Thursday, February 2, 2017

Sadness & Abuse: As You Like It.

Abuse Abuse Abuse

All is not well in this beautiful part of the OLD WORLD that is Austria.

Salzburg, Austria ©2008 Am Ang Zhang

Josef Fritzl, an engineer in his seventies was found to have kept his 42-year-old daughter locked in his cellar since she was 19. The woman, who bore her father seven children during her captivity, was discovered only after one of the children she had with her father fell into a coma in hospital.

Austria does not have the monopoly of family abuse.

I can only quote from Chapter 27 in The Cockroach Catcher:

And your experience makes you sad:
I had rather have a fool to make me merry
than experience to make me sad…..
(from: As You Like It - Act II, Scene 7)

With so many quotable quotes from As You Like It you may wonder why I would chose to pick this one.
      Perhaps it is a warning to young doctors to enjoy the blessings of inexperience. Luckily for me sadness brought about by experience from my clinical work is mercifully little but I would be either dishonest or heartless to say that there has been none.
      As You Like It happens to be one of the few popular plays of Shakespeare that are often performed in schools, maybe apart from Dreams, and for most it is basically a comedy with a happy ending.
      My wife and I went to a recent production at BAM (Brooklyn Academy of Music) by none other than Peter Hall with his daughter playing Rosalind – their New York debut.  Few would imagine Sir Peter picking Brooklyn for his debut but in the end it was a great experience. The New York Times said that it was more reviving than spending a week in the Caribbean. Having been an accidental resident in the Caribbean for two years I would dispute the comparison but totally agreed with the sentiments expressed.
      At the BAM, it was like walking into a renovation site and in many ways I hope they leave it that way as it was rather charming. It was a most fitting setting for Shakespeare. I accept that they have to make sure it is safe.
      It was at the start of my psychiatric training in England when I asked one of my gurus about reading matter.  Apart from Shakespeare, he recommended Ibsen.  I have since read Ibsen's plays but still come back to Shakespeare, who seemed to be able to pick up so many strands of human experience.
      My ideal Shakespeare is indeed one that can be performed on a bed sheet with a few broomsticks for prop and without wanting to sound derogatory, I would say that this was exactly the approach adopted by this production.
      Much was left to the imagination and it worked.

