Monday, August 19, 2019

Anorexia Nervosa & Mountains: Misguided Belief in Psychiatric Diagnosis!

 ©2016 Am Ang Zhang 

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains,
and waters are not waters.
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.

                                                                                                   Adapted from Ching-yuan (1067-1120)

There is a misguided belief that Psychiatry is like other branches of medicine, that we make diagnosis as if we know the definitive cause, course of treatment and prognosis.

I accept that even in other branches of medicine, what we used to know sometimes can be turned upside down overnight. We only need to look at the evolution of the understanding and treatment of Leprosy and Tuberculosis over time, and in the modern era, that of HIV/AIDS.

I was brought up to understand that “scientific truth is nothing more than what the top scientists believe in at the time.” In this modern era of “biotech” approach to medicine, new understanding is yet to be found for many conditions. In these cases, are we content to continue with empirical and symptomatic approaches?

Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history.

Sometimes a diagnosis as powerful as Anorexia Nervosa can be a hindrance to the improvement of “sufferers”. Over my years of practice, I found that those who did well were cases where we indeed moved away from the medical/conventional psychiatric model to a somewhat paradoxical approach.

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.

 ©2016 Am Ang Zhang 
         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. 

 ©2016 Am Ang Zhang 
         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.

         “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 fed 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.

Thursday, August 15, 2019

Autism: Wrong & Right & Temple Grandin

Can wrong sometimes be right? A question I had to face in my years of practice in Child Psychiatry.

The Consult:

Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.

The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.

He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.

Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!

My first thoughts were: Cheat!

Then perhaps: Collude!

Neither would be in NICE or any textbook.

Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.

That saves some money. Failing that steal the tags.

(I can't believe I said that)

Patients come first.

Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.

It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences. 

So spend more time with him and you may well be surprised!

It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!

Innovation again.

Wrong may sometimes be right.

Let me know.

Temple Grandin:

Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.

Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.
Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.
Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.

Temple Grandin Website:

Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.

Autism posts:

Thursday, August 8, 2019

NHS Hospitals: Not for you. Only the Elite!!!

Do you really think that hospitals and what hospitals do are not necessary?

Do you really think that a good health care system is just about Primary Care doctors or in the new world order of things nurses doing what doctors do? (Noctors as our lovely Dr Crippen called them).

The Elite
©2012 Am Ang Zhang

The pretending is over now that it is clear about the current governments plan for dismantling he NHS.

The children of my friends and contemporaries are in good jobs like, lawyers, bankers and dare I say, management consultancies. They are all scrambling to make sure that their Health Insurance will cover IVFs, antenatal care and full obstetric care and for those engaged in sporting activities, knee work and perhaps hip work for later.

For this the Elite of our society, it is not just about GP care. 
They are there to refer them to the best specialist in the best Private Hospital or sometimes at the private section of a top NHS hospital. 
I have maintained for some time that:

Most people in well paid jobs (including those at the GMC) have health insurance. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment (and Bare Foot doctors in the Mao era cannot do the latter either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.

So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

Do we still have those: yes we do!  See here>>>>
In London alone these are specialist hospitals that are famous the world over:
The Maudsley Hospital

Then there is Papworth. Need I say more!!!
I know that when you visit them nowadays, these places seem to be full of: non locals. Or could it be that these are now the new locals, I doubt as you can sometimes see the lovely foreign plated cars parked outside them. If I am wrong, I do apologise.
The truth is that medical tourists come not for the GP services we provide, they come for the cutting edge medical procedures and in England, it is also about value for money.
So, opening up many of these rather precious hospitals for up to 49% private will mean a severe reduction in actual medical times available to NHS patients.

That is why: the pretending is over. No, at the end of the day it will not be the medical care you can get from your GP or Noctors, it will be well trained specialists with up to date complex procedures that you or one of your relatives may need!

The plot to get punters not to use hospitals via A&E is failing. So, they are going to just close them.

Zebra in fact belong to the same family as the horse (Genus Equus) but unlike the horse has never been domesticated. It is believed that the stripes in a herd is protective as many animals merge together and thus appeared larger.     

