Tango

 

 

 

Figure 1  Tango, Buenos Aires

 

         It was on one of the South American Cruises that we found ourselves in Argentina, a country about which we have heard so much and yet because of its size, cruising seemed a reasonable way to embark on our initial overview visit. We did book an extra three nights to spend in Buenos Aires at the end of the cruise, before flying home.

         Argentina, like a few other countries, suffered from a major economical disaster that alarmed the western world.  It was believed that its fragile financial system could not be saved even with the might of International Monetary Fund (IMF). 

         In fact, Argentina defied the IMF and managed to rescue itself a good deal faster that anyone could have expected.  Needless to say that in these situations the big boys with the money never quite suffered as much as the ordinary hard working folks. With their currency devaluation of a massive scale, we could only be thankful that we can enjoy their Malbecs and Torrontes at a very reasonable price.  Then there is their very good grass fed beef too.

         News just came as I was editing this chapter that the Hong Kong Stock Exchange just appointed an Argentinean as its Chief Executive[1] for a term of three years.

         We took the Buenos Aires Citybus which allows passengers to get on and stop at any stop they want, and made a stop at the outrageously colourful La Boca neighbourhood.

         Here the old tenement houses had been built and painted in a haphazard manner.  The result is that of a very pleasing sight that has attracted many tourists.

         Then there is of course Tango, which played a major role in shaping Argentinian culture and society.  Tango is more sensual than any other dance routine and where else to watch it than at one of their dinner theatres where one could enjoy not only the dance show, but also their beef and a bottle of Malbec.

         As a Child Psychiatrist, Argentina is about Anorexia Nervosa, Minuchin’s way of looking at it.

 

         I was fortunate enough to be introduced to Minuchin’s work by my good friend who specialised in Anorexia Nervosa research. I remembered him showing me a book when I went to stay with him before attending a Royal College of Psychiatry Conference.

         The book “Psychosomatic Families” is one I would recommend to anyone working with families and of course with Anorexia Nervosa cases.  There has been too much shift in modern Psychiatry to try and mimic practices in other branches of medicine.  Experienced psychiatrists will soon find out that there is really no simple straight forward treatment any way.  My friend told me that Minuchin’s understanding of these families has been very helpful to him, way beyond the causes and treatment of Anorexia Nervosa.

         I will not apologise for repeating what Minuchin stated in that book about the characteristics of such families: enmeshment, overprotectiveness, rigidity, avoidance of conflict.  For the benefit of those readers who are not familiar with his work, I quote you the following from his book: 

 

“Enmeshment 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.

 

Overprotectiveness refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviours and somatisation are prevalent.

 

Rigidity refers to families that are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioural mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.

 

With Avoidance of conflict, family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance manoeuvres. Everyone would come up with a highly believable excuse. After all everyone is very clever!”

 

         Minuchin has certainly inspired me the most in my work with families, and with Anorexia Nervosa in particular.  Above all, he helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorectic patients. 

         Salvador Minuchin was born in San Salvador, Entre Ríos, Argentina.  After obtaining his degree in medicine, he served as a physician in the Israeli army.  Subsequently he went to US first for child psychiatry and then psychoanalytical training, with another spell of working in Israel (this time with displaced children) in between.   It may be of interest to readers that the current new generation of psychiatrists, including those in the US, were no longer brought up in psychoanalysis and as a result, they probably have little understanding of either the personal psyche or the family dynamics that we grew up in.  Of course psychoanalysis has its many faults but to totally dismiss it is indeed very sad for mankind.  It is lamentable that even before my retirement, at some conferences the Anorexia themed talks were all about which drug to use to induce hunger and eating when treating such cases.

         As in the case of classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own professions.  Many are CEOs of major corporations, hospitals and large organisations.  Minuchin’s insightful understanding of family dynamics greatly enabled me to navigate the often very difficult terrain.  More so than trying to learn Tango!

         While reading “Fragile Lives” by Stephen Westaby, it occurred to me that in most branches of medicine, there was always someone that would have tried something that had never been tried before and if they were lucky enough, it worked and a life was saved.  I was fortunate enough to be at the Sage Gateshead Free Thinking Festival one year when Professor Westaby, a heart surgeon and three others (a Professor of Circadian Neuroscience, a crime writer, and a mathematician) took part in an open discussion about the pace and rhythm of life, contemplating the speed of life and whether that runs fast or slow depends on what you use to measure it.  The event led me to Westaby’s book in which he described remarkable events of his career.  We have been to Newcastle before, but not Gateshead, which sits on the other side of the River Tyne.  The quayside has a vibrant atmosphere, awash with restaurants, bars, cafes and hotels.  The concert and conference venue Sage Gateshead itself is an impressive glass and stainless steel building designed by Foster and Partners, who won the competition managed by RIBA (Royal Institute of British Architects).  The modern Millennium Bridge, Sir Antony Gormley’s steel sculpture the Angel of the North, and the Baltic Centre For Contemporary Art complete the scene.

