188 The Inner Consultation

Statement: ‘I want you to come off your tranquillisers.’

Stone-wall response: ‘Oh I couldn’t do without them.’
In question form: ‘Do you think you’ll ever come off your tranquillisers?’
Possible replies: ‘Yes’, ‘no’, ‘maybe’, ‘not yet.’
Your responses: ‘Good, I’ll help.’ ‘Are you really that pessimistic?’
‘Let’s see if I can push you to a decision.’
‘Would you like to set yourself a dead-line?’
Statement: ‘It’s quite safe to bring a child to surgery with
an earache.’
Stone-wall response: ‘Well you would say that, wouldn’t you?’
In question form: ‘How do you decide whether it’s safe to bring your
child out when she’s not well?’
Possible replies: ‘Don’t know’, accurate knowledge, inaccurate
knowledge.
Your responses: ‘Let me tell you.’ ‘What were you not sure about
on this occasion?’ ‘That’s not quite right; let me explain.’

Reframing
It is not the things themselves which trouble us, but the opinions we have
about these things.
Epictetus
There is nothing either good or bad, but thinking makes it so.
Shakespeare
When we were thinking about eliciting, we saw how the meaning and significance
attached to a problem depends very much on its context. Sometimes we can help a
patient by altering the physical reality that causes suffering, by intervening at a
physiological or anatomical level. But such mechanistic solutions are all too rare;
more often than not we have to substitute or supplement concrete relief by
assisting the patient to take a different view of the situation. We may not always
be able to change the hard facts of experience, but we can put them in a better
light, call them something less paralysing, and nudge the patient’s imagination into
a different network of associations. The name given to this process, when used
therapeutically, is ‘reframing’.
The language is full of sayings and stories that reflect the universal nature of
this phenomenon:
ž the pessimist’s beer glass is half-empty, but the optimist’s is half-full
ž ‘beauty is in the eye of the beholder’
ž one’s prospects can be viewed with a ‘jaundiced eye’, or through ‘rose-tinted
spectacles’
ž if, as Shakespeare claimed, ‘that which we call a rose by any other name would
smell as sweet’, why is there a rose named ‘Peace’ but not one called ‘War’, or
‘negotiated settlement’?
The classic example of reframing in action is found in Mark Twain’s novel, Tom
Sawyer.4 One Saturday afternoon Tom, as punishment for fighting, has been set to
whitewash a fence.
 B5 Checkpoint 3 (handover): communication skills 189

Thirty yards of broad fence nine feet high! It seemed to him that life was
hollow, and existence but a burden. (Tom) sat down on a tree-box discouraged
. . . At this dark and hopeless moment an inspiration burst upon him. Nothing
less than a great, magnificent inspiration! He took up his brush and went
tranquilly to work. Ben Rogers hove in sight presently; the very boy of all
boys whose ridicule he had been dreading . . .

Ben said: ‘Hello, old chap; they got you to work, hey?’
‘Why, it’s you, Ben! I warn’t noticing.’
‘Say, I’m going in a swimming, I am. Don’t you wish you could? But of
course, you’d druther work, wouldn’t you? Course you would!’
Tom contemplated the boy a bit, and said:
‘What do you call work?’
‘Why, ain’t that work?’
Tom resumed his whitewashing, and answered carelessly:
‘Well, maybe it is, and maybe it ain’t. All I know is, it suits Tom Sawyer.’
‘Oh, come now, you don’t mean to let on that you like it?’
The brush continued to move.
‘Like it? Well, I don’t see why I oughtn’t to like it. Does a boy get a chance
to whitewash a fence every day?’
That put the thing in a new light. Ben stopped nibbling his apple. Tom
swept his brush daintily back and forth – stepped back to note the effect –
added a touch here and there – criticized the effect again, Ben watching every
move, and getting more and more interested, more and more absorbed.
Presently he said:
‘Say, Tom, let me whitewash a little.’

