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RECOLLECTIONS: Listening with the Third Ear

RW edited text – 3 Jun 2019

SARAH: Dying With Dignity

Sarah was age 32. She an experienced wife and mother. I was a young inexperienced physician, the
intern in the ward to which Sarah was admitted.
The admission letter told me that Sarah was in hospital to have a blood transfusion, her fifth for
leukaemia, for which there was no cure.
I admitted her in the usual manner, asking all the questions I had been taught to ask, and performing the
usual thorough examination.
Her general condition was not good; she was pale, weak and painfully thin. There was, however,
something about her; an air of cheerfulness and optimism that surprised me, since it was clear that she
was dying. I assumed she had little awareness of her condition, and was staggered when she said to me,
“I am shortly going to die, doctor. “

No one had ever said that to me before. I was considerably taken aback. I had the idea that it was my job
to help her to deny this awful thing happening to her.

“I am sure that is a long way off yet”.

She responded that she knew full well death was close; only weeks away. She then told me about her
family. She had four young daughters and a loving husband, then went on to tell me of the difficulties
coping with young children when one is extremely ill.

I sat there unable to speak, and extremely sad. The feelings of patients about life and death were a closed
book to me and I was only able to see death as a distant and unlikely event for
me.

I listened, but as soon as I could, I left her. These were new feelings for me and I felt overwhelmed.
Sarah stayed only two days and I kept my distance.

Three weeks later she returned for a further transfusion and to my surprise I felt powerfully drawn to her.
I wanted to know her better, (perhaps to know death better?). This time I stayed with her for two hours.

Again, I experienced the profound sadness and admitted it to Sarah. Her eyes watered too and she too
admitted feeling sad. I think Sarah must have realised I was different, more approachable, because she
told me of her plans for dying and plans for the children, after she died I had never before heard anyone
say “when I die”.

A few weeks later she returned. This time she told me that this would be her last transfusion.
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Once again, I felt the by now familiar sadness. She had decided that now was an appropriate time to let
go, because she had done everything possible to ensure the security of her husband and children. She
said she also wanted to say goodbye to me. That was one of the most touching things I have ever heard.

I barely controlled my tears when I walked out of the ward for the last time with her. She shook my
hand, “Goodbye, and thank you”.

In retrospect I think I loved Sarah. She embodied much that I consider good in a human being. Her
courage, optimism in the face of disaster, her gentle acceptance of my obvious distress, were virtues
seldom met by this young physician. I have often wondered how much my later development as a
doctor, especially the development of a “Third Ear”, was due to this short encounter.
This wonderful woman gave me so much more than I did her, and though I never saw her again-she died
a few days later-I can remember her as if yesterday. This is my opportunity to express my thanks and
admiration.

In thinking about it afterwards, I remember wondering about my feelings, and how they seemed to get
the better of me. l am not sure if I had received a projective identification (explained on page 5) or
whether my reaction was based on a well of private sadness I carried.

I never thought, as a recent medical graduate, that patients would cry with me. Even less did I think that
patients would make me cry, that they would allow me to meet in their private domains and share their
sadnesses and suffering.

INTRODUCTION

My purpose in writing this book is to share with interested people some of the joys, the stresses, and
even the occasional pain of being a family doctor; one who was intrigued by the psychological
significance of my patients’ clinical histories and the life experiences that gave personal meaning to
those clinical histories.
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Medicine made huge leaps in the latter half of the 20th century. The discovery of antibiotics allowed
doctors for the first time mastery over infections; vaccinations almost rid the world of scourges such as
tuberculosis, Diphtheria, measles, poliomyelitis. The list is lengthy.

Improvements in public health improved the quality of water in many places. Drugs became available to
help most of the common serious diseases. The World Health Organisation performed studies of such
problems as cholesterol and hypertension (high blood pressure) and surgical procedures have made
simpler the management of conditions traditionally beyond the reach of medicine. Psychiatry has in that
time progressed to having a number of medications to treat that which was previously untreatable.
Depression, psychosis and bipolar disease can be much more effectively treated now.

However, none of these advances have contributed much to our understanding of the misery presented
daily in primary care medicine. In the middle of the 20th century doctors such as Michael Balint in
England, George Engels in the USA, and Knight Aldrich were talking of psychosomatic disease,
postulating that the mind had much to do with some illnesses. This was spoken of as “the mind- body
concept”.

My major teachers have been my patients, who have been generous in their acceptance of my efforts to
understand the nature of their dis-eases and to join me in attempting to help them in their healing
processes. I have been fortunate in having a number of mentors at all stages of my development.

Above all, I have come to believe that my prime task in the consultation is to listen carefully, ask
questions further to elucidate the mystery of the illness, and only when that avenue is exhausted, to
proceed to physical examination of my patient.

When I do this, it is imperative that I consider the culture of the patient to be sure not to invade their
privacy more than absolutely necessary and as far as possible reduce the discomfort, both physical and
emotional, of the experience.

I need to recognize that every person I see comes from a different culture than mine, even if he or she is
a born New Zealander, as I am. Thus, if I plan to perform an intrusive test, such as a rectal or pelvic
examination, I must ensure that my patient understands what I am about to do and is comfortable with
my intention. If my examination is going to be painful I need to explain that in advance.

A refugee from Somalia presented with a gynecological problem. A pelvic examination was indicated,
but it occurred to me that I knew little about Somali culture. Her English was limited, but nevertheless I
detected a certain reserve in her, such that I felt impelled to tell her friend who was present, of the need
for this intrusive examination. The friend gently explained to me that such an examination would be
unacceptable within their belief systems, so I referred this charming softly-spoken woman to a female
colleague.
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Most of us meeting a person of another race will immediately be aware of cultural differences but
foreign-born people are not the only patients with cultural sensitivities. Are we tuned in to the
dissimilarities within our own culture?

MRS J

Mrs J, a New Zealand-born woman also came with a gynecological problem. Again, pelvic examination
was necessary.
Something, I was not quite sure what, about her manner, made me ask if she had any reservations with
regard to my proposed examination.
Hesitantly, Mrs J told me that despite her age – 54 - she had never been asked to “submit” to this very
personal procedure.

The use of this word- submit- alerted me to her sensitivity to issues of interpersonal power. She let me
know that there was a strong sense of shame in her family about sexuality, including genital exposure,
based on certain religious beliefs, and that in fact had delayed her seeking this appointment.

Mrs J surprised me by asking me to describe in detail what exactly was involved in this procedure and
then, I thought rather courageously, consented to the examination, which was performed without any
noticeable upset to her.
She commented at the end of the consultation that she was glad she had questioned my intention,
because she felt she had full control of the event.

Each of us is unique. It behooves those of us involved in the necessary intrusion into the bodies and
minds of our patients to try always to respect a sense of integrity by seeking permission to cross ordinary
social boundaries. Obvious uncertainty may then be a guide to caution and further inquiry into the
origins and psychological significance of that uncertainty.

The follow-up to the history taking and examination is, wherever possible, to formulate a diagnosis that
is understandable to the patient and their family. This naturally proceeds to clearly explaining the
suggested treatment.

Patients usually pose an unstated question which goes something like this:
“Dr, I notice something wrong with my body (or feelings). Listen to me, help me to understand, and tell
me what I can do to help myself get back to where I was before this happened”.

I assume this with almost every patient and remind myself frequently to avoid losing that sense of
mutual undertaking.
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Michael Balint, a psychoanalyst, wanted to teach general practitioners in London, how to practice
psychotherapy. These doctors however, had little interest in psychotherapy. Rather they wanted better to
understand the nature of medical consultations and the mind -body connections. Why do patients
produce symptoms in the absence of signs of illness? How does the mind affect body functions? What
purposes do these phenomena serve?

In response to the doctors’ expressed interest, Dr. Balint established groups of doctors who met
regularly, over lunch. Here in Christchurch, we established two such groups, which have now been
meeting for more than 25 years.

In the meeting, one of the group presents a consultation with a patient.

Mostly the presentation has to do with a particular problem the doctor had experienced with the patient.
The other doctors listen, allow their minds to roam, ask questions, often personal, of the presenting
member and offer possible alternative understandings of the process and the consultation.

In time the doctors come to understand better why the patient has attended – often to the doctor’s great
surprise. I was fortunate to have belonged to such a group and it was not long before I became aware that
patients were showing me that there are different ways of listening, of tuning in; not only to what they
are saying, but also to what they’re not saying, but perhaps alluding to, by accompanying emotion or
apparently unrelated material- derived from life experiences- that needed to be better understood.

Early in the life of the Balint group, the meetings concentrated on the presentation of the patient’s
history by the doctor whose turn it was to present a case. In the early stages of the existence of the group,
concentration was predominantly on purely “medical information”, but as the group became more
experienced and wiser about the psychological significance of patients’ presenting clinical histories,
focus shifted to the relationship between doctor and patient.

Further maturation of the group resulted in deeper examinations of the doctor’s feelings and thoughts
and the group members became increasingly empathic towards each other.

Dr P, a middle-aged, experienced physician, told us in opening a case discussion that he was rather
puzzled that he had considerable difficulty treating middle-aged women with migraine headaches. He
said that he had felt anxious during these consultations and was aware of a wish to close as soon as
possible to “get her out of the room.”
This was so unlike this clever, insightful doctor, that the group also became highly puzzled. All sorts of
questions were asked in a vain endeavour to understand.

Suddenly Dr P. exclaimed; “now I know! I remember seeing my mother lying on the bed screaming with
pain in the head from a migraine, begging my father, a family doctor, to cut her head off”. He smiled
wanly: “I’m glad he didn’t; she was a great mother’.
Having dredged up from his unconscious mind the origin of this uncomfortable experience, Dr. P felt
much more relaxed in the future with middle-aged women with migraine headache.
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Patients often need to be validated for one reason or another during consultations.

Mr. R, an intelligent and talkative elderly Englishman, who liked to let me know that he had had a
Jungian analysis and also enjoyed talking on many subjects, had fallen on his outstretched hand,
bruising his thumb.
I examined him and was convinced there was no fracture and that it would heal rapidly. I told him so. He
seemed happy with that conclusion and after our pleasant chat solving the problems of the universe, he
rose to leave. As he was walking out, I made the usual type of comment on closure; “don’t hesitate to
return if it troubles you. Perhaps we could think of physiotherapy“.

He laughed and said, “oh doctor, it’s not what you do when I come to see you, it is what you have to
say”.

Some years ago my close friend and colleague Dr. Ron Wintrob was visiting us from the USA. As
doctors are wont to do, we were talking shop yet again. This time, though, he surprised me by saying;
“Brian, these tales you tell me of your experiences with patients are remarkable. I just never see people
in my psychiatric practice the way you do, and I’m fascinated. I have an idea. Why don’t you collect
these experiences and write them up for an audience of the public as well as for doctors?”

I agreed, and thenceforth, after a particularly meaningful experience with a patient, I dictated the
summary for my secretary to type. By the time I retired, I had a lot of material and this book is intended
to present my patients and our mutual experiences.

I have altered the names of my patients and changed place names and other material which may make
the persons I write about identifiable. I hope that I write with sufficient respect and admiration, for them,
and for our mutual undertakings, that patients would not be upset if they recognised themselves in some
of the case presentations described in this book.

This book is about the feelings and the language we human beings use to explain our life experiences, in
the service of attempting to gain relief from both physical and emotional distress.

It is part of the richness of the English language that literal expressions are often inadequate in
conveying that which needs to be understood, and we are able to use figures of speech, such as similes or
metaphors, to expand understanding.
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This is particularly true in respect of medical consultations. How does one describe the cramping feeling
of a bowel obstruction? “it feels like something is twisting my gut”, or another cramping feeling – that
of angina pectoris - when the heart is temporary starved of blood; “it feels like a band around my chest”.

Most people are aware of the existence of the unconscious mind; a part of the mind that operates beyond
our level of awareness, coordinating and maintaining our multiple and complex body functions and their
integration with our emotions.
We are also aware of that part of the person that dreams, thinks and reasons, that feels shame and guilt -
that even punishes us - all well away from our conscious understanding and awareness.

It is only in recent times that we have become cognisant of the huge network of connections between
every functioning unit of our bodies, constantly informing and moderating all systems. Some call it
‘Body- Mind’, implying that these connections are not hierarchical, that is, the mind is not like a CEO,
controlling all other parts. Rather the mind works quietly with all other systems- and outside our
conscious awareness, to produce a level of harmony that we call ‘good health’ or, a sense of well-being.

There are many mechanisms for maintaining homeostasis; that is, making the necessary moment- by-
moment adjustments to body systems, in order to maintain good health. Any relative failure of these
homeostatic mechanisms tends to result in symptoms- the ‘dis-ease’ of the person.

On such occasions; for example an itch without a rash, a headache without brain disease or a pelvic pain
without pelvic disease, it is incumbent upon the doctor to ‘hear’ that which is unsaid and ‘see’ that which
is unseen.

That is why I postulate the existence of a ‘Third Ear’, a hypothetical organ which picks up on the often
unconscious nuances behind the patient’s utterances, as well as the exhibition of ‘body language’ such as
sadness, tension and incipient tearfulness.

Thus, we have Donna who learned that her “pain in my face” is a manifestation of grief for her mother,
as she recognises she must ‘face up to’ her grief and “that is a pain”.
The Third Ear picks up messages unconsciously; ‘broadcast’, by the patient, in such a manner that the
listener becomes aware of feeling an emotion - commonly sadness - but other emotions can be involved,
which do not belong to the doctor at that moment.

This is an unconscious communication between doctor and patient which becomes manifest if it grows
sufficiently to force its acknowledgement.
Thus, I pick up on Sarah’s sadness by feeling it in myself and with Robert whose feelings, entirely
unacknowledged, that I felt compelled to address them despite the risk of Robert rejecting my effort and
even me.

The doctor, if aware of the Third Ear interprets this emotion as coming from the patient and reveals it by
such comments as; “I wonder why I’m feeling so sad at this moment”? This generally precipitates a
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realisation in the patient of the presence of this emotion within him/her self and allows, indeed gives
permission, to openly express it.

In psychoanalytic language, this is known as ‘Projective Identification’, and when it is appropriately

processed with the patient can have a profoundly beneficial effect.
I shall endeavour to illustrate the ways in which patients have aroused the awareness of my Third Ear,
and how I use that information to further elucidate the symbolic meaning and psychological significance
of their symptomatology.

My book tells stories of medical consultations in the context of everyday family medical practice. By no
means are doctors uninvolved and objective observers. They are deeply involved in every moment of the
contact.

Not only involved, either, but also emotionally caught up, in ways that we often do not know about
ourselves. I will tell of emotional impacts upon me in these transactions and what effect I think they
have had upon the outcome of treatment.

As we seek to understand disorders and the systems, what we call illness or disease, we need to try to
hear the quiet emanations from those silent parts and translate the signals into understandable
communications.

There are ways the patient can inform us through slips of the tongue (see Aroha, who says ‘mongrel’
when consciously she means ‘uncle’ ) and similes like a ‘vise around my head ‘ and metaphors “I will
fight this disease”. These expressions help the patient to “grapple” with the disease and often will help
the doctor better to understand the patient’s story.

MRS S

Let me describe my first lesson on the existence of the unconscious. I was a young family doctor, in my
first year of practice. I arrived at my office on Monday morning to meet my first patient of the day. She
was a middle-aged, attractive and well-dressed widow. I had been involved in the care of her husband
during his final illness.

“I am here because I have had a very sore neck since the weekend”. She grimaced with pain. I asked the
proper medical questions but the diagnostic issue was no nearer a solution. Physical examination simply
confirmed a tender sore neck. Inquiry into possible trauma yielded no information of value. I asked what
she had been doing on the weekend, thinking of some activity being responsible for her” sore neck”.
Nothing.
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Then; “I went out socially for the first time since John died. There was a man there I have known for
years. He made his intentions perfectly clear. It was quite unpleasant. He stuck in my neck!”

This statement felt like it hit me. I was silent for a moment, then asked her to repeat what she just said.
She did, then smiled, and asked; “did I just find my own answer doctor?”
“I am not sure” I replied. “What do you think”?

Mrs S decided that she had what she came for – to understand, and now to let nature take its course. She
declined any further treatment.
Later she told me the pain had gone by the next day.

Further, she was pleased we had worked together on the solution and thanked me. I pointed out to her
that she did all the work in this consultation.

I learned from this experience that all is not necessarily as it seems. Mrs S knew at an unconscious level
the cause of the problem and with a little help rapidly made her own diagnosis, leaving me surprised and
a little wiser.

It is experiences like this which help to form a close bond with patients, such that they feel understood
and are ready in the future to be more open to questions that cross social boundaries.

MRS. A

Mrs. A was 76. She had lost her husband to cancer five years previously.
Three months before this consultation she mentioned that she lived with a man some years her junior,
that they were enjoying their companionship and outings.
Four years previously she had had successful treatment for breast cancer.

On this day she had a minor problem we dealt with quickly. Then she reminded me, in quite a coquettish
manner, that she had told me previously of her “boyfriend”. I picked up the hint and asked how it was
going?
She sparkled as she told me she had taken a new lease of life. There was a seductive note to this, so I
enquired if she had become sexually active. Her reply astonished
me. “Yes, Dr. we are and it is great! “She leaned forward and said “ we are, but we are not using
condoms. We trust to luck!”
Such are the minor joys of family practice.
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Children

One day my wife gave our much-loved eight year-old grandson a discarded T-shirt. Next day his mother
told me that he wore the T-shirt all day and had slept with it on his pillow. He said that his
grandmother’s scent made him feel good.

This reminded me of Edward, the second of three boys in a family I have known for over 25 years.

I cared for Edward’s mother, Amanda, throughout her pregnancy, and as commonly happens, a strong
relationship was established with the family.

Rather than my staff ushering patients to my office, I prefer to attend the waiting room myself, in the
knowledge that useful information is gained by observation of the behaviour of patients whilst waiting;
that is, with whom and how they sit, and how we behave towards each other as we walk down the
corridor to my office.

EDWARD

Edward and his mother were sitting some distance from each other in the waiting room, and his greeting
to me was lacking in his usual boyish warmth.

Edward was just ten when Amanda brought him to see me. She was concerned that for some months he
had been irritable, tearful, tired, and had difficulty sleeping. His school performance had deteriorated
from above average to poor.

Edward seemed to be depressed.

Amanda, Edwards mother, is a thoughtful and empathic woman. She realised something important was
happening to her son, but inquiry of him led to tearful, angry, rejection of her approaches. John, his
father, fared no better as he expressed concern for Edward.

In my office I was struck by Edward’s changed demeanour. I knew him as a delightful, open and direct
boy. My knowledge of this family is that Amanda and John are deeply committed to each other, and the
boys, and covert activities such as sexual or other abuse were highly unlikely.
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I reasoned though, that if the parents were unable to find out the cause of Edward’s deep unhappiness,
then in some way they must be involved, such that he needed to avoid openness about the situation –
perhaps to protect John and Amanda?

Usually, I prefer to talk with children with the parents present, but when initial inquiries of Edward were
fruitless, I suggested to Amanda and Edward that she leave the room.

I told Edward that I was impressed with how unhappy he looked and that maybe he could share the
problem with me in the understanding that I would not reveal his confidences to his mother without his
permission and only in his presence.

He smiled at this stage, the first positive emotions so far shown, then tearfully, he said;
“She threw it out”.
“Threw what out?”
“My box. My powder box”.
“Your powder box”?
“Well, grandma’s powder box”.
I knew Edwards grandmother, a kindly old woman who died suddenly some months previously.
“Your grandmother that died?”
“Yes that one.”
The whole family attended Amanda’s mother’s funeral. They all grieved her; she had been a good
mother and grandmother.

Edward confided that after the funeral he felt lonely for his grandmother, and had difficulty sleeping the
few days after her death. He wondered where she was, how she was, and could not quite believe that he
would never see her again.

The time came for the family to clear grandma’s house and Edward found a small round powder box of
his grandmother’s. It smelled just like her - and was small enough that he was able to spirit it away,
keeping it as a secret and special connection with grandma.
When he felt miserable in his grief he would take out this box, sniff it and feel better.

Inevitably Amanda found the box in Edwards bedroom and unthinkingly, threw it in the garbage. Soon
afterward, Edward sought the solace from his grandmother’s perfume and it was gone. He felt
devastated, realised what must have happened, but felt unable to approach his mother because he felt
guilty about keeping this memento as a secret.

He also felt angry towards his mother, at the same time knowing that she could not realistically be
blamed, since she had no idea of the significance of the power box to Edward. Thus, not only did
Edward feel a huge loss; but also trapped into silence.
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The relief from liberating the secret was obvious. Initially, as he talked he looked sad and cried, but quite
quickly in this half-hour consultation, he brightened up and began to talk of happy experiences with his
grandmother. I commented to Edward that he seemed relieved and added that it was clear his parents
were deeply concerned about him. I wondered aloud if it might be a relief to them to know all about this,
and what Edward thought about telling his mother.

“She might be mad with me”

“Why?”
“Cos’ I took grandma’s special box.”
“Well she might be pleased you got something special of grandma’s”

“But I didn’t tell her about it.”

“You don’t have to tell your mother everything”
“But I got mad with her”
“Yes, you would. You can get mad with people you love. But isn’t it better for her to know? Then she
can forgive you and make amends”

A little reluctantly Edward agreed to tell Amanda and I asked her to return from the waiting room.
Somewhat haltingly, he told his mother what had happened. Amanda was shocked, burst into tears and
apologized to Edward as she hugged him.

Edward’s depression vanished!

This family does not deal in the currency of punishment and reward. Edward was caught up in a
confusing situation where his feelings of grief, and later depression, over- rode
his awareness of his parents’ acceptance and love. He was trapped by his guilt, of having a secret, and
for being angry with his mother. He was also aware of a pressure inside to unburden and presented with
this opportunity, was able to show the characteristic resilience of children in rapidly healing himself.

This encounter illustrates one of the differences between depression and grief. Before the powder box
was thrown out, Edward was aware of a sense of loss of his grandmother and his ability – symbolically,
through her perfume - to relieve this pain.
This is typical of grief, to be aware of the loss and to experience the concomitant sadness.

However when the box was discarded, he sensed a loss of self, an emptiness which seemed
irrecoverable. This is typical of depression, a combination of helplessness and hopelessness, mixed with
anger and sadness.

I remember being told as a medical student that children lack the capacity to grieve. This certainly fitted
my personal experience, but successive encounters with children who suffered loss and had been able
adequately to grieve, demolished this belief. Rather it seems previous generations have denied children
the opportunity to grieve, by various social manoeuvres such as non-attendance at funerals, refusal to
talk of the losses of loved ones
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and denial of adult grief. It adds to evolutionary faith to observe the behaviour of parents today who
generally do involve the children in the whole process of dying, death and grief.

To Amanda’s credit she realized in an unarticulated way that the apparent lack of cause for Edward’s
depression did not mean that there was no cause; only that it was not obvious and though she did not
verbalize it, she understood intuitively that Edward needed a more disinterested person to expose the
cause.

There is a lesson also in this for those of us who endeavour to help others. People who are emotionally
upset always have good reasons for their feelings. These reasons may not be obvious or even seem valid
to the observer, yet we must consider them in the context of the personal culture of the individual and
attempt to put aside our prejudices about what is “right” in the service of understanding.

I remember feeling a deep sense of satisfaction with this whole scenario. Being allowed to take part in
this kind of healing is a real privilege.

Edward is now a healthy competent young adult who speaks with pleasure of the fond memories he has
of his grandmother.

In family practice, as contrasted with the specialties such as psychotherapy and psychiatry, patients
mostly have not been referred. Rather, they arrive without a professional diagnosis. Thus we are
frequently offered the raw material of symptoms and it is our challenge to synthesise through inquiry,
examination, investigation, and the ever important empathy, a diagnosis which satisfactorily explains the
discomfort presented. This inquiry is based on many factors including history, coloured by the patient’s
past experience and culture and equally coloured by the doctor’s past experience, culture, and medical
beliefs.

Any interview examined in retrospect demonstrates what one writer refers to as “nodal points”. At these
points, the direction of inquiry may follow several possible pathways. The arrival of these crossroads
may be signalled in obvious or in subtle ways. as demonstrated by Bill’s case.

BILLY

Billy was a cheerful 10-year-old with sparkling eyes and quick intelligence. He lived with his brother
Shane, two years his junior, and his father, Robert, in whose custody he had been for three years,
following a particularly unpleasant marital separation and court case for custody.

Three days before this encounter, Billy was taken in the evening to the After Hours Medical Service
with a severe attack of urticaria. This was appropriately diagnosed and he was given an anti-histamine
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medication which had been of some help. However, the itchy, blotchy, reddened rash which can appear
in moments due to some unknown provocation, had persisted for three days.

The cause of urticaria is often stated to be acute allergy, but I have my doubts. It seems more likely to
me that urticaria is a fine example of the body – mind playing tricks. It represents a communication from
the body-mind that something is wrong emotionally, that the sufferer needs to attend to. It implies
something “has got under the skin” This is the itch which in urticaria can be quite intense. The redness
consequent upon scratching is a further reminder of the problem.

I asked Billy what he had been doing on this particular day, and he told me he had been playing in the
park with his brother, but denied any contact with possible allergens such as trees or meadow grass
which remotely could have provoked the urticaria. I asked him what he had been doing in the evening at
the time the urticaria first appeared and he replied, somewhat dismissively, that he had just been
watching a video.

However, something in his manner made me ask him to supply more information about the video. My
Third Ear leaped into action, detecting Billy lowering his head, looking pensive and pausing
thoughtfully.

I mentioned my sudden feeling of sadness, and then, slowly, he told me that it was a horror movie, the
underlying theme of which had to do with a mother being unkind to her children. He burst into tears and
with encouragement talked of a sense he had that his mother didn’t like him, and had rejected him. The
feelings intensified in the session, such that Billy’s father Robert, also cried and I felt intensely sad, as
Billy described visiting his mother in another town in the school holidays; following her promise that
she would spend equal time with him and his brother.

He noticed on arrival at his mother’s home that photographs of his brother were all over the house, but
there was only one small snapshot of him - attached behind the door in the bathroom.

This seemed to epitomize the experience of this holiday, as he found himself increasingly left alone
while his mother devoted time to his brother. At this point his father interposed that every time the
mother made contact with the boys, they would be upset for about two weeks and this would show in
attacks of crying, sadness and anger.
It seems that at no time has contact with the mother provide a sense of nurturance.

As Billy talked, he suddenly remarked that he was feeling quite itchy and to our surprise the urticaria
appeared in parts it had not before.

This boy had been booked for an ordinary quarter of an hour appointment, but it was not possible to stop
at the expiry of that time because Billy seemed compelled to talk at length about his sense of hurt and
disappointment evoked by his mother’s rejection.
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When I suggested to Billy that this experience had “got under his skin”, his smile through his tears
showed that he understood exactly what I meant and accepted the interpretation. I invited him to return
the next week, which was accepted by Billy and Robert.

We met for two further sessions. On those occasions Billy’s brother Shane also attended. He too
acknowledged that he seemed to be the favourite of his mother; but that he also felt sad about the
separation of his parents and added that his mother’s repeated criticism of his father left him feeling
confused and unhappy. I was struck with the empathy demonstrated by Robert and Shane to Billy. At the
end of the second session Billy’s urticaria had cleared and he seemed much happier.

In the year since we last met to discuss these issues Billy remained in good health and his father reported
that he had progressed well in school and social activities.

Often the major information about the course of distress lies within the patient and my task is to uncover
that information by appropriate inquiry. Of course different pathways may have been taken, yet the same
destination reached. I believe that the cause of Billy’s urticaria lay in his relationship with his mother
and while the key to the uncovering of information lay in the questions directed at what exactly Billy
was doing prior to the appearance of the rash, it is equally possible that he may have shown the
disturbance in his feelings at other nodal points in the initial interview.

It may be argued that urticaria has a tendency to disappear spontaneously and with that I cannot
disagree. However the intensity of the feelings experienced by Robert, Billy and me were such that it is
undeniable the experience of hurt and rejection of Billy was extremely painful for him.