         Having been introduced to Minuchin’s “Tango in Child Psychiatry”, one day I found myself dancing the routine without any premeditation or preparation.  Fortunately for me, and perhaps for the patient too, the Sister on the ward was aware of my sometimes unconventional approaches and she managed to make the whole “heart” operation run smoothly.

         One Wednesday afternoon I received a call from our Sister on the Paediatric ward saying that our senior paediatrician wanted me to see one of his patients urgently.  This senior paediatrician was the first to recognize the important role of a Child Psychiatrist in his department and gave me free use of two beds on the ward.  The referral came at a most fortunate time, because it was half term break.  During term time, I would have gone to visit the special school for consultations.

         How did I manage to have overlooked this girl, Lara, lying in the corner of the ward?  I tended to make regular use of the two assigned beds, and I had been in the ward most days.

         Ah, it was because she was on a drip and looked like a “real” paediatric patient, unlike many of my young patients who were healthy looking and running around, one being the five year old girl who was still wearing a nappy.  I should have noticed.  It was unusual for this ward to have seriously ill patients, only fractures and sometimes post operation tonsil patients.

         Both parents stood up as I approached the bed and shook my hand after I was introduced by Sister Wendy.  Sister Wendy was one of the sisters I had a lot of time for, as she seemed to be able to read my mind, just like my clinic secretary.

         “You can use the side ward if you like.  We have just discharged the boy with the fracture.”

        

         Well, I did tell you, didn’t I.

 

         Lara said, “I can walk!” and she carried her drip stand and started making her way there.

         I looked at Sister Wendy, not knowing her paediatrician’s instructions. I thought I would play safe until I get to know the patient.

         Sister whispered to me that the paediatrician said the case was all over to me. 

         I now have full clinical responsibility.

         That was great.  It was not a consult but a transfer.  I could now do as I wish, I mean, do what was best for the patient. 

 

         Sister, sensing my reservation, got a wheelchair to transport Lara in no time and we all settled nicely in the side ward. Drip and all.

         Lara was on Naso-Gastric feeding, and strict bed-rest, but was still losing weight.

         “Sorry, Dad, you are going to miss your golf again!”

         “And, Mum, your book club!”

         “Doctor, I have not played golf since Lara’s admission and my wife has not been to her book club.  She is our only daughter and whatever it takes, we just like to get her better.”

         “But it upsets me that you both have to miss things you love!”

         Already demonstrating characteristics described by Minuchin. 

         I had to try and not look too smug.

         “So, just eat, get better and they will have golf and book club back.”

         Did I say that?  Of course not.  If she could do that, they would not need me.

         But coming to think about it, it really could be that simple.

         “Golf is my passion. I have been Captain for a few years but had to resign because of Lara’s illness. Our house is only yards from the entrance of the club.”

         I knew that club and had played there because one of my colleagues, a close friend, was a member there.   When first inviting me to play at the course, he explained that the club closely enforced the rules of St. Andrews, and if I was to wear shorts, they must be tailored.  I never wore shorts anyway and so it was not a problem.

 

         “I am sorry, Dad, but I think the doctors could not figure out why I was losing weight.  I really really want to get better so that you and mum could be getting back to doing all the things you love.”

         Bingo! Conflict avoidance.

         So, they were not told that this was a case of Anorexia Nervosa, that there was “nothing” wrong in the usual physical sense of the word but something very wrong in the “psychological” sense and she could die.

         No, the doctor did not say that, and this doctor would not say that either.

         So started my marathon session with this family, and it went on for the better part of the afternoon and early evening.  There were many questions which they managed to answer.  Father was very high up in his firm and worked from home on Wednesdays and that included golf.

         Is golf work too?  Most in his position would tell you it is and I would not argue with that.

         For some months now Lara had been having problem with her swallowing and that was when she was referred to the paediatrician. By the time she was seen she had lost a third of her body weight.

         “They have done a lot of tests……” Lara started.

         “……and so far they could not find anything!” Mum continued.

