It was the middle of the morning in the OPD.  There was a long queue of patients out the door.   In came a young woman and her sister.  “Sister July told me to come here” Juliana, a nurse practitioner, had come here with her husband, an orthopedist.  We had gotten to know each other while working on the standards for the physical exams of neonates done by the nurses in the newborn clinic, and going to the Royal tlhimphu College to speak with the students about drugs, alcohol, stress, and other health related issues.  

        I asked the young woman her name and age.  Her name was Mimi. She was 22. That’s ok, I thought.  I see patients up to 21, and some a little older.  It told them to meet me at the Reproductive Health Center at 2pm.  When I arrived, two older women accompanied the two women.  One was very old.  Mimi explained that this woman was to be my patient.  She was to be my patient. She was 96 years old.   Her problem was hiccups.  She had been hiccupping for days without stop. 

       I thought for a moment.  How could I send them away?  The old woman whom I shall call Jedsuen lived with her daughters and grandchildren.  Bhutanese society is traditionally matrilineal.  Husbands move into their brides’ family homes.  Daughters typically inherit family property. 

      Moreover, children take care of their parents, and grandparents in their old age.  There are no such things as nursing homes, retirement homes, assisted living facilitates or any of the other euphemistic terms for places old people go to live out their last remaining years in the our country.  

        Jedsuen wore a full-length kira, of earth colors that matched her leathery skin. Over that she had a green toga; over that was a purple down coat – commonly worn in cooler weather here. She wore a pink headscarf.  Though she was stooped and walked with a cane, she was surprisingly nimble, as we had to hop up onto a bench in the garden courtyard to which I had led the group.  (Though the average Bhutanese man is my size – very short – and most Bhutanese women are equally petite, outdoor benches seem to be made for NBA players; I would need stilts to use the urinals).   As commonly happens in Bhutan, the problem was not as it seemed either.  Hiccups were not her chief complaint.  Asthma was.  Also: leg pains, not surprising for someone who was 96 years old.

         The old woman had lived all her life in a small village in the South, not far from Galipeau, growing rice and vegetables.  Women do much of the farm work in Bhutan.  She had worked dawn to dusk.   I have seen women on the street carrying heavy metal rice threshers on their backs.  They are as strong as the husky fellows I see in the Holyoke Y weight room back home.   The first Westerner to visit Bhutan, Father Estevao Cacella, from Portugal, noted in 1627: “The land and climate are very healthy (healthier than India).  There are many old people, who look healthy and vigorous.”  Of course, to make it past infancy in those days, one had to be sturdy.  The infant mortality rate, when first recorded in 1984, was 103/1000; one can assume it was higher than that in 1627.  (The infant mortality rate now is between 32-41/1000; poor record keeping precludes a precise figure.)

         With here great niece translating (her granddaughter was now absorbed with messaging on her IPhone), I taught Jedsuen some careful diaphragmatic breathing.   Though she was not hiccupping, she was wheezing mildly, and was a little short of breath.  I could hear the sound of the monks’ chants and trumpets from the chorten not far from the hospital.  I suggested that she could remember the temple from her village and the peace it brought her.  She was Nepali but Hindu shrines are remarkably similar to Buddhist shrines here.  After all, Buddhism sprang from Hinduism, the oldest organized religion in the world.  I suggested she imagine herself in a garden, here or in her village.  Children often enjoy the image of the respiratory tree as an actual upside down tree, the leaves of the alveoli opening and closing with our breaths.  I suggested Jedsuen imagine this.  Her wheezing lessened, though her breath quickened.  I asked how she felt. 

            “Sleepy”, her great niece translated.

