The morning has been spent observing the medical students and their teachers in the ophthalmology clinic. Levels of privacy and confidentiality that are considered fundamental in our health services do not apply. It makes me wonder about some of the teaching we do with the Gulu students under the heading of “Introduction to clinical learning”. The feedback we get from the students is that it has helped them establish themselves more readily in the clinical setting but I realise I haven’t discussed with them anything about the potential dilemmas we may create for them with the medical and nursing practitioners with whom they come in contact. I need to discuss this with my colleagues to check whether someone else is taking this into account.

 

My role in the clinic is as a general medical educationalist and as the initiator of some teaching about Liaison Psychiatry. Where does one start given the numbers of people in the clinic, the lack of clinical space and the fact that the students have the pressure of forthcoming exams – enough to contend with without the introduction of a new topic? But this is teaching the medical school have asked me to initiate. So, is there room for manoeuvre with the aid of a carrot and a stick? Pointing out that the topic now becomes ‘examinable’ is accompanied with the provision of some learning resources, but the ‘carrot’ has to be about finding a way of engaging with their curiosity – identical with the dynamics which apply in many high-stakes learning environments. So, it’s back to basics: I sit and observe.

 upforit

A young mother has brought her 3 year old son to be seen. She is holding a baby which appears to be less than a month old. Her little boy stands still and silent, looking at the Clinical Officeri. I’m sitting behind the Clinical Officer and look at the little boy surrounded by a sea of faces. I can only interpret his expression as a look of frozen terror. The urge to intervene feels irresistible but is challenged by awareness of the imperative to avoid impulsive reactions which, however well-meaning , often amount to ‘acting out’. I’ve learnt to manage myself reasonably in these situations by considering the question “What is my place in this here?” Probably, first and foremost, is the need to remember that I am a temporary presence so that ‘do no harm’ is a good guide. My place is as a medical educationalist and as a child mental health specialist. As a doctor I know that the Clinical Officer will be able to carry out a better examination technically and in terms of its emotional impact on the child if the boy is less fearful: this could be achieved by enabling his mother to give her fuller attention to him - both aspects could be incorporated through what I feel would be a legitimate and minimally disruptive intervention on my part. I ask the Clinical Officer if he could ask the mother if she would like me to hold her baby (still sleeping) so that she could take her son on her lap. She readily agrees to this and very quickly the expression on her son’s face changes and the examination proceeds. The sight of the mzunguii Professor sitting holding a baby causes some amusement in the clinic. Later that day I email the students with teaching points and questions from the clinic and ask them if they think I just like holding babies or was there any clinical justification for my actions…

 

The afternoon is my visit to the SOS Village for the training session. I approach it with a degree of trepidation about what I will do as well as excitement at being involved with the work of the Village. Patience is required because we are on ‘Uganda time’ and 2 pm is a moveable feast as a starting time. There are practical issues. Even before any issue about idiom, technical terms or jargon, will we be able to understand each other’s’ accents? Despite my ‘Received English Pronunciation’ this has been a problem, and the Ugandans are often too polite to let me know. The situation isn’t helped by a beeping in one ear letting me know that a hearing aid battery is just about to run out. Then the heavens open and the sound of the rain on the metal roof is all but deafening. The children in a nearby classroom are having a music lesson and they are eager singers. As well as ensuring that Sarah can be present to participate and support me, I had also tried to arrange for a local colleague to join me but there has been a misunderstanding and I have to proceed without her.

 

The session starts with a recap of some of our previous session considering the impact of the children on the practitioners (Teachers and House Mothers) in terms of conscious and unconscious processes. I decided that I would also try out an exercise that had proven useful in other settings: using a grid, I ask people to consider the interactions of a subjective sense of safety or unsafety and objective states of safety and unsafety.iii

 

 

 

FEELS SAFE

 

FEELS UNSAFE

 

IS SAFE

 

 

 

IS UNSAFE

 

 

 

The aim is to examine the emotional states and what behaviour may arise as a result of the different mental processes which may occur depending on emotional and cognitive development, past experiences and contextual facilitating and inhibiting factors.

 

 

FEELS SAFE

FEELS UNSAFE

 

IS SAFE

 

SAFETY

 

DANGER

 

IS UNSAFE

 

DANGER

 

DANGER

 

 

 

The groups’ discussions are animated and the feedback of their thoughts varied and interesting. I am particularly taken by one group feeding back that they thought one could substitute something to do with what they could only call ‘functions’ for ‘anxiety’ - e.g. ‘hunger’. I find it difficult to describe the impact on me of this spontaneous grounding of experience in its fullest psychosomatic sense. I was excited and full of admiration by the ease with which an idea had been extended in its application through practical, thoughtful and reflective practice. It is also consistent with psychoanalytic theory – which reassured me about the theory as much as about the fact that I thought something useful, albeit limited, was happening for all of us in our interactions. It may be that something more significant was happening for me in terms of learning and consolidation of prior learning, but I will have to await further feedback from Sarah and her colleagues. Sarah shared some of my anxieties about this. I try and reassure myself that what I was doing was important in terms of the overall process with which we were involved – my role in the support of the emerging relationship between the Village and my colleagues in Gulu in which there is real mutual respect for our uses, seeking to avoid the oft-repeated pattern of idealisation of the specialist therapeutic role and denigration of the everyday, every day, care role.

 

So, why did I want to try and entice PETT members to consider whether there could, and perhaps should, be involvement in this type of work? There is a hunger in organisations such as the SOS Children’s Village to learn more: but just as happens in the UK this can be directed more towards what additional things the staff could be doing rather than giving proper weight to appreciating the benefits of what is already being done for the children, and the complexity and difficulties inherent in this – not least of the tasks involved is the feeling that whatever one does, one will always be left with a sense of what one hasn’t been able to do, e.g. turn the clock back and change what happened.

 

The feedback I have from my visits to Gulu over the last three years is that insights from our specialist therapeutic experiences, practices and theories can undoubtedly be useful and that we shouldn’t be backward about putting ourselves forward… if we also ensure that we approach the process from a starting place of seeking to learn. Involvement can help us learn more about the fundamental issues in our practice, or at least be reminded of them. It can clear away some of the froth that comes from the political and cultural environment in which we normally practice, where well-intentioned but perhaps misguided or even spurious imperatives may be imposed. The children of Gulu SOS Village would not all be candidates for Planned Therapeutic Environments but some of them would: those that would be are receiving care which is likely to contribute ‘therapeutically’ through ‘the provision of primary experience’ as described by Dockar Drysdale.iv Working with an institution such as this could provide an opportunity to re-evaluate current practice, to learn or perhaps re-learn what has been forgotten and to establish or re-establish in its fullest sense, care which is child-focussed and therapeutic. There could be mutual benefit.

 

So, is anyone ‘up for it’?

 

 

Adrian Sutton, Honorary Consultant, University Hospital of South Manchester, UK: Visiting Professor of Psychiatry, Gulu University, Uganda

 

iSpecialist practitioners without full medical training who are the mainstay of the health services alongside the nurses and midwives

ii White man

iii For description and discussion see Sutton A. (2013) Paediatrics, Psychiatry and Psychoanalysis: through countertransference to case management. New York & London. Routledge 86-88

iv Dockar Drysdale B. (1990) The Provision of Primary Experience: Winnicottian Work with Children and Adolescents. London: Free Association Books