A Return To, and Departure From, Zurich, Switzerland
I’m back in Zurich after spending an enjoyable month in Uganda on the second stint of my psychiatric clinical placement at Butabika Hospital in Kampala, Uganda. My work at the hospital is an integral part of my clinical training as a Jungian Psychoanalyst at ISAPZurich.
On this occasion, I was able to get much more involved in the assessment and treatment processes of the patients because I’m officially a ‘Jungian psychoanalyst-in-training’. The ‘title’ allows me to see patients and clients under supervision by ISAP training analysts and of course continued training. It is such a great milestone in my training as a psychoanalyst and the most exciting part too.
The work is challenging but immensely rewarding. I wore my clinical coat with pride especially because I was working in my country of origin, Uganda, in a hospital overwhelmed by the sheer number of patient and limited resources. The hospital has 550 beds, approx. 1,000 patients, and a daily line up of 50-100 patients per day. It is an intensely demanding environment and also an opportunity as a psychologist or psychiatrist to gain huge amounts of experience.
I feel a great sense of accomplishment working at the hospital. It was good to be back for another month and I’m already looking forward to my next stint at the hospital. Resources are stretched but the hospital team do their best for the patients and clients. I'd love to fundraise for the clinical psychology team at the hospital to have essential books and toolkits. If you're interested in contributing please get in touch with me.
I usually write my blogs in a dynamic way, by that I mean, I write it as and when things happen and post more frequently. This time I’m writing this blog on arrival back in Zurich and reflecting on the experience. I’ve made a big decision since returning from Uganda. I’ve decided to return to London and open my psychoanalytic practice in my home city, to gain the patient/client hours needed to complete my training.
The decision came to me after months of reflection about my life in Zurich. It has been enjoyable, the city is comfortable and I’ve got a great circle of friends here. But the city is a bit small for me, not just geographically, but psychologically.
I would like to continue to pursue my career as an organizational consultant and perhaps do a PhD in the role of the unconscious in artificial intelligence. I’m in discussions with the University of Essex about my PhD proposals and there is a lot of interest. Plus the client and patient base in the UK will be very interesting.
I’m also considering relocating to Washington, DC USA and I’ll soon find out in the Spring whether I’ve managed to secure a work permit or Green Card. I’m also quite interested to explore possibilities to work in Nairobi, Kenya for 6-12 months or so to gain the training hours needed to graduate.
While living in Zurich is absolutely fine, I just feel the need to expand my wings and not restrain myself to life in Switzerland. So it looks like I’ll head back to the UK by the Spring.
This does not mean Zurich is a no go area. I’ll commute back for supervision, analysis and ongoing training which is precisely what I did when I first enrolled at ISAP.
The Lost Bracelet
I flew to Uganda via Doha on Qatar Airways. I’ve never flown Qatar. The airline is known for it’s exceptional on-board service and it certainly lived up to my high expectations. Whilst boarding, I noticed that my bracelet was missing from my right wrist. It seems that it fell of my wrist perhaps when I was washing my hands in the toilet or when I lifted my backpack on to my back. There was a long queue to the aircraft door so I considered going back to the gate and asking the staff whether I could go find my bracelet.
It was a kind of cherished personal item which I bought at the National Museum of African-American History and Culture in Washington, DC last November. The exhibition is harrowing and I really wanted something to commemorate my nearly 6-hour visit to the museum in honour of the plight of African Americans over the centuries.
I knew the staff would not let me past the boarding gate so I reluctantly cut my losses and continued to board. I felt a great sense of loss. I kicked myself for not buying two bracelets, an heir and a spare so to speak. I often buy an heir and a spare with items such as clothing, shoes or jewellery especially if they are quite rare. As I boarded the flight, I thought I should have bought two bracelets, at least I would have the spare so losing the original is not a big deal. It felt very strange to feel a loss of such an innocuous item.
Anyway, I managed to put my saddened thoughts aside and focused on the long journey ahead. I transited in Doha for 24 hours spending the time at a hotel not far from the airport. I paid £21 for the room in a five star hotel, a great saving if you book the room with your airline reservation number. I was too tired to explore Doha having caught an early morning flight out of Zurich so I stayed in and ate at the hotel restaurant. The food was actually incredibly good.