I note here, as I have many times, the development of an emotion which is not in tune with my general
feelings on that day. If Billy had not cried, I would have told him that I felt so sad that I could feel tears
in my eyes. It would be highly likely that Billy would’ve cried at that moment. My experience tells me
to believe in that feeling and to use it on behalf of my patient.

Even if the relationship between urticaria and psychological factors were purely coincidental, it seems to
me that Billy’s willingness to talk about that in an empathic atmosphere, had a powerful healing effect.
Children, just like adults, have many ways of expressing misery, not all of them direct. This is especially
so in situations where the special empathy required to hear and accept the feelings is not perceived by
the child to be available.
I have noticed that when I make an interpretation like in this story, “something got under your skin”, the
response in the symptom is quite rapid, as if it is not needed any more, and the shift to emphasis on the
psychological factors is logical and easy.

Many stories from family practice have uncertain endings. I cannot be sure Billy’s symptoms were from
the loss of his mother, but I’m sure he changed from a miserable boy to an ordinary boy - and with that I
have to be satisfied.
 Page 16

CHRISTOPHER

This 10 y.o. boy came with his father, Tom, a single parent.
The problem was a bright red rash on each side of his face over the cheekbones, extending down to the
corners of his mouth. He was carrying a wet cloth which he kept dabbing onto this bright red area. I
assumed that he was using the cloth because his face was painful and hot. However, something about his
demeanour caught my attention. His father spoke about the origin of the rash a week previously.

I observed that Christopher’s dabbing was rhythmical, three times on one side then three times on the
other side of his face. I asked what had been happening in the past little while, and Tom told me that
before the rash came on, Christopher had developed a habit of placing three fingers in his mouth, wetting
them and then dabbing each cheek with the saliva in a similar ritualistic fashion to the way he was with
the wet cloth. Apart from this, said father, nothing unusual been happening.

I turned to Christopher and asked him what he thought about the rash. To my astonishment, he
responded; “I’ll be alright if he doesn’t marry her.”

Christopher‘s father had in the past three months developed a liaison with a divorced woman, who
herself had four children, all somewhat older than Christopher. One is a 17 year-old schoolboy whom
Christopher told me had a computer; which he, Christopher, was allowed to play with. As he told me this
his face lit up, and I asked; “it seems you don’t mind going around to their place?” He responded that he
really liked this.

I asked him what was the problem about Jane, the father‘s new friend, and again he surprised me by
saying; “going to her place is great and she treats me really well, but if dad marries her there will be
nowhere for me to go”.

He looked sad and lonely as he said this and certainly his father‘s eyes lit up with understanding and he
told me that when Christopher was four his mother had said to him in front of Christopher that she was
sick of the responsibility of caring for his son and wanted to get married again and get rid of
Christopher. The father’s response to this was to take Christopher with him to live, and evidently
Christopher was terrified that the same rejection would happen again with the father’s new partner, Jane.

Further inquiry revealed that though father cared for Christopher in the physical sense, he was somewhat
uninvolved in Christopher’s daily activities. I suggested that they may become more involved. Tom told
me that he had tried to talk to Christopher, suspecting something was wrong emotionally, but
Christopher was uncommunicative. They both reacted favourably to the idea that a 10-year-old might
speak about the problems better when the two of them were doing a mutual project, rather than being sat
down and talked to and questioned.
 Page 17

I arranged for them to return a week later for a half-hour session and when they did so, it was obvious
both were much happier. Christopher had given up his rituals and the rash had disappeared. His father
told me that when they were playing ball together, Christopher had said that he had done some drawings
for his father to see and they were about his fears of separation. I expressed interest in seeing the
drawings at our next session, but they cancelled the appointment and I heard nothing more until six
months later, when by chance I met Tom at a shop. He told me that Christopher has not resumed the
rituals and that he and Jane were soon to be married. Christopher was to be Best Man and was very
excited about the prospect.

It is a matter of pure speculation to try to understand the meaning of the ritual that Christopher
performed. That it arose from separation anxiety seems abundantly clear. Perhaps more time spent with
Christopher would help to unearth the fascinating symbolism, but I think Christopher was not very
interested in that prospect.
Equally it would be of interest to know why the next appointment was cancelled, but explanation would
do little more than satisfy my curiosity.

The ritual certainly served its purpose as an indirect communication about his distress. Christopher and
his father achieved the intent of the consultation; to cure the rash, and it may be seen as a bonus that
father and son achieved improved understanding of each other. We did not discover the meaning of
Christophes ritual, but by then, that was purely academic.

MONICA

Barbara approached me about the fact that her daughter Monica had been refusing to go to school in the
morning for the past few weeks and this had resulted in anger and much distress; though Barbara forced
the issue and delivered Monica to school each day. Barbara thought that Monica would probably talk to
me on her own. When they arrived, with baby sister Jane, Barbara said that she would like them to leave
the room and let Monica and me talk.

Monica settled back quite comfortably in her chair. She was a very pretty and charming little girl and
quite outgoing.

I asked her; “what is the problem?’

She responded, “I don’t want to go to school in the morning.” I asked; “can you tell me why?”. She
replied; “I don’t want to go to school in the morning because Mummy has a new boyfriend and she is
going out a lot and I never seem to see her and I want to see her instead of going to school.”
 Page 18

I asked her how she felt about school and she responded that she liked school, but that in order to see
Mummy she was not able to go. She felt unable to tell her mother that this was the issue, because she
was scared Mummy would just tell her to put up with it and then she would feel unloved- quite a telling
insight from a young girl!

She then continued, surprisingly, by offering that she was concerned that her mother had this new
relationship with Peter, because she thinks that Mummy was hurt a lot by the break-up of the marriage
three years ago and that she might be going too fast in the relationship with Peter and she might get hurt
again.

Further, she went on to tell me that she felt quite jealous of Peter when he kisses her mother, that she
doesn’t like Pete being so close to mummy even though she actually does like him.
I asked Monica if it would be sufficient for her to have her mother on her own for a reasonable period of
time, say half an hour twice a week and she replied that that would be fine.
I wondered whether Monica would be prepared to give up anything for this and she responded that she
would be willing to miss her favourite TV programme! We had agreed that our conversation would be
confidential, so I asked her was she willing to tell her mother what she had told me.

Barbara and Jane came back into the room and Monica told her straight out exactly what the problem
was. Barbara, being a very empathetic mother simply listened, nodded, said she was pleased to know
what it was all about, and agreed without hesitation that she and Monica would get together for half an
hour twice a week, the other children being excluded, this being a “choosing time“ for Monica, that is,
Monica could choose how they used the special time. They agreed that they would use half an hour, no
more and no less and that as far as possible the other children would be excluded. If necessary Barbara
would set up the same situation with the two other little girls.

I cannot recall a seven-year-old talking to me before in such a direct matter about what is to her a major
problem and I’m left with a considerable admiration for both mother and child.

I think it is important in recommending a new behaviour such as ‘choosing time,’ to try to wrap the
suggestion up in such a manner that there are advantages and sacrifices in it for all parties. Thus both
Monica and Barbara each needed to make a small sacrifice, Barbara in terms of her time and Monica
being prepared to miss her favourite TV programme. The advantage to both of them was obvious in
having more quality time together.
I am usually quite specific with the parent in this situation. I carefully explain that the choice of how to
use the choosing time is entirely up to the child, explaining that asking detailed questions of a child is
likely to lead to defensiveness, and resentment, whereas just relaxing and enjoying the time together is
likely to lead to more information about the problem being offered by the child.

The solution worked well and Monica returned to school immediately.

Barbara later told me that Monica needed a lot of reassurance that Mummy’s relationship with her new
man would not lead to rejection for Monica. She has since married him and Monica has settled into the
new arrangement without apparent problems.
 Page 19

ELIZABETH

Elizabeth was nine, a beautiful but shy, retiring, little girl who had a flashing smile. I heard that the
previous day she had been to the after hours medical service following a fall over her father‘s legs,
resulting in her sustaining a cut to her head.
I knew from experience a couple of months previously, that her older brother, Joshua, had been quite
violently abused by John, his stepfather, and I saw John at this time. I understood from him that he and
his wife were in counselling concerning their relationship, and his violent impulses, and I felt angry that
another traumatic injury to one of their children seemed to have happened again.

I asked my nurse, when I heard about Elizabeth, to make sure that Elizabeth was brought in the next day
by her mother.

To my surprise, her father John, and she, turned up early next morning accompanied by her brother
Joshua. I had only 10 minutes free and decided to approach the subject quite directly. I asked Elizabeth
what happened and she became giggly and did not respond. The father then told me that she had been
playing the fool, had tripped over his legs and banged her head on the sideboard and cut it open. I invited
Elizabeth to talk to me on her own but she refused, so I sent Elizabeth and Joshua out of the room and
said directly to the father; “John we have talked about this before and I need to be direct with you. Did
you have anything to do with Elizabeth’s injury?”

“I know why are you asking me that, but I didn’t. I have not raised a hand to the children since I saw you
last – I could’ve done though, because Elizabeth was being naughty at that time. The counselling has
been immensely helpful to me and I’m learning now not to either run away or to attack. I just sit and
listen.

John had an extremely violent childhood and learned that problems are solved by violence if you happen
to be bigger. He told me that he still gets angry and violent feelings, but feels more able to contain them
and then added; “well, I do worry about Joshua. Since I stopped hitting him he has started to be
extremely angry and says awful words to me and it’s as much as I can do not to hit him, because I was
brought up in such a way that when you behave like this you got hit and then you did not do it any
more”.

At this moment I became aware of a feeling of frustration, which I acknowledged to John. He responded
that yes, he did feel frustrated because he knew intellectually that violence was not an answer to
anything, “ But I have had training in violence and I keep wanting to go back to it, even though I know
it’s wrong”.
 Page 20

I said to John that Joshua‘s anger and swearing was a great tribute to the way in which he was working
genuinely at trying to deal with his anger. His mouth fell open! I think he fully expected me to criticise
him for his violent feelings. “I think he is testing you John, to find out if you really have quit hitting him.

He asked me to repeat what I said and then said that he had never thought of it that way and he could
see what I was getting at, and thanked me. He asked me what he should do in this situation with Joshua
and I responded that perhaps Joshua was trying to make contact with him and that it would be helpful for
Joshua and for him if he was to make the unarguable interpretation to the son that he was angry. That is,
“Joshua you seem to be very angry” and then to enquire “can you tell me what it is that you are so mad
with me about?“

What surprised me so much about all this is that it was totally new to John, absolutely outside any
previous experience of his and he was most gratified to hear there might be another way to deal with this
problem.

Some months later I consulted again with John. He spontaneously offered that he had taken seriously my
advice and found that it was much easier to control his anger by attempting to make verbal contact with
his children. He told me that he now made a habit of asking questions when there was anger detected
and on no occasion did that turn into a quarrel. The end result was a much happier home life for all the
family.

To me this was a most gratifying encounter. To feel that I have had a hand in the creation of happier
relationships within a family is hugely satisfying. It is not a way to get rich because these therapeutic
interviews take much more of my time than simple medical cases, but money could not buy the
satisfaction of these experiences.

MRS. B

Mrs. B presented complaining of weakness, spontaneous bleeding and pallor.

A blood test revealed acute leukaemia and she was referred to a haematologist for treatment. After the
haematologist confirmed the diagnosis, he told her that a cure was not likely. Mrs B decided against
having any treatment.
I was asked to visit her at home because she was very upset. We discussed her options; including the
possible deleterious side-effects from treatment. After this discussion she changed her mind and
proceeded to have chemotherapy. This was followed by a period of good health.

About a year later the leukaemia recurred. A short and ineffective course of chemotherapy was given,
and Mrs B was informed by her haematologist that nothing other than palliative care could be done.
 Page 21

At the request of her husband, I visited her again at home that evening. Mrs B was totally demoralised:
she had been told her life expectancy was about six weeks, due to the fact that her bone marrow had
failed and she was no longer producing red blood cells.

Several visits over the next few days revealed that Mrs D had “given up“. She sat in the chair all day,
crying, refusing to do anything, just waiting for death.

Mrs B was an intelligent, insightful middle-aged person, who brought up a family as well as working in
a responsible position. I felt that her behaviour was inconsistent with the way she had lived her life; that
there must be some other factors troubling her, so I invited her to come to my office for a one-hour
appointment, further to discuss the situation.

Mrs D gratefully accepted my offer – a sure sign that she knew something was getting in the way of her
acceptance of her mortality. The session opened with my invitation to talk about what it meant to her to
be told she was going to die. I chose this opening because I had no doubt about her ability to talk about
the facts of the situation she was confronted with, even though it was intensely sad and distressing to
her.

She associated immediately to her experience as a child having her sister die from kidney failure. She
wept copiously as she talked of her sister’s last few weeks, of her nose and mouth bleeding and her
striking marble – like appearance as well as her gradual physical deterioration over many weeks.

She went on to talk about her parents’ helplessness, and then expressed anger towards her sister as the
cause of her relative neglect; as the parents struggled with the sadness of her sister’s impending death.
She had not previously felt that anger and commented that maybe that was the reason that she never
actually grieved her sister. The unconscious anger signalled danger, which warned her off feeling the
loss of her loved sister.

She thought she would experience the same awful physical decline as her sister and expected her
supportive husband and family to be equally as helpless as her parents were. At this point, Mrs B
commented that she had no one to talk to during her sister’s illness and how that might have helped her.

I pointed out that her situation was quite different from her sister’s; that she would not need to suffer
pain and that her death would quite likely be peaceful. Furthermore, she had the advantage of having her
family and me to talk to. At this she smiled and said that she thought she would talk to her husband and
children, about her sister and her current thoughts about dying. She informed me that she had never
mentioned her sister to her family

Mrs B lived the next four weeks fully, and quite suddenly experienced increasing weakness and pain.
The end was near. Painkillers solved the pain problem and she did not have any recurrence of the deeply
depressed feelings. She did as she had planned; to tell her family all about her sister. As may be
 Page 22

expected, the family was highly empathic. They assured her that no one would abandon her and that she
was free to talk about anything she wanted.

Just before she died she told me that before our long interview she had felt like she was in a canoe -white
water paddling, in rapids, being thrown everywhere but after the interview, she found calm water and
accepted her near-death situation.
Mrs B died a few days later, with great dignity, in the presence of her family.

This experience reminded me, as did Sarah, that everything is seldom as it seems and that the extra effort
in trying to discover other factors often brings up material that could never have been obtained by direct
questioning.

LIZZIE

Lizzie was 87 years old. She was short, smiled a great deal and had a distinct Scottish accent. She was a
delight to know.

She had never been seriously ill until three weeks previously when her loving and supportive daughter
Mary brought her as an urgent appointment. She had an inflamed gallbladder and I referred her to a
surgical unit at the hospital, where her gallbladder was removed the next day.

She recovered rapidly, returning to her daughter’s for convalescence a week later.

Two weeks later, I was called by the hospital specialist to inform me that Lizzie’s gallbladder had been
shown to be cancerous and would I please take the matter over from there. I asked my receptionist to
contact Mary; asking her to come in with her mother and two sisters, who wére also loving and
supportive of Lizzie.
Mary must have had an idea of what it was about and arrived the next day with one sister, but not her
mother. She said that she suspected something serious and wanted to know the details before her mother.

I responded that I felt caught in an ethical dilemma because my patient did not have vital information
and I felt that legally and ethically I had no right to give this to the daughters. They understood that, but
went on with the plea that I not tell the mother the bad news.
The daughters were concerned because they believed that Lizzie would collapse under the stress of this
new information. They said that she lived in terror of dying of cancer and that would be the end of her.

At this point I had to rapidly make up my mind how to further the cause for this distressed family. I
decided on the basis of knowing Mary and her mother for 25 years that it was reasonable to break the
ethical constraints for the greater interest of good medicine.
 Page 23

I’ve yet to see a patient collapse in any serious way on receiving news of terminal illness, so I asked the
daughters exactly what they thought would happen. One daughter thought that she would become
hysterically upset and the other that she would decline into a deep depression, but they admitted with a
little gentle pressure that actually Lizzie had never in her life been either depressed or hysterical.

At this point my Third Ear cut in. I said to myself “There is something going on here that doesn’t fit with
their caring attitude”.

Accordingly, I asked them how they thought they might feel being present when such news was
imparted to their mother. One daughter said she would probably get hysterical, the other thought she
would become depressed! From then on, it was not difficult for these two caring women to accept that
the major concern was how they themselves felt about their mother’s illness.

I told them that I believe in telling the whole truth to patients and that I had never seen a patient collapse
with hearing that, and I said that I could not accept conspiracy or deceit in relation to this loveable old
woman. Anyway I said, if the tumour spread Lizzie would eventually find out and trust would be lost
both in them and me.

I left them for a few minutes to talk about it and when I returned they had decided honesty was the best
policy; though they acknowledged their anxiety about the prospect.

Next day they all arrived. Lizzie greeted me as normal with the radiant smile – I felt anxious and sad.
“Dr I hope your news is good”
“ Liz the news is not good, in fact it is bad“
“ Give it to me, Dr”
Well, the hospital called me to say that they examined your gallbladder and found it had a tumour in it”.
“You mean cancer don’t you Dr” – a direct lady this.
“Yes I do mean cancer”.
“So what does this mean for me?”
“Liz, I wouldn’t hold back any truth from you and I won’t tell half-truths either. Not only did the
gallbladder have cancer but a little lymph gland nearby had cancer in it too. That means it has spread”.
“How long do I have?”
“That is a tough one to answer. These cancers are rather slow growing. You may have had it for years.
You’re also quite elderly and often tumours are slow growing in older people.”
“You wouldn’t kid me doctor?”
“No Liz, never’
“So how long?“
“I simply don’t know. Nobody does. My best bet is months, perhaps years”
“Well I’m not going to leave my home. I love that little place. The girls will help me won’t you girls?”
They nodded. Mary cried.
“Tosh now Mary, there is nothing to cry about. We all have to go. It is just old-age you know” They
thanked me and left.
 Page 24

Two years went by and Liz remained well. I saw her from time to time, mostly when she came in with
Mary who was also a patient. I concluded that Liz wanted to keep communications with me open. By
agreement no further investigations were performed. The hospital had nothing to offer, no treatment, and
Liz could see no point in useless examinations which could only either tell us all is well or was not.
Either way she preferred not to know.

One day Liz came back because she had developed a curious red, hot swelling around the umbilicus. I
had never seen such a condition before and after consultation with my partners we decided with Lizzie’s
consent to refer for an opinion from an oncologist.

The next day the oncologist called to inform me that the swelling also contained cancer cells and is a
well-known complication of gallbladder cancer. I was intrigued to discover that the secondary cancer has
a special name “Sister Mary Joseph’s tumour”, named after a nursing sister at the Mayo Clinic who
many years ago was the first to notice a connection with gallbladder cancer.

Lizzie was not well and was staying over at Mary’s home some 25 km away in the country. I called
Mary and asked if I might visit after hours to tell her about the results. This time she did not ask for
details but agreed to ask her and their spouses to join us.

Few people enjoy conveying bad news; especially to people they are fond of. I am no exception to this,
despite over 30 years of doing it from time to time. There is no formula except perhaps letting honesty
dictate behaviour.

The long drive enabled me to shift from daily office practice to the different mode of messenger and
friend. I was warmly greeted by Liz and family.
“Well Dr what is the news this time? All good I hope?”
“No, Lizzie, once again I’m the bearer of bad tidings. I hope you don’t shoot messengers here?”
“Not you anyway, doctor. I think I’m going to need you. Now tell me all”.
“ Lizzie, you have a spread from that cancer of yours. We can’t fix it. I’m sorry”. Now I felt like crying.
To my astonishment her face lit up in a brilliant smile. “I have had 87 good years. My girls and you will
see me through this”.

Then followed the nuts and bolts discussion. I was asked by Liz what the future held, how did I think she
would die, how much pain, how much loss of dignity, how much trouble to the girls?

They resolved that Liz would sell her home and live with Mary, the only daughter retired from work.
She would use me as she saw fit and when she was too ill to come to me I would visit her. We would
mobilise support agencies – district nurse, cancer nurse, and I promised to control any pain and
suffering with appropriate medication. Lizzie agreed to have radiotherapy simply to control the
umbilical tumour without expectations of a cure and this was successful.
 Page 25

It was likely by now that the tumour would have spread to Lizzie’s liver. She did not want any more
tests. “I just want to spend the last days or months with my girls“.

Lizzie gradually became more acutely ill with weight loss, tiredness, and loss of appetite. Pain was
easily controlled and her spirits never sagged. Actually it was Lizzie who kept the family spirits up until
she died peacefully.

To me the lesson reinforced was the importance of absolute honesty with my patients.
I’ve never known a patient to react in a hostile manner to bad news. Often they cry, sometimes look for
someone to blame and sometimes even bargain with their God. But I’m glad to able to say that I have
never experienced any anger from my patients for being honest with them. This has enabled me to
continue with my policy of honesty, though I admit it is a heavy burden to carry.

It was a privilege to know Lizzie and her family and I learned again not to be afraid of being honest with
my patients. The important thing was to be sure that I was open to anything my patient might ask and to
try to understand the feelings behind the questions.

TOM

Tom, a 22 year-old student, entered my office dressed in a cloak and a large broad-brimmed hat, which
he did not remove. From under the brim he began; “I have come to you to organise a neurological
opinion“. He held out his hands, which shook noticeably.
“Tell me more“
“Well, I’ve had this all my life and I’m sick of it. It makes me stand out because it gets so much worse
when I’m in company I hardly know.
“What else, Tom?“
“I have got Attention Deficit Disorder” (Hyperactivity Disorder).
“I have never been able to learn properly, it just goes in here”, putting his hands to his head, “and
disappears. So I need to see a neurologist to find something to make me feel better and be able to learn
more”.
“So here you are a student who can’t learn – sounds miserable to me”.
“Yes – well of course I feel rotten.“ – somewhat irritably.

At that moment I was aware of a similar feeling which I knew had nothing to do with me. But the fact
that I felt it too, indicated to me that it was a very strong feeling in him.
“It makes you angry too?“
“Wouldn’t you be? No one else has been able to help me“.
“Well Tom, right now I feel really sad and I wonder where that’s coming from?“
 Page 26

Comprehension dawned. A cascade of tears.

“Sometimes I just turn away and cry. All those schools I went to and they teased me and they called me
a dummy.”
Tom went to 27 schools between the age of six and 12. He was bullied and fought back. “I was always in
trouble“
“You must’ve moved home a lot“
“Mum and Dad thought they were giving me an interesting and exciting life. I hated it, but I couldn’t do
anything about it“. His eyes brimmed with tears as he talked of his loneliness at school; of his abandoned
plan at age seven to slit his wrists.

“You know Tom, ADD is about shifting around all the time.” A nod of understanding.
“I noticed since you have been here that you haven’t moved much.“
“No, well I have never talked like this before.“
“You are so preoccupied with talking that you haven’t had time to move much. Maybe you’ve been so
preoccupied by moving that you have been unable to talk, to be heard?”
For a person who made claim to intellectual dullness, he picked up this rather tricky interpretation very
quickly.

“You think it’s my life, not my brain?”

“I think that’s a highly likely explanation Tom, worth exploring further anyway.”

Tom had the classical symptoms of depression, which were so usual to him that he thought everybody
had the experience of waking during the night, feeling gloomy, tired and apathetic. This quarter-hour
consultation finished after half an hour, with an agreement that we would delay the neurology referral
until he’d given antidepressants a good trial. In the meantime, he would continue the counselling he had
begun just the week before.

Tom‘s response to antidepressants was dramatic. Two weeks after commencing them, he noticed a
marked change in his mood from gloomy to optimistic. He felt able to sit quietly, to interact comfortably
with his few friends and to study without restlessness. His memory and concentration improved over the
ensuing six weeks so that he now realised that he no longer had a learning disability.

GeneraIly, I prefer to use talking rather than antidepressants, as a first approach to treating depression;
but sometimes patients refuse that course, so I prescribe antidepressants if the syndrome of depression
seems well established.
This means the patient may not have the opportunity to vent painful feelings and learn to deal at a
personal level with others. However, the increase in sense of well-being sometimes is dramatic and the
end result gratifying.

Fortunately, Tom was already having counselling, so I was able to be more ‘doctorly,’ and concentrate
on the effectiveness of the medication.
 Page 27

Having worked for some years in an adolescent psychiatric unit, I often met with children diagnosed
with ADHD. The general consensus was that ADHD is ‘hardwired’; that is, it is a part of the structure of
the sufferer’s brain.
I have difficulty accepting that view when I consider that the ADHD patients I saw mostly were part of
a distressed family.

It is interesting to consider that the drug of choice for the treatment of ADD is Ritalin, which began life
is an antidepressant.
I know this is a controversial position to take but this was how ADD presented in my experience.
I believe that ADHD is the outcome of conflicts, usually within the family. I think the treatment of
choice ought to be family therapy; in which the whole family meets and efforts are made to understand
why a child may feel he or she has to be disorganised in this way to fit in to his or her family and school.

AROHA

St Elsewhere was a television program set in a hypothetical major hospital in Boston. It contrasted in
quality with the plethora of “hospital soapies”, in that it dealt with medical issues in a sympathetic yet
critical manner.

I remember an outstanding episode in which a woman lost consciousness at a social gathering.

She was transferred to St. Elsewhere and the camera followed events from the emergency room through
the admission ward to her discharge from hospital the next day. We saw the emergency room resident
doctor examine the patient, order a multitude of tests, including blood analysis and cardiographs. The
patient was transferred to the neurology ward where she endured the “Neurological Sixpack”, including
CT scan, lumbar puncture, electroencephalograph ( brainwave recordings), muscle testing and further
blood analysis.

As each phase was filmed there was a brief cut to the computer totalling costs for each test and
procedure. All tests returned normal findings. No diagnosis was offered and in the final scene we saw
the patient’s husband approach the front desk of the hospital withdrawing money from his wallet. He
was given the final account of the cost of this hospital treatment- and his look of shocked disbelief -
followed by withdrawal of his credit card, leading into the final camera shot of the detail of the card with
a grand total of charges - of $2,300.
To the credit of the directors of this episode, no comment was offered – none was necessary,. Clearly the
patient seemed to have suffered a simple syncope or episode of fainting.

Aroha, a young professional woman, made an appointment late in my day. She brought a report from the
emergency room. Some days previously she had attended a film with her partner, Alex.
 Page 28

About five minutes after the start of the film, she suddenly felt a choking sensation, intense flushing and
a rapid heartbeat. She lost consciousness and fell heavily into the aisle. There was consternation in the
theatre as she lay on the floor for a time - varying according to the onlooker, from one and a half to three
minutes. The film was stopped, an ambulance called and Aroha accompanied by Alex was transferred to
the emergency room.

The ER Doctor who ordered cardiograph, blood tests, and CT scan competently examined her. These
tests were normal and since Aroha had by then (three hours later) apparently fully recovered, she was
discharged from hospital care. The diagnosis was “possible seizure disorder.”

Aroha was alarmed about the whole episode, especially the consequences of developing a seizure
disorder, a diagnosis she was at once fearful of and in doubt of. She is an intelligent woman and
continued fully to describe the incident without interruption. At the end of her description I ask her the
name of the film. She replied; “Once Were Warriors”.

I had attempted to read the book on which the film is based, but was unable to read past the first chapter
because I found the violence described in that chapter overwhelming.
It is a book about some of the more unpleasant aspects of current Maori culture. I asked Aroha to
describe in detail what she had seen and she told me of a shockingly violent scene
the section I had read before putting the book aside), in which a man brutalises a woman such that her
face was split open, her eye hanging out and she is raped.

I experienced with this graphic description, the fear and horror I had felt when I read the chapter. At this
point in the consultation, I felt deeply involved with Aroha. Her demeanour was quite bland as she told
me this and yet I had this powerful reaction to what she was telling me. My Third Ear had been
energised.

My feelings were mixed. First there was horror, but also anxiety. I was convinced there was much more
to be heard from Aroha.

I commented to her on my mixed feelings and asked if this rang any bells for her. She responded blandly
that she had experienced a lot of violence when growing up in a large extended Maori family.
She commented upon her observations of the consequence of violence between her ‘mongrel’ and her
aunt. I asked her to repeat that and she said “between my uncle and my aunt“, so I thought I had simply
misheard.

