Wednesday, February 27, 2013

Family & Healing: Who Is The Real Patient?

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

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

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, 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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