Thursday, August 1, 2019

Thumb Sucking & Nightmares: Winnicott & Mondrian

In my book The Cockroach Catcher I described how I was suddenly confronted with a piece of work by Mondrian. I have to confess it was not an artist I have heard of at the time. I did not think it was a favourite for most others at the clinic. In a sense I inherited it by accident. Having stared at it for the better part of two and a half years and then spending the next thirty plus years comparing it with other modern art in museums round the world, I have come to appreciate it more and more.

Composition with Yellow, Blue and Red (currently on display at Tate Liverpool)

This is how the scene was described in the book:
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?In any case the Mondrian would be fine on its own.
Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso………”
The Tate now of course has several Mondrian works.

Now you can read the whole chapter here:

Chapter 10  First Encounter

In the winter of 1972, something happened that sealed my fate to stay in England forever.  I was appointed Registrar to a world famous clinic.
         By then I already had one of my higher qualifications (D.P.M. – Diploma in Psychological Medicine) and was in the process of sitting the first ever examination of the Royal College of Psychiatrists. At last we could achieve the same standing as colleagues in most other disciplines - a membership, not just a diploma.  I had moved to London to take the examination for this most prestigious psychiatry qualification. My wife had accompanied me for what we thought was a year abroad.
         On a cold October morning I made my way to one of these old mental hospitals which was running the first ever training course for the RoyalCollege Membership examination. It would be foolish not to be there as most of those who ran the new College were on the teaching panel.
         As you drove into the main gate of this rather imposing Victorian beauty or monstrosity, you got the same feel as in most mental hospitals of the same era. There was the odd one working the kerbs and gardens. A small group might be shepherded by a nurse to cross a road on their way to their morning’s appointment. Many had the typical shuffling gaits from the antipsychotics they were on.
         The last of the summer’s Hydrangea flowers still tried to hang on. They looked tired and ugly. I would never have hydrangea in my garden.
         The Post-grad place was easy enough to find as you just followed the majority of the cars.  Wow, with half an hour to go, the car park was already nearly full.  I suppose we all wanted to have a nearby spot to park on such a chilly morning.
         I liked to be nearer the front as chances of falling asleep would be much reduced. I spotted a gap, made my way in and before I could sit down, someone offered me a hand.

Gail: Thumb Sucking

 “I am Gail. I am from the Tavistock.”
         The Tavistock?  Many others would think this was the place they had pop concerts, and doctors would know that the British Medical Association was at Tavistock SquareLondon.  But I knew. I was too astonished. I did not know what to say. Then I managed to utter my name and said that I would be going to the Tavistock, and that I had just been appointed a Registrar there.
         Where I came from no longer seemed so important.
         Synchronicity[1], you see. Gail put her thumb in her mouth and started sucking it vigorously.
         “Sorry, my mother’s fault and she has already paid for my analysis for the last three years. Between you and me, I preferred my thumb. Who is your analyst?”
         “Haven’t got one.”
         “Oh, yes. Dr Collinwood is the odd one out. Her registrar does not need to be in analysis.  However, one good thing the thumb sucking did was to get me my job at the Tavi. I was already in analysis.”
         Analysis for thumb sucking? I thought to myself. Never! Whatever next? And a sought after job in London?
         What did I do wrong, or right to get my job?
         “Ah, you see you are Chinese. You don’t need analysis. Your predecessor was Greek. She had the collective culture of the Ancient Greeks.”
         Perhaps her next registrar would be Egyptian.
         Over the next six hours or so, I began to understand the scale of her problem. It was really like having sex in public and she could be so engrossed in it. It would be wrong to suggest that she tried to reach orgasm but sometimes from the sound she was producing it was not far off. Now and again she noticed that I was paying more attention to the thumb sucking than to the lectures. She stopped and apologised.
         It would be odd to have gone through years of training at a place where the perceived wisdom was that all problems big and small could be traced back to our childhood and more particularly to our sexual development that I should write about my work without any reference to these aspects.  It would also be peculiar if I, having been brought up in a Psychoanalytic Centre of world class reputation, could pretend that sex did not play a significant part in human psychopathology.
         My first encounter with my future colleague certainly shocked me. What was I getting myself into? Was I going to see even crazier people?
         The staff, not the patients.
         My start at the Tavistock was straightforward enough. They had a good introductory pack. I was first briefed by Miss Frys the social work team leader. She was the nicest person one could meet and work with. Warm, kind and she listened carefully. She looked normal enough. I found out later that she was a Quaker and she came from a family where every female member lived to over a hundred. She looked like she was heading that way too.
         She told me Dr Collinwood was very fond of her previous registrar who was a Greek girl.  She was going back to Greece to have her first child before starting a Child Psychiatric clinic there.
         “We are rather fond of Greeks here right now, as there are two others whom you will meet probably at lunch.”
         One later on became a Health Minister in charge of Psychiatry and the other started the Athens Psychoanalytic Society. I too became very fond of both of them and continued to meet them occasionally at international congresses.

