Monday, September 25, 2017

Sadness & Mahler :My first adolescent patient!





Yosemite ©2007 Am Ang Zhang

I am lost to the world
with which I used to waste so much time,
It has heard nothing from me for so long
that it may very well believe that I am dead!
 
It is of no consequence to me
Whether it thinks me dead;
I cannot deny it,
for I really am dead to the world.
 
I am dead to the world's tumult,
And I rest in a quiet realm!
I live alone in my heaven,
In my love and in my song.


I do not know Mahler. No, not when I started at the Tavistcock in 1972.

One day at our referral meeting, a very interesting referral turned up from none other than the much revered paediatrician at the Royal Free up the road from us. In the early 70s referrals are specific to the individual teams and I have a suspicion that she likes to refer to my consultant as much of her cases landed into our team. I suspect that Dr Collingwood’s solid paediatric base having worked with Winnicott may have something to do with it. She is a very flamboyant character as I have met her at a couple of child protectopm conferences where she is much revered or indeed feared. I must admit I prefer her kind of consultant that knows her specialty and show great respect for similarly capable colleagues. Her flamboyance command much respect.

Dr Collingwood does not routinely put patients on psychotherapy as very often the management is through good practical advice. This is more so with this paediatrician and so when we got this referral where she specifically asked if the 14 year old could have psychotherapy and preferably with someone that knows a bit about music, we all gasped but nobody said much. 

Looking back now, it is amazing that I joined Tavistock not knowing what to expect and after nearly three years of training there, it has never occurred to me that one should use any medication on children. I have never once written a prescription. I know of a friend in California where the son was diagnosed with ADHD and was on Ritalin until well into late teens. Her youngest sister was diagnose Schizophrenic because she had such a vivid imaginary friend and was put on one of the newer antipsychotics. Yes, you guess right she is now a balloon. Not to be outdone, the middle sister who is quite a charmer was diagnosed, you guess right, bipolar but was not put on Lithium but the other mood stabiliser and a novel antipsychotic.

My prime years of child psychiatric training in a drug free environment was fantastic in ways that I only realised years later.

Miss Frys spoke up for me, “Dr Zhang is very fond of music and he is forever carrying boxes of discs from the Swiss Cottage library!”

Well, that settles it then. But this will be my first adolescent. The small kids I can cope by playing with them. This is real talking therapy now. I put on a brave face as they are all looking at me now at the meeting.

So I told them that from an early age, I sat in on my cousin’s piano lessons, then I was introduced to classical music at primary school by my village friend. My first record he lent me was Beethoven’s 5th Symphony. I have built my own sound system at high school as it was the cheapest way to get good sound and I even ran the school music club playing classical music at lunch times. Moving to England meant that my music playing equipments were left behind but I did purchase a reasonable disc playing set up and on Miss Frys’ tip, use our Swiss Cottage library extensively.

“Your favourite composer?”

“I now pick up some unusual works. At Swiss Cottage Library, I tend to go for new records and often box sets so that they are often complete segments of works. Older records are rather scatchy so I tend to look out for brand new arrivals and sometimes they can be some rarer music.”

“Like Mazart’s Quintets!”

So one does not escape the eyes of Miss Frys who is also a keen music lover and often goes to the Royal Festival Hall as she lives virtually next door to it.

“And Peter Grimes, which of course is Dr Collingwood’s territory!”

I love the way the referral meeting turned into a cultural one. Looking back now, it has as much significance to the likes of Nobel Laureate Kandel as it did in my humble early child psychotherapy training.

Dr Collingwood has a nice bungalow in Aldeburgh which is of course the home of Benjamin Britten and Peter Pears. The opera, I have never heard of until one day the librarian was placing new discs onto the shelves and hinted to me that it was a great one to listen to. Dr Collingwood is one of the volunteer ushers at The Maltings and some years later when our family spent a week at Aldeburgh and we pay pilgrimage to The Maltings for a Peter Pears recital. We met Imogen Holst, daughter of the composer at the sea front.

It took over 30 years for us to see a performance of Peter Grimes at the Royal Opera House[1].

I have by now seen quite a few children in therapy and I have on the whole been quite relaxed about using the toys and drawings throwing in Winnicott’s squiggle game[2] now and again for the children who are a bit too old for the set toys we have. It is interesting that most other junior doctors are more at ease with the older adolescents where they often come round to our case presentations to hear about the younger kids. It was only when I became a consultant that I realise it was unusual to have a preference for the very young children whereas many of my colleagues somehow avoided them.

Jonas

Now what do I do with this adolescent that our paediatrician thought needs some fairly deep therapy as he seem to be struggling with everything and most serious of all with his mother.

Unlike working as a consultant, I did not get to see the parents at all. Most of the time it would have been Miss Frys or her Social Worker trainee. The Psychologist only access a child if referred by the Consultant.
Some other time, Dr Collingwood would see the parents.

As it turn out, Jonas’ father is a Surgeon at the Hospital where the paediatrician works and his mother teaches piano at his school, one of the best known state school in the area. It is so good that many of the professional class living in Hampstead send their children there. Do we still wonder why good areas have good schools! Of course it is only natural that good areas with intelligent pupils attract good teachers. It goes on.

