21 July 2019
[Above photo: A drawing by our patient of herself in her future toy store, taking inventory. She is 9yo and quick as a whip.]
Since there were two holidays this week, I cancelled classes and only three of my students were in clinic the two mornings we were open. The others were on “holiday”, caring for their children, giving lectures, working in their private clinics, etc.
In our clinic we saw a 9 ½ yo girl who told her mother that she wanted to have sexual intercourse. In the course of her mother trying to understand this, the little girl confessed to having been touched in preschool as a 4yo and having seen pornography on her mother’s phone recently. The girl is a whiz in school and has lots of friends. She wants to open a toy shop when she is grown and drew an elaborate picture of it for me [see above]. My student did a wonderful job of psychoeducation with the mother and daughter, further enquiring about the possibility of molestation, and reassuring each of them that the above incidents seem to have sped up her timetable. In addition, we talked about her intelligence and curiosity and how we want to celebrate them but help her pull the reins on her sexual actions. All in all, I was so proud of him, as he felt of himself, learning to understand. We are taking her off the antipsychotic and antidepressant she was put on by another psychiatrist! When I asked her to play the Squiggle game, in which two players alternate making a mark, which the other player elaborates into a drawing and a brief story, in sequence she drew the sun rising over the mountains, a very cute kitten, and a hen or duck with 3 eggs. She also autographed it, like the little artist she is. She looked much less anxious at the end of our visit than at the beginning, which may have resulted from familiarity with us but also from a frank discussion of sex with her mother in front of her. She seems like a happy child pressed forward by experiences. We’ll see her in follow-up in a few weeks to determine if psychotherapy is indicated.
We also saw in follow-up a 12yo intellectually disabled boy. He was initially seen by us because of his aggressive behaviors and as we discontinued one antipsychotic and tapered off the other a general practitioner had started years ago, he improved. He recently got the flu, with a high fever and aching joints, and became quite difficult again. He told his mother that he wants to have sex with her. I’m not exactly sure what he means by that. When we saw him he was initially quite agitated but as we talked he calmed down, giggled appropriately with me, and ceased posturing aggressively. The parents are quite pleased, overall, and feel that his febrile illness triggered the latest deterioration in his behavior. They are happy to decrease the medication he is taking. We’ll see him in a month or so, as he lives a long distance from the clinic. I think the students are catching on to how powerful being heard and understood, as well as family interventions, are as therapeutic tools.
I managed to contract giardiasis just before my short trip, the fourth such infestation on my passage through this life: in the Soviet Union in 1972, Yosemite back country in 1974, Malawi in 2017 and, now, Myanmar. It isn’t wildly discomfiting, since I sleep alone, but the gas is thunderous. Metronidazole, which I am now taking and with which I feel better after 1 day of treatment, costs $.33 for 25 tablets. The equivalent in the US costs $16, which is 50x as much. It is possible for me, a retired physician, to pay an exorbitant amount for drugs but it isn’t fair for those who struggle. More is spent on Marketing than Research and Development in the Psychopharmacology Industry, not surprisingly. I don’t know if that is the same with other medications. The massive profits are for shareholder returns and executive salaries/perks. Capitalism is a powerful system but needs reasonable containment or it becomes a devouring monster. It’s like a force of nature, neither moral nor immoral; morality, as with DT, isn’t in the discussion. And like him, it needs firm minders to contain and clean up.
There was a poker game again last night at Kelly’s. A British woman and an Indian man cleaned us out. I have read a bit about Texas Hold ‘em today and ordered a classic book about strategy. I am the least experienced, if the oldest, and I don’t like to seem like a dummy. Nor lose my $. But I enjoy the game and the company. I’ll read about it and begin to use my brain more, which should improve my chances. I have drawn crummy cards, however, so I want to be ready to seize the moment when the good ones begin to appear. It is a funny thing, poker. It has a cool, in-the-know aura about it, all sorts of rules and regulations, and nicknames like “the hole”, “the blind”, “the turn” or “4th street”, and “the river”, plus names for various card combinations: Ace-Ace can be “Alan Alda”, “Batteries”, or “Tee-pees”, whereas Ace-King might be “Anna Kournikova” (Looks good but never wins), “Kalashnikov” (AK-47), and “Korean Airlines”. King-King is “Brokeback” (after the film of the same name), “Gorillas” (King Kong), and “Donuts” (Krispy Kreme). Double nines would be “German Virgin” (“Nein, nein”), and so forth into the very scatological. I don’t care about the cool, so much; it just doesn’t hold much interest for me. I do want to know how to play a good hand. I’m capable of folding a poor hand. Mostly, I want to know how to distinguish one from the other.
School begins again tomorrow. I’ll assemble some more talks to complete the syllabus but what the students really need is more supervised therapy practice. Since they interview, and do role plays, in Myanmar, I have to sense from their non-verbal cues how they are doing. I’ve heard a few of them—My god, there is a stupendous storm with rain simply gushing from the clouds!—ending sentences repeatedly saying, “No?”, as if lecturing and demanding affirmation. I have to get them back to asking open-ended questions, making facilitating statements, and listening. I have 2 ½ months only left with them, and the last week will be examination week. I want to fine-tune my teaching to the areas where they need the most help. Perhaps it’s the giardia or the late night poker, but I feel kind of weary today.
My sister turns 90yo next week. Given how early people die in our family, that is miraculous and inspirational. Her children will gather from afar to celebrate with her. I’ve always assumed I’d die young like my father, grandfather, and older brother, but, since I’m no longer young, that isn’t a possibility. I do, on balance, love this life and its possibilities. I must buy a car and arrange for a home when I return to Maine. I’ve been thinking about one of these—http://thegohome.us/—plunked on a couple of acres of waterfront but it may be overall more sensible to buy a home intact. Or even rent for a year or so while I decide what’s ahead. My mind is definitely turning toward home these days.
A Psychiatrist in Myanmar 