Growing Into Medicine (20 page)

Science is good at analysis, but not so hot when it comes to synthesis, mainly the work of the right side of the brain. There is a danger that the task of integrating things into a whole is falling into the hands of the crystal gazers, the iridologists (who make diagnosis by looking at the iris of the eye and nothing else), diet fetishists and others. I find McGilchrist’s scholarly book an important antidote.

I don’t want us to dismiss the scientific method. If we were to do so our luxurious western lives would become similar to those of pregnant Tanzanian women in the hinterland of Arusha. When I visited in 1994, I heard that they had to walk twelve miles to the nearest hospital to give birth. They tell their existing children, ‘I am going to the sea to fetch a baby. The way is long and hard and I may not return.’

But the traditional scientific approach in medicine can sometimes lead to consultations and services that are dehumanised. Marshall Marinker, who was Professor of General Practice at Leicester, has suggested that ‘not all consultations are problem solving, some are more like a piece of theatre, a celebration or an expiation; not to be valued as crosswords but more as poems.’

My introduction to the importance of the body/mind connection started when I joined Michael Balint’s group for general practitioners in 1958. By the time we moved to Kent I was already seeing patients with sexual difficulties in my own time before and after family
planning sessions. The patients had revealed their distress to me during the normal consultation and included those who had already identified a problem. Others presented indirectly, often with difficulty finding an acceptable contraceptive method. A woman might discover that touching her own genitals to insert a diaphragm was deeply distasteful, yet taking the pill gave her headaches. The idea of an IUD, a foreign body inside, could produce a fantasy of damage out of all proportion to the true risks of the device. A condom interrupted their lovemaking and the rhythm method was too complicated and premeditated. Following some of my colleagues I began to suspect that it was sex itself that was unsatisfactory. The skill of picking up unspoken clues, observing the mode of dress, eye contact or its absence, feelings of anger, despair or withdrawal, was hard to learn. But if one could remain quiet and give patients the opportunity to talk, they might find a way to get in touch with underlying sexual unhappiness.

A particularly interesting part of the work was meeting those people who developed genuine symptoms, often pain in various parts of their body, or irritations and discharges for which no obvious physical cause could be found. During my traditional medical training such patients were often labelled as suffering from a ‘functional’ disorder. This word, defined in the dictionary as ‘characterised by impairment of functions not organs’, was usually spoken in a disparaging tone. Functional has come to mean ‘in the mind’, or even ‘caused by the mind’. It is a small step to those pejorative words ‘neurotic’, ‘malingering’, ‘imagined’. The conclusion could be reached that functional pain was not real pain: even that the patient was not feeling pain at all.

It is impossible to assess another person’s pain. On every occasion it is felt on the body and in the mind. My personal experience of pain has been small. Labour pains were relieved by analgesics and toothache has never lasted very long. I have never suffered from renal colic, said to be one of the most acute agonies, or the persistent, gnawing torment of cancer cells growing within the bones.
Occasional attacks of back trouble have provided my only experience of life-restricting pain.

I was shocked when my daughter said I often developed back pain when she asked me to look after her children. What me? Suffering from neurotic symptoms? Never. On reflection, I saw this to be a simple example of the mind and body intertwined. Before such childcare visits I would spend more time on my feet, cooking food to take with me and tidying my house, straining the ligaments in my back and producing reflex muscle spasm. At the same time, the prospect of being responsible for the children made me anxious, tightening my muscles further. In this example, a few minutes’ thought helped me to see the connection. Other ways in which the body and mind are connected lie at a deeper level of the psyche.

During our time in Maidstone, in the first half of the 1970s, I was becoming ever more interested in the patients I was meeting, and I was only too glad that I had no responsibilities towards Ralph’s work. Prisoners did not come to work in our garden as they had at Parkhurst. No one pushed my car in the way the borstal boys had done during our first visit to Pollington. Even at Wormwood Scrubs I had been inveigled into helping with the chapel flowers and had been escorted inside the walls from time to time. On our return to Pollington I had run the playgroup; but in Kent accommodation was spread about the town. Staff wives could find company and recreation in the community, removing the need for them to run their own group.