         “Doctor, as I told you earlier, we will be happy with whatever test you deem necessary!” Father finished.

 

         “Something must be very wrong……..as her……” Mum continued.

         “Period stopped.” Dad finished.

         “And she is growing……” Mum intercepted….

         “All these funny……”Dad continued….

         “……long hair over her arms and her body!” Mum finished.

         For the first time since this interview started, Lara stopped her pleasant smile and looked a bit embarrassed.

         “Sorry, darling, but Grandma told me the Kotex was clean and she told me about the hair too!”

         “Grandma usually baths her before dinner; we like a good routine, just like on Wednesdays we order Pizza as Dad has to play golf and I have my book club.” 

         A 17 year old girl being bathed by grandma?

         Overprotectiveness! Enmeshment!

         “Friday is always fish. You must have guessed.” The smiling Lara was back.

         I could see why modern fashion houses prefer very thin girls as Lara remained attractive despite her dangerous weight level.

         “Roast beef on Sundays with Yorkshire pudding.”

         “Which I love, but I could not swallow it.”

         Rigidity!

         “The paediatrician decided to tube feed her but not only is she not gaining….”

         “……she is losing still.” Mum finished Dad’s line.

         “It started after her Cambridge interview and I thought the weight loss was due to anxiety over the conditional offer on all As.”

        

         Well, that was Cambridge.  Oxford offers EEs for students they like, knowing all As or even A* would be what these students will get.

         At least now we had touched on a possible stress factor.

         “Which College?”

         “Newnham!” Lara replied.

         “She is at an all girls school now.  We thought she might……..” Mum explained!

         “…..cope better at an all women’s college!” Dad completed!

         It was amazing how the Minuchin family dynamics came to life! 

         Over time, I came to the conclusion that marathon sessions could break down conflict avoidance extremely well and it was more productive to spend a lot of time especially in the first session than to wade through many short sessions.

         As it turned out, Lara was very different from the other anorectics I had treated up to that point.  A “one size fits all” method simply did not exist.  I found myself quickly adapting my approaches. 

        

         Her apparent naivety was dangerously inducing collusion.  You had better not start to feel sorry for this possible future Cambridge educated model.  Watch out because conflict avoidance might well be contagious. 

 

         To convince this trio of what we were trying to deal with, I had to try and put what they already knew in a different context. 

         When I hinted at isometric exercising (contracting muscle without body movement), Lara blushed without having to admit that was how she fought the tube feeding.

 

         “So what do we do now?” Dad assumed his lead position.

         At this point the door opened and a push trolley appeared with four cups of tea and some biscuits.

         “Lets all have some tea and biscuits.”

         “Would…….” Mum looked at me….

         “…..her stomach……”Dad looked worried….

         “…..be able to take the biscuits!” Lara was quick to complete the sentence.

         Although I was at the first ever London Family Therapy course, I had not had much practice.  I was now struck by the manifestation of enmeshment, and all the Jungian teaching about failure of Individuation was making sense.  Not eating was indeed a final desperate attempt at individuation and this good doctor was plotting to destroy it.  Would it be the right way forward?  It might take a while to find out whether this step would save a life.

         I asked Sister to remove the Ryle’s (feeding tubes) and Lara was so trusting in this new found doctor that she ate her two biscuits and drank her tea.  I sent for two more biscuits.  At dinner time she finished everything on her plate and drank a whole glass of milk, full cream for that matter.

         Mother was in tears.  Father went home when Lara was waiting for dinner to bring Grandma, who could not stop thanking me.  I told her that the three of them did most of the talking and I just listened, which was basically true.

         On leaving I asked mum what book they were reading at her Book Club.

         “Joy Luck Club!”

         “Amy Tan!”

         “So you know it.  Next time I turn up at the book club, they will all be very jealous that I actually talked to a Chinese in person! And a Psychiatrist at that!  Thanks for saving Lara and for saving us.”

         It must indeed be one’s aim to tap into the strength rather than weakness of either the patient or the family.  Anorectics and their families are very intelligent people and Minuchin’s treatise on family characteristics offered a lot of insight that enabled me to fathom and guide such patients and their families. 

          With the tube and the drip removed, Lara obviously stopped her secret isometric exercises and started to put on weight.  Soon she was allowed out on leave to sit her A level exams.  All “As” of course.  She eventually got to Newnham College, Cambridge.

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[1] https://www.scmp.com/business/banking-finance/article/3121140/hong-kongs-stock-exchange-operator-finds-ceo-replace