Miss Frys had some impressionist prints on the wall and they just seemed to match the colour of her hair. A peculiar picture with coloured squares was by the cupboard and was obviously not hers.
         “Ah, an imposition here. You see, our local library is very good. They have all these prints they lend out to clinics and public offices. This one seemed to be the one left when everybody else have had their pick. I thought, well it is not my type of picture, but it is mathematical and perhaps a Chinese would appreciate it.”
         There were not as many Chinese in the U.K. in those days, and multicultural understanding was almost non-existent.
         Well, it is not in my nature to speak my mind, not at a first meeting with someone who seemed to ooze wisdom and kindness. I took another look and asked, “Who is the artist?”
         “Very neat,” I said.
         “It is rather, I think you should have it in your room.” Miss Frys replied.
         “Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?  In any case the Mondrian would be fine on its own.
         Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso.
         Now I am going to be cultured as well.
         “Do you like music? The library has a superb collection of records and they get every thing new as well. I live very close to the Festival Hall. I must take you to a concert there some time unless you have been already.”
         I must confess that with all that studying and preparing for the arrival of our first baby, concerts seemed like a lot of trouble; but I would certainly try and get the records as I had a very good sound system.  Radios and electronics had been my hobby from the age of nine, and over the years I had built at least eight systems of my own, starting with a simple crystal radio set, then graduating to a triple valved receiver system and ultimately to a high fidelity amplification system with EL84[2], which remains the gold standard of the industry.
         It was not until some years after her retirement that I finally took up her offer and met up with her at the Royal Festival Hall. There is no better place to be in London on a late June evening when the light never seems to want to disappear.
         “So you are having a new baby in March. Dr Collinwood is very pleased because you will be able to observe your own baby’s development. It will save a lot of time. But I shall arrange for you to do your nursery observation about three streets away.
         “Now here is Dr Collinwood, I can hear her coming down clanging two cups. She had this kidney stone problem years ago, and her doctor advised her to drink lots. So she takes two cups of coffee instead of one. Oh, I see the coffee lady is bringing down two more. I presume one is for you and one for me.
         “We have this coffee lady who comes in at ten to make coffee. I do not think they pay her very much, but the clinic is thinking about instant coffee and tea-bags so that they can save some money. She has been here twenty two years, as long as I have been, and is part of the fixture. We are all writing letters.”

         I greeted Dr Collinwood, my consultant. She put the coffees down and shook my hand. She looked less scary than the first time I met her. There were now more smiles. What was she making of this young Chinese doctor from across the globe, I wondered.
         Her first concern was the baby. Well she was a real children’s doctor. I later found out that she had worked for years with Winnicott. Winnicott is someone I still have a lot of time for. He was really a paediatrician but his psychological understanding of children and mothers was nearer to my heart than many of the Viennese psychoanalysts such as Sigmund Freud, Anna Freud, and Melanie Klein etc.  Dr Collinwood continued to show great interest in both our children and after she retired the whole family had spent quite a number of summer holidays at her retreat in Suffolk. One time the grand parents came with us too.
         I knew straight away that I would be fine at the Tavistock.
         “There is this case I need to talk to you about.  We missed the last two case presentations (maternity leave and all that) and I promised that we would try and do one six to eight weeks after your arrival.
         “I do not normally give my new junior any old case to take over but this is a nice boy and you might get on with him. I shall continue to see his mother.”
         Meeting with the psychotherapist was another really nice experience. There was so much gesturing that I later discovered was a Jewish thing. But Miss Horowitz you cannot fault. Her father was a famous child psychiatrist and she was really an Anna Freudian[3]. Not so much of the penis envy or bad breast good breast stuff that Gail kept talking about.
         We had twelve cupboards all with individual keys.  Each therapy patient got assigned one and they could put their first name on it. There were packs of toys that the other psychotherapist sorted out and it included drawing material. Drawing paper was multicoloured and we tried not to let the children take their drawings home as a rule, as they were important material for analysis.