At that moment I felt intensely sad. I could feel an unbidden tear in my eye and knew better than to
disregard this powerful response. I was fairly sure I had received a projective identification. I interrupted
Aroha and told her how I felt. She responded, now tearfully, that she too felt moved.

“Of course my father was violent to my mother, so they finally separated. In fact they consulted my
younger sister and me about whether to part, and we encouraged them strongly to do so, because we
could no longer tolerate the anger and unhappiness of these two “enemies“.
 Page 29

She related that in the few minutes she watched the movie, she felt shock and outrage; such that; “I
wanted to get up and punch the mongrel off the screen”. I asked her to repeat what she had just said and
again she used the word mongrel. I reminded her that she had used this term before that, and perhaps I
had not misheard it after all.

A look of comprehension on her face was followed by; “yes, that is the link. It is the link with my own
childhood and my sense of outrage at what was happening between them.“ She added that she now has a
close relationship with her father with whom she lived after her parents separated, but is quite distant
from her mother, who is now an alcoholic.

Aroha’s mother grew up in a violent abusive alcoholic atmosphere. But Aroha’s father, by contrast,
experienced gentleness and love in his childhood. Aroha could only speculate on how her father later
became violent, but believed her mother had some primitive need to be treated in this way. She realised
that she had always felt uneasy about what happened in her childhood.

There was a sense of unfinished business, accompanied by dread of opening old wounds if she should
attempt to discuss these issues with her parents. I suggested to her that given her remaining attachment
to her parents and what she described was the truth, she had little to lose by talking with her father. She
said she would do this and return to keep me informed; but that may not be for quite some time because
her parents lived at the other end of New Zealand.
During the session, which took somewhat longer than the usual consultation time, I saw Aroha change
from a patient with a medical diagnosis through anger, outrage and sadness; to a relaxed and
comprehending person. My feelings paralleled Aroha’s and ended with a mixture of elation and gratitude
to Aroha for allowing me to join her in this moving experience.

There is much to be learned from this.

Aroha’s “Freudian slip“ in the use of the word mongrel was probably the key to unlocking the
connection with her lapse of consciousness and her conflicted life experience. How else could Aroha
have escaped the unbearable reminder of her childhood? She was not consciously aware of her
association so did not feel compelled simply to walk out of the theatre.
My Third Ear was responsible for my recognition of her use of the word ‘mongrel’ and the interpretation
of it followed naturally.

‘Mongrel’, then, was a message from her unconscious mind drawing attention to the turmoil within.
I often use the analogy with patients that our minds may be likened to a room divided down the middle
by curtain. One side is the conscious mind dealing with day to day concerns and feelings. On the other
side of the curtain is a cage containing repressed, often painful, memories of a form like wild animals –
controlled but potentially dangerous.
We are often aware of rustling of this curtain, making us slightly uncomfortable, but possible to ignore.
Sometimes with provocation from certain life events, the rumblings behind the curtain escalate to a roar
and the curtain threatens to be blown aside.
 Page 30

Our efforts to contain this disturbance may be manifested as anxiety, in which we feel a sense of
impending danger, without awareness of the nature or origins of threat to our sense of internal well-
being.

On the bright side, experience shows if the curtain is deliberately or forcibly drawn by anxiety, Freudian
slips, or dreams, or during the course of psychotherapy, and the cage opened, we may be faced -not with
destructive monsters but pussy cats.

In Aroha’s case her cage was filled with memories of monstrous violence from the past, well suppressed
generally, but poised to demand attention given the right signal.

The keys to opening her cage were two. The first directed her attention to the event immediately related
to her life experience, on screen that corresponded to the violence she experienced in her life as a child
that is, the identification with the violence and the second in recognition of the power of her unconscious
and repeating the word ‘mongrel’ which encapsulated her fear, rage and disgust.

One might speculate too about the Aroha’s unconscious motivation to see this particular film. At one
level it was apparent disregard of the subject material before attending this cinema performance
followed by a powerful emergence of the film’s personal meaning to her. She confronted the ‘ mongrel
within’ made plans to befriend it, and resolved finally to put it to rest.

I believe that patients usually ‘know’ at some level the factors that underlie the psychological roots of
their illnesses. It follows that an important part of my role as Dr is to help unearth these memories and
images. Sometimes a simple question such as “what ideas do you have about the cause of the problem?”
can be followed by an observation that I could not discover with 1000 direct questions.

To return to Aroha, she clearly ‘knew’ unconsciously what this was all about and that is why it took so
little time and effort to focus on the connections with her past, both at the factual and the emotional
levels.

Our next meeting was only a month or so later. Aroha had decided that she urgently needed to attempt
resolution of the conflicts about her parents, so she took time away from work to visit her father. She
told him in detail of her experience and our consultation. He listened intently, and cried with her. They
talked for many hours and then she told him she planned also to visit her mother. He asked to
accompany her. Mother and father talked, held each other, cried and expressed regrets. “A lovely
wonderful time with them”.

A year later Aroha consulted me again, this time about a purely physical matter. A the end of this brief
contact, she told me; “my father died recently. I was with him and we said all we needed to. He is at
peace and so am I.”
 Page 31

The commonality with the St Elsewhere story is quite strong. Two women experience syncope (fainting)
and both are admitted to the emergency room and extensively investigated. In both cases a “cause“ was
not found and they were both discharged from hospital in a short time.

It seemed that in both cases, it was difficult for the hospital doctors fully to acknowledge their inability
to understand what happened in these cases. We don’t know what was on the mind of the fictional
characters in St Elsewhere, but we do know of a striking factor in Aroha’s case. In St Elsewhere the
point is strongly made of the great expense involved. I do not know the cost of emergency care, but it is
not cheap and this includes, as it did, a large number of unnecessary tests that were potentially
avoidable.

If Aroha had been carefully interviewed in the emergency room and some weight accorded to the
possibility of the fainting being in service of greater comfort and protection against psychological
trauma, it may have been possible to avoid these unnecessary tests.

It is of interest that the meaning of the name Aroha in Maori is Love.

MRS. D; UNIQUELY FEMININE

Mrs. D, her husband and two infant children emigrated to New Zealand from India and shortly after
arrival she came for obstetric care. This pregnancy was welcomed by the family and proceeded without
problems, culminating in the birth of their second son.

The new life they embraced in New Zealand has not been easy for them. In common with many migrants
Mr. D’s professional qualifications were not accepted in this country and he had to undergo retraining at
a tertiary institution. They relied on social welfare to survive and did so without complaint.

Two months after the birth of their son, Mrs D, who was at the time breastfeeding, became pregnant
again. After confirmation of this, we discussed the options. Both Mrs D and her husband were quite
clear that they wanted the pregnancy terminated. I knew they were Catholic and felt some reservations
about this decision.

As a doctor I’m always uncomfortable about abortion, less from a moral standpoint than a pragmatic
view based on the experience of a number of women who have opted for abortion, then changed their
minds, without exception being happy about the change of heart.
This, combined with having seen women suffer grief and depression post abortion, has made me
uncertain about “medical grounds“ for abortion. I’m not at all certain that the declaration required by law
 Page 32

that a woman’s life and health is seriously threatened by an unwanted pregnancy is as frequently true for
patients as claimed by our more more militant proponents of abortion.

My approach is to try to ascertain what patients really want - often at variance with their initial request -
then fully support that decision.

I asked Mr and Mrs D to think about the issue for a few days. When they returned, they asked for
referral for termination. The procedure was arranged without problems, and Mrs D returned two weeks
later, after termination had been performed. She seemed well.

I enquired about sadness, which she denied, apparently satisfied that she had made the right decision. I
commented that I was concerned about her lack of emotion and I wondered if she was really denying the
import of their decision and subsequent action. We agreed she would return if she experienced untoward
emotional pain.

New Zealand has always been a conservative country – our immigration policy has only in recent years
allowed a lot of people of different skin colour to settle in significant numbers. As a consequence we -
and I am no exception - have tended to be intolerant through sheer ignorance and a touch of
xenophobia, of our more recent immigrants. I guess we should be thankful that “cultural sensitivity“ has
become one of the buzz phrases of the new century, encouraging us all to try to understand views of life
that are different, but just as valid, as those that predominate in our culture.

The D family is a special illustration of this. Their spoken English was good, their understanding better,
but I was considering how well I understood the nature of their problem. I asked if they would let me
know if I transgressed any of their cultural boundaries and they agreed to do so.

At that time my major concern was that the gulf between us in national customs and heritage may lead
me into some horrible gaffe. In their beautifully soft way they assured me that I was not out of line to
enquire about my patient’s welfare and, yes, they realised grief and even depression was a possibility.

Emphasis upon “cultural sensitivity“ draws correctly upon recognition that it is only too easy
unthinkingly to assume that the values of others are the same as my own, especially in medical practice
where the capacity to offend is generally greater than in ordinary encounters.

I was not surprised when Mrs D returned and told me; “my heart is on fire, it is breaking, I should never
have done this“. Though quite deeply distressed, she reassured me that she was not suicidal and was
comfortable with my offer of an extended consultation next day.

Mrs D was not depressed. Rather she was desperately unhappy, as she told me of her sense of guilt,
shame and her thought that “God will never forgive me, and nor will my baby”.
 Page 33

I could not fully repress my own tears as this profoundly sad woman poured out her feeling of being
damned forever, not only by her God but also by her never-to-born child. It was not helpful that her
assigned counsellor attached to the abortion clinic had assured Mrs D that “what is inside you is not
human” (ie; can easily be disposed of). Mrs D. an intelligent woman, saw through the falsity of that
statement, at the cost of increased guilt. “I killed my baby, doctor“ is a comment I’ve heard before and
it never fails to move me profoundly.

At that moment I too felt hopeless and helpless. It is true that she had by her decision been responsible
for that baby’s death. It is also true that in the eyes of the church she had committed a serious sin.

How could I, a non-Catholic talking to an Indian Catholic woman half my age help relieve powerful
feelings of sinfulness, guilt and regret?

As she talked about her feelings, I realised just how great the cultural gap was. To my surprise though, it
was not the racial gap that was most troublesome – perhaps because of their gentle reassurance - but the
sense of our religious differences were too great for me to think of a possible solution.

I asked her if she would like to talk to a priest.

She lowered her head and said quietly, that she just could not, such was the depth of her shame. The
tears streamed down her cheeks in a quiet, almost expressionless manner - a sign of deep despair.

We sat quietly, Mrs D despairing, and the doctor sombre. We seemed to be stuck in a combined
helplessness. This was not an occasion to let my patient’s distress be the force to keep the momentum
going. I needed to intervene. I asked if she would tell me about her God, acknowledging that I’m not
Catholic. She smiled a little and gave a quite cheerful version of a bountiful, caring, loving God. I asked
if she felt Him to be vengeful and she seemed surprised with that idea.
“But you seem so frightened of Him“
“I have done something so awful, He would never forgive me”.
A loving God can’t forgive a young mother who felt forced to give her baby up?“ “
“I wasn’t forced. I gave her up because I thought I would not be able to manage four children. I was
selfish“.
“So it was a her“.
“Oh, yes“
“Shall we give her a name?“ A long silence, then, shyly; “yes“.
“In English or Indian?“
“English – she was made here“.

Now Mrs D stopped crying and seemed engaged in something which aroused her interest.
“How about Sarah; that’s about as English as I can think of.“
“Yes, Sarah“.
“What is she like? A smile, a motherly smile.
“I think she’s like my husband“.
“Can you describe her to me?“ Silence, then a gorgeous smile.
 Page 34

“She smiles at me!”

“This little girl who hates you? You know, this reminds me that Jesus died for others. Maybe Sarah died
for her two brothers and sister, that they might live their lives just like he did”.
Mrs D responded to this again with a smile “I didn’t think of that. Perhaps so“.

It felt at this point that we had both done enough, experienced enough emotion for one hour, and we
agreed to stop, planning to meet again after the weekend.

At the next consultation Mrs D said she had talked with Mr D, and they had agreed that perhaps they
could be forgiven by God -and by the baby. She looked and sounded more optimistic. I suggested she
might like to talk to a retired nun whom I have known for many years and trust absolutely, and she
agreed without hesitation.

A week later both parents came in. Mrs D looked and sounded much happier. Mr D told me that he had
converted to Catholicism in his marriage, from Buddhism, and in view of his beliefs in reincarnation he
had no great problem seeking termination of their pregnancy. He did however, seem to understand his
wife’s unhappiness about her share of the decision, and to be truly empathic towards her, as evidenced
by the way he held her hand and looked at her lovingly.
Mrs D said; “you know I really believe that God and Sarah, will forgive me, and I would like to seek
forgiveness from the church, which I hope to do when I visit the nun, as arranged.

When I asked Mrs D about her view of God, I had no idea at that moment where the question came
from. In retrospect, I think at the moment we were “at–one” to use a self psychology expression, - a
state of closeness where the boundaries between people can become blurred and awareness of each
other’s thinking and feelings heightened. In other words, Mrs D was thinking of the nature of God and I
simply verbalised her inquiry.

As usual after such an encounter the relationship between Mrs D, Mr D and I was deepened, such that
future care was made easy by the sense of mutual trust.

A NON TERMINATION: CAROLINE

One day Caroline, a 39-year-old woman whom I vaguely remembered, sat down and said; “you won’t
remember me, the last time I came here was 17 years ago. I consulted you requesting a termination of
pregnancy. We spent half an hour together twice and at the end of that time I decided against the
termination.”

“I want you to know that I now have a delightful 16-year-old son”.

It seems that as quite a young woman, she had experienced some pressure from her boyfriend and her
family to have an abortion, because this was not a convenient time to start a family. She reminded me
 Page 35

that I had taken a fairly neutral stance and quite quickly she had made it apparent that she was at best
ambivalent about terminating the pregnancy. She had the impression that I too was doubtful that
abortion was an appropriate solution to the problem and eventually she and her boyfriend married and
remain so to this day.

Though the answer was really obvious, I nevertheless asked her if she was at this point satisfied with the
decision and she replied that she shuddered to think that her son might not have existed at this point had
she chosen otherwise and went on to add that a number of her friends had had terminations and had done
uniformly badly in terms of grief, self-recrimination and depression.

As she was talking, I remembered the number of people I had seen in similar circumstances and I
could not remember where the decision not to terminate had been other than the best decision. That left
me wondering how many of those who terminate pregnancy in fact make the wrong decision.

ANOTHER TERMINATION: LYDIA

A woman sat in my consulting room and without preamble said; “you are the fourth Dr I have seen the
past week. If you do not arrange termination for me I’m going to shoot myself”.

At that moment my telephone rang. I usually do not take calls during consultations, but my receptionist
said that it was urgent; to do with the woman currently in my office.
I spoke with a woman whom I knew professionally, and trusted, who said; “this afternoon you’ll be
seeing a friend of mine and if she tells you she intends to shoot herself, take good notice of this because
I know that she has a loaded gun in her wardrobe.”

I arranged the termination of her pregnancy.

Later she told me that this was the right decision for her, given a disturbed marital and family situation
and that indeed she would’ve shot herself. Few terminations of a pregnancy are so unequivocal in their
indications!

MARIAH
 Page 36

Mariah, age 26, presented one morning concerned about colicky abdominal pain and pelvic pain and that
her menstrual periods had been very scanty since she stopped contraceptive pills five months
previously.

I have known her for several years. She is a healthy intelligent young woman and never presents with
trivial symptoms.

Discussion of these problems did not elicit any more information. At that point I performed a pelvic
examination which apart from minor tenderness in the abdomen was absolutely normal.

After she dressed and I re-entered the room, I asked what effects she thought it had on her, that her
husband, a soldier, was overseas in a peacekeeping force at that time. She thought that the situation with
her husband serving overseas did not have much effect on her because he had left over a month
previously and before he left, there had been quite a few arguments and upsets between them over the
fact that he was going to a place that could well be dangerous.

I said that I was asking this because I wondered whether the symptoms may have anything to do with
any marital upset. That is; pelvic symptoms often seem to be related to that part of the person’s body to
do with reproduction or sexuality or both.

She responded that she had been wondering this herself and when I commented that I knew her whole
family and that I knew that the family tended to downplay the importance of emotional experiences, she
told me that she too was aware of that, saying;
“I did not want to go to work irritable and tearful and dump these feelings on someone else, but I sure do
have those feelings. And I couldn’t tell mum about how I felt, because as you know, she is really very ill
and can barely cope with what she has on her own“.

I then remarked that Mariah seemed quite cheerful and smiley and wondered whether underneath she felt
as bright as this? I was feeling far from bright as I said this.

She said; “well I don’t want to leave the doctor’s crying”.

I responded; “why not, people often cry here when they’re telling me about what they are really feeling.“
At that point Mariah burst into a flood of tears and talked not only about the pain of a husband being in
the army - and possibly at any time involved in major conflict - but also the difficulties that they had in
their marriage, aside from his military service overseas and the difficulties she experienced with his
family who only rang occasionally, but seemed relatively unconcerned about her husband’s safety.

This quarter-hour consultation had now taken about 25 minutes.

I thought it was time to close and did so by suggesting that she come back and talk more about this
when she had had a little more time to think about the disclosures she had made during this consultation.
 Page 37

She asked me what I could do to help and I said I thought she had taken a major step in admitting she
had some very strong feelings which seemed relevant to her symptoms.
She said that at this point she felt much better and added; “I don’t think I should leave this matter to
think about it because I might start denying again. What I would really like to do is make another
appointment now to see you for an hour - in a few days - and then I can do what I need to do; which is to
talk about it and allow myself feel whatever I feel.”

Mariah returned as arranged and commented that despite feeling much better, she had realised she had
some uncertainties about her marriage and could she talk about that? “I want to know how compatible
we are. We seem to have drifted apart. There is nothing in my marriage that I can object to. My husband
is a decent man, faithful and hard-working. He is a good father to my children”. She decided to wait
until he returned before making a final decision.

A few months later, Mariah returned to tell me that her pains rapidly disappeared, after our longer
session; that her husband had returned from his army obligations and she realised that she did love him.
She thought that her anxiety about his safety had been the cause of her uncertainties about her marriage
and now that he had safely returned that anxiety had settled, as had her doubts about her marriage.

The critical moment in this consultation was when I asked Mariah if she could connect her pain with her
husband’s enforced absence, and his vulnerability. It shows how closely links like this coexist with the
symptoms in the patient’s unconscious.

My question was well worthwhile, and even if the connection did not exist, no harm could be done by
asking.
There is considerable satisfaction for me in ‘guessing’ correctly, though perhaps guessing is not accurate
- it is more than a guess, in that we know that separation can lead to emotional stress, and that may
engender psychosomatic symptoms.

1000 SICKNESS INCIDENTS

Some time ago I read an article in a medical journal, which described the outcome of 1,000 Illness
incidents. These were defined as any happening to a person that that person would describe as a negative
alteration in the state of his or her well-being.

I have long forgotten the exact numbers presented, but for the sake of discussion approximations will do.

Of the thousand such incidents about 750 were dealt with by advice from family or friends or without
consultation at all. These cases range from sore throat, common cold, minor trauma and headache; the
 Page 38

sort of minimally unhealthy experiences we are all familiar with. Remedies included hot tea, rest, aspirin
and many other time-honoured treatments.

It seems to me that most of these remedies have little scientific relevance, which in no way detracts from
their usefulness, symbolising as they do the nurturance of the suffering by carers and relying mostly on
the passage of time to bring about symptomatic relief.
My biomedical colleagues may view this time as a period when the blood mobilises its defence
mechanisms, the immune system does its thing producing antibodies, white cells and hormones attack
invading organisms - and repair of minor damage occurs.

The remaining group of 250 people recognise features of the discomfort that seemed beyond their
personal resources and sought help from various non-medical sources such as pharmacies or “natural“
health product shops. Most of this group also recovered in a short time, leaving only 50 people of the
original thousand with symptoms of such magnitude that, having tried home remedies, without relief,
they decided to visit their primary care physician.

At this point of entry to our western medical system, the process becomes formalised. It is usually
necessary for an appointment to be made, and if not specified otherwise, this is most commonly for a
finite time; 10 to 15 minutes. Both patient and Dr have an expectation that the appointment will allow
sufficient time to communicate relevant thoughts and feelings, physical and emotional, to allow the
problem to be solved.

I believe patients present with a number of unstated questions, one of which is; “I have discomfort. My
adaptive mechanisms are not working. Let me tell you about this, help me to understand, and relieve not
only my discomfort but also my anxiety.“

The proper response is to invite the patient to explain and elaborate. The patient’s story is presented
through verbal and non-verbal communication. The verbal aspect of this depends on many factors
including intelligence, education, life experiences, personality and medical knowledge. It is catalysed by
a sense of trust between doctor and patient.

Most primary care physicians will acknowledge that from the very beginning of a consultation they are
forming hypotheses from the patient’s communications. Most will further acknowledge that 90% of
diagnosis comes from the time spent listening and talking with the patient and only 10% by physical or
other examinations.

DONNA
 Page 39

Donna is a case in point. She was a 19-year-old science student, who opened the consultation with; “I
have had a pain in my face for quite a few weeks. I’ve been to the doctor several times and he’s given
me pills and things but nothing makes it any better”.

If I followed the medical model of my early training, I would have invited Donna to describe the nature
of her pain – always difficult to do – the site of it, any known relieving or aggravating factors, the timing
of the pain and its severity.

However, something about her demeanour, suggesting suppressed anger, made me deviate from the
traditional approach.
“It sounds like there’s a diagnostic and treatment problem here.”

This is a simple response, actually only rephrasing what she had already said. It carries the virtue of
being undeniably true and indicated I wanted to hear her views and I was not about to jump to
conclusions.

“Yes, nobody seems to be able to get it right and fix me up, and I want relief from my pain.“

At that moment I felt a sense of sadness, that I knew had to be coming from Donna, so because I trust
sudden changes in my own feelings, as signals from the patient, I responded; “would it surprise you if I
said I suddenly felt sad.”
“No”. Her eyes filled with tears.
I asked what was on her mind and she said; “well I have had a terrible time for a while now. My mother
died four years ago, only 39 years old, of malignant melanoma. She was diagnosed at the end of
November and died six weeks later. She had radiotherapy and chemotherapy. I can’t believe in all that
stuff“.
She looked angry again and continued to cry.

“So the hint I picked up when you sat down and began to talk; that maybe you were a little angry about
something, seems to be reinforced by what you just said. Is there something about doctors?”

Again, simple undeniable comments which focused on her current distress.

“I saw them giving her radiation one-day and it was horrible. She had chemotherapy, lost her hair and
lost a lot of weight and she didn’t look like my mum any more. She just lived for the moment and had no
future. She knew it and so did I and it was overwhelming.”

“So you felt the doctors were not achieving anything?“

“Yes; their treatments never did any good“
Just like the doctors treating your pain?“
“The same“
“And then she died?“
Donna cried bitterly.
 Page 40

“Yes they didn’t save her – didn’t even help her or me“

She went on to tell me that she had been to counselling, working through issues to do with the father’s
remarriage, her stepmother’s family and leaving school. There were many changes and many losses. The
counselling was helpful she said.

“So you worked through this stuff, but it seems like there is still more?“
“Yes, well, you see, I didn’t cry after mother died, nor at her funeral. I think I’m just starting now.“
“So you are having to ‘face up’ to things now and it is quite a ‘pain’.

This bright young woman’s face smiled through the tears as she got the inport of those two words “pain“
and “face“ and she said; “I think I knew all along that that was what my face pain was about. I just
needed someone to tell me“

She then confided that she had come to this consultation expecting she would be given tests and referred
to a specialist. I asked if this was what she still wanted.
“No; definitely not. I think I can get on with grieving mum and I would like to see if the pain goes away
through that“

The session concluded with my invitation to return as necessary.

Two months later I saw Donna for a minor matter. She offered that she was still actively grieving and
was astonished how painful the experience was for her. She was not surprised that a part of her had
denied this grief. Her facial pain rapidly disappeared after our initial meeting. She had come to terms
with her father‘s new marriage and formed her first heterosexual relationship.
I have not seen her since.

I have no idea what Donna’s pain was like, where it was, how often she got it. I do not know the details
of the central nervous system functioning, nor do I know her blood pressure and I certainly have not
tested her urine. In fact I have never examined her.

I need to keep in mind that at least 90% of the most useful information about my patient lies in her or his
Body-Mind. Patients are the real experts about themselves. Until I have explored their agenda and their
knowledge, I am the bereft of anything except the coldness of a sterile medical inquiry.

Of course, it could have been the case that Donna did have some undetected illness that I would not have
detected in this consultation. However, I’m sure any worsening of some undetected disease would have
resulted in another consultation.

To return to the 1000 in this article; of the group of 50 that entered into primary care, 45 will experience
resolution of their problems and five will be referred to consultants.
 Page 41

We refer for a number of reasons. Usually there is a parallel with the reason for the patient coming to us.
This is that we are uncertain, having exhausted our personal knowledge and skills and need recourse to a
‘higher authority’.

AMELIA

I referred Amelia, a married woman, aged 65, to a gynaecologist, because I had consulted with her
several times regarding vague genital soreness and itching. I found no abnormality on examination, and
laboratory tests had not helped to solve the problem.

On each occasion I saw Amelia, I had asked the ‘appropriate’ questions related to her physical health;
including checking her for diabetes and infection, but the symptoms persisted, despite my prescriptions
of various medications.

The gynaecologist found nothing abnormal and referred her to a dermatologist.

I have a problem with inter-specialist referrals because it is only too easy for a specialist who finds
nothing in his/her field, to refer to another specialist without my knowledge. Communication is then
limited to specialists and somehow the overview of patient-body- mind, and soul, is lost.

Such was the case with Amelia. The next time I saw her she informed me of the consultation with the
dermatologist; “who gave me these little pills and I feel a lot better“

I enquired of the specialists their views of my patient and it was clear they had no more idea of the
nature of the problem than I did.

The dermatologist had given Amelia a small dose of amitriptyline, an antidepressant; “because
sometimes amitriptyline relieves pain and discomfort“

That information made me realise that once again I was faced with the situation of a patient with
symptoms but no objective physical cause.
The set of symptoms Amelia presented with suggested the problem may fit into a branch of medicine
known as “Somatoform Disorder’ or ‘ psychosomatic disorder’.

In my view there is a quite unconscious “trade-off“ involved in the common situation of physical
symptoms emanating from psychological pain and conflict. Often the psychological pain is the worst of
the two evils and without realising at the time, the patient chooses the physical symptoms as the most
bearable.

The choice is frequently not a random one. The symptoms develo in a part of the body
 Page 42

which has symbolic meaning related to the emotional distress. This was the case with Donna, who
could not “face“ up to the “pain“ of loss and grief.

One day Amelia consulted me about another matter which was quickly resolved, so, rueful about once
again missing obvious clues, I asked about the genital symptoms - which had disappeared two weeks
after starting the amitriptyline tablets. She discontinued these tablets because she felt “spaced out” -a
common side-effect from this medication.

The symptoms had returned a few days before. I asked Amelia how she felt and she burst into tears as
she explained that she had felt depressed for months because of her relationship with her eldest son.

Her son Ian, now age 40, had also been my patient, until he married and left the district.
He was a cold, hostile, rough and unkempt man, quite the antithesis of his mother, who is attractive, well
groomed and responsive.

Ian‘s marriage broke up because his wife could not tolerate his uncouth manner and angry outbursts. He
had formed a liaison with another young woman, with whom he had three children. This relationship
also failed and the female partner left, taking Amelia’s three grandchildren to a city 400 miles away.

Amelia felt a deep sense of loss related to these life experiences, aggravated by the failure of the son to
visit her, except when he needed help.

At this point I said to Amelia that I could understand better her symptoms because, after all, where did
Ian come from?
She looked quite puzzled for a moment and then, as she began to understand, she asked me to explain
exactly what I meant.

I told her that sometimes loss can be unbearable; especially when it involved those we could and did
love. It followed from that, that some adjustment would have to be made and perhaps her redirecting her
pain to that area was at once a symbolic act and a trade-off.
She surprised me by agreeing and offering that when she took the amitriptyline her pain got better but
she actually felt more tearful than before. I invited her to return the next day, this time for an hour and
she agreed.

The next session was centred on Amelia‘s early life.