Mrs Coleman
      Now and again in our work we get an indescribably sad case.  Sometimes what started out as a rather straightforward case might begin to roll downhill so fast that we would be forever taking deep breaths thinking: can it get any worse?  We would question if what we were doing was making any difference at all to what seemed like a predetermined course where no intervention would be able to make any impact on the final outcome.
      One thing is for sure, real life is not like a play – you have only one chance to perform it and often not everything is clear.
      Mrs Coleman came to see me about her daughter within months of my appointment as a consultant.  With my new job came advantages and disadvantages. I used to be able to ask my seniors about cases, especially the difficult ones. Suddenly I was supposed to know it all. I used to have a big team working on a case, to the point that when the patient came to me there was hardly anything left for me to discover. Single-handed consultants are “on their own”. They are lucky to have a social worker and perhaps a psychologist. I had both but the psychologist was not really part of our team – she happened to be sharing the same building. She belonged to the old school, which meant she knew her field and she did not try to be a social worker.  For a while it became fashionable to blame everything on background and upbringing. Any disturbed child not performing well at school had nothing to do with teaching methods or intelligence but everything to do with social background. What were the implications for the social background of bright high achieving children?
      There was some excitement in the clinic when it was known that a shepherd’s family had been referred.
      Shepherds?  "As You Like It" sprang into my mind.
      We have lambs so we must have shepherds – so I thought.  It is true that we seldom had referrals from the farming community. I can only remember one other case and that was when I was a trainee. Shepherds also conjure up scenes of nativity and there is a sort of biblical romantic feel to it.
      What we did have was something quite different. As it was unfortunately the lambing season, the shepherd Mr Coleman, though making a valiant appearance, was as good as asleep during most of the session. Mrs Coleman talked through the session with her rather charming old Sussex accent.
      Mrs Coleman at the time had two children but it was the older daughter Laura of nine with whom she was having trouble.   Tom, some eighteen months younger, was a happy-go-lucky sort of boy. Laura had a whole range of behavioural problems. She had recently taken to soiling in her pants.
      It was often our practice for the social worker to do a preliminary home visit, and my social worker told me that she was most impressed with their home when she visited. They lived in a tied cottage on the farm. The children’s grandfather was a shepherd and he had two sons, the older one working on the dairy side. There was also a daughter, the children’s aunt, and her husband was the local milkman. The aunt had children similar in age to Laura and Tom. She worked part time in the local greengrocer’s and between her and Laura’s mother they split the fetching from school and childcare. The aunt unfortunately was recently diagnosed with breast cancer and was having different kinds of treatment at the local hospital. Luckily her husband was a milkman and could take over the afternoon part of the childcare arrangement whenever necessary. Mrs Coleman took the children to school on the days when the aunt had to go to hospital.
      The aunt was a strong lady, Mrs Coleman told me, and she was sure she would outlive her.
      It was an old cottage they lived in and my social worker told me that Mrs Coleman kept the place clean and tidy. It was therefore most upsetting to her when her nine year old daughter started soiling herself.
      It was mostly in the afternoon but not everyday.
      As my social worker had just started her training at the Tavistock Clinic on child therapy it was a good chance for her to take the girl on for some individual therapy sessions. Like my old consultant did when I was in training, it was now my turn to see mother.
      This seemed to be a simple enough family and I did wonder at the beginning if there was much to unfold.
      I was proved wrong.
      Within two to three weeks of Laura starting therapy, Tom the younger brother refused to go to school. It was natural for everybody to think that there was some jealousy involved. So I arranged for mother to bring him to see me. It was rather obvious from the start that he was not very bright and that his not going to school had little or nothing to do with Laura but more to do with the fact that he could not keep up with the work and was being teased at school very badly. He tried to hit back at one particular boy and was told off by one of the teachers on duty at play-time. He did not want to go back. I arranged for the psychologist to assess him.
      Yes, he was functioning at a much younger age and yes, he needed to go to a special school. In those days it was called an ESN school – school for the Educationally Subnormal.  The SSN school was for the Severely Subnormal.  In the 90s, it was deemed more polite to call the subnormal children “special”.
      Both schools were local and extremely well run. Tom was transferred and seemed to have settled down well there.
      Not bad. I congratulated myself.
      Laura was getting on well with her new therapist. She was attending without any problem and was doing nice drawings, according to my social worker.
      Mrs Coleman was grateful that I sorted out her son.  Tom, who had always been a Daddy’s boy, had upset father very much with his escapade but as he had now settled in his new school father was rather pleased. He in fact went to the same school so he made it a point to turn up to thank me once everything settled.
      Mmmm, perhaps we are not escaping the genetics theory.
      As a precaution, we also tested Laura but she turned out to be rather bright.
      Genetics, you are wrong.
      Not so, Mrs Colman must have thought. She was rather perturbed when I told her. She started crying and pleaded with me to keep the secret she was about to tell me.
      Her husband was not Laura’s father.
      Mrs Coleman had worked at the local butcher’s since she left school and he was always all over her. Before long he was having intercourse with her at the back of the shop. He always gave her extra for that part of the service and she was happy with the extra bit of money. The butcher’s wife had a stroke a few years back and had been bed ridden.
      “It was not the money,” Mrs Coleman assured me. She did not want me to think of her as a slut.
      None of the mothers I saw wanted me to think badly of them and it often took a while before they would reveal their secrets.
      Mrs Coleman had also been seeing the shepherd but never gave him much thought as she felt he was rather stupid. The butcher was much brighter.
      Then one day some accident happened and she found herself pregnant. But the butcher was not going to divorce his wife. She was the one with the money.
      She decided that the next best thing was to let the shepherd sleep with her as long as he married her. He was so pleased with himself and they had a big white wedding in the local church. 
      So Laura was the butcher’s daughter and not her husband’s. Now that I had proved Laura was clever, she was afraid I might ask awkward questions although she doubted if her husband would ever really work it out for himself.
      Once a parent realised that you had ways to get to the truth, they often started revealing things that you wished they never did.
      The butcher had some idea that Laura was his and had been slipping even more extra money for mother to buy her things. He never had any other children.
      I never broke my promise and to this day I do not think that her husband ever knew.
      What was to unfold was what caused most sadness.
      I attended some special seminar on sexual abuse and at the time some rather ugly looking anatomical dolls were produced for the sole purpose of diagnosing Sexual Abuse. They were anatomical in that a whole family set including parents and grandparents, children and adolescent all had what was described as anatomically correct parts - females with breasts, nipples, vagina and anus; and males with penis and anus; and all the orifices were so to speak fully functional. These dolls all had proper clothes on and yet all the clothes could come off.
      The idea was that normal children played with them as normal dolls but abused children would perform with the anatomical parts.
      I had a full set ordered, having spent sometime persuading the managers that others had labs and X-rays and so on, but these were the only tools we required for the specific job.
      Laura was the first to discover them and before my social worker’s eyes one of the male figure’s penis was in the girl’s mouth. She told my social worker that was what Uncle Tom liked.
      What followed were special “disclosure” interviews conducted under camera. Uncle Tom was the milkman. It happened to both girls. When the boys were in the kitchen playing computer games on the TV, slowly the girls were made to suck him. That was when Laura started soiling.
      Mrs Coleman went berserk. Arrangements had to be made for alternative child care which really meant she had to cut short her hours at the butcher’s. Uncle Tom moved to his mother’s as a temporary measure pending Social Service investigation and Police enquiry.
      Mrs Coleman could not sleep at night and called her GP. He asked her to pray with him as she had to be forgiving. She was so angry and when she was cleaning around the house she managed to get some caustic liquid all over herself and had to be admitted to hospital. She was also referred to the adult psychiatric department.
      She started attending an anger management group at the hospital.  It was thought to be the best way to help her deal with recent events.
      One day when I went in to work, my social worker was already there and in tears. Mrs Coleman had just taken a massive overdose of Paracetamol and her liver was thought to be too far gone to survive.  She died a rather painful death and we were all deeply saddened.
      Could we have done any better?  Was the truth too much for Mrs Coleman to bear?  Would she still be alive if we had not discovered the sex abuse?  We would never know. We might have rescued Laura from sex abuse but now she had lost her mother. Mrs Coleman was right about one thing though, her sister-in-law did outlive her.
      As Shakespeare said, “…….And your experience makes you sad…..”
      I wanted to hide the dolls.

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