I left the next day for Entebbe arriving in the late afternoon. On arrival at Entebbe, the air was warm and the sun was blazing. It felt good to be back home. It was Saturday so I had time to relax over the weekend with friends and family before starting work on Monday. I head straight for my favourite Indian restaurant in Kampala - Khana Khazana Restaurant, and discovered a new favourite, Tamarai Thai. The food is simply exceptional. Highly recommend if you ever find yourself in Kampala.
The Experience of a Clinical Placement - Patient Mental State Assessment, Psychoanalytic Diagnosis, Bipolar Affective Disorder, Conversion Disorder, Drug and Alcohol Addiction, and Why I Chose to Work as a Jungian Analyst
So what’s it like to work in a psychiatric hospital as a psychoanalyst? Well, this is my own experience which as you can imagine is unique to each individual. My own psychological development and training plays a huge part. There is also a great sense of duty that goes along with the role, perhaps best expressed in terms of empathy and a willingness to help others. Both the patient or client and the clinical psychologist, nurse, counsellor, psychoanalyst, and psychiatrist learn from, and help each other. It is not a one way street i.e. the medical team just assessing and treating patients. Of course, the patient benefits from the treatment, and they also impact the clinical team.
Carl Jung, whose analytical psychology is the mode of psychoanalytic theory that I'm training in, began his training in psychiatry in 1900. He lived and worked at the Burgholzli Psychiatric Hospital in Zurich, Switzerland. He learned how psychiatry was practiced and also worked to understand patients with psychotic illnesses and developed theories to explain the processes of the human mind in both health and illness.
As psychoanalysts, our own psychoanalysis, a total of 300 hours before the completion of training. is fundamental to our work. Essentially, this means working through our own emotional difficulties, past and present, often involving experiences in childhood, adolescence and adulthood. It is quite some work to do, meeting an analyst once a week for an hour to talk about one’s life, both conscious and unconscious.
Psychoanalysis is an in-depth exploration of one’s entire psyche, especially of the unconscious and it’s impact on one’s general health and well-being. If involves dream analysis and often takes a long time for benefits to emerge. However, the process can be transformational and people’s lives often change for the better. In a psychiatric clinical placement of four weeks, it is impossible to get into in-depth psychoanalytic therapy but it is possible to make a difference.
Here is some of the work that I was able to do over the course of the placement and some of the common mental health issues that I encountered during my supervised ward rounds.
Patient mental state assessments
Assessment of the mental state is the first step in the diagnosis and eventual treatment of a patient or client. I say patient or client because mental ill health is like a spectrum. It can be mild or severe. It can be psychotic or emotionally disturbing. Some people are treated as in-patients and others as out-patients. Some people feel a need to mature psychologically. So when I use the terms ‘patient’ and ‘clients’ I’m referring to wide range of people seeking help from psychologists and psychiatrists.
The assessment of mental state is usually in the form of an in-depth interview with the patient. The information collected from the session informs the diagnosis, mental health evaluations, psychosocial narratives, progress notes, treatment plans, closing summaries of treatments and the like. Our training gives us a structure to carry out the interview and best practice guide like the Clinician’s Thesaurus ease our workload as it sharpens our questioning technique and writing because it does the following (Zuckerman, L. Edward. Clinician’s Thesaurus. The Guide to Conducting Interviews and Writing Psychological Reports, 2019):
Presents dozens of related terms to enhance the clarity, precision, and vividness of reports.
Offers behavioural descriptions for a range of psychopathology to help you document your observations, formulations and conclusions.
Suggests phrasings that can individualise and personalise a report or description.
Stimulates your recall of a client’s characteristics (we all can recall more when we prompt our memories by reading related terms).
Suggests ‘summary statements’ where only a brief indication is needed, such as when cognitive functioning is within normal limits.
Contains extensive cross-references and a helpful index for ease in locating materials and ideas.
Replaces the drudgery of narrative construction with playfulness, spontaneity, and serendipity.