I have at least learned from Winnicott’s squiggle game the importance of the therapist’s quick response and spontaneity and why should talking to the older child be any different.

Traditional psychotherapist will probably throw up in horroe but at least those I am learning from do not have or suffer from that kind of rigidity.
Much later as a consultant I have adapted this approach well as it helps to establish rapport very quickly especially with parents.

But my supervisor wants to throw me into the deep end and I have no idea what to do.

Jonas first noticed the Mondrian on the wall.

“Did some kid do that? Very neat!”

Perhaps he is right. Picasso wanted to draw like a kid too.

Then he noticed the records I was about to return to the library: Mozart Quintets.

“Mozart’s best as he wrote for himself!”

That was how we started. Some might think I plotted it by putting the records on my desk. I wish I could have claimed to have planned it. I think sometimes spontaneity may be best.

But this boy knows his music and yet I am not quite prepared for what he gave me as the sessions progress.

Many thought the therapist is suppose to be a mirror and be there to let the patient see more clearly about their own psyche. Others are more assertive and felt compelled to make interpretations not realising that often one is limited by ones own psyche or understanding of it. Hence the need for some personal analysis to deal with that aspect.

There is of course a world of difference between reflection and interpretation. My personal feeling is that there needs to be a balance between the two.

Psychotherapy is thus quite far removed from medical history taking. In a severe medical episode, there is a need to get a clear view of the events leading to the episode in order that appropriate investigation is carried out to be followed by the right course of treatment.

Psychotherapy afforded us with the luxury of a deeper understanding of the patient without having to ask probing questions. It goes without saying that with the more frequent sessions of therapy the therapist gains a very deep understanding of the patient without the need to go through an intensive and compact history taking. We also tend to remember these patients literally for ever.

Jonas hardly sees his father as he is busy his patients. His mother would have been a concert pianist but she had to make a choice between bringing up Jonas and looking after a rather nice house on the Heath. But she has high hopes for Jonas, her only child.

Yes, to be something she could only dream of, a concert pianist. Jonas has been a good piano player but once he turned nine told mother he would like to learn the violin.

He picked that up in no time and is now on to Grade 8 exam for violin. He left his Piano at Grade 5.

As I progressed with Jonas, it became clear the very strange role I am playing. I am his mother that he can talk to and argue with. And perhaps practice with. In truth it was easier as I am not his mother and on the other hand I am. But I am the one who could provide some answer his mother would not give him.

One day I have a complete set of Brahms Symphonies on my desk, from the library of course, and he casually asked if Brahms was my favourite composer or not.

Brahms 1st Symphony was a present given to me by one of my uncles when I made my amplifier. He worked for Abbotts in Hong Kong and when I got to medical school, he gave me my Littmann Stethoscope.

“I love the 1st especially the solo violin part in the last movement.”

“Well, you should listen to Mahler as he used various bits of singing unlike Beethoven’s Choral Symphony. And my best Mahler is his Third Symphony, though everybody else I know prefer the 2nd.”

The truth is I have two commuting friends that are fond of music and Mahler has not been one they talk about.
Yosemite ©2007 Am Ang Zhang
I tried that day to secure any Mahler and could only find one: Das Lied von der Erde.

It was a shock to my commuting friends especially when they read the details: Chinese poems translated by a German?

During the next session, I have not seen Jonas more enthused and energetic. He could not wait to tell me more about Mahler[3]. The 3rd Symphony[4]s all about nature and is so positive and energising.
I have to say now that I have probable gained more from this one patient than I have from any other. To be introduced to Mahler at the time when London was just waking up to it and wake up it did.

We were able to talk about the struggle of Mahler and of the sadness of the death of his daughter and eventually him dying of Rheumatic Heart Disease[5].

One day he was able to declare that his struggles were nothing compare to Mahler’s.

It is interesting that he never really talked about his own sadness as Mahler’s overshadow his and yet in true traditional psychotherapy style he has gain his own insight.

His time with me, or was it my time with him was coming to an end. Dr Collingwood is highly intuitive and on the recommendation of my psychotherapy supervisor helped me to terminate the therapy. It was perhaps a credit for a state funded system like the NHS that one does not need to hang on to therapy for ensuring adequate income. The main danger for privately funded psychotherapy is the unnecessarily prolonged therapy periods with the result that the patient is addicted to the therapist or the other way round.

On his last session, he told me he has got his distinction in Grade 8 Violin but he did not want to be a violinist.

He wants to be a conductor.

As I wrote this, I Googled and found that he is now a conductor for a German Opera Company.

No, Jonas is not his real name.

In 2009, Das Lied von der Erde was performed in Hong Kong and The Mahler 3rd in December of 2016[6], a sort of home coming. Thank you Jonas for introducing me to Mahler.




Nature & Mahler: Royal Festival Hall!


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[1] http://cockroachcatcher.blogspot.com/2011/06/peter-grimes-individual-against-mass.html
[3] http://cockroachcatcher.blogspot.com/2010/08/proms-mahler-nature.html
[4] https://www.youtube.com/watch?v=9Yr720ftjaA
[5] http://cockroachcatcher.blogspot.com/2009/11/sadness-songs-superstition-mahler_29.html
[6] http://www.hkphil.org/eng/concerts_and_ticket/concerts/concertdetail.jsp?id=554

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