She grew up with emotionally distant parents who were excellent caretakers, but offered little emotional
sustenance or approval. Her father occasionally drank alcohol excessively and could be violent towards
his wife. Ian, Amelia‘s son; “is a carbon copy of his granddad.”

Amelia‘s husband grew up in a similar family and because of these backgrounds both Amelia and her
husband have never found it easy to be openly affectionate.
 Page 43

Sexuality for Amelia was never more than a marital commitment, and she cried as she wished she could
just go back all those years to get help and be able to live a more emotionally fulfilling life. She has
never been orgasmic and talked of her envy of her friends who told her about their satisfying sexual
experiences.

My observation that she gained little satisfaction either from what goes in, or what comes out of the
symptomatic area was accepted by Amelia as literally a lifelong truth for her.

Throughout this one-hour session, Amelia experienced powerful sadness and then anger, but expressed
the view that too much time had passed to change all this and decided against further discussion.

She did however agree to accept medication for her depression, this time with an antidepressant which
did not produce uncomfortable side-effects. (Amitriptyline causes uncomfortable dry mouth and often a
‘spaced out’ feeling.)
Her pelvic symptoms rapidly cleared as did her depression. Three months later she discontinued
antidepressants and remained well.

When she returned to my office every three months for treatment for her hiatus hernia, she often referred
to our discussions and always kept me up-to-date on happenings within her family.

It might be argued that this patient could have received more help to achieve a more intimate and
gratifying life style, and I would wish that had been the case, but Amelia was quite adamant that enough
was enough and made the choice that suited her thinking and feelings at that time.

In New Zealand, hospital patients are not treated by family physicians. Most family doctors are
comfortable with that, because we feel unable to maintain the level of expertise necessary in the
management of seriously ill patients. We do, however, take over care after discharge from hospital; so
the communication with specialist hospital doctors is necessary throughout and after the hospital stay.

Of the thousand illness incidents, only one patient will proceed to a tertiary care unit. This expression
refers to a highly specialised unit which deals at a high-tech level with a narrow spectrum of conditions.

In day-to-day family practice, most of the decisions I make are based upon - to use the common catch
phrase - “Evidence Based Practice“; history, examination, investigation, diagnosis and treatment follow
an orderly sequence

MR. J.

Mr J presented with chest pain. Inquiry revealed that the pain was precipitated by exertion, situated
behind his breastbone and radiating to his chin and arm. He was 62 years old,, moderately obese and a
smoker. His father had died of a heart attack.
 Page 44

This clinical history is typical of pain originating from the heart.

The usual next step is some basic tests, including cardiogram and blood tests. These were in favour of
the diagnosis of angina pectoris ,a reduction in blood flow to the heart muscle, but not a full blockage
which would have caused a heart attack, or myocardial infarction.

Mr J consulted a cardiologist who recommended that he undergo angiography, in which a catheter is

passed into the coronary artery of the heart to ascertain the level of obstruction to his bloodflow. This
indicated 90% narrowing of his main heart artery suggesting he was at immediate risk of a heart attack.

Mr J underwent coronary artery surgery, and felt a new man.

This is a comfortable history. There are no surprises or diagnostic uncertainties. The end result was
excellent and Mr J‘s life was almost certainly prolonged.

It is a fine example of “linear reductionist medicine“; in which only the technical and biophysical factors
are considered, sometimes at the risk of losing sight of the core issue – that a distressed human being is
the subject under consideration, not just a troubled organ.

There are more often than not other cogent, relevant happenings that can have a profound effect on
recovery. It would be much easier, though perhaps less rewarding, if all our medical problems were as
easy to correctly diagnose and treat as those of Mr J.

I notice, as I return to the story, that neither I nor Mr J paid any attention before surgery to his thoughts
and feelings about this experience. He was a pragmatic man who seemed comfortable with the practical
“no nonsense“ approach.

However, people have a regrettable tendency to pose problems which do not fit in the textbooks, or
worse, seem outside our philosophical certainties.

STEVE

A much more difficult problem for me was Steve, age 57, who had been a patient at my practice for five
years. He is a solidly built open-faced man, a hard worker determinedly independent.

He worked for many years as an employee of a large department store and saved hard to accumulate
property assets in order to provide an income for his old age.
 Page 45

Steve grew up in New Zealand during the years 1938 to 1984 when this country was highly socialistic.
We were proud to be members of a caring society, with a’ cradle to grave’ philosophy of health care,
education and other social benefits.

This generation, of which I am also a member, took for granted that if we paid our taxes - which were
very high - in 1980 I paid 67% of my income in taxes - we would all be rewarded with free hospital care,
free education to a tertiary level, and a liveable pension from age 60. We felt safe, though at times
frustrated, living in a highly regulated society, administered by an army of bureaucrats.

A national election in 1984 changed everything. A new Labour government announced that the economy
was in serious difficulty and the old philosophy was simply not economically sustainable. Change to a
user-pay system was extremely rapid and within a year or so the country was in economic and social
turmoil as the people realised that we no longer had a paternalistic government that guaranteed access to
all the necessities of life.
Until these changes were introduced into national life, we tended to regard money as something
desirable that had to be worked for. Money subsequently become a commodity - as in other capitalist
countries.

The public health system underwent major structural changes; with resultant increase in surgical waiting
lists, even for quite serious illnesses. For a time, the new governing class – the business people – even
insisted that hospitals should show a profit!

At the age of 54 Steve developed angina pectoris. ( acute chest pain caused by narrowing of the arteries
of the heart ). It soon became clear that Steve would need heart bypass surgery for relief of this crippling
pain, and to provide him with some hope of a longer life.

Despite appropriate medication, Steve experienced angina several times each day. He carried on working
and maintaining his modest property assets, but life became a struggle.

His name had been on the waiting list for coronary artery bypass graft surgery ( CABPG or cabbage, as
it is often called) for over a year ,when he decided he could not bear to wait any longer.
I strongly supported this decision based upon my concern that he may, in the interim, suffer a major
heart attack.

Steve had limited privat insurance which would pay part of the cost of surgery in a private institution,
but a substantial amount of money was required in addition; money he did not have in realisable assets.
This, by now desperate, man, decided to mortgage his home to pay for surgery. He entered the local
private hospital and had extensive heart surgery.

The surgeon was satisfied with his recovery and Steve left hospital on the fourth post-operative day.

A month later he came to see me for a routine follow-up visit, after the surgeon had discharged him into
my care. He was now free of pain, his chest wound had healed perfectly and all should’ve been well.
 Page 46

However, he was clearly not the same man that I had known for years. His manner was subdued, his
answers monosyllabic, he slumped in his chair. He was depressed.
“Steve, despite the miracle of heart surgery, you are not yourself“.
“I’m okay“.
“No you are not yourself“
“I’m a bit upset“
“Upset?“
“Well, actually I’m really angry and frustrated. It is the system. It has let me down again. I have worked
hard all my life. I planned to retire at 60; but the government has taken that away from me. I cannot
receive a pension until I am 65. I got sick and nobody cared They just stuck me on the waiting list and
forgot about me. I feel so angry I could do something really violent, though I know I wouldn’t. I have
known for two years I needed the surgery and have waited patiently. And all of a sudden you people say
I’ve got to get it done straight away. I’ve had to mortgage my house. They cheated me again“

His tone was angry, but desperation and sadness were evident too.
“Steve you look so desperate and unhappy“. Steve began to cry.
“the system is not dealing fairly with you Steve”.
“Right. It is not. My brother Joe had the same problem. He went on the waiting list for 3 1/2 years; then
his heart began to fail. One day my wife and I went shopping with Joe and he collapsed on the ground. I
used CPR and revived him and the ambulance took him into hospital. They decided to operate on him in
a week’s time. They sent him home to wait; and he died suddenly, that night.“

By now the floodgates were wide open; Steve could hardly control his crying.
I waited a while, then commented. “You did your best for him but still he died“
“The system let him down. I wasn’t going to let it screw me up too. I know I have done the right thing,
but I feel so awful.”
“When did these feelings begin, Steve?“
“Well I was okay the first night, still pretty doped up with morphine and stuff, but next day I felt better. I
got up and walked around, my pain just about gone. I looked forward to going home. That night I
couldn’t sleep. I could hear noises from others, snoring, coughing, nurses talking. My mind wandered
and I felt terribly lonely“
Steve cried again “I don’t like to ask for help“
“How come?“
“There were people who needed help more than me. I knew I wasn’t going to die. The nurses were so
busy. I have heard of difficult patients who demand their services all the time. I wasn’t going to be
labelled one of those. It was a very long, very lonely night.“
“And next day?“
“I felt okay, had visitors, they were all pleased at how I was and my doctors were pleased too“

“What then?“
“That night was worse. The loneliness really was so intense and my anger kept growing and I felt
trapped. What could I do? Nothing at all. It was horrible. The next day my wife arrived and I burst into
 Page 47

tears. She was shocked -she had never seen me like that before, so she arranged to stay the night with
me. That was much better. The next day they let me go home“

“it would be a relief to get home?“

“Yes it was, but we had business concerns regarding lease of the property and my wife had to keep
going out to deal with that. She also works as a nurse. She has time to care for others, but not for me!
The last three weeks she has been mostly away, the weather has been rotten all that time, and the
loneliness has come back. I am okay physically but my nerves are shot”. Steve cried again. “My
daughter realises something is wrong. She has suffered from depression“

“You seem to feel some resentment to your wife though?“

“Yes; I am put aside for customers and for patients. This never worried me in the past, but now I can’t
stop thinking about it.“

It occurred to me at this time that what I was hearing did not seem to fit with Steve as I knew him. How
did it come about that this independent, solid, man, who prided himself on his ability to cope with his
world, was reduced to a pathetic dependent child-like person?

I decided to explore this aspect further, because the actual events seemed not to explain the intensity of
his responses. Perhaps some earlier experiences had bearing on all this?
“Steve is there anything about all of this that reminds you of your earlier life? Were you ever lonely?“

“No, my father drank a lot. He was wonderful when he was sober, but half the time he was drunk and he
would rant and rave all night so we couldn’t sleep. He never worked for a living. He was a clever
inventive man, never still, never relaxed“

“So he gave you your dislike of idleness and he also gave you some sleepless nights?”
“For sure he did. I never drank though.”
“How is it for you and your wife to be idle?”
“I don’t know. We never have been”
“So in this situation, you are having enforced idleness and your wife continues as before?”
“Yes. I suppose I’m not being fair to her. Someone has to do it, but I feel so trapped, so impotent”
“Impotence has several meanings doesn’t it?” Steve laughed a little sheepishly.
“That too, ever since I got heart trouble – another little difficulty in our marriage”

I thought that issue should be left at this time. This was a nodal point - as described in another chapter.
Where it is possible for the interview to follow various options. The decision about which path to follow
is usually taken very quickly, spontaneously, guided by gut feeling, whatever that is.

“Steve, you haven’t mentioned your mother“

“Oh, she was great, soft, loving, caring. Life was hell for her. I suppose she could have left, but she had
eight kids, of which I was the youngest. As a kid you don’t have that option to leave. I couldn’t walk
 Page 48

away from dad’s violent behaviour. There is anger of course, causing a trapped feeling. I wished he
would stop and I could not do anything to help mum. Our (family) system didn’t function very well”

I find it helpful to try to use my patient’s language. That indicates I am with them in their struggle to
understand the sources of their emotional distress.

“Your system?“
“Yes my family was my system and it let me down“
“Like the health system?“
“Exactly“

“So you are mad and frustrated? Can we then equate your father with the government?“
“Yes, they got control and they have betrayed me. Just like dad did.”

“So Steve, my fantasy is of this little boy lying in bed, feeling somewhat helpless, hearing all these
noises, wanting help but not able to ask for it. He feels incredibly lonely, sad and angry.

These early life experiences prime the pump of loneliness and anger. This little boy becomes the man
and the scars are not really healed. You’re okay as long as you can maintain your independence but it
was a real body blow to feel so helpless and uncared-for; just like in childhood. Only it was worse
because mum, as represented by your wife, wasn’t available to you either.“

“Yes; when you have lived this way all your life, with a background of trust in your system and it
betrays you, what can you do? I felt like giving up.“
“And now?”
“Well, I guess the worst is over. I suppose I need to be prepared to ask her when I need help. How else
can she know and she is a very good wife to me“

“I have a couple of suggestions Steve. Firstly, it may help to explore this further, so we could arrange
another appointment. Secondly, I think a course of antidepressant medication will speed up your
recovery. You have all the signs of depression, and we know that depression slows the healing process.”

Steve agreed with these suggestions and made another appointment.

He started antidepressant medication that day. A week later he phoned and insisted on speaking with me,
and said that he had decided not to keep his further appointment, on the basis of cost and because he felt
so much better.

I thought initially that that meant I had failed fully to engage him, that something put him off further
talking. After all, there were still unanswered questions. Why was he sexually impotent? Where did our
relationship fit into the system? Were antidepressants really necessary? Had this discussion been
sufficient to restore his self-esteem?
 Page 49

However, Steve faithfully took antidepressants for three months and then, after discussion with me, he
discontinued them. He had overcome his symptoms and taken up some new interests. He decided not to
return to work, and was able to get some financial assistance from the state. He managed to keep busy –
his major defence against loneliness and depression - and declared himself fully recovered. Even his
impotence had resolved.

Steve visited me every three months, until I retired. He was a little embarrassed by his “breakdown“, but
never failed to mention “our little talk“. Was this keeping the door open,in case of some future need to
talk about his life again?

The scenario of an apparently independent person who experiences a major stressful event, then
collapses into a state of dependency and depression is not uncommon. We all have defences against
depression and to people like Steve, the defence of busyness is a powerful one; until an overwhelming
experience renders him incapable of controlling his world and then he feels as if all is lost.

It may be argued that the depressive aspects were immediately obvious at the beginning of this
consultation; so that proceeding straight to antidepressant medication after becoming aware of the
depression would have been appropriate treatment, thereby saving the patient the money and time
involved in this one-hour session. It could further be argued that he would have recovered his
equilibrium with the lifting of the depressive symptoms and therefore much of what I have written about
was unnecessary.

However, my view is that an opposite stance can be taken, it being argued from this point of view that
antidepressants were probably not really necessary after he had expressed his deepest concerns. General
practitioners are people who like to fix things quickly and l have no hesitation in firing both barrels from
my therapeutic armamentarium.

Furthermore, I think that the understanding we reached had ramifications within the relationship
between doctor and patient, and should Steve have further problems with life events and depression, he
would probably easily be persuaded to express these concerns. This is one of the great virtues of the
longitudinal care in family medical practice.

A LOVEABLE MORPHINE ADDICT: GEORGE

George first consulted me about his chronic back pain. There was no history of injury.
Examination of his back revealed nothing of significance. X-rays weren’t helpful.
I told him that I could not understand the symptoms from which he had suffered for three years, from the
age of 16.

He insisted the pain was severe and prevented him from working.
 Page 50

It is difficult as a doctor to admit inability to do that for which I am paid; to diagnose and treat patients’
problems. I know also, that patients frequently present complexes of symptoms which do not readily fit
with known syndromes and are often manifestations of emotional distress. There is, however, a
possibility that the patient suffers some physical condition of which he is unaware. This situation can
sometimes be relieved by referral to a specialist colleague.

In George’s case I did not choose this course for two reasons. First, I had examined him carefully and
could not detect any abnormality. A normal x-ray was only a little reassuring, in that ordinary back x-
rays seldom show any abnormality that is unequivocally related to the symptoms. CT scans and MRI
scans are highly sophisticated tests, but were not at that time readily available. Anyway, by this time I
was fairly convinced that George’s problems were not located in his spine; but in his mind and that
further specialised tests were unlikely to help.

My second reason for not referring is more difficult to explain. There is a term ‘reification’ used to
describe “setting in stone“ of symptoms. In my experience, the more we investigate physically
symptoms of psychological origin, the more fixed they become and the more likely a shift of the
doctor’s focus to psychosocial and cultural factors may be perceived as an insult and rejection. This shift
needs, where possible, to emanate from a comment by the patient which leads naturally to inquiry into
that area. The earlier that shift in diagnostic focus, the more likely it is to be acceptable to the patient.

Having made the decision not to investigate further, I had to decide what treatment to offer George. One
option was simply to state that I could not help him- not productive but honest.
I could fob him off with the offer of physiotherapy or acupuncture. This would have been dishonest and
unhelpful.

The final option, which I chose, was to state honestly my findings and suggest that perhaps if I knew
more about him, I may be able to understand better the cause of his back pain.

George protested “it’s not all in my head, doc“ and I agreed with him that the pain was far from his head
and that I had no doubt of the sincerity of his symptoms. I gently insisted that it was possible that events
in his life may have contributed to the pain, even if only to make him more sensitive to those life events.

Reluctantly, he agreed to return for a 30-minute session, as a beginning to understanding him as George
rather than ‘sore back.’

He was a tall, handsome young man, the product of a racially mixed marriage, being partly Maori,
partly Caucasian - called Pakeha in New Zealand. Regrettably in New Zealand today, that suggests a
high probability that he will be economically, socially, and educationally deprived. George confirmed
this by telling me that his father, a drug addict, died when George was eight years old.

He described his mother as a bright, loving Maori woman, who had difficulty setting limits on behaviour
for George, from infancy onward. He was allowed to choose whether to attend school or not, and petty
theft was not really frowned upon.
 Page 51

He described himself as living on the criminal fringe, involved in petty burglary, car theft and
shoplifting. As we talked, he progressively relaxed and I was treated to his brilliant smile, which seemed
to mellow the room. I began to appreciate his wit and innate intelligence, though he seemed not to be
psychologically minded.

He boasted of his ability to steal a car in less than a minute, and even offered some tips on how to avoid
having my car stolen!

In that half hour I developed a little “feel” for who George was, but I was somewhat concerned with the
conspiratorial nature of a petty thief advising me how to avoid intrusion of crime into my life.

This was later to become an important theme, as George seemed to validate himself in terms of success
of crime. It also was a barrier to deeper understanding.

At the end of this preliminary session, in which I realised that his problems probably started from birth, I
thought it unlikely that he would benefit from insight–oriented psychotherapy, and it was quite clear
George would not want that. I said so.

He surprised me with a striking insight. He said that he really enjoyed talking to me and really wished he
had had a father to talk to.

Time was up, decisions had to be made, and I was still unsure how to help.

Not only was I doubtful of the potential of psychotherapy for George, but I knew he had no way to pay
for that kind of treatment.
I have learned over the years, to consider carefully the impulse to offer long-term help at no cost for my
patients. The argument is often made that people do not value what is free, and this applies especially to
talking treatments. This may be true; but I’ve never had a patient say so.

I have not had much success with such charity work. After a period of time in such a relationship, I
notice that I tend to feel disillusioned with treatment and gradually resentful of lack of payment for my
freely given time and expertise. In this situation I’m not receiving sufficient emotional reward in terms
of improvement in the patient, to compensate for the monetary loss.

This is very unfair to the patient; who should never be responsible for my sense of well-being.

I have no problem with free family practice consultations. I think we all do this to ensure people do get
basic medical care. Regrettably, funding agencies have little interest in “long consultations“

When I get paid for my work this is a major reward. When my patients respond to treatment, then
together we have done a good job.
 Page 52

George offered a compromise. He asked if we could meet for 15 minutes each week, for which he
would pay my normal fee.
I prescribed some nonaddictive pain relievers and accepted his offer.

At the very beginning of our first session George admitted to being a drug user; mainly morphine and
diazepam ( an ant-anxiety medication ) in small doses.

In our weekly meetings, George regaled me with the stories from the minor crime world; which. whilst
interesting, gave me a feeling that in some way I was colluding with his antisocial lifestyle. I tried, with
limited success, to persuade him to shift discussion to his
non-criminal life, but he always denied his problems had any relationship to his childhood or that his
view of the world was distorted.

Six months later, he failed his appointments. I learned that he had been arrested for burglary and
sentenced to one year in prison.

After discharge from prison, George presented in a distressed and depressed state.
He said that prison had been a terrible ordeal, in part because he is of his mixed racial heritage. Maori
are overrepresented in New Zealand prisons, a consequence of many years of economic and social
oppression. In prison Maori tend to associate with each other, to the exclusion of both Pakehas and other
races. There is an expectation the new prisoners will align themselves according to racial background,
but George knew little of Maori culture and was excluded by other Maori prisoners.

Accordingly it was a lonely and frightening ten months until his discharge on parole.
He told me he had been taking drugs in prison and since discharge his back pain had worsened. He
claimed he would have to resort to crime in order to get his desired morphine. He begged me to supply
him with a regular small dose of morphine.

I refused his request on the basis that in New Zealand it is a crime for a doctor to supply narcotics for the
maintenance of drug addiction.

Experiences like this make family doctors suspicious of “drug seekers“. Most are easily recognised by
obviously fictitious stories which have a certain commonality, such as those who are just visiting the city
and have lost or had their drug supply stolen.

One young man presented with a plaster cast on his leg having “just come out of hospital in another
city, and urgently needing to visit my mother here, who was suddenly taken ill. In the rush, I forgot to
phone for my morphine pills.”
When I said I would be glad to help – after I had called his doctor – he gave me a smile and said; “well
done doc. I think I’ll be off now.
 Page 53

In George’s case the request was much more transparent, based on his belief that he would be able to
avoid prison, stop offending, perhaps get employment and change his ways. This formulation had a
certain logic to it from my standpoint.

It is clear that morphine taken on its own, is in fact a very safe drug. The worst features of addiction are
a result of denial of morphine by the state, and the misuse of it with contaminated needles.
I do not espouse the view that morphine should be made freely available, but there must be many cases
where everyone is better off if diseases such as hepatitis and AIDS are prevented and petty crimes are
reduced.
Morphine has few side-effects and is probably a much safer drug than alcohol.

Such was the power of George’s pleading, combined with my sense that he was fairly trustworthy, that I
agreed to discuss the situation with my partners. They were sympathetic, but mindful of the risks too.
They thought that supplying George without legal authority would have me sailing too close to the legal
winds. We agreed that discussion with the local medical officer of health would be a sensible move,
because he was an independent judge.

This senior doctor had sympathy with the case I presented, and in view of the fact it was not possible to
get an appointment with the methadone clinic, agreed that I would supply George with an agreed-upon
dose, to be collected from my office daily. It was agreed with George that any deviation from the
agreement would lead automatically to the cessation of the agreed-upon arrangements.

George maintained the terms of our agreement and our growing attachment was displayed when he
mentioned one day that he owned three guns – a.22, a.303 rifle and a sawn-off shotgun. I asked him why
he had the guns and he explained that he planned to sell them if he had sudden need of money.
I was horrified, and said so, emphasising that whilst I thought it unlikely he would use them,
nevertheless if he sold them and someone else used them, it would be in part his responsibility.

I ask him to give the guns to me and I would hand them in to the police.
It was quite amusing the way he responded to this request from me-as if I was suggesting something
absolutely unimaginable! Then I suggested I would give him $100 for them. He said no and we parted.

Later that morning, however, George called me; saying that he had decided to sell the guns to me and I
arranged to meet him at my office in the afternoon. It was agreed that I would drive my car to the place
where the guns were stored.

I called the police to inform them that I would be coming in to deliver the guns and initially was told that
I could not do that because I did not have a gun license! This piece of idiotic bureaucracy was rapidly
dealt with, and George and I drove some distance into the city, until he told me to stop as he would
rather walk the rest of the way. He explained that a fancy car like mine would attract the wrong kind of
interest where he was going.
 Page 54

A few minutes later he arrived back at the car with a sinister looking bag – just like in those American
mafia movies. I directed him to put the guns in the trunk of my car then paid him as we had discussed
and agreed. I was surprised that he accepted my offer of a cheque in payment. He told me; “you trusted
me!”

We drove into the city and a few blocks before the police station, George asked me to stop, saying he did
not much like police stations.

I then parked outside the police station and told the constable why I was there.He invited me to bring the
guns in and after I told him I would not handle a gun, he went to my car, carried the guns inside and laid
them on the counter, showing me the registration signs. I gave him a formal statement, in which I
refused to include George’s name, but did include that I had paid $100 for the guns.

I thought that was the end of the episode, but to my amazement, a month later, I received a note from the
police thanking me and enclosing a check for $100 “without prejudice”!

One day a few months later, George appeared looking very drugged.
A urine sample confirmed the presence of a number of different drugs. I felt betrayed, disappointed, but
not very surprised. This venture had always carried this risk.
My practice nurse and I spoke with George, telling him that we had to cancel our agreement. He was
terribly upset, cried, begged forgiveness, swore it would never happen again.
I weakened and gave him another chance. Three weeks later it happened again and we suspected he was
selling the morphine we supplied him with.

We cancelled our arrangement. I told him I was willing to continue meeting him, but he refused and left
my practice.
He was back in prison within a month.

This story has been discussed with colleagues, whose opinions widely varied. Some said I was naive in
thinking this could work. More liberal friends took the view that though the success of treatment was
limited, George did stay out of jail for many months and was crime free for that time. One colleague
even suggested that the dose of morphine given was too low and failure was inevitable. Would I do this
again? Probably.

I have heard indirectly that now in his 30s, George has given up drugs and is free of crime.

TAMATE
 Page 55

Tamate was a quiet, thoughtful man, Maori, and had the Maori custom of not looking directly at me.
Accordingly, I needed to look less intently at this patient than is my wont, out of respect for his cultural
traditions.

Tamate had experienced rheumatic fever twice as a child, ( rheumatic fever has a higher incidence in
areas of low wealth. It coexists with streptococcal throat infection, which is a causative factor with this
illness. )

As a result of his childhood rheumatic fever,Tamate has a damaged valve in his heart and has had
another valve replaced in open-heart surgery a few years previously.

I had not seen Tamate for a year. However I had just received a letter from his cardiologist, informing
me that his heart condition was much worse than a year ago. I had written to the specialist, noting I had
not seen Tamate for a year and wondering what that meant.
I had received no response from the cardiologist.
Clearly Tamate had not been taking his prescribed medication.

He had chosen to consult me independently.

I asked how it came about that he came to see me this day.
“Well, I knew I had to face the music at some stage with you Dr. Jones, and I did not want another
doctor. But I was scared to come.“
“What made you scared to come?
“Of course I knew I was supposed to come, but somehow I could not summon up the courage. I thought
I would be punished by you“

I felt awful! What could I have done to offend and frighten this man of my own age who only wanted
my help?“
A silence, then; “Tamate I wonder if you think there’s something about me that you have found difficult.
I need to know what I have said or done to put up barriers that interfere with your treatment? I can’t treat
you if you don’t come, so if that is my fault, can you help me to understand?”

“Well um, actually I can’t remember now just what it was. It must have been your manner. You seemed
abrupt and I felt just like as a child when my father was being hard on me. I know it is not really your
way of doing things, but it was how it seemed to be then“
“Then you had good justification for not coming back. I’m just wondering if my way of looking at you is
at fault?”
“I have been told at times that my gaze is very intense, and now I’m remembering how Maori
prefer not to be stared at”

“You got it, Doc. ( His saying this was accompanied a large change in mood and affect, symbolised by
his use of the word ’Doc, to lighten up communications between us. )
“
“I think I noticed you seemed to stare at me the last time I was here”
 Page 56

“Well, Tamate, I’m feeling bad about this. I can only apologise. Will that do.?”
“Yes Dr.( graciously) I appreciate that you want to know and of course I accept your apology“

This exchange allowed us to be more relaxed. I did not have to disengage from Tamate, but simply look
at him more briefly. It was interesting that just as I learn this unfamiliar way of looking at the other
person, so Tamate was emboldened to look more directly at me.
We parted much warmer to each other than we had following our past appointments.

This is an example of the power of the transference. Tamate unconsciously identified me as his father
and expected me to punish his transgression.
My error was to gaze at him too intently - a combination of two errors- ‘just like Dad’ and in
transgression of Maori custom.

In reviewing this experience, I wondered if the reasons for not attending the cardiologist were the same.

The consequences of us not working this out could have been serious. If Tamate continued to fail
appointments, his heart condition would certainly have deteriorated and death ensued.

Tamate decided to keep his appointment with the specialist and eventually underwent surgery for his
damaged heart valve. This was completely successful and Tamate returned to work and continued to
keep his post- surgery follow-up appointments.