The last point is valid. There are two main manuals for the assessment of mental ill health. The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association and the International Classification of Diseases (ICD-10) published by the World Health Organisation. Both are designed to promote international comparability in the collection, processing, classification, and presentation of mental and behavioural disorders, clinical descriptions and diagnostic guidelines. Uganda’s psychiatric profession uses the DSM for its diagnosis of mental disease and this manual is a must have as a psychoanalyst.
Psychoanalysts do not diagnose but it is important for us to understand and to identify symptoms. This is why the placement in a psychiatric hospital is an integral part of training. I need to be able to identify symptoms as they present themselves in a psychoanalytic session. This enables me to ensure I provide the right support and refer patients or clients to psychiatric care if necessary.
During my placement at Butabika I carried out mental health evaluations with recently admitted patients or as referrals from the outpatients department. The session must be structured to obtain the most comprehensive information from the patient or client. A typical approach beginning and end the interview as recommended in the Clinician’s Thesaurus is also my preferred approach in the circumstances:
Introducing yourself and noting possible communication difficulties.
Assessing the client’s understanding of the interview situation.
Obtaining informed consent.
Eliciting the chief concern, complaint, issue.
Eliciting the client’s understanding of the problem.
Dimensionalising the concern, problem.
Ending the interview.
Naturally, I have my DSM close to hand to read descriptions of symptoms and possible diagnoses. On these occasions, sometimes a diagnosis has already been made by a psychiatrist so often I’m validating the symptoms and diagnosis from a psychological perspective and thinking about a treatment plan, usually psychotherapy, to ease the patient’s symptoms. Ultimately, I’m asking questions about signs, symptoms, and other behaviour patterns. The patient may be well enough to respond to my questions or perhaps remains so unwell, I might need to postpone the interview until they are less disturbed. A combination of instinct, knowledge and observation helps me to decide whether to go ahead with an evaluation postpone it.
The clinical psychology team at Butabika is small, approx., 5 or 6 clinical psychologists for a patient population of over 1,000! The work to assess patients can take hours so I could have spent my time carrying out assessments and do nothing else. It is really a great challenge for the clinical psychology team to get through the assessments. The work is supported by people like myself, interns, training psychiatric officers etc who work at the hospital for a few weeks or months at a time, evaluating patients and contributing to their treatment.
The screening of people for psychopathology by interview can be challenging in terms of time- and effort-efficiency. An efficient strategy is to use a symptom checklist and then conduct an interview to follow up on what the screening checklist found. Interviews should be reserved for in-depth evaluations of the severity, impact, development, dynamics, and duration of the psychopathology. As a psychoanalyst, I felt this is where I could add the most value during my placement, working with specific individuals and cases.
Of course, there is a psychoanalytic approach to diagnosis which I considered using during my placement. Also known as psychoanalytic case formulation, the approach is less structured. Psychoanalytic information is not objectively describable, full of discrete observable behaviour as set out in the DSM and ICD-10.
We aim to understand the person’s psychology: temperaments and fixed attributes, developmental history, defensive operations, affective tendencies, identifications, relational patterns, methods of self-esteem regulation, and pathogenic beliefs. Our efforts focus on understanding each patient as fully as possible so that we can make the most informed treatment recommendation. Psychoanalytic case formulation: effort to give appropriate advice to the multidisciplinary clinical team treating the patient, and to exert a therapeutic influence on the patient’s subjective world.
I carried out Word Association Experiments (WAE). WAEs is a psychoanalytic approach to identify complexes and to inform psychoanalytic treatment. This is quite a lot to talk about so I'll cover it in the next blog in the series.
As I carried out the mental health assessments, I was struck by some of the common mental health issues that the patients were suffering from. Their diagnoses were severe enough to necessitate hospitalisation. I encountered once again, conversion disorder, which afflicts young girls in Uganda and is pretty much non- existent in developed countries. Drug and alcohol addiction remain at high levels particularly among young people. Psychosis, or ‘break from reality’, remains common and prevalent given Butabika is the only national referral psychiatric hospital in the country. Bipolar disorder is also common affecting both men and women. Some of the patients that I assessed were hospitalised for manic episodes, very high moods, talkative and psychotic in some cases. It was difficult to assess such individuals while they are in such a state, it was necessary to delay the assessments until the patient is back to their normal self. The symptoms of bipolar were very observable in some of the patients that I assessed.
