Saturday, May 19, 2018
Botanical Diversity: From Cloud Forest to Vegetables!
Cloud Forest of Volcan Baru, Panama:
High Altitude Vegetable Farms of Cerro Punta, Panama: 5500 -6000 ft.
All Photos © 2015 Am Ang Zhang
Others
Saturday, May 12, 2018
Photography: Black & White beauty!
Torres del Paine, Patagonia.
© 2015 Am Ang Zhang
Nikon D70 (!) 180/2.8 ED
Others
Friday, May 11, 2018
Mental Health Awareness: Clozapine & Finland
Gold Standard!
Autumn Gold and Gold Standard in Finland:
© 2012 Am Ang Zhang
will remain the Gold Standard for the treatment of Schizophrenia for a long long time.An extract from The Cockroach Catcher:
……...Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
Martina was not very communicative but her records and observations by her outpatient psychiatrist indicated that the diagnosis was robust enough. However, after over a year in hospital she was not improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put her on Clozapine.
I was once at one of these big drug firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the opposition might come up with but as far as I was concerned no other pharmaceutical would touch them for decades.
After today’s Lancet publication they might not need to worry at all!
The Lancet, Early Online Publication, 13 July 200911-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al.
According to Reuters:…………An analysis of 10 years' records for 67,000 patients in Finland found that, compared to treatment with the first-generation drug perphenazine, the risk of early death for patients on clozapine was reduced by 26 percent.
By contrast, mortality risk was 41 percent higher for those on Seroquel, known chemically as quetiapine; 34 percent higher with Johnson & Johnson's Risperdal, or resperidone; and 13 percent higher with Eli Lilly's Zyprexa, or olanzapine.
"We know that clozapine has the highest efficacy of all the antipsychotics and it is now clear, after all, that it is not that risky or dangerous a treatment," study leader Jari Tiihonen of the University of Kuopio said in a telephone interview.
"We should consider whether clozapine should be used as a first-line treatment option."Tiihonen estimates clozapine is given to around one fifth of Finnish schizophrenia patients, but less than 5 percent in the United States.Clozapine's side effects include agranulocytosis, a potentially fatal decline in white blood cells, and current rules stipulate the drug can only be used after two unsuccessful trials with other antipsychotics.Tiihonen and colleagues wrote in the Lancet medical journal that these restrictions should be reassessed in the light of their findings, since not using the drug may have caused thousands of premature deaths worldwide.
According to AP:James MacCabe, a consultant psychiatrist at the National Psychosis Unit at South London and Maudsley Hospital, called the research "striking and shocking." He was not linked to the study.
"There is now a case to be made for revising the guidelines to make clozapine available to a much larger proportion of patients," he said.
Tiihonen and colleagues found that even though the use of anti-psychotic medications has jumped in the last decade, people with schizophrenia in Finland still die about two decades earlier than other people.
Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.
Abstract:The Lancet.
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Antipsychotics: Really?
Humber Mental Health Teaching NHS Trust: Learning From The Past.
Wednesday, May 9, 2018
Mental Health Awareness: Fake? Or What?
Child psychiatry is not about asking questions,
but about feeling the answers.
It is a discipline where empathy rules.
Protea, Cape Floristic Region (CFR) of South Africa
South Africa reminded me of my junior doctor and my hiccup boy.
The Cockroach Catcher: Chapter 13 Hiccup Boy
J
|
ohnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital Queen Square and Great Ormond Street . Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help.
At the time my junior doctor Dr Zola was a girl fromSouth Africa who decided that, given the new situation in her country, she wanted to emigrate to Israel where her doctor father, mother and three brothers were. She was an eager learner and would follow me to every single case I saw and even to meetings. She truly shadowed me. I had no complaints at all and she still writes to the clinic every year to tell us how she is doing. After training with us she was able to get into the professorial child psychiatric department in Jerusalem .
At the time my junior doctor Dr Zola was a girl from
For what I did to her on this hiccup case she would never forgive me and to this day she will still remind me of it.
Johnny was an unattractive obese boy of twelve with a similarly unattractive obese mother. Together they looked a picture, an ugly one.
This led me to draw my first impression: he was a “bullyee”, i.e. someone who would be a target of bullying – in school, in the streets, in football matches and in fact everywhere.
He was holding a big bottle of Coke - the two litre bottle, and so was mum. It was August and England was having its unusual heat wave.
This led me to draw my second impression: (no, not about obesity – that is too obvious) he did not hiccup when he was drinking from the bottle.
So within the first few minutes, I knew what to do.
“Dr Zola, would you mind taking mother to the other room to get some history?”
I knew from her look she was reluctant. She had heard of my many magic cures and she knew she was about to miss one. But she had also come to like my style and my work. She really had no choice but to take mum to another room. Meanwhile Johnny was happily hiccupping away between sips of Coke.
I have often said to many of my juniors that child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.
Dr Zola, I think, felt it too. She knew I was going to perform one of those cures.
By the time I asked both of them to come back the hiccups had stopped and I had a mother who looked both surprised and embarrassed, and Dr Zola looked as if she would not talk to me till after the next Sabbath.
After sending the patient and mother off with instructions and another appointment date, I had to deal with a very unhappy junior.
“What did you do?” she demanded to know.
“You really want to know?”
“Yes, I need to learn.”
“Something unorthodox.”
“Did you hypnotise him?”
“No. Maybe I shall tell you another day as I am not sure if he will sustain his recovery.”