All that medical training and exams and so on had not prepared me for what I had to do. I had to start from scratch. I was not even going to take a history. The first session with Michael would be a play oh, sorry psychotherapy session.
         “You will be fine, although it would have been better to learn on a new case.”
         All the Nation’s pride and glory was up to me now. I could only succeed.
         Michael turned out to be a very nice boy as I was promised. He had two problems: nightmares and soiling.
         The nightmares annoyed mum but she really could not stand the soiling.
         “There must be something physical, Dr Collinwood. He has already seen the Greek doctor for six months and now you want him to see this Chinaman?”
         “Oh, very nice to meet you,” she said, putting her unlit cigarette back in her big handbag. She had a very Jewish look with a very Cockney accent. If I knew what I know now, she looked exactly like one of those handing out drinks in one of the New York Hassidic Jewish camera stores. The way her eyes were scanning she did not miss a thing.
         “I brought his pants from school.  He soiled it again.  I thought the doctor might want to see it.”
         I was beginning to “like” her.  Such consideration!
         “Sorry mummy.”
         “There is no need to show Dr Zhang. I hope with a few more sessions we may get to the bottom of the problem.”
         Dr Collinwood was confident. I was not sure if I was.  But my tough medical training saved me – the important rule of using long words and never expressing doubt.  I did not hesitate and said, “Sure we are going to.”
         Mrs Green was evacuated during the war. Dr Collinwood and Miss Frys were trying to put a series together on the effect of evacuation on problems for mothers with the next generation. It was quite unique in its way as hopefully there was not going to be another war and perhaps evacuation would not be used if there was one.
         Her husband was probably Jewish as well and was on Incapacity Benefit as a result of some illness or other.
         Michael soiled only at school and almost always just before going home or coming to the clinic. He often woke up screaming in the middle of the night and insisted that mother should go and see him. She now put him in bed with her to save getting up, she told Dr Collinwood. Mother cleaned for the school so Michael stayed at home with father.
         Mrs Green was so fed up that the previous week she took Michael up Archway Bridge ready to jump. She called Dr Collinwood instead.
         At least in those days we did not have tons of local authority social workers around you once something like that happened. Nowadays Michael would probably have been placed with another family at some point.
         Michael got into a routine pretty quickly. First, we played football - a soft ball. I kept goal three times and he three times. Then we wrote the score on the little black board. He wrote his name on the card provided for the cupboard but insisted on putting three black lines round it.  What would Miss Horowitz say? Then he played with the animals and then arranged the family dolls around the table. Mother, father and a little girl. A boy would probably be too close to home.
         Though he was eight, he was more like six in size and was very timid. He asked permission for just about everything.
         He would then finish with a game of draughts. I made the mistake of leaving the pieces as they were. He saw me three times a week, and he was my first and only patient then.  He asked if I saw anyone else. I quickly learned to put some names on the other cupboards and tidied up the draughts. An obstetrician delivering his first baby must not let the mother know it was his first.
         He soon started drawing. Mother, father, and a baby girl in the middle. We religiously put all these in his cupboard.
         “I like that drawing,” he pointed to the Mondrian, “So neat.” He was right.
         We saw mother and son separately at the same time for fifty minutes twice a week.   Mum always said goodbye to Michael outside my door, with a kiss and darling this and that.  One day after a few sessions, as she walked with Dr Collinwood to her consulting room, she said very loudly, “Is your new doctor any good?  He seemed quiet and sensible, but Michael tells me he only plays football and draughts with him.”
         It was much later that I realised that children are equipped with defences so varied that it sometimes takes one a while to understand what has happened. Michael was an intelligent boy. He had set up decoys. He had now established with mum that I only played football and draughts with him. No wonder we only ever played for a few minutes each time and no wonder it did not matter if the draughts game finished.
         Now instead of putting the girl in the family group, it was a boy, and he no longer drew a girl on his pictures. He drew a boy.
         He kept putting the father in the toilet in the doll’s house.
         One day Michael drew me a picture that I could no longer hold back from Dr Collinwood until supervision time. I intruded into her fluid loading time.
         Michael drew a naked mummy complete with big boobs and pubic hair. The boy in the middle was naked too and had a rather large tool on him. Father was in his pyjamas and Michael drew tears down his face.
         We made the case presentation. It was well attended by nearly everybody including those from the other teams. Word must have got out that Dr Collinwood had a case that had sex features.
         Father suffered from severe diabetes and had been impotent for years.  Mother had very bad abuse history from the evacuation days and had become rather needy of sexual gratification. In a desperate attempt to shame her husband she slept stark naked and put Michael in the middle. She would get Michael to have an erection and then say to her husband, even your eight year old can do better than that. She would not contemplate leaving him, as the benefits were good and she got to drive his car. Dr Collinwood did not mince words on erotic stimulation etc. etc.  All the way through, Gail never sucked her thumb. We passed around the drawings. Freudians made their bid with Oedipus and all that. Kleinians[4] insisted on bad breast. To me it was just an abused mum having a bad time and using the boy to get back at her husband.  But it was only my first case.
         Gail gave me a thumbs up (the other thumb) approvingly afterwards and said I passed the test. I told her that attending Dr Collinwood’s case meetings could save her lots of money. “It’s my mother’s anyway,” she said.
         Michael continued to see me for the best part of the rest of my stay at the Tavistock.  His nightmares disappeared and he stopped soiling.  Nobody knew if his mother stopped fiddling with his penis but to me it was an eye-opener. At least being Jewish she had no qualms about bringing Michael to the clinic three times a week for his therapy sessions. Since then, I have collected quite a few other similar cases, but I shall always remember Michael and Mondrian.