POST TRAUMATIC STRESS DISORDER

Post Traumatic Stress Disorder (PTSD) is a psychological process, a reaction to an overwhelming event
or series of events, such as a car crash, rape, earthquakes, or ongoing cruelty in which the person is
helpless to control the outcome.

In the initial stages, the sufferer might experience a sense that their world has come apart; nothing that
happens has meaning; accordingly it can be difficult to love or be loved.
There may be flashbacks of past traumatic experiences, hyper-vigilance, in which the person is
constantly on guard against further traumatic experiences, and attacks of florid anxiety.
Eventually all this may lead to chronic helplessness and hopelessness, a feeling of complete defeat.
The sufferer is at risk of severe treatment-resistant depression. The afflicted person may give up on life
and travel through it as a passenger, rather than a participant.
Traditional psychotherapy is generally not helpful and neither are antidepressants, tranquillisers or
antipsychotic drugs.
 Page 57

DIANE

30 years ago, Diane went to an evening school meeting. Martin her husband, 10 years her senior, was at
a friend’s house, fixing their car. Her two children were left in the care of Martin Junior, aged 15,
Diane’s stepson.
When she arrived home accompanied by her brother, she stopped by the children’s bedroom, to check on
them.

She looked at Wayne, aged five, first. His bed was covered in blood. He had been hacked to pieces.

Diane calmly walked into the living room and said to her brother; “I think he’s dead“.
The brother rushed in, with his wife, to find both children dead- and horribly mutilated.

Diane remembers the screams of her sister-in-law, her brother’s rage and distress and her own icy calm.

“I knew I should’ve been upset; I could understand him being like that, but I felt nothing“

She remembers going through the formal police procedures; of being told her stepson had admitted to
the crime, but only feeling numb and distant. “It was as if I wasn’t really there“

At the funeral of her two children – her only children – Diane was totally composed, while those around
her were distraught and reacted with prolonged weeping and grief.

Apart from never returning to their house, life rapidly went back to normal. Diane vaguely wondered
why she never cried and never felt rage towards Martin Junior, who was sentenced to life in prison. Even
sitting through the trial was a nonevent, emotionally, for Diane.

I had looked after Diane for nearly 20 years. She came with her first pregnancy, which was perfectly
normal - but the baby died 24 hours after birth of no known cause.
She became pregnant again and this baby died two days after birth; again no cause.
She tried again – a courageous woman – and quite quickly had two children, who some years later were
murdered.

I was in America when all this happened. I returned two years later and in the second day of my
resumption of practice, Diane arrived for a consultation.
I had no prior knowledge of the events.
She sat down, looked steadily at me and asked; “where were you when I needed you?“

I shall never forget my response when she told me this horrific story.
 Page 58

My eyes filled with tears and I felt anxious and guilty. My impulse to apply closure, to escape somehow,
was countered by my realisation that my response was not just personal grief, but also a resonance with
something going on beneath her calm exterior.

I invited her back to tell me more and she agreed.

We had several hours together, but we never broke through her calm demeanour. She refused the option
of transferring to another therapist, so we were stuck in the denial that seemed her way to cope with the
horrifying loss of her two children - and I accepted that.

After discussion she decided to have another child, delivered by Caesarian section a year later. This
decision was made despite the fact that her husband’s minor asthma problem had become disabling since
the death of the murdered children. I attended the birth and joined in the joy of the healthy normality of
this newly born little boy.

When their son was eight years old, Martin senior deteriorated rapidly. He developed a psychotic state
apparently due to the heavy dose of steroids prescribed for his disabling asthma, during which he talked
repeatedly of the murdered children. He died quite suddenly.

Martin’s death was not really unexpected.

Diane coped brilliantly - until Martin Junior, now out of jail, arrived at the door.
She felt a terrible shock, a physical feeling, but controlled her agitation and let him come inside. Martin
junior behaved as if nothing had ever happened. Over the time of the funeral of her husband and in
subsequent days, Diane began to think more and more of the dead children. She became agitated,
sleepless, panicky and had suicidal ideation. She thought she was going crazy, could not sleep and only
with difficulty managed to suppress the memories of that terrible night.

For the next 2 to 3 months, Diane put up with the suffering.

Eventually, her denial system must have mastered the intrusiveness of her thoughts, because the anxiety
settled.
However she suddenly felt anxious again and presented to me with florid anxiety, combined acute
symptoms of depression. She agreed to enter into psychotherapy and to take antidepressants.

The antidepressants were helpful, but the psychotherapy was not.

We agreed that she would continue with the medication - which she did, and maintained a kind of
steady-state; not happy but not unhappy.
She acknowledged this numbness and settled for it as an alternative to the active anxiety and depression
she had been experiencing over the years since her two children were murdered.

It is worth mentioning that Diane had wonderfully supportive parents, who never wilted under the strain
of this marathon traumatic experience.
 Page 59

It was with sadness that I said goodbye to Diane when I retired. She had not been a ‘successful case’ and
I so wished I could have done more to comfort her, and help her to cope with her emotional pain
subsequent upon the loss of her two children in such a cruel manner.

LINDA

Linda and I had been associated medically for many years. As an early middle-aged woman, she was
severely depressed, and unresponsive to any antidepressant medication. Many hours of talking over
these years did not provide much relief and the on-going depression seemed to have invaded and
practically destroyed her sense of self.

She had experienced a deprived, brutal life during her childhood.

Her father had left their home when she was an infant, and her mother, a sadistic woman, seemed to
derive pleasure from constantly beating and depriving Linda. This was a case of “Soul Murder” in which
the unprotected child or adult is subjected to such constant abuse that normal psychological and
emotional development is not possible.

At the age of 17, Linda met a man who gave her her first experience of love and approval. She was
happy to leave home to marry this man. Her happiness though, was always limited by almost total lack
of self-esteem. She has always been quiet, to the point of verbal and emotional retardation, though she is
of at least average intelligence.
“After all”, as she said, “you don’t venture an opinion if you know it will be ridiculed and perhaps
followed by a beating.“

She was pleased and proud two years after marriage to give birth to a healthy son.

A year later Linda had a miscarriage which she accepted philosophically.

She became pregnant again in a few months and this time carried the pregnancy to term.

Her baby, a boy, died a few hours later. The baby’s distress was noted immediately after birth and he
was placed into an incubator. Linda was not told until the next day that her new- born son had died. The
doctor and nurses refused to allow Linda to see the child, who was taken away and buried without
ceremony. Linda was also not told of this till the next day. She cried and cried but was told not to be
silly and was discharged on the fifth post-natal day.
She was offered no information as to the cause of her baby’s death.

A long period of profound depression followed, during which time Linda became pregnant again. A year
to the day after her previous baby was born and died, Linda delivered an anencephalic baby.
 Page 60

Anencephaly is the term describing the failure of development of the head, including the brain. Such a
child is grotesque in appearance when born.

This baby, also a boy, died three days after birth. Again, Linda was not allowed to see him.
“If only I could’ve just held him. I wouldn’t have cared what he looked like. He was mine. They
shouldn’t have done that to me“

Linda was accustomed to abuse and accepted this, as she had every other traumatic experience in her
life; with intense sadness and further diminution of her self-esteem.

Her husband seemed to be unable to understand Linda’s reaction. He was a practical man, not given to
emotional expression, and reflected the view that life can hand out bad deals “, but you just have to get
over it, and get on with life”.

I remember vividly when Linda first told me of this. I had been treating her for some time for depression
and she had been quite reticent about her past. She sat, looking emotionally distant and recited these
experiences in a flat monotone which seemed somehow to make the story even more vivid and
horrifying.

I felt overwhelmed and could think of nothing to say that would help.
There was a long silence. “Linda I am so shocked by your story I don’t know what to do or say.”
Another long silence. Then, with tears flowing; “at least you don’t condemn me. I couldn’t tell you that
before because I thought you too would say I was just being silly“

Linda consoled herself for many years by being a foster mother, at the same time bringing up the son she
had borne and another son that she had adopted after the last obstetric catastrophe. Her love of children
was well known to the Department of Social Welfare, who knew that Linda would also give abandoned
children a caring home on a temporary basis.

We had always had an agreement that Linda could make a special half-hour appointment just to talk. I
could never detect any apparent progress in relief of her depression. Linda said it helped just to talk;
“because who else would listen to me without disapproval?“

Over the next few years we met intermittently. Referral to a psychiatrist was not helpful.
It seems Linda had a “treatment-resistant depression - one that could not be relieved by any
antidepressant medication.

Three years later, Linda reported feeling a pain which seemed to emanate from deep in her pelvis. I
could not find any cause, despite repeated examinations and appropriate laboratory tests.

Linda consulted with two gynaecologists; both of whom confessed they too could not offer a diagnosis.
 Page 61

When she first presented with this pain I thought it likely that it was of psychological origin, but the
intensity of pain she experienced during routine examination and the rapidly escalating severity of it
contributed to my decision further to investigate.

At this point I was forced more seriously to re-examine the earlier hypothesis.

One of my earlier mentors, Dr. C. Knight Aldrich, taught me the importance of primary diagnosis of
psychosomatic disease. He showed me that if we treat a condition we suspect is psychosomatic, as
physical, and adopt a “ rule–out” approach, that is, exclude all known physical conditions before
pronouncing the condition to be of psychological origin, the patient is likely to interpret this as a
“garbage tin” diagnosis. “He can’t think of anything else, so he says it’s in my head“.
Making the transition to emphasis upon emotional factors is likely to be impeded by the patient’s sense
of belittlement or even disrespect. Just as in physical disease, psychological distress requires a firm
diagnosis based upon evidence, gained by informed, detailed interviewing of the patient.

In Linda’s case I had no option but to backtrack, so I invited her to talk more.
She accepted the offer to come weekly to talk about her symptoms and her life experiences in greater
depth.

She described again, and in greater detail, her oppressive, brutal childhood, as well as a sense of further
brutalisation by her obstetric experiences. She wept a little, visited the graves of her two infant sons.
We talked and talked; but Linda’s pain got progressively worse. She sat in my office begging me, with
pain on her face (and clearly in her heart) to relieve her pain and distress.

Nothing I did helped. We tried every medication I could think of, from muscle relaxants to tranquillisers
and antidepressants. All were useless.

Her pain escalated such that she was unable to live a normal life. She could not visit the supermarket, or
even her few friends.

Linda’s husband, a simple man, became increasingly exasperated with her and less obviously, with me
as well. In desperation, I tried her on a small dose of morphine twice daily. This helped a little, but not
enough to restore her enjoyment of life.

The use of morphine for pain relief has traditionally been restricted to the terminal stages in the
treatment of cancer. It was said in the past that morphine was a highly dangerous drug with severe
addictive tendencies.

I had recently attended a seminar devoted to the relief of pain. I was impressed with the new views
about morphine, supporting the idea that unlike most other medications, morphine should be prescribed
in sufficient dosage such as to adequately relieve pain and that the actual numbers of milligrams used
should be of little clinical significance. That is, we should prescribe whatever amount of morphine it
takes to relieve the patient’s pain.
 Page 62

The presenters of this seminar emphasised that addiction to morphine, given the circumstance of severe
pain, is in fact uncommon.

After much thought and further discussion with a colleague, I recommended to Linda this course should
be tried. She readily accepted the offer and we started with the small dose of morphine previously tried,
rapidly increasing to several times that dose. At quite high – by previous standards – one hundred
milligrams twice daily, Linda’s pain came under control and she resumed activities she had not been
able to participate in for three years. The pain has been controlled now for some years without further
increase in dosage.

The obstetric events Linda experienced should not have happened.

She experienced what today would be regarded as negligence. Yet in the 1950s, such conservative,
apparently uncaring behaviour by physicians was common. I do not think in these days of better
mutuality in medical and nursing care, Linda could possibly be so medically traumatised. However, the
neglect and brutality that Linda experienced in childhood set the stage for her effectively to be
destroyed, in terms of self-esteem and the consequences of this set of experiences seemed not to be
treatable.

I find it distressing that a woman of her innate kindness and basic decency should have to experience a
lifetime of misery and now pain.

I have no doubt the Linda’s pelvic pain is psychosomatic. She does not imagine this pain, it is real and
crippling. I think that she unconsciously trades off her unbearable emotional pain for the more bearable
pain in that part of her body most intimately concerned with love, reproduction and children.

It may be that Linda fits the diagnostic category of “post-traumatic stress disorder ( PTSD). She certainly
has suffered many times more than her fair share of traumatic events.

Unfortunately, brutality towards children continues to be commonly encountered. In fact, PTSD seems
to have become more prevalent in our contemporary society and one wonders whether a significant - and
growing segment of the future community - is going to be so damaged psychologically, that living a
normal life may be impossible for them. Many of these people will choose illness as a method of
communicating distress, and it is incumbent upon us in medicine to endeavour to sort out the
psychological factors at the root of their distressing symptoms.

Linda continues to take her morphine in the same dosage and to be free of significant pain.
 Page 63

DORIS

Living in a small city inevitably leads to complex personal and professional connections.

When Doris and her husband, David, joined my practice 25 years ago, Doris informed me that her niece
had been a good friend of my wife during their nursing training.

Not only that, David had worked as a dental technician with my father, a dentist, for many years.

These connections whilst coincidental, are often quite important in the early development of the
relationship, as they are in ordinary life. They serve to establish some sense of specialness.

This later proved to be to have considerable significance in my relationship with Doris.

When we first met, Doris was a 62 year-old healthy woman with hypertension (elevated blood pressure),
well-controlled with medication. We dealt mainly with minor complaints for the first two years. I
noticed though that she always emphasised and exaggerated the seriousness of her symptoms. However,
I made no attempt to explore that issue.

Ten years ago, she presented with a lump on her left breast which was shown to be malignant. She had a
mastectomy and made a good recovery. Doris was indignant that the surgeon seemed not to care for her
as an individual. She believes that little heed was taken of the severity of her condition or the extent of
her suffering.

Her hypertension eventually worsened and a more powerful medication was needed to control her blood
pressure and the resultant strain on her heart.

A year later she presented again - with a malignant lump in her other breast, and adamantly refused a
mastectomy. Instead she opted for surgical removal of the lump only, followed by radiotherapy.
The course of radiotherapy caused complications in her lungs and marked swelling of the right shoulder.
She experienced worsening chest pain.
Doris’s visits to me became more frequent, at least weekly and she had a multitude of complaints each
time she came.

I assumed that her serious illnesses made her more introspective, as well as making her death seem more
imminent and very frightening. It seemed the consequence of these feelings was a concentration upon
minor complaints which I was expected to cure.

My feelings towards Doris changed. I began to dread her visits, in the knowledge that I would have to
deal with all these symptoms, the severity of which would be underlined repeatedly during the
consultation. I knew that I was not able adequately to diagnose the symptoms and that any treatment I
suggested would not be effective in relieving her distress.
 Page 64

I also knew that I could not deal with the major problems of breast cancer, lung damage and a painfully
swollen arm. Accordingly the consultations mostly ended in mutual dissatisfaction and I usually felt
deflated and incompetent as well as hostile by the time she left.

Often much can be achieved in an standard 15-minute consultation, but with Doris I felt overwhelmed
with the sheer bulk of complaints, in addition to feeling frustrated and angry with her whining recitation
of her miseries.
We carried on in quiet desperation, until suddenly she said; “you know Dr I have noticed that I seem to
become vaguely ill in bouts every two or three months. What could that mean?“

Referral to my notes verified her statement. The frequency of her visits did seem to be in clusters in
regard to symptoms that defied diagnosis in terms of anatomical or physiological disease. I had often
wondered if Doris was depressed; but inquiry has not revealed the typical symptoms of the depressive
syndrome. In fact, there was insufficient evidence of depression even to consider a trial of
antidepressants.

I remembered that ten years ago I had attended David, her husband, at home, when he died suddenly
from a heart problem and that she was devastated by her loss.

“Could this have anything to do with David’s sudden death, Doris?“

She thought for a moment then; ”perhaps, but my thoughts run to my mother.”
She started to cry, initially just a few tears, then a gush accompanied by sobbing.
I was astonished. It was as though floodgates had been opened. I waited, passed her a tissue, and in a
minute or two she recovered enough to say; “she was an old devil. She never cared for me. She told
everybody I was no good. She even said; “don’t ask Doris to do it – she’s no good at anything you
know“

Doris‘s father was a reserved man, who worked hard to support his wife and three children. He was
never emotionally available for Doris. Her brother, seven years younger, was; “the apple of my mother’s
eye. He could do no wrong”.

A sister ten years younger was her father‘s favourite.

Doris remembered vividly seeing her sister sitting on her father‘s knee, being read a story and Doris
wishing that someone would do that for her.

It was now 25 minutes into a 15-minute consultation. Doris smiled through the tears, as the sun through
watery clouds and she said; “I have held this secret of my lifelong unhappiness to my chest all these
years. Every single night I go to sleep wishing my childhood would have been happier”.
“I have cried so much. Only David knew. Marrying him, I found love for the first time. How I hated my
mother; but you can’t tell anyone something as horrible as that. Now I have and I feel like a weight lifted
off me”
 Page 65

At this moment I realised just how little I really knew of Doris; many years of care and not knowing she
hated her long dead mother! What could I do to help her? Clearly the problem of the occurrence of her
symptoms in clusters could wait.

I decided to offer to know her better. I took the opportunity to signal the end of the consultation and
invited her to return each week for 15 minutes to talk more.

Doris is a pensioner, not financially well off, and I was intrigued with the whole story; so I added that I
would like to do this without charging her any fees.
I also added that we needed to put aside all medical issues for that “special” time.
I told her that I considered this to have been a special experience- and important for me - and that
perhaps there was plenty for me to learn.

In typical fashion, she initially declined my offer, saying; “I’m just being a silly old woman” - but I
persisted in my view that it could do no harm to let me get to know her better.
She quite quickly accepted my offer.

We agreed that we would meet six times, that she would begin each session with whatever she chose and
that as well as not talking about physical symptoms, we would not exceed the time allocated for her
appointment.

I have used this technique a number of times over the years, with people who present with frequency of
consultations, the content of which seem rather trivial and had led me to think that there is some greater
significance to the attendance than meets the eye. The most natural tendency of such patients is to start
the sessions in the language they know best-that is, the language of sickness. It can be quite difficult for
them to use a different language - that is, of feelings and life experiences.

Patients who harangue the doctor with lists of puzzling, unexplainable symptoms may be labelled as
“hypochondriacs,” an old expression, referring to that area just beneath the ribs, thought in the past to be
the origin of “neurotic“ manifestations. This diagnosis still has a place in the medical lexicon though not,
I suggest, an honoured one, occasioned more by the doctor’s frustration than scientific or clinical
acumen.

I anticipated that the beginning of the first session would be characterised by an account of further
symptoms; but such was not the case. Doris started by saying that she felt much better. For the first time
in her memory, she had gone straight to sleep without giving her mother a thought.

She recalled that her mother‘s parents were kind and loving towards her. In retrospect she thought that
they knew she was lonely and rejected. She agreed that her grandparents were probably the people who
gave her the capacity to love, despite her abysmal lack of self-esteem.
 Page 66

Her grandparents had given her a jointed wooden doll – presents were not common in Doris’s life. She
treasured this doll. Her brother chopped it to pieces with an axe when he was 12 years old and she 5. Her
mother‘s comment about this terrible incident for Doris was; “too bad, you shouldn’t have left it lying
around.”
She cried for days at the cruelty of her mother’s comment and she further cried when she told me that a
year later her grandparents died quite suddenly and she felt totally alone.

During her adolescence Doris complained one day of a sore throat. Her mother told her it was her
naughtiness coming out and to get off to school. She persisted in her complaint o feeling too unwell to
attend school, but to no avail. Two days later, she was rushed to hospital with diphtheria and underwent
emergency tracheotomy, a life-saving operation to allow her to breathe.

When she finished telling about the diphtheria and the emergency treatment required to overcome the
infection, I commented that however hard she tried, her mother could not, or would not, hear her
distress; that perhaps she had felt something similar about telling me?

She seemed surprised by my comment, then agreed; at the same time reassuring me that I’m not at all
like her mother!

As a child she tried in every way possible to gain approval from her mother.
Once her mother made her enter a cake baking contest. She won first prize in three sections but at home
there were no congratulations; only a chilling comment about her failure to gain a place in another
section.

During the third session she said that she now felt medically secure. “Before, I used to go home with the
pills you prescribed and wondered why I didn’t get better. Now I think it was because I didn’t reveal
myself to you and your help was always a guess”.

I noticed too that I felt better; in fact, I looked forward to these special and intimate sessions.

About this time, I discovered that she had developed mild diabetes. She took this in her stride as if- (as
was true)-it had little importance. I wondered at the time how she would have coped with this
information six months previously.

She also had bronchitis, based in part upon lung damage caused by her radiation therapy. Again, her
response to treatment was prompt - and as complete as could be expected.

By the fifth session Doris had spoken of the happiness she experienced in marriage and in being a
mother. A few months before, her daughter had moved 25 miles away and had become much less
available to Doris.
Doris was initially angry towards her daughter, but during the course of her “therapy” (which she quite
spontaneously called it), she lost that resentment and accepted that her daughter, now retired, had to
move to a different life stage.
 Page 67

It was evident that Doris felt rejected by her daughter’s move and she suffered some recapitulation of her
desperate loneliness. However, this cleared with her revealing to me that she had these feelings and
recognised that they belonged with her mother, not her daughter.

In the last of the planned six sessions, Doris described an incident from childhood involving her mother;
“that woman with no soul, no sense of justice, no pity, no love ”

This happened about 1940. Her brother then aged ten, delivered milk to neighbours, for which he was
paid a small sum. On this day he left the money in an empty container, for his mother, but failed to tell
her so. Later mother accused him of having stolen the money. She gave him a merciless beating. Doris
said this was typical of her mother’s behaviour towards her and her brother.

She had an amazing capacity to surprise me, exemplified by her follow-up comment. “I’m beginning to
feel some compassion for mother. As I remember, I realise life was very hard for her. She had
experienced little of goodness in her life”

This final session included a summary of this treatment experience from her point of view.
She finished with the comment that; “I feel that load on my shoulders is gone. I haven’t felt this good in
years; despite my infirmities. I know now that I don’t have to keep repeating how bad I feel, that you
will hear me the first time.“
“I sleep right through, never waking up, no longer thinking of my mother or brother.
I just wish that it had never happened, that I could get rid of it. It went round and round in my head and
has finally gone“

Several weeks later Doris had another chest infection and I recommended a chest X-ray.
The report stated dogmatically; “the appearances are those of tuberculosis (TB)”.
Having recently consulted with two elderly women with reactivated TB, I called on Doris at home with
the bad news.

She was very upset and had several sleepless nights before her consultation with the chest specialist. He
told her the problem was not TB, but in fact due to the already known radiation damage.

I felt guilty of poor judgement for not casting doubt on the x-ray diagnosis and apologised to Doris in the
course of a home visit. She accepted my apology with the comment; “you are only human doctor, like
the rest of us. Would you like a cup of tea?”

Perhaps Doris did have a lifelong depression.

It is true that the elderly have the tendency not to express their depression in as obvious a manner as
younger people. Perhaps a trial of antidepressants 10 years ago with this complaining angry woman
would’ve helped her to feel better? What a pity that we had not done this work many years earlier.
 Page 68

Yet perhaps Doris would not have been ready? I wish that I had picked up on Doris‘s feelings many
years ago and maybe then I could have helped her to her present state of acceptance- or even
contentment with her lot in life.

I also wondered how many patients in my practice were similarly holding secrets, the symptoms or the
signs of which I failed to detect? When I asked Doris for her permission to include this account in this
book she gave me a radiant smile and said; “now I feel really special“

I wondered too what was the meaning of the cyclical presentation ? That this was the opening gambit
that led to our ‘little talks’ makes me think that perhaps at an unconscious level, Doris knew that she had
to change her treatment in some way and this was a safe way to seek such change.

Sometime later I was surprised when Doris asked for documentation with respect to travelling to
Australia. Her daughter offered her this trip to Brisbane and she was greatly excited.

She came again a month later. I noted her sparkling eyes as she walked into my office.
“I had the most wonderful time.” She regaled me with anecdotes of her trip – without mentioning the
medical reason for her attendance.

The owner of the motel in which she stayed offered the loan of an electric wheelchair.
She accepted and rapidly mastered the gentle art of using it freely to perambulate through department
stores at considerable speed. On one such occasion, she mistakenly pressed the reverse button on what
she called her “infernal machine“, with the result that she cannoned into a showcase for small toys
which fell on the floor with considerable noise, much to Doris’s amusement.
As she told me this, I remembered the miserable whining woman of a few months before.
I remarked on the changes. She gave me a huge smile and said; “I’m sure enjoying my life now-and, by
the way, I need some more of my tablets”

Doris lived a further six years and died suddenly from a stroke. She suffered little.
I think Doris died happier for coming to terms with her feelings towards her mother and I’m grateful to
her for a shared intimate experience from which I learned much.

Doris’s story has been about the lack of ‘specialness’, which in my view, is an emotional food absolutely
necessary to every child and every adult.
Perhaps the brief therapy aided in the need for specialness for this special woman.

MRS. C.
 Page 69

Mrs C aged 41, presented wondering if she had had a heart attack.
During the previous night she woke with an extremely rapid heart beat, probably about 160 per minute.
She got out of bed, wandered around for a while, had a cup of tea, and tried to waken her husband - who
was too deeply asleep to respond.

After a couple of hours, her heart beat settled down and she managed to go back to sleep, though she
woke again at about 6 a.m.; aware of discomfort in the chest but no palpitations. She had no memory of
any dreams, though this attack occurred about an hour and a half after going to sleep.

Examination was unrevealing, an ECG was normal, as were her heart and blood pressure.
The medical term for her condition was Paroxysmal Atrial Tachycardia.

I asked her to sit down after she dressed, and invited further discussion, because despite her normal
examination, she still looked troubled. I asked her if something emotional was troubling her, but she
could not think of anything. I then said to her that there must be something that triggered this attack, and
wondered if she had awoken with the palpitations or had they begun after she awoke?
Mrs C remembered that she was wakened by a burglar alarm going off in a neighbour’s property. She
got out of bed to investigate and suddenly became aware of the palpitations. She remembered feeling
acutely anxious at that moment.

She then remembered that two years ago, whilst living in Fiji, she and her husband arrived home from an
evening out, to find their young woman baby sitter locked in the dining room, the children unattended,
and three men in the living room. These men promptly attacked her husband - they were all drunk - and
she rushed to protect her children.
One of the men followed her and demanded that she put the children into the living room, intimating that
he intended to rape her.

She bravely refused to do anything he told her, and as he was about to take further action they heard a
police siren. The attackers ran away.
This had quite a profound effect on her, such that, when her husband recovered from his quite severe
head injuries, they came back to New Zealand for six weeks. They returned to Fiji after that, but she was
unable to live in the same house and they shifted.

However, after three months, Mr and Mrs C decided to return to New Zealand because she was too
frightened to stay in Fiji.
It took a further nine months after their return to New Zealand before her fears settled.

As Mrs A recalled this terrifying experience, she sobbed, looked very frightened, then smiled and said;
“I am so glad this happened. I realise now that it has been on my mind ever since we arrived home, but I
was just not aware of it. Suddenly I feel safe again”
 Page 70

We agreed that her paroxysmal tachycardia was undoubtedly a response to the unconscious memories of
that event.
Mrs A. must have unconsciously been aware of the origin of her palpitations because it took little more
than a slight pointer from me to release the inner pain she was experiencing.
The healing took place quite easily once Mrs A became conscious of her feelings related to that
traumatic event in Fiji and there was no recurrence of the tachycardia.

Further therapy was not needed, in that she lost the fear that had built up inside her.

One of the advantages of Family Medical Practice is that follow up is relatively easy. It is not a big
decision to; ‘go to the doctor’, compared with a specialist appointment, and the ‘ticket of entry’ can be
anything the patient chooses.

ROBERT

Robert, aged 29, was a student at a local Polytech, an institution devoted to higher learning in the trades.
He made an appointment one day because he had a cold which had not resolved after two weeks.