It was here that Ralph met many more prisoners who were serving a life sentence for murder. This detention is for an indeterminate length of time, at least eight years, but can be extended as necessary, determined by the parole board. A governor has to supply a report to this board and Ralph took immense trouble over the task, spending several hours with each prisoner in an effort to make an accurate assessment of his danger to the public if released. The board uses other reports and a close study of the case in order to reach their decision, which is usually right. Of course there are
occasional mistakes when a man released on parole kills again. Ralph maintained that the system could never be totally foolproof. If every murderer was locked up for the duration of his natural life, large numbers of people would be shut away unnecessarily and the prison population would explode.

Not long after we arrived, I joined a group at the Cassel hospital, led by Tom Main under the auspices of the Institute of Psychosexual Medicine (IPM). At the time when the majority of family planning services were handed over to the NHS doctors working in marriage guidance clinics run by the FPA felt they needed a special training organisation. They asked Tom Main to be their chairman as he was already running groups to discuss the sexual problems that presented in the clinics. He was a psychoanalyst with a fund of understanding about human beings and a rigorous approach to our study; but he inspired strong feelings of attachment and antagonism. An unsympathetic doctor referred to his acolytes as his ‘lovely ladies’. We were in the main women, because the work started with family planning doctors who were almost exclusively female. In addition, something about the nature of the work might have appealed to us more than to male doctors. Many men found Tom’s personality overbearing. Prue Tunnadine, the training secretary of the IPM for many years and who succeeded Tom as president, described a ‘stags at bay’ scenario that could develop between him and some men.

I travelled to London by train with a colleague, Pat Roberts, a gentle, charming person. I was delighted when Ralph asked her to become a prison visitor. Although we were enjoying our life together in a large house and pleasant garden it was good to have a friend with interests in both our worlds. We talked on the terrace, looking out at a trellis of roses running down one side of a lawn with a pond on the other.

After Pat had gained some experience in the prison she gave a talk to the IPM about her role. She explained that she had not been appointed as a doctor or as a person with training in psychosexual medicine. She was only an interested member of the public who
wanted to help in any way she could. She had no powers within the prison and no set agenda, other than to be a friend to the prisoner, within the rules of the service. When she had finished her talk someone asked if she had ever felt frightened in the company of men who had committed murder. She said no, but added, ‘I have to admit to a small
frisson
when I heard that the charming man who recently offered me one lump or two in my coffee had poisoned two wives.’

In common with most doctors who start training with the IPM, both Pat and I found the seminars frustrating. The acquisition of facts had played such a large part in our previous education. All through my training I had believed that there was a body of knowledge that I must master, either by being told or by studying the recommended books. I could not understand why Tom Main was not teaching me how to help my patients. Doctors are supposed to have the answers and I was not equipping myself with them. The idea that I was learning how NOT to know, to stay in ignorance with the patient, only dawned slowly.

In the world of psychoanalysis and dynamic psychotherapy Tom is probably known best for furthering the idea of the therapeutic community. After serving in the RAMC as a psychiatric advisor he was posted to Northfield hospital to develop group studies in the care of disturbed servicemen. Soon he was appointed medical director of the Cassel hospital where he developed a more dynamic psychosocial role for nurses and where he established a family unit.

Michael Balint had been his analyst and they worked together to develop the group training method for general practitioners which I had experienced briefly in 1958. Some of Tom’s seminal thoughts are captured in
The Ailment
, a collection of his papers edited by his daughter. The last three chapters that deal with the defences of doctors and the training method of the Institute of Psychosexual Medicine are of vital importance. His most salient ideas have reverberated in my head down the years.

The clues to an individual’s discomfort with his or her sexual feelings or performance lie inside that person. All the doctor can do
is to work with the patient to try and discover what these internal feelings might be. Over time I learned that preconceived ideas learned from books or teachers can only muddy the waters. Indeed, Tom was so concerned that his original ideas might be turned into accepted truths that would be passed down and block further thought that his work with us, alas, covers no more than three chapters of the book. But these are of vital importance for psychosexual medicine.