[1] Synchronicity – In The Structure and Dynamics of the Psyche Jung describes how, during his research into the phenomenon of the collective unconscious, he began to observe coincidences that were connected in such a meaningful way that their occurrence seemed to defy the calculations of probability. Unfortunately it is often quoted as a scientific basis for astrology and other improbabilities.
[2] EL84 - a vacuum tube (a.k.a. valve) of the power pentode type. It has a 9 pin miniature base and is found mainly in the final output stages of amplification circuits, most commonly now in guitar amplifiers, but originally in radios and many other devices of the pre-transistor era.  However, even now, hi-fi connoisseurs still prefer sounds produced by valve amplifiers to digital transistor sound.

[3] Anna Freud - Anna Freud moved away from the classical position of her father, who was concentrating on the unconscious Id (a perspective she found to be restrictive) and instead emphasized the importance of the ego, the constant struggle and conflict it is experiencing by the need to answer contradicting wishes, desires, values and demands of reality. By this, she established the importance of the ego functions and the concept of defense mechanisms. Focusing on research, observation and treatment of children, Freud established a group of prominent child developmental analysts (which included Erik Erikson, Edith Jacobson and Margaret Mahler) who noticed that children's symptoms were ultimately analogue to personality disorders among adults and thus often related to developmental stages. At that time, these ideas were revolutionary and Anna provided us with a comprehensive developmental theory and the concept of developmental lines.
   As such, the formation of the fields of child psychoanalysis and child developmental psychology can be attributed to Anna Freud.
“……I think that a psychoanalyst should have...interests...beyond the limits of the medical facts that belong to sociology, religion, literature, ,[and] history,...[otherwise]his outlook on...his patient will remain too narrow. This point contains...the necessary preparations beyond the requirements made on candidates of psychoanalysis in the institutes. You ought to be a great reader and become acquainted with the literature of many countries and cultures. In the great literary figures you will find people who know at least as much of human nature as the psychiatrists and psychologists try to do.”        Anna Freud

[4] Melanie Klein - child psychoanalyst who worked in London (as the US required a MD degree to practise psychoanalysis) had a strong following and some severe critics too. Her theories – (as portrayed in Nicholas Wright’s 1988-Mrs Klein) include references to: "good breast" and "the bad breast"; "symbolic urine"; playing the violin as "a repressed masturbation fantasy"; automobiles  being penises and mountains being breasts.