He sat sideways, avoiding eye contact as he related the history of his current problem.
His manner was curt; grunted replies, with no spontaneous information.
I could feel myself becoming angry and wishing to punish this hostile introvert who had the audacity to
spurn me in my professional role. He even repeatedly called me “mate“ – hardly, I thought, an
appropriate title.

I wondered at the time why I was reacting so badly to this young man. I reasoned that there was
something in him which was troubled and reflecting to me as a projective identification.
I decided that I had better try to understand, rather than further antagonise him.

“You seem not to be too happy today, Robert.“ (an obvious and fairly undeniable statement).
“You wouldn’t be either if you felt like I do“
“Possibly, but as a doctor, I’m not sure I understand how you feel yet“
“I’ve already told you“
“No, you have only told me about having a cold“
“Well that’s all it is about”

“Maybe So, but I sense something else, something like unhappiness.

Actually I can really feel it, something gut-wrenching ( by this time I had his attention. He turned
towards me, though still avoided eye contact.)
“What do you mean?“
 Page 71

“We haven’t looked at each other since we met, yet somehow you are showing me a lot of distress. I
don’t want to intrude upon you, but neither can I ignore what my instinct tells me; that I’m talking to a
very sad young man.”
I wanted by now to get through to him, my anger quite dissipated. I knew this had to be reframed as
unhappiness rather than anger; to be able to help Robert to let his defences down, even a little.

You don’t want to hear this stuff“

“Stuff?”
“All this stuff from my childhood”. My turn to be surprised! I hadn’t got as far as Robert.
“What makes you so sure ?“
“Nobody ever did”
“Your parents?“
“No, not them. They weren’t there.”
“They left you?“
Yep, they sure did – they died“
“Died?”
“When I was 13.“ Robert’s eyes filled with tears - and mine were not totally dry either.

By now we were well engaged.

He knew I was interested and at last he looked directly at me, saying; “what’s it to you, doc?
I only came to see you because I have a cold.”
“I think I need to tell you that I don’t see you just as a ‘cold’. You have shown me more of yourself and
I’m intrigued with the way you have changed as we talked. There is a softness in your personality I
didn’t see before”
“It’s nothing much – Dad had a heart attack, then Mum had cancer and she died too.
It happens to a lot of people“
“How far apart were these events?“
“A few weeks“

“So… You were just 13 years old and both your parents died and it was no big deal?“
“They sent me straight back to school, told me not to worry, and after mum died they said my brother
Jim would look after me from then on. But Jim never talked to me. I’d come home from school, get the
meal ready – Jim was at work, and he’d come home, sit down without saying a word, eat, tell me to
clean up, then watch TV.
It wasn’t his fault. He was only 20”

By now Robert was eyeballing me with an intensity I have seldom experienced.

He sighed deeply, gave a half smile, then shrugged and said; “what the hell, it’s all in the past now, I
can’t bring them back”

There was a quality to his resignation that was unconvincing; his steady gaze was maintained and
suddenly I thought; “Is this hope?“ Then, to myself; “I feel hope, I guess he does too”.
 Page 72

“There was no one else, Robert?”

“That’s it. Where were they? Those people who came around after mum died and said they would be
there for me. Vanished, just like my wife, and my little boy“

This was new and pain-laden material and time was rapidly passing by.
This was supposed to be a 15 minute consultation. How to extricate myself?

“You know, Robert I’m really interested in what you told me. I would really like the opportunity to hear
more, but I’ve got a problem with time. Would you be willing to come back to tell me more?“

“That’s what they always say; it’s kinda like ‘see you later mate’ “
(That title again)

“So, it’s like those people who said they would be there for you and weren’t ?”
“Just the same, mate“
Well I’m not going to make any promises I can’t keep. How about we make another appointment and
see what happens?“
“Okay, but I only came about the cold“

“I guess you got me so interested I completely, forgot about that. Let’s check it out“
I examined Robert, finding no important physical pathology, as I expected, but knowing I had to respect
his defences, and take seriously what Michael Balint called his “ticket of entry“,
I prescribed antibiotics, probably totally unnecessary from a physical viewpoint, but I think an essential
“gift“ to him - and a cough mixture.

We agreed to meet again one week later, this time for half an hour.
The next appointment was important - and disappointing too - in that Robert failed to arrive!

I have a tendency to accept therapeutic failure as my total responsibility, and followed my usual train of
thought; “I was too intrusive, too hurried, insensitive. I should’ve stopped sooner, given him more
breathing space. Now he’ll probably never get the care he needs”. Then, more soberly; “maybe this man
is too scared to come; Perhaps he is frightened he’ll be abandoned again, and it’s best to cut his losses
before I do it to him, just as others had throughout his life.

Brian; I can see the point of including the following paragraph -but I think it is a distraction from
Robert’s story and would suggest deleting it.

I once treated a self-confessed gangster, in the USA. We were talking about his tendency to miss
appointments, and he commented how hard it was to believe I would continue to see him as I proposed.
He added that he would not return if he had doubts of my trustworthiness. He said that he fully expected
I would get sick of him and refuse to continue with him.
I said; “you would do a preventive strike by getting in and sacking me first?”
He looked puzzled and then he smiled and replied; “oh you mean a sucker punch doc?“)
 Page 73

It is a delicate point of judgement whether to make another move in this situation.

If indeed, I made an error trying too hard to persuade Robert to reveal all, and further alienated him, then
further contact may only aggravate the situation, making an already suspicious person more so.
On the other hand there is a risk that he might conclude that I’m not really interested in him and the
opening could be forever lost.

After some thought, I decided that Robert had made the choice to advance our discussion, by his
spontaneous comment about his childhood, and it was worth the risk of making direct contact with him
about his failed appointment.

I called him at home. He seemed surprised, not exactly thrilled, to hear from me, and rather reluctantly
agreed to meet the next day.

Usually I wait for my patient to begin in the belief that his agenda will surface spontaneously without
input from me, but on this occasion I opened with; ”I missed you yesterday, Robert“
“Yeah”
“You don’t want to tell me what happened?“
“I just decided I didn’t want to come back“
“You seemed quite keen last time“
“Yeah, but then I thought about it. It won’t be any different. You will be the same as them; say you’ll
help, then vanish. Better for me not to hope, not to trust“
“So you had some hope, then it vanished. In that short time. What did you hope for ?“
“Maybe someone would understand me”
“What?“
“That I’m not a bad guy; that I just don’t know how to be normal. It’s easy for other people who had
someone to teach them, but I was only a little boy who had no idea“

It sometimes pays to appear to be quite dumb, to force the patient to be absolutely clear about what he or
she is communicating.

“No idea about what?“

“About life, about doing school work when you come home, about how to be sociable.
When I was 13 I was right into puberty. I didn’t know what was right and wrong. I felt trapped- all those
changes going on, my brother not telling me anything, but punishing me when he thought I did wrong.
He beat up on me lots and I never knew why. I didn’t know what I had done wrong. So by the time I was
13, I was right into drinking – more than my mates, to show them I was as good as them. Then my
brother got the social welfare in because I was out of control“

Robert was now deeply involved – I felt like a spectator- all the distressing stuff poured out of him, as if
it had been rehearsed many times over in his mind.
 Page 74

Then he paused, smiled wanly, and said; “I do need to talk don’t I? It’s like a pressure inside me, but it’s
scary, I might even cry!“
“True, – what then?“
You would think I’m weak, despise me“
“What does it matter what I think?“
“Mate, you’re the first person in my life who’s got me to talk. If you hate me, then I’m back to the
beginning“
“So, we are past the beginning, you have started to talk about important things and you don’t want to go
back?“
“No“
“Then it might be a good idea if we can come to some agreement about how I can best help you. I can’t
give any guarantees, but I think you don’t need to go through the rest of your life feeling so miserably
depressed. We could consider medication to relieve your depression and talking to help me better to
understand you. Experience tells me that if you can make me understand, then you certainly will
understand too“

We then negotiated an arrangement to meet each week for a half hour and before closing discussed more
fully the syndrome of depression.
Robert decided to take a course of antidepressants.
Just before we concluded this session, Robert raised the subject of his failure to attend the previous
appointment. “Doc! I’m sorry about yesterday. I just couldn’t believe you were really interested, but
when you called me I felt great, and today, despite how I might have seemed, it was good to be here”.

The next week Robert came into the room looking defiant.
My first thought was that he had re-entered his male-type defence of denial, and wasn’t going to have
any more of this “soft“ psychotherapy nonsense.
He looked me straight in the eye, and said; “Brian, I know you told me not to plan what I want to say,
but I’ve been thinking a lot this last week and there is something I want to talk about, have to talk about“
The first time he had called me ‘ Brian’!

There was quite a long silence. To my great surprise, I suddenly felt a depth of sadness I have only
experienced in my own life in the face of great loss. I sat quietly controlling my tears.

Then: “I was only five years old. I loved the busy ways of the port where I live. There were ships being
loaded, the rough talk of the seamen, the trains coming and going and it seemed to help me feel better. I
was such an unhappy kid. Dad was always drunk or bad tempered, and I thought mum did not care much
about me. So, I’d just go down to the port and watch all the goings-on. This day Jimmy, from down the
road, came along. He was a big boy of 14, seemed huge to me. I was so pleased when he asked me if I
would like to walk around with him”

The atmosphere in the room became in some curious way supercharged with emotion, we were both
struggling with our tears, and I had not yet heard the point!
 Page 75

Of course, I had a fairly good idea what was coming. The emerging horror though was almost palpable.
Robert lowered his head, his voice dropped to a whisper.
“And he said would I like to look under the floor of this big building?! I did. And I don’t have to tell you
what he showed me“

Usually, I am reluctant to make any assumptions, but on this occasion there was no doubt about Robert’s
meaning.
“And then?”
“You know“
“I could make a guess Robert, but you are here and if you tell me then I won’t make some horrible error”
“He grabbed me and took my pants off and forced it into me. I was only five years old, Brian!“

The despairing tone of Robert’s voice, the hurt like the cry of an injured animal was just too much for
me. I felt the tears forcing their way through my professional composure, coursing down my cheeks.
Even as I write this, I am again acutely aware of the power of that moment, of those feelings.

A helpful memory came to mind.

I once asked my good friend, Dr Roy Muir, what he did when a patient made him cry?
He looked at me in his characteristic, half-quizzical, half- humorous way and replied; “why Brian, I pull
out my handkerchief of course”
This kind of simple statement from my respected mentor has over the years been a comfort and
revelation to me.

Robert gazed at me expectantly. A long pause. “I can’t think of anything I can say to you Robert. I just
feel overwhelmed with sadness”.

A glimmer of a smile; “well that’s exactly it. I was too! Then I went home and went straight to my bed.
I was bleeding, and hurting so much. Dad was in bed too. He was, as usual drunk. Then Mum came
home, and wanted to know why I was in bed. I told her, and she sat beside me and held me for hours.
She cleaned me up and told me she would sort it out. She must have too, because that boy disappeared
from my life. At least then I knew she loved me.”

Robert’s composure returned quickly, and so did mine – we both needed respite, I think. Again, there
was a long silence. My mind wandered, thinking about what had just transpired, then moved tangentially
to consideration not only of the content, but also the process of this discussion with Robert.

I thought that we had been in a kind of cocoon of pain and grief; as if in another dimension. I looked
around this spare, severe, white-painted room with its medical paraphernalia, the stethoscope, medical
diagrams, otoscope, the spatulas, the examination bed and no white coat.
And I wondered what all that had to do with this kind of medicine, and, characteristically, had I deviated
too far from the straight and narrow? Only one of my medical instruments seemed of value at value that
moment – my pack of tissues and our handkerchiefs!
 Page 76

Then it occurred to me that in some way, Robert and I had travelled a little way on a journey, and the
process felt as if it occurred within another dimension, divorced from “real“ life.
This lead me to wonder whether we might describe the world of feelings as indeed another dimension,
perhaps not measurable as are those of space and time, at least with the current available tools, but
certainly in this experience almost palpable. That this ‘dimension’ exists within us is undeniable. But a
dimension cannot be confined to the boundaries of the human body. Rather it must be assumed to have
some extension.

The power of Robert’s feelings had been so great that it was transmitted across space directly into both
my conscious and my unconscious, provoking a powerful reaction.
For those moments we were “at one” and the outside world had no meaning. This experience seemed to
project us into such a different dimension.

This process, known by psychoanalysts as “projective identification“, is believed by some to have a

powerful healing effect, as the transmission to “the other“ results in a deeper level of empathy being
established.

“Robert, you said you had never told anyone except your mother and now you have“

There are different levels of trust between people. The first is the ordinary trust established by
professionals of all kinds: that we will not reveal any information about the consultation. The second
level of trust is when the patient trusts that we will not show judgement; either by facial or verbal
expression.

These levels are not difficult to achieve.

However, the third level of trust is much deeper; when we believe the other will not even think
negatively about us. I was surprised that Robert demonstrated this when he replied; “I know, I knew
from the beginning that you are a good geezer, mate, I mean Brian”.

Sometimes we all do things we quickly come to regret, and then experience the twin corrosive emotions
of guilt and shame. These feelings can lead us to merciless self-criticism, often manifested in depression.

The next half hour consultation with Robert started with; “I’ve been feeling very despondent the last few
days. On Saturday night I was alone in my apartment. I felt rotten, depressed and lonely. So I decided to
have a couple of drinks, and in no time I drank a great deal – pause – I got so drunk I passed out on the
couch. I’m not worth your time and energy, doc. I’m worthless, no good“
“All because you got drunk one night?“
“I shouldn’t have done it. I’m not a drinker usually. No, I’ve let us both down“
“So what was going on? There must be a good and sufficient reason for your action“
 Page 77

“Just bad behaviour I guess. I had a horrible dream on Thursday night. I was in the place - that place I
told you about, where he did it to me –under the building, and he was holding me by the shoulder – I
could not get away. I’ve had this dream lots of times when I was 7-10 years old, but this time it was
different”.
“There was a man peering in. He seemed okay and I wanted to go to him, but the space between us was
like a steep incline and I could not reach to him”

I asked Robert to think about who this man might be and after some time he decided that it must’ve
been me - someone who cared, who looked into things.
With this he started to cry and said; “ I had no one except mum, and she died“

The dream suggested Robert was not sure that he could get to me- he reached out but could. not touch
me. I interpreted that to Robert and his reply was simple; “I know I’ve touched you Brian.”

I cannot remember a more apt response. For him to use the metaphor from the dream, in such a direct
manner, indicated that Robert was well engaged.

He woke from the dream feeling anxious and that anxiety persisted for two days.
Then he got drunk and shifted from anxiety to self-disgust.
Thereafter Robert returned to me expressing his guilt and shame.

An important issue about shame is that it is usually about something we would not want to discuss with
another person. It is hugged into oneself in a vain effort to protect oneself from damaging criticism.
Fortunately, Robert had broken the ice with me and getting drunk is not a serious misdemeanor, so he
was able to talk about it - even to include my presence in the dream.

He also quickly expressed a sense of hope; commenting with a slightly embarrassed laugh, that he even
had been able to invoke my help in the dream.
It did seem that Robert had experienced a sense of hope in his dream and this carried over to waking, so
his depression was much less obvious.

It was clear that his emotional scarring was deep and lasting. We talked at length about what to do and
finally decided that he needed longer-term therapy than I could offer him.
He accepted that suggestion, which in itself demonstrated his progress, in that he did not feel rejected by
me.

I saw him a few months later for a purely medical matter. He told me that he now felt well, especially in
his relationships - and intended to continue in psychotherapy as long as it felt necessary.

Experiences such as this make practicing medicine in primary care a joy, and immensely satisfying. I
have noticed that after sessions like this I feel quite ‘ high’, a sense of great satisfaction and reward,
which monetary considerations could never satisfy. And it is not just the emotional satisfaction; but the
 Page 78

intellectual gains in formulating hypotheses which then can be proven with the aid of the patient,
through exploration of feelings and their relationships to important life experiences.

SIMILES. AND METAPHORS

The English language is scattered with metaphors and similes, the purpose of which seem to be to evoke
in the listener, associations that clarify understanding of feelings or events created in our minds or
bodies.
Ordinary words are often insufficient adequately to describe pain; of which there are many varieties,
both physical and emotional. How does one describe the feeling of a headache? Or abdominal colic?
How can we properly communicate the distress of grief?

In medical interviews, some or all of these figures of speech are used in many accounts of illness by the
patient. “He’s a pain in the neck“ describes the impact of one person’s behaviour on another, which
sometimes may be translated into a symptom of the very area spoken of.

“My heart lurched“ is a common way of describing a sudden fear-provoking experience. The medical
equivalent of this feeling is called a premature ventricular systole and it is characterised in the
electrocardiogram by a succeeding heartbeat occurring early, and being followed by a compensatory
pause, of which we become aware. “My heart missed a beat“, while not medically accurate, certainly is
easy to understand and identify with for the listener.

Similes are used to clarify the exact nature of the symptom. “It feels like something is twisting my guts“,
is not a bad way to describe colic in the bowel. “My stomach feels like it’s on fire“, is often used to
describe the reflux of stomach acid into the oesophagus as a symptom of hiatus hernia, a common
problem in middle aged people.

Thus, similes tend to place a symptom in the body, and also to use the universal language to describe
the nature of the sensation experienced. The pain of angina pectoris, due to a temporary, or in the case of
a heart attack, lasting, loss of blood supply to the heart muscle, is described as; “ like a band around my
chest” ,or, as “a heavy weight on my chest.”
This tells the listener exactly where the sensation is located and the common-ness of the description
helps the doctor to compare it with others and more readily develop working hypotheses about
diagnosis.

Metaphors seem to serve a somewhat different function. They are more symbolic, appearing to arise
from a different style of thinking, to do with abstract derivatives. According to The ZenCart dictionary, a
metaphor is a figure of speech in which a word or phrase that ordinarily describes one thing is used to
designate another, thus making an implicit comparison which implies a split in thinking, – two parts,
each of which uses a common phrase to express an idea.
 Page 79

The combination of metaphor and simile conveys a message about the presenting symptoms. There arise
from this, two messages. One overt; “I have a certain feeling“, the other, more covert ,arising I think
from the unconscious part of the mind, represents understanding by the sufferer of the cause of the
symptoms, at a somewhat deeper level of consciousness, yet not buried so deeply that it is difficult to
consciously access.

That the skin responds to emotional stimuli is beyond doubt. Expressions showing intuitive
understanding of this abound in our language “I blushed with shame”, is an indication that our
innermost thoughts, our private fantasies, can be only too embarrassingly obvious at times. “His face
was suffused with rage“, is another indication of a basic knowledge of the physiological processes
involved in the mind – skin dialogue.

Of all parts of the body, the most expressive and symbolic terms seems to involve the skin, and perhaps
the most common feeling is an itch. This may be present with or without rash or signs of inflammation.

An early researcher, Philippus Aureolus Paracelcus ( 1493 to 1541) described the signs of inflammation
as Rubor, Tumour, Calor et Dolor ( redness, swelling, heat, and pain). These signs are common in skin
diseases such as eczema ( dermatitis), infections, infected animal or insect bites and psoriasis.

I believe that for many patients, skin disorders are an outward manifestation of inner psychological
conflict or hurt. It is as if a trade-off occurs, in which the symptoms somehow promote the denial of the
underlying emotional pain.

Jack, ‘the reluctant soldier’, is a fine example of this; in which the symptom somehow promotes the
denial of the underlying pain. Frequently the patient is aware of this, as evidenced by a close friend, a
highly intelligent man, who said; “please do not heal my psoriasis, Brian, I may have something much
worse to deal with.“

In the consulting room, we are constantly reminded that patients are the experts regarding their own
bodies, and if we fail to listen to them, we may correctly diagnose the condition, but miss the point of the
illness which carries a subtle message about suffering.

“Dermatitis“ as a diagnosis means only inflammation and puts us nowhere nearer to the cause. However,
if we listen well, patients have an uncanny ability to find a simile or metaphor which can lead to
understanding – we must listen with the “third ear” to the underlying communications.

A reliable indicator of a metaphorical communication is the symptom of an itch not accompanied by

other signs of inflammation, such as rash.

KEN
 Page 80

Ken was age 29. He presented with “an itch and rash on my penis” and the comment that his wife had
recently had severe vaginal thrush.( an infection caused by an organism called Candida Albicans). Ken
had been seen by my partner a week previously, who commented that there was little or no evidence of a
rash.

I could not convince myself when I examined him, that there was anything abnormal to be seen. After he
dressed I believe it is unacceptable to talk about other matters than the actual examination if the patient
is in the “one – down“ position of being undressed) this conversation ensued.

“I wonder, Ken, what ideas you have about your problem?“

“Well, I thought I may have thrush from my wife“
“Was that all you were concerned about?“
Ken responded rather sheepishly; “Well, actually I had an extramarital affair six weeks ago, and I am
scared I may have picked up a sexually-transmitted disease, and that I may have passed it on to her. We
were separated for a while and it happened during that time. We’ve gotten together again, and I don’t
want this to break us up”.
“I cannot see a rash or anything physically wrong at all“
“Now you say that, I do get rashes that come and go quite quickly when I’m nervous about something
and I sure as hell have been nervous about this, as well as terribly guilty.”
“So if I reassure you strongly that there is no evidence of a sexually transmitted disease on examination,
and that all the tests performed by Dr B are negative; that is, there is no evidence of STD, can you accept
that and can you live with your guilt?“
“I certainly can”, Ken replied-with a broad smile.

I later saw Ken about another less worrying matter. He told me that the itch cleared after a few days and
had not recurred. He had, after much reflection, decided that no good purpose would come from
revelation to his wife, and though still feeling guilty, acknowledged it was a great relief to have talked
about it.

This is a striking example of how feelings - in this case guilt and fear - may be translated into physical
symptoms. The response of an itch was not much help, in that he still had his conflicted emotions as well
as the itch to contend with.

The itch did not seem to serve any useful purpose. One may speculate though, that Ken’s ongoing
problems relating to his thoughts and feelings about his infidelity were not tending to resolution and the
development of the itch had the effect, in the long run, of forcing him to reveal the source of his problem
and to seek relief.

ALBERT
 Page 81

Albert was a 60 year-old retired engineer, a plethoric, rotund man, who was a long-time patient in the
practice. Some years ago, he had triple bypass heart surgery for the second time and has kept well ever
since. He complained of a sore, red eye. It was a minor, but irritating infection, easily treated by local
antibiotic applied to the affected eye.

In a; “just before I go, Dr” kind of statement, he mentioned that he had had an itch over his whole body.
Sometimes it was accompanied by a red rash and was unrelated to any life events that he was aware of.
The redness appeared only after scratching and lead to the development of dry and scaly areas. He
wondered if he had dermatitis.

On examination, there were some small dry patches with no signs of an inflammatory process. I said;
“Albert I have noticed that at times people can get an itch when they have something on their minds. It
seems the rash only comes on after scratching and I then think that there is a message of some kind from
inside, demanding attention. It’s as if a part of you is saying to another part of you; “something is getting
under my skin“

He responded; “well, maybe it’s about my son. He is 41 now and he’s about to have coronary bypass
surgery.

I was quite shocked, not only because I have a son of the same age, but also because Albert’s
presentation of this information was quite matter-of-fact, even indifferent. To me at that moment, I
thought his calm demeanour was a cover that implied some kind of deeply hidden feeling. In fact, my
response was both intellectual and emotional, as I was aware of a pricking sensation in my eyes, and told
him so.
I asked him how he felt at that moment. He blinked and his non-infected eye watered.

“Nothing much”
I felt at a crossroads at this point. Albert obviously was consciously denying his sadness and fear. Should
I honour this, or attempt to get him to admit and cope with his feelings, in the belief that a part of him
was clamouring for attention; that is, the itch was a symbol of an unresolved process. I decided not to let
the matter rest.

“It is difficult to accept that you don’t feel anything about your son having major surgery, in view of the
fact that you have had it twice and you know all about the hazards attendant upon heart surgery.“

He replied that when he had his operation, nobody told him anything about it and he felt no anxiety at
all. He was confident that he would survive and just wanted to get on with it.
He added that his wife felt quite differently about it, and in fact, wanted to postpone their overseas
holiday, due in three weeks.

Albert said that his son was terrified of the surgery.

 Page 82

Again I expressed doubt that he had no feelings and he said; “maybe I’m feeling it in my skin?“ He went
on to talk about his Anglo-Saxon heritage and the need he had to keep a “stiff upper lip”. I
acknowledged that it seemed dangerous to him to admit within himself, that he really was worried about
his son, and that bringing that worry to the surface might, in some mysterious way, result in a bad
outcome.

We agreed I had nothing medical to offer and that we would “wait and see“ - a common “treatment“
As often happens, the result of this consultation was not evident for some time.

At a later date Albert returned, telling me that his son had successfully undergone surgery,
for which Albert had postponed his vacation. The itch had not so far returned; “if it does I shall think
about what it may mean”.

This is an oblique reference to the educative value of the doctor behaving as a distorting mirror;
reflecting back to the patient a combination of the words heard and the non-verbal messages received,
such that symbolism and reality converge into a coherent whole.

In Albert’s case, the itch was a metaphor to do with, on the one hand, a need to deny his anxiety about
his son, and on the other hand, a wish to be available for his son and his wife in a time of stress. The
problem was quite literally getting under his skin.

SALLY

Sally, a student, presented with a rash on her left ring finger.

It appeared the week before her recent 22nd birthday. I was immediately struck by two features of the
story. The first was a potential symbolism in the site of the problem, and the second was the fact that she
was in my office at all.

Most people are familiar with eczema and know that the first treatment usually given is a steroid cream,
readily available from any pharmacy. I did not verbalise these issues, but commented, as I most often
do, that eczema can often be a reflection of inner psychological conflicts.
Sally’s response to this mildly stated view was to burst into tears!

She had always been close to both parents, especially her father.
For her 21st birthday, they gave her a gold ring which she wore on the affected finger.
A few months later she came across her father in ‘flagranti delecti’. Brian; I suggest using plain English
here
She was shocked, but elected not to tell her mother, who found out anyway.
 Page 83

The parents stayed together until after Christmas, in order to give their daughters the last holiday time
together as a family. Sally was dismayed by the parting, feeling a mixture of betrayal and despair, that
these two precious people could not resolve their differences.

She told me that the eczema had appeared the week before her 22nd birthday.
When I pointed out the connection, she looked dumbfounded. After a short silence, she talked about her
sense of grief, especially for her father, who by now had a new partner and lived in a far-away city. She
visited them once and found her father’s partner intrusive; in the sense that this comparative stranger
touched Sally in a too intimate fashion for comfort.

Sally became angry with the woman and an argument occurred, her father siding with his new partner, to
the extent that Sally was banned from the home indefinitely. That the anger was in part diverted from her
father to the partner was obvious to Sally, but as she said, her predominant feeling was of being rejected
and isolated from her father, so that she was unable to tell him how much she missed and also loved him.

Sally was by now sure that this was not an allergic reaction, but connected with her emotional pain. She
decided she would wear the ring around her neck in future. I commented that I thought it quite likely a
time will come when she would be able to wear it on her finger again, given that resolution of the family
problems was probable.

She asked; “so my rash is caused by my distress. Why a rash? Why not something else like a headache?“
“Maybe you are itching to do something about all of this? I suspect dad is feeling pretty bad about all
this too.” It seemed we had reached a good level of understanding and Sally was clearly convinced of
the connection between her rash and the events described.
It remained only to prescribe a steroid cream and let nature take its course.

Sally started to thank me for listening to her, when quite unconsciously she began to scratch her neck.
She laughed and said “And now I’m starting to itch. I’m sure it’s about all this. I think I should write to
dad and tell him what happened today. I think you are right. Dad is not good at talking of his feelings.
Maybe he’ll find it easier for us to get together by mail. I don’t have to go back to work later today, so
I’ll go home and do it now.

Sally wrote to her father, who responded very positively, apologising for his heavy-handed behaviour
when Sally was with him and asking whether they could make up and get together again.

Once again, I am reminded of the advantage of having a high level of suspicion when I hear my patient
say something incongruous, especially if that is followed by an expectant pause. In this instance, Sally
offered that the rash recurred a week before her 22nd birthday, then she paused, offering me an opening
to change the direction of the conversation.
Sally’s natural openness and intelligence, meant that she was able to pick up on my comment and do the
rest of the necessary work to elucidate fully her problem.
 Page 84

EVE

At age 41, Eve had been married twice, having had a child in each relationship.
A year previously, her husband had a serious industrial accident, resulting in quite marked brain damage.
He only partially recovered and had changed into a childlike and childish man, from an active self-
employed person.

