Friday, April 5, 2013

Hiccup Boy

Child psychiatry is not about asking questions, 
but about feeling the answers. 
It is a discipline where empathy rules. 

Protea, Cape Floristic Region (CFR) of South Africa
 ©Am Ang Zhang 2005

South Africa reminded me of my junior doctor and my hiccup boy.

The Cockroach Catcher: Chapter 13  Hiccup Boy

ohnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital for Nervous Diseases at Queen Square and Great Ormond Street.  Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help. 

          At the time my junior doctor Dr Zola was a girl from South Africa who decided that, given the new situation in her country, she wanted to emigrate to Israel where her doctor father, mother and three brothers were. She was an eager learner and would follow me to every single case I saw and even to meetings. She truly shadowed me. I had no complaints at all and she still writes to the clinic every year to tell us how she is doing.  After training with us she was able to get into the professorial child psychiatric department in Jerusalem.

         For what I did to her on this hiccup case she would never forgive me and to this day she will still remind me of it.

         Johnny was an unattractive obese boy of twelve with a similarly unattractive obese mother. Together they looked a picture, an ugly one.
         This led me to draw my first impression: he was a “bullyee”, i.e. someone who would be a target of bullying – in school, in the streets, in football matches and in fact everywhere.
         He was holding a big bottle of Coke - the two litre bottle, and so was mum. It was August and England was having its unusual heat wave.
         This led me to draw my second impression: (no, not about obesity – that is too obvious) he did not hiccup when he was drinking from the bottle.
         So within the first few minutes, I knew what to do.
         “Dr Zola, would you mind taking mother to the other room to get some history?”
         I knew from her look she was reluctant. She had heard of my many magic cures and she knew she was about to miss one. But she had also come to like my style and my work.  She really had no choice but to take mum to another room. Meanwhile Johnny was happily hiccupping away between sips of Coke.
         I have often said to many of my juniors that child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.
         Dr Zola, I think, felt it too. She knew I was going to perform one of those cures.

         By the time I asked both of them to come back the hiccups had stopped and I had a mother who looked both surprised and embarrassed, and Dr Zola looked as if she would not talk to me till after the next Sabbath.

         After sending the patient and mother off with instructions and another appointment date, I had to deal with a very unhappy junior.
         “What did you do?” she demanded to know.
         “You really want to know?”
         “Yes, I need to learn.”
         “Something unorthodox.”
         “Did you hypnotise him?”
         “No. Maybe I shall tell you another day as I am not sure if he will sustain his recovery.”
         I did like to tease some of them. Dr Zola was having none of that. It was Friday and I knew she had to leave early for Sabbath, but sunset was later in August.
         I asked if she noticed that he could take long sips of Coke without hiccups and this often did not happen with true hiccups.
         Dr Zola said, “I thought the Coke was one of the factors for his and his mum’s obesity.”
         That was obvious but I decided not to say it as it would be too patronising.
         What happened was I said to Johnny, “It is school, isn’t it?” He nodded. “Now if I sign you off school as of now, do you think these hiccups might go away?” He nodded.
         Dr Zola said, “That’s it?”
         “That’s it. But I really do not think he would have stopped had anyone else been there. I gave him a sense of security. His secret was safe with me.”
         I think in the end Dr Zola understood, but to make a boy who sustained the hiccups for so long stop without resorting to heavy medication like Chlorpromazine or Haloperidol is indeed one of life’s sweet events.
         I do not think my secretary ever got over it when she typed my notes and letter.
         It is often better though if you can somehow get the parents to do the magic cure.

The Cockroach Catcher has a full review on Amazon.

Here is an excerpt:
BOOK REVIEW, by Peter Chang. 

Reading this book was truly a trip down memory lane for me. Although Zhang settled in the United Kingdom, and I in Canada, I can identify with much of his experience as a psychiatrist. This book helps to demystify mental illness and humanize the doctor-patient relationship. I am very impressed by Zhang's down to earth approach to problem solving. The secret to his success in therapy is the respect that he gives to his patients, their families and his colleagues. Just by listening to his patients and believing in their stories, Zhang is able to perform miracles, such as the "Seven Minute Cure" (Chapter 1), Ping Pong (Chapter 24), and "Bullying" (Chapter 23).

Zhang has a special talent for engaging difficult patient in therapy, as exemplified in "Wrong Foot" (Chapter 12), "Hiccup Boy" (Chapter 13), "Failure" (Chapter 34), and "Yellow Card" (Chapter 46). As Zhang finds coercive treatment distasteful, such as force feeding an anorexic patient, he is good at negotiating with patients so that they would voluntarily eat again to achieve their own individual goals. For instance, the patient in Chapter 34 started to eat again because she did not want to be "sectioned" (meaning certified under mental health laws) which would prevent her from going to the United States to pursue higher education. 

While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them". 

As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy). 

Full review on Amazon.

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

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