Tom yields up the brush ‘with reluctance in his face, but alacrity in his heart.’ Soon
boy after boy has bribed Tom into allowing him a turn with the brush. The fence
has three coats of whitewash. Mark Twain continues:
(Tom) had discovered a great law of human action, without knowing it,
namely, that, in order to make a man or a boy covet a thing, it is only neces-
sary to make the thing difficult to attain. If he had been a great and wise
philosopher, like the writer of this book, he would now have comprehended
that work consists of whatever a body is obliged to do, and that play consists
of whatever a body is not obliged to do.

General practice is full of people like Ben Rogers, and fences that have to be
whitewashed. Tom Sawyer was able to reframe his punishment as an enviable
privilege. One of the greatest kindnesses a doctor can do for a patient is reframe a
distressing or painful problem as something that can after all be coped with.
Suffering is inevitable – inherent in the human condition – and it is always
difficult to bear. If you call a difficulty a ‘problem’, you are committed to trying
to find a ‘solution’ for it. If a solution can be found, so well and good. But if
there is no solution, you are left with an ‘insoluble problem’, which may be
worse than what you had to start with. If on the other hand you reframe the
initial difficulty as an ‘opportunity’, it can become something to be gratefully
learned from.
This idea of ‘symptoms as opportunity’ is potentially one of the most far-
reaching shifts in medical perspective, consistent with the present widespread
interest in holistic approaches to health restoration and maintenance. It is not a
190 The Inner Consultation

doctrine of laissez faire, but rather an additional dimension to your therapeutic

options. Pain, while still being diagnosed and relieved, can in addition be seen as
the body’s way of alerting the patient to the need for corrective action. Angina
can be heeded as a timely warning that a stressful and unhealthy life-style needs
some reappraisal. Post-bereavement depression means that a widow has not yet
fully expressed the love and sadness in her heart.
The more you think about the power of reframing, the more chances there are
in practice to use it. So often the answer to a difficult question is, ‘ask a different
question.’
The behaviour of a twelve-year-old who steals from her parents might be seen
as ‘bad’ by her father and ‘mad’ by her mother. If you can offer them the alter-
native view of their daughter as ‘sad’, you might manage to enlist their parental
love rather than punishment or rejection.
A four-year-old starts ‘wilfully’ scratching the face of his new baby sister. If this
is seen as ‘attention-seeking’ behaviour, the natural response is to impose sanc-
tions, which usually make things worse. Call it ‘attention-needing’ instead, and the
solution becomes obvious.
Persistent truanting can be interpreted either as the child refusing to go to
school, or, often more profitably, as being afraid to be away from home.
Secondary impotence need not be the ‘last straw’ in an already flagging relation-
ship, but a hint of the cure, namely a period of enforced abstinence.
We spoke earlier in this chapter of the patient’s ‘Framework’ – the implicit
skeleton of assumptions, attitudes and beliefs that shapes the outward configura-
tion of a person’s responses to new information. It should be apparent now that
it is vitally important that the doctor ‘frames’ his management plan in terms
that are congruent with the patient’s belief system. A single suggestion – ‘Let the
nurse check your blood pressure next month’ – can be framed in a variety of
ways, according to what will best fit in with the patient’s framework. The straight-
forward instruction may suit a compliant patient. An apologetic patient will under-
stand you ‘delegating’ his case ‘because, as you know, my surgeries get so busy.’
A third might like the explanation, ‘since the nurse is trained to go into greater
detail about all the things you can do yourself to keep your blood pressure low.’
Another might prefer, ‘because, after all, you’re not ill and needing to see a doctor.’
Trying to reframe at least part of every patient’s presenting complaint is one of
the challenges I most enjoy about the consultation. If you are successful, the
patient leaves the room feeling buoyant with the novelty of an unexpected shift of
perspective. A considerable body of literature about this single concept has been
built up. Books by Bandler and Grinder,5 and by Watzlawick and his colleagues at
Palo Alto,6 will amply repay study.

Shepherding
I feel almost ashamed of the word I have chosen to describe a group of
‘influencing’ techniques, and yet no image so succinctly captures the ideas I have in
mind as that of a shepherd with his dog trying to get a flock of sheep into a pen.
If you can rid yourself of the invidious ‘patient ¼ sheep’ associations, you will
perhaps recognise the task of persuading some patients to see the merits of a
particular course of action as similar to that of a shepherd with a recalcitrant flock.