I did like to tease some of them. Dr Zola was having none of that. It was Friday and I knew she had to leave early for Sabbath, but sunset was later in August.
I asked if she noticed that he could take long sips of Coke without hiccups and this often did not happen with true hiccups.
Dr Zola said, “I thought the Coke was one of the factors for his and his mum’s obesity.”
That was obvious but I decided not to say it as it would be too patronising.
What happened was I said to Johnny, “It is school, isn’t it?” He nodded. “Now if I sign you off school as of now, do you think these hiccups might go away?” He nodded.
Dr Zola said, “That’s it?”
“That’s it. But I really do not think he would have stopped had anyone else been there. I gave him a sense of security. His secret was safe with me.”
I think in the end Dr Zola understood, but to make a boy who sustained the hiccups for so long stop without resorting to heavy medication like Chlorpromazine or Haloperidol is indeed one of life’s sweet events.
I do not think my secretary ever got over it when she typed my notes and letter.
It is often better though if you can somehow get the parents to do the magic cure.
Here is an excerpt:
BOOK REVIEW, by Peter Chang.
Reading this book was truly a trip down memory lane for me. Although Zhang settled in the United Kingdom, and I in Canada, I can identify with much of his experience as a psychiatrist. This book helps to demystify mental illness and humanize the doctor-patient relationship. I am very impressed by Zhang's down to earth approach to problem solving. The secret to his success in therapy is the respect that he gives to his patients, their families and his colleagues. Just by listening to his patients and believing in their stories, Zhang is able to perform miracles, such as the "Seven Minute Cure" (Chapter 1), Ping Pong (Chapter 24), and "Bullying" (Chapter 23).
Zhang has a special talent for engaging difficult patient in therapy, as exemplified in "Wrong Foot" (Chapter 12), "Hiccup Boy" (Chapter 13), "Failure" (Chapter 34), and "Yellow Card" (Chapter 46). As Zhang finds coercive treatment distasteful, such as force feeding an anorexic patient, he is good at negotiating with patients so that they would voluntarily eat again to achieve their own individual goals. For instance, the patient in Chapter 34 started to eat again because she did not want to be "sectioned" (meaning certified under mental health laws) which would prevent her from going to the United States to pursue higher education.
While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them".
As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy).
Full review on Amazon.
Monday, May 7, 2018
Mental Health Awareness: Bobby Baker & The Peril of Diagnosis
In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.
It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?
It was no coincidence that right next to the Madness and Modernity exhibition is the show of Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.
It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?
It was no coincidence that right next to the Madness and Modernity exhibition is the show of Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.
Bobby Baker Wellcome Trust
Bobby Baker is a successful performance artist who had suffered acute psychiatric problems including self harming, which she captured over a period of 10 years in hundreds of 'diary drawings'. These paintings (158 drawings, selected from a total of 711) and commentaries demonstrated her anger with the mental health service and any viewer thinking of entering psychiatry might be put off forever.
Bobby was told by the first psychiatrist she saw that she suffered from borderline personality disorder. (Time article link)
Bobby was told by the first psychiatrist she saw that she suffered from borderline personality disorder. (Time article link)
As her story unfolded in her drawings, one gets an uncomfortable feeling about the state of our psychiatric service and wonders if we are even at the 50th step. She has triumphed over some of life’s most frightening experiences despite all.
Bobby Baker Wellcome Collection
“As my ability to function improved, hell became more firmly encased in my skull. I’ve formed the opinion…..that psychosis is a metaphor for extreme suffering. My delusions led to paranoia that a network of professionals was constantly searching for evidence that I was wicked. …….Medication didn’t help – it just made me fatter and fatter.” Bobby Baker Wellcome Collection Exhibition pamphlet.
As a psychiatrist, I could not help being curious about the lack of an early history, having just come from a room showing a replica of Freud’s couch. According to Freud most mental disturbances have roots in one’s early childhood.
The puzzle was solved when I read in the Observer of an interview with her:
“I don't know how but I must ask about her father next - the classic therapist's question is, in her case, inescapable. Again, a picture speaks first. In Telling Keith, she is weeping, her tears bizarrely swirling upwards. Her mouth is open and a sea floods out - in the middle is a tiny, drowning figure. ‘That's my father,’ Baker says. ‘I know,’ I say. I know because, in her autobiographical show Box Story she told audiences about a summer holiday in Brancaster, Norfolk when she was 15 and had just received her surprisingly good O-level results. Telling her father her news was 'the best moment in my life' and he gave her the happiest of hugs. She asked whether he was coming to lunch? Not straight away, he replied. He would have a dip first. A bit later, they heard a woman's voice shouting, ‘Help! Help! Help! A man's been washed out to sea.’ Her mother leapt to her feet shouting, ‘My husband! My husband!’” Kate KellawayObserver, Sunday 28 June, 2009.
Like my own patient, Bobby Baker suffered from bereavement.
You won’t be able to see the Madness and Modernity as it has finished, but the Bobby Baker drawings are on show at the Wellcome until the 2nd of August. Those running our psychiatric services should perhaps have a good look as they may well be featuring in a future Wellcome Exhibition.
Slide Show: Guardian.
Related:
Can They Draw: From Picasso to Matisse
Picasso, Medicine and Lloyds
Picasso and Tradition
“Wake-up Call” to British Psychiatry
Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?
New Link:
Jobbing Doctor: What a way to run a service.
Thursday, May 3, 2018
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.
“Sammy……”
“Yes……”
“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.
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