Mind & Ecology: Who is the Real Patient?

The mind is fascinating and more fascinating in Child Psychiatry if you can afford the time to try and understand it.

There is little doubt in my mind after spending 30 years trying to think like a child (un-ashamedly borrowed from Picasso), I have come to realised that our creator has provided our mind the facilities to heal and recover. It is perhaps important that we should not jump in and use medication Willy Nilly. Unfortunately nowadays they might be used for the personal gain of the psychiatrist!

From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 2

 The early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K. was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

Both plays vividly captured family interaction that has hardly been bettered by any other modern writings.

Wayne

         Wayne must have been about thirteen when he was referred to me. As with many similar cases he had not attended school for the better part of a year. I thought that this was another case of some degree of maternal depression rubbing off on the boy.

         Wayne’s father was a Sea Captain for years but for some years now he preferred to stay with Wayne’s grand parents. “Who could blame him?” Wayne would remind me and himself. There was never a question of divorce and he did not want to involve the psychiatrists either.  He preferred to just stay quiet about it.

         Wayne had a very impressive crop of hair very much like that of Art Garfunkel. He was also very good looking, which immediately made him number one target for bullying. His favourite subject was English. He liked poetry and Shakespeare best – further cause for bullying.  He enjoyed classical music as his father had a vast collection of records. But he kept this secret hobby to himself as the bullies already had too many reasons to pick on him. It was a rather sad reflection of our society.

         The crisis came when his English teacher went on maternity leave. Before then, he was teased as the teacher’s pet. His attendance at school was erratic at the best of times and when she went on leave he stopped going entirely. Then when he realised she was not coming back Wayne decided that school was finished as far as he was concerned.

         To me Wayne had managed to find a good excuse to relieve himself of some rather petty and chronic bullying which could sometimes be worse than being severely beaten up. I condone neither, but both kinds occur with serious regularity in our schools although generally denied by school authorities. The side effect of this is that it is often a relief for all concerned when a request is made that the child should not attend school. It is when you start asking for other educational provision that troubles generally begin.

         Wayne, once you got to know him, was the most pleasant boy you could wish to meet. He was not only courteous and well spoken, but also very knowledgeable about his subjects of poetry, Shakespeare and music. I do prefer to see more of the Wayne type than some other types I do not care to mention. It might be unprofessional but I know a few of my colleagues felt the same way too.

         Some patients kept us interested.

         Despite his age, Wayne was always brought to the clinic by his mother. They both cycled in. The reason was quite simple: Wayne needed protection, not from anyone in the clinic but from the possibility of bumping into someone on the journey to the clinic and back.  When I realised this, we shifted the appointments to school hours and Wayne managed to turn up now and again without his mother.

         His mother was always well turned out, always soft spoken and always waited in the waiting room through the whole session except when she saw our social worker. But those appointments were spaced out as nothing much came out of them. 

         After nine months, Wayne finally opened up to me.

         Mother never threw away anything. Nothing at all!

         Except wet waste, which was a relief.

         This was a serious case of OCD (Obsessional Compulsive Disorder). It was still a great shock to have the full extent of the things that were kept detailed to you. Even a five bedroom house soon ran out of space.

         Wayne told me that as far as he knew, mother had always been reluctant to throw away anything but it seemed to get out of control about five years ago when she discovered that father kept a woman in a port in the Far East. She moved out of the master bed-room and the rubbish moved in. Everything was neatly put in big rubbish bags and properly tied up. Some were in apple or other supermarket boxes. Even vacuum cleaner bags were kept.

         Mother did a good job of it so that there was no bad smell at all, Wayne would reassure me. Just no space.

         All these months, I had been thinking that the bullying was the cause of Wayne’s problem. Did I get it wrong? All the time I spent trying to improve his self esteem, was it time wasted? Was there something I could have done earlier? Why did he take nine months?

         Perhaps he needed that time to find out if I was going to send his mother to an asylum. Perhaps he needed all that time to trust me enough to talk about the sickest person in the family. Perhaps he never had any plan but the secret just came out.

         Perhaps these were all valid explanations, but what could we as a clinic do?

         It would be great if I were able to tell you that we carried out some wonderful therapeutic intervention. Mother was able to get rid of her “collection” and Wayne went back to school and eventually went to university and became a Professor in English or the Classics or something like that.

         It would have been nice, but that would only have been a fairy tale.

         We tried to arrange a couple of mother/son meetings but we really got nowhere. Wayne made vague promises in front of his mother that he would get back to school if this and that happened but I think he knew that neither he nor his mother could really initiate any change.