             I then told a story about my grandmother.  My mother’s parents, Mayme and Murray Gillette, were very close to me.  My father worked very long hours as a well-known professor of periodontics at Columbia University.  We saw little of him.  My grandfather was a peddler on the streets of New York, who made a small fortune as a haberdasher.  He lost it during the Great Depression, but made some of it back.  He always wore a three-piece suit with a gold pocket watch and chain, and a natty kerchief in his suit pocket.   He spoke fake French to my grandmother who he liked to call the most beautiful girl in the world.  He had a heart condition, which, in those days, meant he was not to do any physical activity.  But he still grabbed my grandmother by the hand and pull her up to dance.

         “Now Murray, you know what the doctors said,” my grandmother chastised.

          My grandparents would come up every Thursday from Weehawken, N.J., in my grandfather’s finned silver Cadillac.  They would take us out to Daddy Michaels for milk shakes, and buy seven layer cakes at White Plains bakery. 

           In the summer we would go to there summer place in Tannersville.   It had a coal stove in the kitchen, a living room filled with books by Somerset Maugham and similar writers, and an old-fashioned icebox in the adjoining garage.  The view from the backyard of the Catskill Mountains was pretty enough that artists used to ask to paint from their backyard.  My grandfather, and Uncle Sam would dress in their coveralls to go out to do important yard work, like pulling the weeds from the cracks in the sidewalk.  I still remember the smell of my grandfather’s garden tools as he oiled them, and the taste of my grandmother’s borscht with sour cream.

            After my grandfather died, my grandmother lived until she was 97 in their duplex in Weehawken.  I would take my daughters to visit her, picking up tiramisu at an Italian bakery on the way.   My grandmother would make us tuna sandwiches, and tell us stories.  Like how she would see Frank Sinatra’s mother at the hairdresser in Hoboken, and how my mother got their phone number.  My mother, a great lindy hopper in her youth, was a bobby soxer.   She reached Mrs. Sinatra over the phone and said, “I love your son!”

          “You leave my son alone!”  Mrs. Sinatra said.

           When utilizing hypnosis as a tool, or in any therapeutic relationship, it is essential to have rapport with the patient or client.  How does one achieve rapport?  By tapping into our personal experiences, and then using them to understand the commonality of all experience among human beings, despite the vast differences between cultures.

            So I talked about my grandmother, and our visits. My grandmother suffered debilitating arthritis in her later years.  But I described how my grandmother would become absorbed in the memories of her interesting and long life, and how being with her grandchildren lifted her spirits.  This helped to alleviate her suffering.

          Jedsuen was transfixed by this story.  Her eyes closed, her breathing became slower, easier.  Soon she was asleep.  At the end of the session, I woke her up.  She said that her breathing was easier, more comfortable.  And her legs felt better.  I had never noticed hiccups anyway, so I didn’t bring them up.  I suggested, of course, that she practice as often as she could, with her great niece helping if necessary.

         Her granddaughter finished with her phone calls, and gave me her phone number, and invited me to join her and her friends at Karma’s Coffee.  Karma’s Coffee is the nicest of the “chillip bars” in town, with comfortable cushioned chairs, great coffee, and jazz playing all day.  Flirting is one of the favorite hobbies in Bhutan among all age groups.  I declined but thanked her for the invitation.

             My next consult came from Dr. Allen.  I had already given a lecture to their staff on using hypnosis for anxiety.   I had begun with a group hypnosis session that the workers in the room much enjoyed.  One of the male therapists that he went into a deep trance, with total amnesia for the ten-minute session – though he was not sleeping.  Traditionally called somnambulism, this kind of trance indicates a high degree of hypnotizability.   I found this to be a not uncommon experience among the students I taught.    

          I taught the maxim – taught to us by Michael Yapko – that all of us ask questions about the future, but those who suffer from anxiety disorders don’t have any answers.

And anxious people tend to overestimate the risks of the future, and to underestimate their own resources.  They cannot tolerate ambiguity.  To overcome anxiety, one must address all those issues.  I also talked about depression and its relationship to anxiety.