Eve presented with an itchy rash on her right wrist and arm. I wondered aloud what this might mean and
she answered that it might be infection, but quickly added that she also wondered about ‘stress’.

“You think something has got under your skin, Eve?”

“I thought I had gotten over my husband’s crippled state, but something has happened that makes me
wonder about that. We had this big storm and a large gum tree blew over. I heard it happen and saw the
tree leaning precariously against a shed, which was buckling under the pressure. The tree was also lifting
out our small aviary and the birds were escaping. My husband was standing there not really
comprehending what was going on and apparently not able to do anything about it. I knew the house was
under threat. I had to take my younger son out to an appointment, It was late afternoon and the evening
meal was half cooked. I just felt trapped”.

“Then Paul, my eldest son, arrived home. He got a chainsaw and proceeded to climb the tree in order to
cut off some big limbs .I knew it had to be done, but I was really scared for Paul’s safety. Thankfully he
did tie on a safety rope. My husband seemed to realise something had to be done about the birds but it
seemed he just could not do anything useful.
Suddenly I had this awful feeling of desolation and hopelessness.”

“What do you think was going on in your head, Eve? It all sounds highly symbolic to me.” There was no
need to beat about the bush with this intelligent, insightful woman.

Her reply was almost instantaneous. ”My life - it’s all fallen over - just like the tree. It’s coming to bits
and there is nothing I can do.”
A wonderful use of metaphor here.

She went on to describe her concerns for her future - that she would have to spend the rest of her life
caring for a man crippled in mind and body, and from whom she had been going to separate before the
accident occurred.

Despairingly, she said; “I’m a healthy young woman. My life is a trap and I’m afraid I’ll just stagnate.”

It seemed like an opportunity to question some of her assumptions, so I asked her why she was so sure
she would stagnate, and why she was certain she could not still separate, if that was her wish.
 Page 85

She had never considered this option, though her husband’s disabilities were not such as to render him
incapable of looking after himself.
Eve’s mood lightened considerably and she prepared to leave.
“We haven’t done anything about your rash, Eve.”
“No and I don’t think I need to either. I realise all I came for was to talk.”

Later Eve told me that she had separated from her husband and she was relieved that he was coping well.
I was amused when she said that that was a good itch she had, which proved to be the catalyst that
enabled her to reorganise her life.

JULIE

Julie Smith, a bright intelligent woman, age 33, complained of a constant itch of various parts of her
body. This had begun ten days before the consultation, on the day before she was due to return to New
Zealand from Australia, where she had been on holiday.
Examination showed some scratch marks of her skin, without a rash.

In line with my view that an itch without a rash is of psychological origin until proved otherwise, I
invited her to tell me whatever seemed relevant about herself, since we had not met before.
She was a single parent with two daughters, whom she had taken on holiday with her and that proved to
be a happy experience for all of them. She denied any unhappiness in her current life.
I commented to her that it seemed to me ;“that {something has got under your skin.”

She thought for a moment or two and then said that there was trouble at work.
A workmate, who happened to be the girlfriend of the boss, had been caught by video surveillance
stealing money from the company. Julie had known that this was going on, but felt constrained by the
complex relationship to keep silent.

She knew, however, that the investigation was to be completed whilst she was on holiday and she was
aware of increasing tension during the holiday, as return to work approached.
Julie agreed that it was highly significant that the itching appeared the day before she returned and that it
had got significantly worse.

She responded positively to my comment that she was; “itching to get away from work.”
I was impressed with her grasp of these metaphors and her sense that they fitted perfectly the stressful
situation she was confronted with at work.
 Page 86

As usual in family practice, I considered prescribing medication. but it turned out that Julie was allergic
to antihistamines, and I was able to state that other treatment was not necessary; and with this she fully
agreed.
Her itch disappeared when the matter at work was resolved.

GRAHAM

I was in the next building, consulting our secretar,y when the receptionist came over and asked me to
come back to the office urgently, because there was an emergency in one of our side rooms.

Graham, a 40 year-old panel beater, was lying on the bed looking pale, sweaty and breathing rapidly. He
looked for all the world as if he was in the throes of a heart attack.

His vital signs and blood pressure were normal, except for a rapid, regular pulse at 180 beats per minute.

He told me that he had been spray painting a car in a rather confined space and not using a respirator,
when quite suddenly, he developed an intense itch in both feet , which rapidly spread to his ankles and
lower legs. He put his spray gun down, walked into his little office and sat down, feeling “absolutely
awful”.

He thought he was having a heart attack and felt intensely panicky. This resulted in a rapid heart beat,
sweating, a sense of ‘angor animi” - a feeling of impending doom - and rapid breathing,
hyperventilation, and its consequence, numbness and tingling in the hands.

An electrocardiograph indicated a rapid heart rate but there was no evidence of a heart attack.

He had no pain suggestive of a heart attack either and I felt comfortable in assuring him that he was in
no immediate danger. It seemed to be a panic attack.

At this point it was puzzling to me, especially when he reminded me that the previous year he had had an
intense allergic reaction to drinking a glass of orange juice, which resulted in rapid breathing and a sense
of choking. This was associated with a hive-like rash.

The conversation went something like this. “This sounds like a reaction to something, Graham.”
“Yes, I wondered if it was, because I was not wearing a respirator”.
“I doubt that, because your symptoms and signs don’t seem related to your heart and lungs. Could it be
something on your mind?”
“Well, you know me, I’m a worrier and I have been particularly worried about work lately “
“Tell me”.
 Page 87

“Well, I have this small business and two employees, and they come to work every week wanting their
pay, but the trouble is, the people I work for, such as insurance companies, often delay their payments
for two months and I can get caught short quite often. I really worry about this a lot, though that is not
always appropriate.”

“How does that relate to today?”

“Well, I had a restless night last night, woke around 3am, hoping that some money would come in with
it being payday for my employees today. When I was spraying this car, the postman arrived with the
mail. I put my spray gun down and went over and riffed through the mail, but there was no money. I felt
really disappointed; quite upset in fact. I then went back to my spray gun and within 30 seconds my feet
started to itch.”

“ What were you itching to do?”

He laughed. ”Well, if you want to put it that way, I am itching to get some money into my business so
that I can carry on.”
“So what happened when the itch came on?”
“I knew I had to get these new sneakers off, and then I wondered whether I was having a heart attack,
then I felt really frightened. You know I have a wife and two children and they need to be looked after. I
can’t have anything bad happen to me. I know I am pretty fit though. I can run miles and I do all kinds of
sports. I also thought that maybe I was going to have another allergic reaction like last year, so I sat
down for a couple of minutes, then rushed to the car to see you immediately. I felt quite faint in the car
and when I got out of it here, I nearly passed out”.

“So do you think this itching and panic attack may have something to do with your business worries?”
“Yes, in fact I wonder, looking back now, whether that episode I had with the orange juice might have
been a similar thing, because I am always worrying about work and it doesn’t make any sense that I
would be allergic to an orange drink that I have had so many times in the past, and in fact I have drunk it
since the allergic episode, without any problems.”

“How do your feet feel now?”

Looking surprised; “actually the itch has almost completely gone and I don’t feel any panic now.”

Within another ten minutes, Graham had completely recovered, was able to take a cold drink and return
to work, leaving me with a sense that we had done something useful for him, but also a reminder that we
need to be alert for these psychosomatic reactions, as I clearly was not on the previous occasion of his
ingestion of orange juice.

We discussed briefly what to do in the future and Graham had some ideas of what could help with the
problem of running out of money temporarily.

Speaking with him some months later he said that he had been drinking orange juice again, without
problems, and had not had any further episodes of itching or panic feelings.
 Page 88

RHONDA

Rhonda presented about another matter, but in the course of conversation she became tearful about her
mother’s death, which was nine months previous to this encounter. The concern was about medical
issues, so I invited her to come back.

Her mother had a motor accident two years previously, in which she was struck down on a pedestrian
crossing and thrown some distance, suffering multiple injuries; including a fractured leg and arm and a
minor head injury.

About ten days later the hospital discovered that she had a cancer of the bowel. She was operated upon
and had a colostomy. A month later the colostomy was undone and all seemed well.
However, some months later she developed an obstructed bowel, and it was found the cancer had spread.
She died just a few weeks later.

Rhonda’s first question was whether the motor accident could have caused the bowel cancer.? My
immediate response was to say no, there would be no relationship, but in fact as I thought about it, I
realised that nothing is proven in regard to cancer and trauma, so I responded in that vein.
Furthermore, I added, another question needed to be asked; and that was whether the trauma had
activated an already present but quiescent cancer. I regretted that I could not answer that question either.

Rhonda went on to talk somewhat tearfully, about the loss of her mother, and her grief.
She reminded me that her mother had willed her body to the medical school for anatomical study and as
a consequence of that decision, that therefore she felt unable properly to grieve her mother and say her
final goodbyes.

At the hospice, she had been told in some detail what happened to a person who had gifted her body for
medical research. She had been given a clear and truthful picture, but she had been wondering what
happened at this stage.

Therefore, I asked Rhonda if she wanted to know the truth as I knew it.
She said “yes”, so I told her of my experiences as a student of anatomy; starting with the first meeting in
the anatomy room, when we were told very clearly about the need to respect the body of such a person,
including the need to respectfully cover the body after each afternoon’s dissection. I also mentioned the
fact that we did indeed dissect the body and took out organs for further examination, and that the bodies
were unrecognisable.

Rhonda seemed very relieved after this talk.

 Page 89

The session concluded with her realisation that her grief had some way to go and perhaps will not finally
be resolved until her mother.’s remains, that is, her ashes, are restored to the family and proper burial
can take place.

ANNE

Anne was troubled by a variety of bowel symptoms.

Examination was unrevealing. I arranged an X-ray of her bowel.

The report returned with an equivocal result. The radiologist asked for a repeat in six weeks.
I informed Anne of this and she agreed to return. However, she did not in fact return for two years. I had
quite forgotten about the repeat appointment, so I hurriedly arranged further Xrays, which, along with
other tests, showed she had bowel cancer with spread to the liver and lungs.

I admitted her to hospital where an operation was performed, but the result was gloomy,
in that Anne was suffering from serious spread of the tumour - with the consequence that resection of
the tumour was not possible.

She came to see me on her return from hospital and I was staggered at her appearance.
She was pale and thin and looked like she might be close to death.

We talked honestly about her current condition, but not about the failure to keep up her follow-up
appointment two years earlier.

She recognised that she had a very short time to live and asked me what I could do to help her,
particularly at that moment as she was in considerable pain. I reassured her that I would be able to keep
her pain-free and then gave her an injection of morphine, which produced good relief.

I repeated the injection that evening at her home, thinking it did not matter how much morphine I gave
her, and addiction was not a problem with such a short lifespan.
I arranged that I would visit her each evening, to give her a morphine injection and attend to any other
needs, She and her husband were comfortable about that.

Most surprisingly, Anne lived for many months.

I continued to visit every evening throughout the harrowing experience of her gradual downhill course.
She hung on grimly, never denying her death, but quietly accepting that the time would soon come.
 Page 90

After nine months of this arrangement, I went on holiday, arranging for my locum tenens to continue the
morphine injections. Rather surprisingly these injections suppressed her pain for 24 hours and there was
never a need to add any extra injections at any other time.

While I was on holiday Anne died suddenly. I was told of this on my return three days later.

After I heard the news, I went to the home, knocked on the door and Anne’s husband answered it. He
looked at me and said; “Oh, it’s you. We don’t need you anymore. Goodbye.”
I was horrified and felt deeply hurt, because I had given many hours, at no fee, to care for this patient,
and felt that I had been hard done by.

I was a member of a Balint group at the time, in which a group of doctors met to discuss their practices. I
presented the case of Anne and her husband. A number of ideas were offered to explain this rejection by
her husband. At no stage throughout the last few months of her life had there been any suggestion that it
was my fault by not recalling her, that she died.

Whilst living in the USA some years later, I was asked to write up a case history that was problematical,
for a book to be published. Anne’s case seemed like a good example of what can happen in a family
practice and the pain that both patient and doctor might suffer.
Needless to say, I felt intensely guilty about the whole scenario and I recall, with some pain, that I never
processed the events with my patient or her husband.

To my astonishment, when the book was published, the commentary on my case was about my failure,
indeed my negligence, to call Anne back. No reference was made to the issue of my rejection by her
husband. There was no reference to the failure of my patient to return for further examination.

I have carried the emotional pain of my failure ever since.

Several years later, I met Anne’s husband in a non-medical situation.

He is a simple decent man, of few words. I said that I had many regrets about my management of Anne
and could understand that he might feel very angry with me.
He replied that it was difficult for him to determine where his anger came from, but he knew a part of it
was that while he watched his wife progressively fail and suffer, I was the one who could come in and
with my magic injections that relieved her completely of her pain and then walk out, leaving him with a
sense of impotence and incompetence.

He was also aware that he was angry with me that I was not there in her final days; and not present after
her death. He said that he recognised my need for a vacation but that he was nevertheless angry at my
absence. He added, however that his anger had long since subsided.

In retrospect I think that my failure to remember the need for a recall appointment led me to neglect this
family. I can vaguely remember talking with them briefly, but never spending time with the whole
 Page 91

family and the patient; to discuss management of her needs in the future and I sense that this left her
husband without a sense of having an ally in his care of his wife’s terminal illness and suffering.

Failures of this kind, not common, are emotionally difficult for the doctor who needs, but often
does not have the opportunity, to talk and explore the experience, to learn and to be freed of his or her
sense of guilt and remorse.

STEPHEN

Stephen was a video-communications student when he came to see me.

He had had an injury to his shoulder some months previously. A special X-ray was supposed to have
been arranged by the hospital, but he did not receive the appointment.

I arrange this appointment, then he told me that he had a sore throat again.
He had intermittently experienced a sore throat for several years. I examined his throat. It looked red and
swollen. I concluded this to be a streptococcal infection and prescribed penicillin.
About 4 weeks later he returned and once more complained of a sore throat.
On this occasion I found little on examination, reassured him and he went on his way.

A week later, he arrived again with the same complaint. On examination I could find nothing wrong. By
now I was wondering if there was something happening we were unaware of.
I asked him what the significance of a sore throat was to him.

He looked thoughtful, then said; “when I was aged 12, seven years ago, I had staphylococcal pneumonia
and I was in hospital for two weeks, at death’s door. I remember the sore throat and the cough - and, by
the way, I have a cough today and some yellow phlegm.

I thought he was offering a new connection, perhaps to his body-mind, and I invited him to elaborate on
this past experience.
He said his strongest memory was of being desperately ill - and terrified of all the technology that was
imposed upon him. He acknowledged that the fear of this was always at the back of his mind. It was not
a big worry, but he was aware of the memory and the fear quietly niggling away inside.

In addition, his mother seemed to have a similar concern about him. Any time he had anything wrong,
his mother would remind him to tell the Dr that he had had staphylococcal pneumonia. The previous
day, he had told his mother about his sore throat and once again she became a little alarmed and
suggested that he should quickly get to see a Dr.

There were a few crackles in his lungs, suggestive of infection.

 Page 92

Usually, I would not offer any treatment for this very minor ailment, but on this occasion I asked
Stephen what he would like to do, having told him of my findings.
He replied that he was rather worried about the sputum and wondered if this was a recurrence of the
almost overwhelming pneumonia that he suffered previously. I thought not and he went on to say that he
wondered if the pneumonia was still quietly going on in his lungs.
I suggested an X-ray of his chest might be more reassuring for him than simply my physical examination
and he rapidly assented to this idea.

The X-ray was normal. Stephen accepted a short course of antibiotics. I asked him what exactly was so
frightening to him about pneumonia.
He responded that when he had it, he was sure he was going to die and was terrified.
Since then, he had developed fear in relation to the equipment he had seen in the hospital and even was a
little frightened by the equipment in my office when he first came. He added that since he had his X-ray
he was aware of feeling much less frightened and now that he was reassured by examination and X-ray
that his chest was normal, he was hopeful that this fearfulness, which we labelled as a minor phobia, was
settled.

The outstanding features of this story were the need in the consultation to recognise that, whilst my
agenda is important, that is, to find out what- if anything, is wrong with the patient, the possible
meanings to him may be much more important . He had no great concerns about his present symptoms,
except insofar as they might constitute a link with his staphylococcal pneumonia, which was terrifying to
him.

We need, therefore, to pay careful attention to the concerns of our patients, particularly asking them the
broader meaning of the symptoms as they present in the course of an illness.
By this approach it is possible that healing of the ‘dis-ease’ may occur.

BETSY
Brian; I suggest deleting this case – even though it is a humorous account – on the grounds that it is not
really relevant to thepsychological issues inherent in your other cases in this book.

Betsy was age 92 when this incident occurred.

She was round, apple-cheeked, Irish and totally loveable.

It was 8:30 on a Monday morning. I was about to leave for my office, when the telephone rang in my
home. It was Betsy’s daughter Nancy. She was in quite a state - telling me between bouts of crying that
she thought Betsy had suffered a stroke. Apparently Betsy was practically incoherent and could not tell
her daughter what was happening.

Nancy lived several miles away from her mother. I was much closer. “Will you go to Mum, Dr?”
“Yes, of course Nancy. I was about to leave anyway.”
“I should get there in about half an hour, Dr.
 Page 93

”
Ten minutes later I rushed into Betsy’s house, calling her name. The back door was open, so I entered.
There was a feeble call from her bedroom. She was up, and dressed in her dressing gown and weeping.

“He’s gone Dr”

“Who’s gone Betsy?”
“Tiger. He never goes away. He comes into my bedroom in the mornIng and never lets me out of his
sight. Something terrible has happened to him, I know it has.”
By now I understood she was talking about her much-loved cat, whom I had met before.

“Nancy was worried you may have had a stroke, Betsy.”

“Don’t worry about me, Dr. Where could he have gone?”
“Well, I’ll go look in your backyard.”

Betsy lived in a little old cottage with a large backyard, in which was her extensive vegetable garden and
a number of mature trees.
As I walked down the lawn, I heard plaintive noises emanating from one of these trees. It was Tiger,
having an adventure, I thought.
Betsy came outside when I called, still in her dressing gown, on a drizzly unpleasant day.

“We have to get him down. He is quite frightened of heights is Tiger”

I knew better than to question how Betsy knew what her cat felt about heights and responded. “Well,
how about you get some meat and I will try to tempt him down?”
Betsy came out with a piece of steak, gave it to me, and I did my best imitation of a circus athlete,
attempting to climb the tree. Tiger sort of sneered at me from his position high up the tree, showing no
interest in the steak.

I moved closer to tempt him, but he showed a lofty indifference.

By this time I had climbed quite high in the tree. I now understood what the expression ‘being out on a
limb‘ meant.
With encouragement from Betsy I climbed a little closer to Tiger.
He put his nose in the air and strolled past me down the tree into Betsy’s loving arms!

I, on the other hand did not retain my dignity, slid down the tree, landing on my knees on the grass.
My suit was a mess, so after I quickly checked Betsy to be sure she had no illness, I drove home to
change my clothes. My wife was surprised to see me, enquired about what I had
“been up to” and I thought, with some humour, that that was the quickest I had ever cured a stroke
victim.

Betsy and I remained good friends until she died peacefully a year or two later.
 Page 94

ANDI

Andi was a 48 year-old woman whom I have always regarded as having a high level of emotional health.
She was brought up in a happy, close family, describing her deceased father as; “a great chap”, and her
mother as having been a wonderful mother -though now very frail.

Andi had been to see me six weeks previously; having suffered a temporal headache for many months.
At the first consultation I asked her about her emotional state. She could not think of anything relevant.

At the next consultation, a week later, I decided that there was a distinct possibility that AndI was
suffering from temporal arteritis - inflammation of an artery near the ear- which can be very serious, in
that sudden blindness can occur.
I sought advice from a specialist colleague and took his recommendation that she should be started on
steroids immediately. I also arranged for her to have a biopsy of the artery. This gave a negative report,
so the question was; “what now?”

On the premise that most headaches are of emotional origin, I asked Andi again about her life. This time
she told me that she and her siblings were having considerable anxieties about their mother. She was
aged 80, living alone in a small town 50 miles away.

She had, over the past year, experienced visual and auditory hallucinations. In other words she was
showing signs of a psychosis. Aditionally, mother had some loss of recent memory.

The family took their mother to a psychiatrist.

At this point in the tale AndI started to show emotion - largely sadness.
But she was angry with the psychiatrist, who spoke with the family, ignoring her mother.
He gave her a variety of medications; which AndI said made her mother; “like a zombie.”
She was heavily sedated and drooled; behaviour she had not shown before.

Later the family took mother back to her family Dr, who discontinued most of the medications she had
been given by the psychiatrist. She substituted Stelazine, an anti-psychotic, which made mother very
drowsy, but did control the hallucinations.

At this stage, AndI had tears in her eyes, as she talked of the frustration of having an elderly mother a
long way away, very much at risk of experiencing some catastrophe, such as leaving an electric heater
on, or the mental torture of believing that she was being persecuted or had committed some dreadful
crime.

Once again Andi expressed her anger towards the psychiatrist and told me that the family intended to
meet with the family Dr that week.
 Page 95

I asked her; did she think there was any connection with her headache - and she was quite astonished.
However, in her customary thoughtfulness, she did not reject that idea - especially when I pointed out
that the headache might be seen to represent an explosion of thought and feelings in her.

We agreed that she would meet with the family doctor and we would meet again to talk some more
about her headache and her feelings.
The family did meet with the mother’s doctor, who arranged for proper care of mother to protect her
against the complications of her brain disease.
The family felt much better after these measures were put in place; and Andi’s headache vanished!

It is worth noting that once again the symptoms ‘chosen’ by the patient were in the same area of the
body that her mother’s symptoms originated.

A RELUCTANT SOLDIER: JACK

Jack was age 82 when we first met. He was an extremely thin, nervous man, who spoke in a low
mumble, at times difficult to understand.
He had recently moved from another city, to live with his son Malcolm and daughter-in-law Alison, after
the death of his wife, who had been extremely supportive of him.
The family believed her loss was responsible for Jack’s marked physical and mental deterioration over
the past few months.

His loss of appetite and weight, his mournful manner, as well as his sleep disturbance, associated with
serious loss, made the diagnosis of depression obvious.
I recommended antidepressant medication and monitored his considerable improvement over the next
six weeks.
We agreed that Jack would continue this medication indefinitely.

A few weeks later, he returned, complaining of an itching, burning rash on his left upper arm on the
outer surface. As I was examining this angry dermatitis, Alison, who had accompanied him, said with a
half smile, that it had developed after Jack had listened to a radio programme commemorating the
exploits of the New Zealand Army Corps during World War 2.

Jack was an ANZAC, an acronym for the Australia and New Zealand Army Corps. I picked up the
implication in this and asked what the war was like for him.
He immediately associated to directing traffic in the middle of the night, near Monte Cassino during the
Italian campaign. There was a total blackout and during this time, Jack was knocked over by a Jeep,
fracturing his left arm.
 Page 96

He was transferred to a medical dressing station and left overnight lying on a stretcher. He was offered
no care and complained bitterly - to no avail - until the next morning when he was moved to a casualty
clearing station.
An X-ray revealed the fracture and he was transferred to a base hospital, where he was given an
anaesthetic, the fracture was reduced and a plaster applied from his shoulder to just above the elbow.

Later that day, presumably in response to swelling, the arm became painful, itching and burning at the
upper edge of the plaster. As he told me this ,he put his hand directly over the area of his current
dermatitis!

He spent four months in hospital recovering and by this time the worst part of the Italian campaign was
over. I wondered aloud if he had felt guilty about his slow recovery, but he responded that he felt; ”jolly
lucky to be out of it”.
He went on to say that the radio programme reminded him of his mates who had been killed in that
fighting and that he felt very emotional afterwards.

Jack’s retrospective view of himself as a hopelessly incompetent soldier seems to have accompanied him
through the following 60 years; that his wartime traumatic experiences had reduced him to an
incompetent civilian after the war - one who always felt in his job, that he never gave of his best and felt
like a failure in life.

The loss of his wife recently had special significance, in that she was a woman who did much to keep his
self-,esteem at a reasonable level.

Ending an interview can be difficult. It seems a pity to interrupt the flow of unburdening, especially in a
patient like Jack, who had never talked in this emotionally revealing way before. Sometimes I am
concerned that if I terminate a consultation in full flight, a precious moment will be lost, never to be
recovered, and indeed this has happened occasionally.

However, under all the emotional turmoil there is usually a close rapport developing and this can be
relied upon to survive a temporary break in the relationship, and to promote expression of the thoughts
and feelings demanding attention.

Nevertheless, timing is important. I was aware that at that moment I had just experienced an emotionally
warm feeling and I knew I was “getting through” to Jack.
At this point in the consultation, Jack sat upright, and looked intently at me.
”What has this got to do with my arm anyway, Dr? I only came to get that rash fixed”.

“I am not sure at this point, Jack. How about I give you an ointment in the meantime, and perhaps you
could come back tomorrow for an hour to tell me more? I do think that there is a connection here and I
believe it would help us both to take our time to explore that further”.
 Page 97

This emphasis on the mutuality of our task seemed to reassure him, in that he accepted my offer with
alacrity.

In the session next day, he talked of being of two minds about volunteering for the army,but that
dilemma was solved by the introduction of conscription in early 1940. He was never very keen on
becoming a soldier and described himself as a coward and a failure.
He said that he came back to New Zealand a ‘nervous wreck’. The war, to Jack, was a continuous
nightmare. When they were not involved in close fighting with the Germans, they were harassed by the
German air force at night.
He could clearly remember being afraid all the time.

Around the time of his first consultation there had been a number of programmes broadcast on radio on
the 50th anniversary of World War 2. And in one of them there was a description by an infantryman of
being on the ground, under attack by enemy aircraft.

My patient described this experience and gave me a sense of the horror of it, particularly in the
screaming of the engines of the Stuka bombers, as they dive-bombed helpless troops.
He went on to describe that every day was terrifying for him, even when he was not in action.

On one occasion he was asked by his platoon sergeant to take a German prisoner through the lines for
interrogation. He did so and found his way back to the platoon on the eve of a major action. When he
arrived, the sergeant expressed surprise, saying that he thought Jack would have made sure that he did
not get back until the next day.

My patient emphasised what he believed that man’s attitude towards him was - as a coward. He was
surprised when I commented upon the bravery of his action, when he could legitimately have avoided
the engagement next day. He was also surprised with the idea that perhaps the sergeant meant that he
would not have returned, had he been in Jack’s situation.

In remembering the end-stages of the campaign he was involved in, he described vividly to me a Stuka
attack in which a bomb fell on the trench next to his with such force that he was lifted up bodily out of
the trench and on to the ground.
He had developed an acute anxiety attack after that and was sent back to base hospital where he was
seen by a specialist and diagnosed as having an ‘Anxiety State’.
His interpretation of that was that he was unreliable, cowardly and too nervous to be of any help to his
platoon.

He was concerned that the nervous condition that he had had at that time had come back since he had
been listening to the commemorative radio programmes, and when I commented, it certainly seemed to
get under your skin, Jack”, he smiled wanly and agreed that such was the case.

He said that he had come back to New Zealand a “nervous wreck”.

 Page 98

He could not settle in to his work and moved from job to job over the next 35 years. He always felt that
he had made a mess of everything he did during the war and in his later life.

During his military training before leaving New Zealand, he received a smallpox injection and again
pointed to the site of his dermatitis. Perhaps the injection symbolised the possibility of going overseas
and being killed?

After his wife died, his already low self-esteem rapidly crumbled.

We ended a second one-hour session with his comment that he had never been able to talk about his war
experiences before, and he felt gratified that his account of his wartime experiences had been accepted
without blame or criticism.

I was touched as he left the room, when he not only thanked me, and shook my hand, but asked me
never to repeat his story to his family.

