the school authority and educational psychologist failed to get her back to school. This was a pity as Catherine was really university material.

         She had eleven older brothers and sisters. Two older sisters were married.  One of them had a little baby of ten months. The other had two children at school. The youngest of the brothers attended a public school (i.e. an English private school) on a scholarship, and with financial assistance from the older siblings.

         After an initial visit by the social worker, the team decided to approach the case in a family therapy sort of way – big family therapy in every sense of the word.

         At that time, family therapy was a relatively new development and had probably grown out of some group therapy principles. One of the first courses was established at the Group Therapy Institute in London when I was still at the Tavistock. Little did I know then that it was history in the making. Of the people I was with then, either teachers or co-trainees, many have become prominent practitioners in the field.

         Even the rather adventurous social worker was feeling a bit dubious.  “Do you belong to the school that insists on everybody in the family attending?”  She asked, hoping I would be a bit eclectic about it.

         “Let’s try and get everybody at least for the first session.”

         “I will do my best,” she promised.

         Good old Miss Kimble. She always got things done.

         As some of the family were working, the session had to be organised for the evening.   There is so much mystique attached to our kind of work that families often oblige without asking too many questions, at least at the early stage.

         One of the older unmarried sisters took it upon herself to organise the meeting. The main one that caused some problem was the oldest brother who was a long distance lorry driver going all over Europe.  The meeting needed to be on one of those nights when he was back from his delivery tour. The brother at the public school had a cricket match and he was apparently one of their best bowlers. One of the other brothers agreed to go to the match and bring him to the meeting as soon as the match was over.  The sister with the baby would have to bring the little one but the older children would look after her at the meeting.

         I told them that they could all join in.

         Luckily with so many children the family had a reasonable sized council house and the family room was fairly long.  They moved the dining chairs through to provide seating for everybody.

         The scene was set. We just had to deliver the goods.

         “We have come this far.  We just have to do it,” I told Miss Kimble.  She probably had more faith in me than I had in myself.

         Father looked after the parks and gardens for the council and had been with them since leaving school. Mother had not worked outside of home since the first child was born. She used to work in the Council Offices and that was where she met her husband.

         All the unmarried children who had left school had jobs except for the one who organised the meeting. She was in fact the eldest sister. All hope was on the boy and Catherine, except now Catherine was not going to school and had not been for nearly a year.  Two of the sisters worked in an insurance company, which was a very important local employer. Three boys worked for the Parks and Gardens department. One girl was a life guard at the local public Sports Complex that just opened and one boy looked after the gymnasium. The parents had done well and you could see that it was a very close knit and caring family.

         Only the truck driver was absent. We chatted and waited. The baby in the meantime was crawling in the middle with the two older children fussing over her. Catherine sat close to mother and now and again would hold her hand. I was not too sure who was comforting whom but then family therapy was about observing the family interactions.

         Cricket boy was busy devouring a plate of food mum left for him as he missed his school dinner.

         Others were exchanging various gossips about boyfriends and girlfriends.

         I thought that this was fun but there was also a lot to take in. The traditional approach would have allowed one to be more focused but it would probably have taken a long time to get to where we wanted to get to quickly.

         When I heard air brakes, I knew that big brother had arrived. Everybody else knew as well. Swiftly Catherine let go of mum’s hand and went to the door.  One of the other sisters had the plate that had been kept warm in the oven set in a tray complete with a big can of beer.  I declined the offer of beer as I was working.

         Big brother was quite a big fellow but was friendly enough as he shook hands with me. After a few bites and some gulps of beer he turned to me and said:

 “We are all here now. What is this about?”

         To this challenge, I explained in a very simple fashion why I wanted to see the whole family. I went on to use what I had since described to my juniors as a journalistic approach to history taking, as distinct from the traditional topic-by-topic approach. With the journalistic mantra – Who?  What?  When? Where?  Why? How? – the patient or the family would just enter the conversation barely aware that you were taking a history. To keep focused, you do need to have clearly in your own mind the information you are seeking.

         If you are not experienced, you can follow a printed questionnaire and take three hours of history but you will just end up with loads of seemingly unrelated information.

         With my favoured journalistic approach you follow leads.  The whole session becomes more integrated and it is easier for patients and families as you are not likely to appear to be jumping from one thing to another. It also comes across as more professional.

         One thing led to another and my break came when one of the boys let slip that he remembered mother going into hospital after Catherine was born and big sister gave up a good job at the insurance company to stay home to look after the rest of them.

         Mother was in the local mental hospital and had electrical shock treatment.

         Mother started crying and big brother was rather upset and asked me what relevance this had except to upset mum.

         At this point, the little baby who had been crawling around stopped in her track and crawled to Grandma and started touching one of her slippers. She started crying too.

         I have my own theory that even before acquiring language, babies are able to retain emotional memory of early experiences. Later on in life it becomes difficult to grasp the source of the upset as there are no words to describe such emotional experiences. Traumas in early life have diffused effects; those happening later on in life are more focused and perhaps easier to deal with.

         One famous psychiatrist once talked about his own experience of his mother’s depression. He talked about having images of a wooden arm and it was through years of psychoanalysis that he reconstructed the whole image of his very depressed mother who had a rather catatonic posture in the deepest depth of her depression. He could remember himself as a toddler running into the house after play to be met with the wooden arm, sharply quietening down and then backing off. It was a rather moving seminar he gave at one of the conferences and a rare occasion when a British psychiatrist talked about psychoanalysis.

         Back with the big family – all went rather quiet. A couple of the girls were sobbing. Catherine tried to comfort mum who said she knew it was all her fault. The eldest brother thanked me for making things clear for him.

         All were relieved to hear that I would not be forcing Catherine back to school and that mother would not be prosecuted.

         All agreed that Catherine would be wasting her brains if she did not have some form of education and I explained that I would be looking into alternatives.

         Miss Kimble told me later that I was lucky to have that break and that it was a good job the baby was there.

         It was uncanny that in my thirty plus years of experience, over half of the children who had problems attending school in a big way had mothers who had serious puerperal (post-natal) depression.  Was the school refusal (school phobia) a clinical manifestation of genetically transmitted depression, or was it the psychological effect of living with a depressed mother? I really do not know.

         Catherine never managed to return to “proper” school but with a fair bit of individual therapy we managed to get her to attend a tutorial unit. This we achieved by getting mother to find some part time work. Big sister too started working part time.

         It was daunting for me to think that a single family session brought about so much change, but then I was reminded that the strength was with the family – we just tried to tap it.

         Catherine had good exam results on the limited subjects she could sit but was immediately offered a trainee post at the insurance company.

         Years later I bumped into one of the older sisters at the Sports Centre.  She thanked me again for what I did for the family and told me that everybody was fine.

         I told her I was scared by the lot of them especially her big brother. She told me I did all right. Catherine was his favourite sister.

         I cannot remember seeing another big family since and with the disintegration of families it became increasingly difficult to do that type of family work.

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