           Anxiety is the leading mental health problem among children.  Anxious children tend to become depressed adolescents and adults.   This is because depressed people use the past to predict the future, according to Dr. Yapko, and other experts in the field.  And for anxious people the future is filled with danger, both real and imagined.  This is why our culture, fueled by the 24 hour news cycle, is a hot house of worries: everything from comets hitting the earth, the person next door catching the Ebola virus, how President Obama will take everyone’s guns away, while the real dangers, like global climate change leading to one natural disaster after another, are denied.   Repression and denial are defense mechanisms that work well for those real worries.

          The mental health workers are beginning to learn cognitive behavioral therapy (CBT) and other forms of psychotherapy.  This is due to the presence of HVO volunteer staff, like Dr. Allen, and other visiting professionals, like the Australian psychologist George Burns (no not THAT George Burns) an Australian psychologist and friend of Yapko’s, who wrote the book 1001 Healing Stories…  George Burns has been to Bhutan many times, sometimes with an entourage of students with him.  The mental health worker Uden said that Dr. Burns led a group hypnosis session in the woods behind the Golden Buddha.  Built with gold leaf from China, this stature is the largest Buddha in the world.  After three years, the exterior work is done.  The interior is still under construction.  It is an impressive site.  

            But when I emailed Dr. Burns, he said that he has not taught clinical hypnosis yet in Bhutan, because “they have to learn good psychotherapy yet.”   He did allow that he thought it would be ok for me to use and teach clinical hypnosis for medical indications, because this would be for pain relief, not psychotherapy.  However hypnosis is a psychological procedure.  Furthermore, the mind and body are inextricably linked.  Use of hypnosis for any reason is all about altering perceptions, developing new cognitive skills, and realizing how feelings affect bodily sensation.  In other words, it’s psychotherapy.

         Dr. Allen called me the day after this lecture.  Could I come over right now to see a patient?  It was a 21-year-old woman whom I shall call Sonam. After an argument with her mother she had stopped talking the day before.  No, I said, I was in the middle of the OPD clinic, with a poor confused intern, and the usual chaos surrounding me.  But I could come in an hour or two.

        “Ok,” he said, “I’m just going to go ahead and admit her anyway. Everyone is admitted here” Without private insurance companies, there is no barrier to admission.

Even though it means sharing rooms, bringing your own sheets and clothes, and having family members bring food in to eat.  (Rumor has it that the already modest culinary budget at JDWNRH is being siphoned off by an unethical hospital administrator).

           I went to see Sonam later that afternoon.  She was sharing a room with the aforementioned elderly schizophrenic man.

         “She just stopped talking,” her mother said. “Before 5 yesterday afternoon, she was normal.  Then she just stopped.  She used to talk, now she doesn’t”

           Hysterical symptoms are common in Bhutan.  “It’s like psychiatry in the United States, 50 years ago,” Dr. Allen observed.  “I see conversion disorders all the time.”

           People don’t tend to complain about sad feelings.  Instead they suffer somatic complaints.  “Giddiness”, in which patients complain of light-headedness, roll their eyes, and seem to faint, is the most common syndrome.  This constellation of symptoms is apparently often treated as seizure.

           This was the case with Sonam. She lived in a small village in the eastern part of the country. There was “an evil step mother” involved, but the young woman was now living with her mother.  Sonam had a history of depression.  She had been treated with amitriptyline, and older tricyclic antidepressants, and one of the small handful of psychiatric medications available in the kingdom.  She had also been on Dilantin for seizures.

          I said to Sonam, “Though you are not talking right now, I bet you are able to write.”     We went to the lounge with Kinley the therapist and translator, and her mother, whom Sonam motioned to join us.   I asked Sonam when her symptoms began.  She wrote 5pm.  I asked how she was feeling then.  She wrote “sad”.  I asked how she slept last night, and she wrote, “I didn’t” She’s very tired, Kinley said. Her mother repeated several times how she had been able to talk, and then she wasn’t.

        Then Sonam began to list to the side in her chair.  Her eyes rolled up.  “She’s having one of her seizures,” her mom said.

