Monday, November 11, 2013

Anorexia Nervosa:Failure & Enmeshment!


Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.       Minuchin


 ©2013Am Ang Zhang  
From The Cockroach Catcher
Chapter 34  Failure?



I
t is not easy to admit to failures and harder still for doctors to do so especially if they did everything right and according to protocol. 


         Doing the “right” thing is not an indication of success.  

         Hardly.
         Yes. I am coming back to Anorexia Nervosa again and I do not apologise for it. I am apologising for our failures though.

         The British Daily Mail reported in March 2007[1]:
         “It is thought there are between 60,000 and 90,000 adults being treated for eating disorders at any one time in the UK. The average age of diagnosis is between 16 and 18between 60,000 and 90,000 adults are estimated to be treated for eating disorders at any one time in the UK.
         Over a 13-month period from March 2005, 206 preteenage children across Britain and Ireland were newly diagnosed with serious disorders ranging from bulimia and anorexia to binge eating.
         Half were admitted to hospitals for in-patient treatment. Some were showing symptoms of starvation such as a low temperature and a slow heart rate, while 10 per cent had to be fed by tube.”
        
         In the same month, the British Independent[2] reported:
         “Anorexia Nervosa has the highest death rate of any psychiatric condition. In ten years 3% of these patients died, and although half were by suicide, the rest were related to the starvation process.
         Just this week in Rome a 27-year-old model identified only as Ilaria died of Anorexia after an illness lasting ten years. She weighed 35kg at her death. Luisel Ramos, 22-year-old Uruguayan model died at a fashion show in August, 2006 after suffering a fatal heart attack that was thought to be the result of Anorexia. Ana Carolina Reston Marcan, the Brazilian catwalk queen died only three months later in a Sao Paulo hospital.”
        
         When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it.  It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.

         What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.

         It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine.  Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening. 

         The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”.  They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.

         I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.

         On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.

         With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.

         We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.

         Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts. 

         To me, the moment a psychiatrist turns to the law he is admitting that he has failed. 

         At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.

         There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.

         Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.

         I had to find an answer, an answer for Sammy and an answer for myself.

         Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.

         “At least we did all we could,” my staff constantly reminded me.
         “And she is the most determined of all the Anorectics we have right now.”
         More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself. 

         Yes, I could be as determined as they were.

         The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.

         The modern trend is certainly moving away from blaming families.  Or that is the rhetoric of most who write publicly about it.

         Whatever the official line, families cannot help feeling blamed.

         “If we are not to blame, why do we need family therapy?”

         “There are so many other families like ours.  Why do they not have the same problem?”

         We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.

         Yes, it might help if they do find a gene like they did with obesity.  Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.

         So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.

         Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.

         For Sammy and her family the message was simple and clear enough, no matter how hard we lied.

         The family had failed and the hospital had to take over.

         That was the blunt truth. 

         But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens. 

         I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law. 

         In short, I had to reverse just about everything that had gone on before, and more.

         Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.

         Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.

         I could not see any other way either.

         Unless …….I could reverse everything that had gone on before.  

         If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative.  Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.

         I had a plan.

         These meetings were attended by just about everybody who had anything to do with the patient.  They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress. 

         My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor. 

         Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?

         Could I achieve that?

         After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”

         “It is so unfair.  Now I shall not be able to go to Harvard.”

         It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.

         I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.

         “Before I say anything else, can I ask you a few things?”
         “What? Sure!”
         “Do you smoke, drink, take Ecstasy or go out clubbing?”
         “No.  Why?”
         “Do you have piercings and tattoos on you?”
         “Tattoos—yuk!  Yes, I having my ears pierced. That is all.”
         “Do you like Pop music?”
         “No way. I play the violin and I like Bach and Bartok!”
         Everybody was attentive now.
         “Do you shoot heroin or smoke Cannabis?”
         “No way!”
         She was getting annoyed.
         “What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.
         “How can you even ask and in front of my parents? You know I don’t do things like that!”

         I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.

         I then turned to the parents.  Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.

         “You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”

         “We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”

         “And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.

         “So she always had her way.”
         “She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”
         A tidy bedroom! My goodness, everything was falling into place.
         “Sammy……”
         “Yes……”

         “You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”
         Then I turned to the parents.
         “And you, FAILED parents!”
         “And we FAILED you. We failed you because we had to hide behind the law and force feed you.”
         Sammy said, “I can’t do all those things even if you make me.”
         Ah, the turning point.
         “No, don’t get me wrong. I don’t want you to either.”
         I then told her that I would like to take the tube off her despite lack of progress, or because of it.
         It simply had not worked.
         I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.
         Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.
         The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.
         I took her off the Section as she started to put on weight and before long she was discharged. 

         We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.






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[1] Daily Mail report on 26th March 2007 – Children as young as six suffering from aneroxia.
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=444646&in_page_id=1774
[2] Independent report on 29th March 2007:  The Versace family: Allegra and the curse of anorexia
http://www.independent.co.uk/news/europe/the-versace-family-allegra-and-the-curse-of-anorexia-442347.html
[3] Salvador Minuchin:  (born 1921 in Argentina), in 1965 became the director of the Philadelphia Child Guidance Clinic, which eventually became the world's leading center for family therapy and training. He is author of a number of books including Families and Family Therapy and Family Kaleidoscope and coauthor of Psychosomatic Families: Anorexia Nervosa in Context and Mastering Family Therapy.
[4] Richard Saul Wurman: (born 1936) an architect by training, published over 81 books including his best-selling book Information Anxiety and his award winning ACCESS Travel Guides. His latest books are UNDERSTANDING Children and UNDERSTANDING Healthcare (January 2004). http://www.wurman.com/rsw/

[5] Micropore™:  Micropore consists of a conformable, non-extensible non-woven fabric manufactured by 3M from 100% viscose, coated with a layer of an acrylic adhesive.

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