During this time, the mid- to late seventies, the new discipline of Sexual Therapy was developing. Treatment was based on the work of Masters and Johnson who had published their book
Human Sexual Inadequacy
in 1970. They had studied the physical changes that took place during sexual arousal and orgasm, using human subjects in a laboratory. For many years a behavioural approach was advocated with enthusiasm. Men and women were told how to have sex and given exercises to desensitise their hang-ups. Deeply personal and interpersonal feelings were labelled ‘Sexual Dysfunction’ defined by the frequency and adequacy of sexual performance. A new terminology developed to classify symptoms. Thus impotence became erectile dysfunction, retarded or premature ejaculation. Frigidity was subdivided into dysfunction of the arousal phase or orgasmic failure. Lack of desire was often seen as a hormonal deficiency.

The use of these terms removed the stigma of words like impotence and frigidity, which can imply something about the person rather than a medical condition. Despite this advantage, I disliked the new terminology. The old words were useful and poignant. Frigidity suggests something of the painful sense of being out of touch with one’s feelings. The word also helps us to understand the atmosphere that may develop during a consultation. Tom never referred to the transference or counter-transference, preferring ‘doctor–patient relationship’ and ‘atmosphere’ as being more descriptive of the dynamic whole.

‘Come
on
,’ he would say. ‘How did the patient look? What was she wearing? How did he enter the room? What was it LIKE to be with this person?’

I might find myself becoming very active, chipping away as if at a block of ice with questions and ideas. Yet, somehow, the patient could let out none of the feelings that mattered to her, except the despair of being how she was. ‘I am standing at the sink, he puts his arms round me and I freeze.’ The pain of the moment can be powerful and present in the room.

One of the first things I learned in the seminar was the futility of asking questions. ‘If you ask questions you get answers,’ Tom would say. ‘What use are they? You have no idea if the patient is trying to please you, give you the expected reply or fishing for the answer they want. Your question is dependent on your ideas and may be miles from the patient’s concerns.’

In the scenario described above, questions would have been useless. If the patient had known why she felt this way she could have remedied the situation herself. At that moment, what she longed for was to have her feelings understood. If the doctor makes a guess, based on other patients or what has been written in books, he or she is likely to be wide of the mark. The best response is to recognise the misery. ‘That must be awful for you.’ At least then the relationship with the patient has a chance of developing some warmth.

Another early lesson was the destructive effect of reassurance if it is given too early. Unless one can get near the core of the anxiety, reassurance is felt as denial. I remember once, when I was overcome by despair at my inability to help, I told a patient that she was not the only person to have these feelings, other people suffered in the same way. She leant forward and banged the table. ‘I am not other people, I’m ME.’

Learning to recognise that our own feelings and actions might be a response to the patient, a signpost to his or her difficulty, was the central idea that Tom brought to our work, which he believed was ‘applied psychoanalysis’. At the time I thought it was a ridiculous exaggeration of our skills, but with the passing of time I have come to believe he was talking about an approach so fundamentally different from many forms of counselling and behavioural therapy that he might have been justified.

During training for psychoanalysis and psychodynamic counselling, based on this idea of the relationship, the worker is required to undergo a varying amount of personal therapy with the aim of disentangling emotions produced by the patient/client from those arising from the psyche of the professional. Although some of us decided to have our own therapy this has never been a requirement in the IPM. Tom made a deliberate decision to ban discussion of the doctor’s personal feelings in the group. He had no wish to produce some lower species of therapist. His objective was to sensitise and improve our skills during our day-to-day work. (He was always ambivalent about special sessions where I believe important work can be done.) We were to remain, before everything else, doctors. Our personal feelings were not denied, just ignored. Any attempt at self-understanding was to be done outside the training seminar. With hindsight I see that this emphasis acted as a powerful stimulus to keep the consultation focused on the patient. For example, the doctor who admitted he had been angry with a woman in surgery might explain it to himself by saying he was in a bad temper because of an argument with his wife that morning. Tom would point out that he had not lost his temper with the preceding patients, so why this one? After some thought the doctor might say she reminded him of his wife. Instead of wanting to know in what way, Tom would wonder what it was in this patient that led her to ruffle people who were trying to help her.