         One of the distinguishing characteristics of a seizure is that the person is not responsive to verbal or tactile stimuli during the episode.  

         “I know you are tired” I told her, “but I can help you.”

          I instructed her in simple breathing exercises, and then used a hypnotic induction I learned from David Patterson, a psychologist from Harborview Medical Center in Seattle, who has treated army veterans and others with severe burns.  He wrote the text “Clinical Hypnosis for Pain Control”.  It involves grounding the patient to the present moment in time. I said, “You’re sitting on the chair, your feet are on the floor, you’re breathing in and out.   Your feet are on the floor, you’re breathing in an out, you can begin to feel comfortable and relaxed.”

          By repeating what is called the “Yes set”  (no one could argue that she is not sitting and breathing), one can begin to introduce suggestions for comfort.  Sonam shifted slightly in her chair, and her eyes steadied.  I gave suggestions that she could be in control of her mind and body, repeated over and over.   At some point during this time, I had her mom leave the room, because her anxiety was not helping matters.

         After the giddiness had abated, I asked Sonam if she wanted to continue.  When Kinley repeated, “She is very tired, she wants to rest”, I said, “I know that.  You need to rest.  And I’m going to teach you some ways of helping yourself get the rest you need and deserve.”

        I went on to suggest that Sonam go to a place of comfort, rest, and safety.  I mentioned a bunch of places I like (mountain streams, forests, etc.), but when I asked her what she was experiencing, she wrote “my own bed”.  This is a common favorite place for many adolescents.  I then went on to make suggestions for comfort, and control and safety, and said that with her many years of experience talking, I’m sure she will remember how.  Sonam cleared her throat, and made some slight gasping noises, as if trying to talk.

         I mixed in suggestions about knowing that she could “have a voice” in things affecting her life.

         I then told a story, about my own daughter Liza, who spoke barely a word until she was two years old. She received speech therapy until third grade.  She also was painfully shy in her years.  But then by secondary school and high school, she blossomed.  She made lots of friends, became secretary of her eleventh and twelfth grade classes, and graduated Phi Beta Kappa from the University of New Hampshire, with a double major in international relations and psychology, fluent in both English and Spanish.  But we can still go for long stretches of time when we are together when she will say little.

        “She knows how speak, and speaks very well,” I said, “but she only talks when she has something to say.”

          Kinley noted the next day, that Sonam was paying very rapt attention when I spoke these words.

          Ending the session, I asked Sonam if she would like me to come back to see her the next day. 

         “Yes” she whispered.

          I arrived late the next morning, Saturday.  I had been with an intern in the OPD again.  It had been another busy session.  The nurse on duty said that Sonam was talking again, participating in a group session that morning.  I had her come in the lounge to see me.  Sonam did not remember the details of why she stopped talking.  But she did tell me some of the details about her life.  She lived with her mother, and did not work nor go to school.   She said she could not because she had been depressed for years.

         Depression as a disability is something I am used to hearing about in the States.   As Robert Whitaker documents in “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America”, as we have developed an increasing number of medicines to treat depression, anxiety and bipolar illness, the numbers of adults and children (especially children) on the social security disability rolls has skyrocketed.   And as Michael Yapko points out in “Breaking the Barriers of Depression”, the idea of depression as a disabling disease can be a self-fulfilling prophecy. 

         I suggested to Sonam that one of the best things she could do to help herself is to get out of bed and to call a friend, get some fresh air and exercise, go back to school. As Dr. Yapko emphasized in his sessions with us, “Why don’t people who are depressed do the things they need to do to help themselves?  Because they don't FEEL like it.”

        “They have to learn not to focus on their feelings.”

          I said Goodbye to Sonam.  She left the hospital that morning.  Time will tell if she breaks her own pattern of depression.  But she was able to learn, quickly, that she could learn to break her own “seizures” or “giddiness” and to “have a voice again.”