Bipolar affective disorder
A manic-depressive disorder that can have psychotic symptoms. Bipolar episodes consist of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day. The episode is hypomanic if there is persistent increased activity or energy lasting at least 4 consecutive days and present most of the day, nearly every day.
The common symptoms include:
Inflated self-esteem or grandiosity.
Decreased need for sleep (e.g. feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking.
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli).
Increase in goal-directed activity either socially, at work or school, or sexually).
Excessive involvement in activities that have a high potential for painful consequences e.g. buying sprees, sexual indiscretions or foolish business investment.
The episode is associated with a change in the person’s character when not symptomatic.
The disturbance in mood and the change in functioning are observable by others e.g. family and friends.
The episode may not be severe enough to cause marked impairment in social or occupational functioning or not to necessitate hospitalisation.
The episode is not attributed to drug abuse, medication or other treatment.
A common somatic symptom which afflicts young girls in Uganda. It is literally a conversion of an emotional disturbance into a physiological symptom such as weakness or paralysis, abnormal movement, swallowing symptoms, speech symptoms, attacks or seizures or sensory loss. The most common somatic symptom seen at the hospital is seizures. Young girls aged 12-18 turn up at the hospital reporting episodes of fainting. Interestingly, conversion disorder was formerly known as ‘hysteria’, common in what are now developed nations way back at the end of the 18th century and beginning of the 19th centuries. The disorder greatly influenced the development of psychoanalysis as a therapeutic intervention so it feels quite strange to be experiencing the same albeit from my own psychoanalytic training and in the modern age.
Drug and alcohol addiction
Addiction to alcohol and drugs is a national concern in Uganda. The country has a very heavy drinking culture coupled with socio-economic problems, you have a recipe for disaster, especially for young people. Alcohol and cannabis addiction can have serious consequences for one’s mental health. It can actually lead to psychotic symptoms such as delusions and hallucinations. I interviewed several patients who had presented or were presenting episodes of psychosis as a result of cannabis or alcohol addiction. The initiation of the psychosis was often as a result of long term, heavy consumption of alcohol whereas a few days or weeks of cannabis may produce psychosis. The culture of Uganda certainly does not help. Mental ill health remains a taboo subject. The patients at Butabika are often termed as ‘mad’ by Ugandan society in general but in my view they are the most courageous people because they are doing something to improve their health and wellbeing. Family members are often too afraid to visit their loved ones at the hospital simply because of the stigma about poor mental health.
Why I chose to work as a psychoanalyst?
I’m always open about why I chose to work as a psychoanalyst. I went to therapy myself and literally transformed my life as a result. It was such an adventure, I became curious about the psyche and psychoanalysis in particular. The sense of wanting to help others, particularly in my own community, came gradually. Working at Butabika is a privilege. It feels meaningful, impactful and enriching in terms of my own psychological development. I’ll be back later this year for another 5 weeks and to complete the placement. It could be quite a good place to get some of the hours I need to graduate but working without pay limits the amount of time that I can spend at the hospital. My placement is entirely voluntary and I am grateful for Butabika’s support in providing me with the experience that I need for my training. But more importantly, I am really pleased to be working in my country of origin and making a difference to people’s lives.
A New Bracelet
I’m back in Zurich after an enjoyable month in the motherland of east Africa, with great artefacts from the trip. Maasai cloth, gold-shaped African continent bracelet, beaded bracelet, safari boots, basket and a Giraffe! If you've never been to Africa (by the way, Africa is a continent, not a country) do check out Uganda and Kenya.
I travelled to Nairobi for a weekend with some family members where I was able to buy a new beaded bracelet and then later back in Kampala, while browsing a craft’s shop, I saw a gold bracelet that attracted my attention. It seems the loss of my cherished bracelet at Zurich airport was short-lived. I returned with two bracelets that have even greater meaning for me.
I hope to be back in London soon. Look out for more details about my psychoanalytic practice.
Thank you for taking the time to read my blog.