         Could a mother or son in such a relationship make a bold move to get the other going? I fear not. It was a kind of symbiotic relationship that had gone too wrong for too long.  By making a move to get “better”, one party would be putting enormous pressure on the other to do likewise. Often either party would be afraid to become better in case the other one might become even sicker.  It was just too risky to get better.

         It is not uncommon for young and enthusiastic juniors to be attempting the bolder approach to force a change. I have come to realise and respect that many forms of mental illness are a kind of defence and in the end the mind or the gene that is the engine driving it knows best.

         Similarly with drug addicts, alcoholics and many with sexual deviancy and perversion, our belief that they may change is perhaps misguided at the best of times and at worst, dangerous to others in society.

         I was young then and a plan was soon hatched to somehow persuade mother that we would arrange for her “luggage” to be cleared. She indicated that she would find it difficult to watch. We managed to persuade her to go on a short break in her favourite seaside resort so that she would be away.

         To our great surprise she agreed.

         On the day, we had a phone call from the car that we had arranged to pick her up.

         “She did not answer her door.”

         Our social worker rushed there. Wayne’s mother refused to let her in but talked to her at the door. She had changed her mind. She did not want to go ahead with the plan. By then the firm we engaged to remove the rubbish had turned up too but she was adamant that she did not want it done. After an hour of hard negotiation everybody left.

         She turned up for her next appointment to say that she could not sleep the night before thinking about what we offered to do for her (or perhaps to her). She felt it was such an imposition. She would need to dispose of those things herself when she was ready. When she was ready! I have a great admiration for the English way of understating things.

         Wayne I never managed to get back to school. He never sat any examinations.

         On the official school leaving day he asked me what he should do next. I told him that perhaps on leaving my clinic that day he should go to the local Job Centre to find a job.

         To my great surprise he did. He was immediately offered a job at the local Water Works department as a receptionist/secretary. There they had problems keeping any female secretaries and Wayne fitted the bill. He had been typing since eleven and his English was good.

         As far as I know, he is still with them. I do not think mother ever threw her things away.

         Some cases you remember because of good dramatic changes. Others you just remember.

From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang

In psychiatry, sometimes patients do not want any help. Often they positively refuse help and family members collude. At other times the “help” may not be all that good.

As a result many children grow up in very “unusual” environments. Yet we sometimes get very “unusual” outcomes as some individuals can turn such an experience into something ……well, something quite extraordinary.

Obsessional Compulsive Disorder (OCD) is one such condition that many families prefer to cope with secretly and often for many many years.

                                                                     Chapter 19 The Cockroach Catcher

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang

Recently, I visited The Museum Of Modern Art ( MOMA) in New York and saw something that reminded me of my patient’s mother.

Mr. Song Dong is the artist and his mother is called Ms. Zhao.

Here is a write up in The New York Times:

“Mr. Song was born in Beijing in 1966, on the very eve of the Cultural Revolution, a period of ideological danger and economic want. His mother came from a wealthy family that lost everything after one of its members was jailed as an anti-Communist spy. His father, trained as an engineer, spent seven years in forced labor after being accused of counterrevolutionary activity.

“When Mr. Song’s father died, in 2002, his mother was inconsolable. She continued to live in the jammed Beijing house, throwing nothing away and obsessively bringing more stuff into it, as if continuing to feather a nest for a now-absent family. And despite the threatened destruction of the surrounding area, she would make no move that entailed parting with her possessions.

“Finally, in 2005, Mr. Song proposed that they turn the accumulated junk into an art project. In this way, he argued, nothing would be discarded and lost; everything would be meaningfully recycled and preserved. His mother agreed to this and together, with the help of Ms. Yin and Mr. Song’s sister, Song Hui, they emptied the premises.

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang

“Seen in the museum’s immaculate surroundings…….it is disturbing to imagine anyone growing up, as Mr. Song did, in so smothering a physical environment. Finally, it is deeply moving to see the span of one person’s life — his mother’s — summed up, monument style, in a work of art that is every bit as much about loss as it is about muchness.

“And five years after the piece was conceived……..mother agreed to collaborate with her son, empty her home and effectively let go of her past, she moved into the more manageable setting of a Beijing apartment near a park, where she died last winter after falling from a step ladder while trying to rescue a wounded bird in a tree.”

Life could be cruel.

Waste Not: Projects 90: Song Dong

June 24, 2009–September 7, 2009

The Donald B. and Catherine C. Marron Atrium

MOMA

From Wild Duck:


"Deprive the average human being of his life-lie, and you rob him of his happiness."

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Waste Not: OCD & MOMA

Monday, December 12, 2011