As he walked out the door, he told me of one good experience in the war, a vivid memory of General
Freyberg, the Commander in Chief of the NZ army, walking among the troops, saying they would soon
be repatriated and be able to return to their homes.
He added that he had no idea what his job would be when he returned. Jack was pleased to point out to
that the General became Governor General of New Zealand.

Jack’s dermatitis cleared in the week between the first and second sessions.

A cynic might well ask what this admittedly sad story and the revelations within it had to do with Jack’s
recovery.
He was treated appropriately with steroid cream, and antidepressants. Perhaps these treatments would
have been sufficient for him to recover? Who knows?

Over the next year, I saw Jack regularly and the last time I saw him before he died suddenly of a stroke,
he told me that he had taken his courage in both hands and told his family about his war experiences.
He was terrified that they would agree with his shame and humiliation, but their response was gentle,
loving - and even, to his surprise - they expressed their admiration of him.

Brian; I suggest deleting the poem. Even though it is interesting in itself, it is not consistent with the rest
of the book. I was so touched by Jack and his story that I wrote this poem.

ECZEMA IN AN ANZAC (Australia and New Zealand Army Corps)

Someone said “life is Hell”

 Page 99

I never really understood that.

But Jack did.

Five years of Hell incarnate,

Sixty years of Hell in his head,
World War 2 for Jack,
A reluctant soldier.

A peaceful man,
This was no place
For this ANZAC

Fifty years later,

He came to me,
bared his arm,
A patch of eczema, red, itchy, raw.

Anxiety, sadness, guilt and shame,

The corrosive tetrumvirate of internal anguish,
Portrayed his current mental state.

Aloud, I wondered why.

His daughter,
Smiling softly,
“He’s reminded of the war”

He’d listened that week,

To 50th programmes ,
It all came back.

He scratched his arm,

Scratched at the horror.

It seemed there was a connection.

The Stuka bombers shrieking down,
Screaming their hatred,
Spewing bombs.

Enemy tanks, shells spitting out,

Panic fear, mates being killed,
Blood and guts being spilt over the desert sand.
 Page 100

One day in the desert, fighting all around,

A Jeep rolled over, trapped him,
Broke his arm.

To Field hospital, overnight,

Abandoned, no care, only pain,
Next day, anaesthetic, a plaster cast

Reluctantly back to frontline horror,

Met his sergeant on the way.
“Now you’re out of it son “ he said.

And Jack went back to base as told,

His war for now
Placed on hold.

His arm swelled that night,

Plaster tight, irritating edge
Again I saw him scratch that spot,

Along with relief, awareness

Of luck,
His guilt appeared,
“A coward no less”

Six weeks for the fracture

Sixteen for the eczema,
Discharged, sent home y
In ‘45.

Back from the war a broken man,

He hated his job,
Himself far more
“What use a bloody coward? He asked.

He married a woman,
strong, loving supportive,
Constricted life to
His wife and kids.u

Then six weeks ago

She died
 Page 101

Unimaginable separation, devastation,

and grief

Programmes talked of loss,

Those who survived,
And those who didn’t.

Overwhelmed he scratched his arm,

Lo, behold,
The rash was back in full severity.

A simple man
He asked me next
“Could all this be connected Doc?
“I dunno Jack. It’s your story”.

This letter tells something of the meaningfulness of relationships in family practice-something I could
never trade for anything.

Dear Brian,
Many, many thanks. I’m typing this with tears rolling down my cheeks. My poor dad; what he put up
with, and we think we have problems!
Mum and Dad kept so much inside them, they thought I wouldn’t understand. Maybe I wouldn’t, I don’t
know, but I would never think of him as a coward, but always a gentleman, pure and simple. He was one
of those genuinely nice people who you have pleasure to come into contact with in your life.
So, once again, thank you from the bottom of my heart.
I’m glad he felt comfortable with you; to talk about it all.
I can never imagine what he went through in his life and I am so glad he talked with us briefly before he
died.
Thank you,
Malcolm. (Son)

No amount of money could replace this simple ‘ thank you’.

It is interesting but probably not productive to consider whether Jack suffered from Post Traumatic
Stress Disorder. In the end Jack showed his courage by talking about his guilt and shame.

AARON

Aaron was a stocky 20 year-old, whom I had known most of his life.
 Page 102

His overt reason for coming to see me was a minor rugby injury. I knew Aaron was totally committed to
rugby football and have heard from him of his many successes in the game. He has an open, honest and
quite gentle manner and I have always warmed to him.

We dealt with his injury, then he made a further comment, common in family practice; “by the way, I
thought while I was here I would mention that I am having trouble sleeping.”

This ‘by the way’ comment has many variations, but is characterised by occurring when I think the
consultation is finished. It is often made when the patient is approaching the door to leave, and mostly
followed by an invitation to sit again and tell me more.

Aaron said that his sleep disturbance dated back a year and a half and was characterised by getting to
sleep easily but waking through the night and having difficulty getting back to sleep. This history always
makes me think of depression, so I enquired further into that syndrome.

Aaron felt unrefreshed on waking, but his energy improved as the day progressed.
He was not aware of any sadness and had never thought of suicide. He was aware that he was not
enjoying life as much as usual - and worst of all his performance in rugby had deteriorated.

I pointed out to Aaron that sleep is a natural process and sleep disturbance suggested there was
something on his mind. He seemed to accept that explanation, but was unable to think of anything
causing the problem. Nor could he think of any precipitating event.
He told me that he currently did not have a girlfriend, having recently ended a not very serious
relationship, but did not feel troubled about that.
Every avenue I explored in this now extended consultation was unrewarding in terms of possible causes
of his sleep disturbance.

I call this ‘being defeated by normality’.

I now had a young man who had mild depressive symptoms, but could not make sense of them for us. I
told him he seemed to have depression, which is usually based on loss.
Furthermore, I emphasised that depression always has a cause and the fact that we had not found it did
not mean that there was no cause.

We discussed the possibility of antidepressant medication which would help the sleep disturbance and
possibly relieve the other symptoms he was experiencing.
I added that this would not supply any answer to the main question; which was about the cause of his
distress.
Again I said that despite his normal responses to my direct questions, I believed it did not mean the
condition had no cause in his life; only that we had not yet found it. I added that simple sleeping pills
had no place in his treatment, that they only work for a few days and carry the risk of habituation.
He heartily agreed with that conclusion. We decided to meet again for half an hour, in the hope that
somehow his memory would be jogged by the present encounter.
 Page 103

At the next consultation, Aaron reminded me that he had been brought up since the age of two by his
father. I had thought his mother had died, but in fact she had left her husband and two sons, apparently
having fallen in love with another man.

Aaron then remembered that just before the onset of his sleep concerns, his mother called; him wanting
to reestablish her relationship with him and his brother. He felt angry with her, aware of his feeling that
she had abandoned him, and mindful of the fact that his father had been a devoted parent to Aaron and
his brother all their lives.
He felt that seeing his mother would be disloyal to his loved father.

By now Aaron was in full flight, as he recovered memories and associations relevant to his early sense
of abandonment by his mother. He said that now he could understand why he always had difficulty in his
sexual relationships. One girl had accused him of being distant, aloof and uncaring.
He further expressed his anger towards his mother and said he had no intention to see her now, or
anytime in the future.

Somewhat shamefacedly, he said he did meet her once after she called, but that meeting was
disappointing, in that his negative feelings were so strong that he could not recall the conversation or
even what his mother looked like.

I wondered aloud how it could happen that a mother could leave her two little boys and a loving husband
for the possible ephemeral love of another man?
Aaron looked surprised, as if my question was irrelevant; but I persisted in my view that we didn’t know
enough about that early situation.

He acknowledged that he had never been able to discuss his mother’s leaving with his father, and added
that his father was15 years older than his mother.
I pointed out to him that his refusal to see his mother who called him from time to time was self-
defeating, in that he was reluctant to seek more information about his own early life history. Knowing
the truth in more detail was unlikely to hurt him further.

Aaron considered this point of view and called his mother to arrange to meet her.
He resolved he would tell her of his anger, hurt and long-standing feelings of being rejected by his
mother, for no fault of his own.
I reassured him that his mother would not be hearing anything new in that and that I thought she showed
a lot of courage by persisting in her wish to see him in the full knowledge that recriminations were
inevitable.

Aaron promised to return after his meeting with his mother and that happened about six weeks later.
He started by saying be felt much better, and was sleeping well. He had a new girlfriend in whom he had
confided fully - that in itself was a healthy sign - and she fully supported him in his intention to meet his
mother.
That meeting proved to be successful.
 Page 104

Aaron told his mother of his feelings and she accepted them with considerable tearfulness.
With this long-experienced load of pain exposed, he felt able to ask her about the marital separation.

To his amazement, he discovered she had not left with another man, but apparently had suffered from
severe postnatal depression after the birth of Aaron’s older brother - and had experienced another
depressive episode after Aaron was born.
She did not seek professional help and subsequently left home- and her sons - because she was terrified
that she would harm her little boys; a common symptom of post-partum depression.
With this revelation they both cried, Aaron for the first time in his adult life.

This story does not have the ending one might have hoped for- that Aaron and his mother might have
experienced reconciliation, resumed contact and developed an harmonious relationship.

Aaron still felt rejected. However, he came to understand, to some extent, the emotional distress his
mother felt prior to the break-up of the family, and to her great relief, he forgave her for leaving.

He was pleased that he no longer had any difficulty in feeling emotional warmth towards his girlfriend
and spontaneously ascribed that to his forgiveness of his mother.

Aaron’s depressive feelings settled without having to take antidepressant medication.

He resolved to keep an open mind about whether to see his mother again.

Moki

Moki first presented 6 weeks previously. On that occasion he had complained of vague pains in the neck,
shoulder and arm. He had quickly identified these pains with being somehow connected to current
emotional problems.
Uppermost in his mind was his wish to reestablish contact with his father, an alcoholic, who left the
family some years ago. Once again he complained of aches and pains.

The symptoms he presented seemed to be what Michael Balint called, ‘the ticket of entry’ and he paid no
further attention to them as the consultation proceeded.
I took his lead and invited him to tell me more about what was going on for him.

As he talked, his eyes became moist. He told me that he had recently completed a programme for
alcoholics, having recognised last year that his drinking was out of control, at the age of19.

This pleasant-faced young man recalled with some pain, his sense that his father was never very
interested in him; but at the same time a feeling that he really wanted to try to reestablish contact.
 Page 105

At that time, there seemed to be no physical relevance to his aches and pains and I did not physically
examine him, as the pressure within him to see his father seemed paramount.
We finished the consultation with an agreement that he would return to work, that he would not take any
medications of any kind and that he would make a decision about seeing his father quite soon.
When he was offered the opportunity of psychotherapy, he said he would consider that too.

When he returned, he stated that his reason was once again to discuss his intent to see his father. He
brought with him a five-page letter he had written to his father whilst he was in the Alcoholics Course.
In this letter, which he invited me to read, he told his father how much he hated him for being abusive to
Moki’s mother and uncaring of him. He gave a vivid description of a small boy trying awfully hard to
gain his father’s attention. But his father was unresponsive to Moki’s efforts at closeness and seemed
absent.

I was moved by the letter, which by the end, also told Dad how much he loved him and wanted to
establish contact.

I was not certain what Moki wanted from this consultation, until I asked him how he felt after the last
time we met. He responded that somehow it felt important to him to be able to discuss the pros and cons
of meeting his Dad.
I then asked how he felt towards me after the last time we met.

He looked blank-faced and dazed after this question- and I waited a full minute or so before commenting
on his appearance. He shook his head - as if to clear it - and then said; “Well sometimes I’m like that
when I face something that is emotionally difficult for me.”

I was puzzled and asked what was emotionally difficult about my question.
He replied; “I was going to say something about love towards you but that would not be right.”
I wondered aloud if this might mean I was somehow connected with his Dad and he replied; “yes ,that
was the point.”

It seemed like I was, to Moki, the good and loving Dad that he never had and that it made sense to him
to talk with the good and loving Dad about the un-good and un-loving father, in the hope the latter might
change into the good and loving father he wished for.

This is a fine example of a psychological process we call Transference.

In this process, the Other (in this case me) is accorded a position and feelings are developed towards the
Other as if that person - me in this case - were someone of profound importance in the person’s early
life, in this case his father.

Clearly Moki didn’t know me in any other role but that of Dr, and it would seem that a sense of love
towards me is totally misplaced and irrational, Yet, if we recognise the importance of transference in
relationships, then we can recognise the power it has in allowing the person to speak freely of their
 Page 106

feelings, good and bad, about others, especially the original person who is usually someone close, like a
parent.
In this way the relationship with me enabled Moki to practice being open with his father in a safe
environment.

Transference is regarded as an inevitable consequence in psychotherapeutic relationships, but the point

of Moki’s story is to illustrate that in fact Transference is common- just not usually talked about.

Moki returned about three months later, to inform me that he had contacted his father.
This contact was entirely unsatisfactory, in that Moki found himself so disliking his father that he left
quickly and resolved not to try making contact with his father again.

It was interesting to note that Moki declared himself satisfied with this outcome, believing that seeing
his father in the flesh dispelled any illusions he had held regarding his father’s essential goodness.
“So I have divorced him Dr, and I feel free of him now.”

There is another process called Counter Transference which is the mirror image of Transference. It
occurs in the doctor and is characterised by the doctor identifying with the patient in such a way that the
doctor reacts to the patient as if he or she were someone else.

MRS. A

Mrs A illustrates this very well.

She had attended my practice for some years. One day she came in, sat down, and without preamble
said; “You don’t like me do you, Dr?”

To say I was stunned is an understatement!

Since both patient and I knew her statement was true I had to agree with her.

“Can we talk about that Dr?” Now, that is usually my question. I hardly knew what to say.
“How did you know Mrs A?”
She responded that her husband found me friendly and relaxed, but her experience was that I was
uptight, tense and defensive.

This comment triggered an immediate set of associations for me, the main one being my recognition of a
striking resemblance she had to an aunt of mine, whom I had found to be unkind, critical and dismissive.

It became clear that I had quite unconsciously identified Mrs A with my aunt and reacted the same as I
had to this aunt some forty years earlier.
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I told Mrs A of my association. This woman, whom I now know to be a gentle and kind person, replied
that she knew she had done nothing to offend me and now she could understand my brusque response to
her, as it had to do with an error of judgement of mine, rather than some failing in her.

Now, to continue the metaphor, she had become my gentle caring mother and I could only, with some
regret, apologise to her- which she graciously accepted.
Our relationship after that was characterised by warmth and closeness.

Some years later she moved home and changed doctor. I was quite saddened by her loss.
About two years later I was surprised to see her in my waiting room. She had accompanied a friend who
came to see me. The friend told me it was Mrs A’s birthday and I was delighted -and so were the
patients in the waiting room - to go wish her a happy birthday, accompanied by a big kiss on the cheek.

This, then, is a typical Counter Transferential reaction, but with a happy ending which is not always the
case.

MR. YEONG CHAN and Dr. Ng

A man of my age was describing an incident in his childhood.

I felt intensely sad and in line with my general policy of informing patients when I think I am
experiencing a projective identification, I told him so. To my surprise, he was quite unresponsive
personally, but pleasant in his denial.

I then realised that he had described - almost exactly - a similar and long-forgotten experience of my
childhood and had pressed the right buttons in my unconscious to provoke this strong reaction.
This realisation enabled me to carry on the consultation and later be able to discuss the whole episode
with a colleague.

He was Mr Yeong Chan.

I was Dr Jones aged 23, very recently qualified. I was the resident doctor in the genitourinary ward. Mr
Yeong was admitted to our unit with a diagnosis of terminal cancer of the bladder.

As was customary, I went to the bed of my patient in order to perform the ritual of admission, to
‘interrogate’(that old fashioned and arrogant way of saying to take a history). Mr Yeong however, spoke
very little English and clearly was not going to try to talk with me.
I was stumped until I thought of Jim Ng. Jim was a final year medical student, of Chinese extraction,
who, when I explained the situation, generously offered to come to my ward and interview my patient.
In a few minutes I could hear him talking to Mr Yeong. After some time Jim emerged and asked me to
sit with him and the patient while he explained the situation.
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Mr Yeong, he said, was aware of his medical problems and did not want any further tests.
He believed he would die very soon and wanted to do so with the greatest possible dignity.
In effect, he wanted to be allowed to turn his head to the wall and quietly die with his family around him.
How could we deny this wish, despite our training that we should fight to the end?
I agreed with Dr Ng, who transmitted this agreement to this amazing old man.
He smiled at me, turned resolutely to the wall and closed his eyes.

We asked his family to attend him and he died quietly in dignity that night.

This was quite a shock to me, having been educated in the Western philosophy of denying death to the
bitter end.
Dr Ng, like me, entered Family Practice and later in life became famous for his definitive history of
Chinese gold miners in the Otago gold fields in the 19the century.

ELLEN

Ellen made a one-hour appointment.

She had had some previous experience with me in psychotherapy, and rather than present a physical
illness, she had decided for herself that there were things she needed to talk about. Ellen was a pleasant
and very insightful person, of above average intellect.

She started by saying that she had never recovered from her hysterectomy, performed three months
previously, that she had a sense of loss, nervousness, headaches, breast soreness, abdominal pain and
stomach churning.

She went into a long litany of complaints about the behaviour of her partner, James, an
ex- alcoholic.
This seemed not to be getting anywhere.
I became aware of a restless feeling in me and responded to this feeling by asking her if all this had
anything to do with the past.

She replied that life now was just like it was with her husband who drank a lot and was verbally cruel to
her. She added that she was not going to put up with this behaviour from her partner.
“You are a victim who wants to change?”
“Yes, I can’t stand going on like this.”

I then asked her about ‘the children’.

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Ellen has no children. At age 17 she had given birth to twin sons, whom she adopted out in
circumstances we had discussed in previous psychotherapy. The ‘children’ in this case were those of her
partner.

“They all use me about their problems. They say they can’t talk to their mothers. There are three from
James’s marriage and two from extra- marital affairs and whenever something goes wrong for any of
them, they come rushing round to me and I get upset by them.”

“They listen to you because they think you will listen, understand and give them good advice?”

To my surprise her jaw dropped visibly, and her eyes widened also in surprise.
She pondered a moment or two then said; “I never thought of that. I haven’t brought up any children, so
I assume they think I don’t know anything.”

“That’s your thought not theirs. They treat you as a mother don’t they?”
“My husband had three children by a previous marriage. They would come to him for help and he would
tell them to move in without even asking me. I have assumed these kids would use me too.”
“Have they?”
“No, actually not, when I come to think of it Lots of things come to mind now. For example, I think that
maybe I am confusing the two relationships, and expecting to happen now what happened in my
marriage. You know, his grandchildren come to me and they hug me and tell me they love me, and I am
dumbfounded, shocked. I feel like I don’t deserve it”

Why do I get it? Well, I looked after lots of kids as a schoolgirl, bathed them, cared for them and really
loved doing that for them. I suppose that’s why little kids like me.”
“I am sure that’s a part of it, but it seems to me to be more that they find you loveable and you them.
That’s a fine trade off. So you haven’t brought up children yourself but you are kind of doing it now. But
you have had children, what about that?”
“Well, I had my two boys, you know about that, they were taken away and I still can’t accept that I have
given them away. I should have brought them up myself, I have missed out on all of that. Part of my life
is missing. I haven’t any grandchildren. Well ,I sort of have, but they are actually James’s- but they feel
like mine.”

She cried and looked sad.

“It helps feeling and being sad because you haven’t been able to express this before.
By now there were tears in my eyes too.
“So you feel both deserving of love and undeserving of it at the same time?”

“ Now I have had a hysterectomy. If I hadn’t had my tubes tied, I would have had a baby to
James. All this had brought it all back to me - no boys, no more children, not bringing them up. I went
through nine months of pregnancy and years later a hysterectomy and there is nothing to show for it
really”.
Ellen cried copiously.
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Time was up and she agreed to come the following week.

The next session began with Ellen blaming her hysterectomy for how she felt, then shifting to her
partner, and following that, associating from one love object to another, backwards in time; namely
James, then to her husband and finally to the children she adopted out.

She was able, comfortably, to express the sad feelings as she made these shifts and also some of the
anger that she felt towards her former husband who had been cruel to her.
She also recognised that her anger towards her partner was in fact displaced from her husband, because
her hopes and expectations were never realised.

She had now successfully linked the events of her life leading up to her present distress.
The loss of her womb, of course symbolised the end of any hope of the replacement of those beloved
twins.

Ellen presented a week later about another medical matter, which was unrelated, and said that she felt
much better now; that her anger with her partner had disappeared.
She had sat down with him and told him of her experiences in our consultations, and in her current life
and they had worked out, amicably, the negative feelings that had been between them.

DONALD

Donald was aged 18. We had never met before.

He was quite frank in telling me that the reason he had come to see me was that his own doctor was
away on holiday and he did not like the locum tenens.
He had asthma and had come for more medication. He told me he had had asthma since he was 12.
Something - his hesitancy, I think, made me ask; “do you remember your first attack?”
“Yes, it was the day my parents died.”
“Did they die close to each other in time?”
“Yes, they were together when they died. Dad was electrocuted, and Mum was just 50 yards away and
saw it happened and she dropped dead!”
The antennae of my Third Ear were vibrating!
“How did you find out?”
“I came home from school and found them”.
“What happened then”?
“I rang the ambulance. Of course they couldn’t help my parents, so they rang my relations, who took
over from there”.
“What were your relations like?
“Oh, they were very kind”.
“And the asthma.?”
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“I was lying in bed unable to sleep, and I had this vision of my parents in their coffin. I felt unable to
breathe- and I started to wheeze and I’ve gone on wheezing ever since”.

I invited Donald to come back to talk more about it but he declined, saying that somehow his asthma
kept his parents close to him.
I regret I never had the chance to follow up Donald. My guess would be that he did not get rid of his
asthma because it was too emotion-laden.

I have wondered about the reason Donald never returned.

A pointer to that may be that at no stage during the session did I detect any hidden emotion. Even when
he talked about his parents’ deaths, he did not show any sadness, so I concluded that Donald was in
denial, being frightened to experience the power of grief, combined with the fantasy that if he did grieve
fully he would lose his parents iccompletely.

I was too aware of his vulnerability to insist on the need to face up to his need to grieve.
This awareness was intellectual within me, but sufficiently strong to encourage me to leave matters as
they were, hoping that another opportunity would arise for Donald to get in touch with the painful
feelings that I am sure must exist in his unconscious.

Of course, it is possible that I was not the right person for him; that we were just not a ‘fit’, a given
condition for all types of exploration of patients’ emotional distress.

It is interesting to note that I heard of this fantasy from two other patients with asthma.
In neither case was I able to follow up.

POST-SCRIPT – Brian, I suggest deleting the following paragraph, since the account does not describe
one of your patients.

I was telling a close friend about this experience recently. He was intrigued because he had a story from
his adolescence.
At the age of sixteen, David was swimming in a river mouth when he slipped accidentally into much
deeper water. He struggled to swim to safety, to no avail, but fortunately a man who was a strong
swimmer dived in and rescued him.
While In the water and struggling, he thought he was going to die. His rescuer helped him to shore, and
he took some time to recover, having inhaled some water. Eventually he went back to where he was
camping and went to bed.
He had a restless night and when he got up in the morning, he had a florid asthmatic attack, never having
had one before.
He found an innovative cure for this -a cold shower! The asthma rapidly disappeared and never
relapsed.
He is convinced that the near-drowning and the panic he experienced, was the major cause of the asthma
attack, rather than the inhalation of water.
 Page 112

In this book I have attempted to describe and explain the techniques I learned in over forty years in
Family Practice, to be able to treat emotional illness and pschosomatic diseases’

I am uncertain which factors were the most important in my education.

First, my patients. They taught me to believe in the detection of emotional states which were not labelled
as that by the patient at the beginning of the consultation. They also taught me to notice when I felt a
new emotion in myself, and to be honest in my expression of what I was feeling. They taught me that
trusting my patients leads them to trust me, an absolutely imperative condition for this type of
exploration of their innermost thoughts.

The development of the Third Ear was a slow and at times painful process, as I made many mistakes in
interpretations of what I was ‘hearing’. I can only be grateful that my patients were forgiving of my
idiosyncrasies. I have a fairly spontaneous (some might say impulsive) nature and have at times been too
quick to assume some elements involved in investigations of puzzling symptoms. In that situation I have
never had a patient refuse my apologies when I have erred.

I grew up in a typical middle class New Zealand Family, the fourth of seven fairly rambunctious
children. Though we were encouraged to express disagreement with each other, we certainly never
admitted to upsetting emotional states. I was very pleased to have entered Family Practice, believing I
had the mind of a generalist, rather than a specialist. I first went into practice in a small town near
Christchurch, in partnership with Dr. Robert Hunt, who was quite psychologically-minded, a good
influence for a fledgling practitioner.

In the middle 1960s I joined a Balint group, which was fortunate in having Dr Balint, himself, as a guest
for six weeks. I remember when I first presented a case to this world- famous psychiatrist and teacher of
General practitioners.

He insisted I put my voluminous notes aside and speak from memory and heart about my patient. It was
a sobering experience, as I struggled to describe the feelings I was exposed to in my attempts to help this
woman who, fortunately for me, had sufficient trust that I could help her despite my ignorance.

Brian; should you get Sallyanne’s permission to include this paragraph? My daughter, Sallyanne,
reminded me recently of her memories as a teenager of my excited commentaries about my practice,
around the dinner table, and how that intrigued her; such that she became, and is, a psychotherapist now.

So, my education was based upon day-to-day experiences, clarified by the Balint group, and a number of
mentors who were so generous in long telephone conversations.

In 1978, I joined the staff at the Family Practice section of Brown University in Providence, Rhode
Island, where I took up the post of Residency Director and had the opportunity to train under Dr Nate
 Page 113

Epstein in Family Therapy. This was to stand me in good stead for when I retired from Family Practice,
and transferred to psychiatry, in the Youth Specialty Service, in Christchurch.

It was there that I became so impressed with Family Therapy as a model of treatment for adolescents. I
believe that Family Therapy should be a routine for almost all of the younger people treated in a
specialist unit for ‘behavioural problems’; that is, emotional distress masquerading as behavioural
problems.
It was at Brown University that I was able to have psychotherapy supervision with Anne deLancey PhD,
who once commented that I seemed to have an exquisite ear for sadness, rather surprising really, because
I have not suffered an inordinate amount of sadness in my life.

This suggests that my Third Ear was the result of resonating with the sadness in my patients, that being
the most frequent emotion detected by this theoretical organ.

Psychotherapeutic intervention was for me the most satisfying part of Family Practice.
The privilege of being a participant in a healing situation is hard to over-estimate in terms of my
emotional satisfaction, and more than compensated for the extra time spent in listening and trying to
understand my patients’ signals of distress.

A study performed some years ago, in which a group of patients with the diagnosis of ‘Idiopathic
Depression’ (Depression of unknown origin) were re-examined to determine whether there were
dynamic factors, such as childhood deprivation of love, severe financial hardship, and loss of loved
people present in their histories.
In almost all the patients studied, there were one or more of these factors present and the professional
participants drew the conclusion that the ‘missing factors’ were due to ineffective interview technique.

I do not believe that depression is simply a disturbance in brain chemistry. That we do not find reasons
for the occurrence of this state does not prove that there are no psychodynamics responsible, but simply
means we have not found them, probably because we have not enquired sufficiently.

The idea of a ‘broken brain’; with the implication that it can be ‘fixed’ with antidepressants, has not
stood up to research - as explained in Johann Hari’s book, ‘Lost Connections’.
Rather, it seems that depression is largely based upon serious loss, the overwhelming of coping
mechanisms, and the estrangement of the very soul of a person. As Hari points out, depression is so
much more than an intrinsic illness, being related to many societal issues such as childhood abuse,
unemployment, poverty, gender and political persecution.

Brian; I’ll ask Paul to forward my edited copy of REPRISE to you.

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REPRISE

I wonder if I could go back to, and revisit myself, after 40 years’ experience in medicine, what I would
say to the young doctor, struggling with the vagaries of human beings, struggling to understand why the
patient was with me, and what the real message was?
First, I would counsel patience. I was frequently astonished by the revelations patients made when
allowed to take their time to explain their presence.These revelations often apparently had little to do
with the stated reasons for their seeking help. I recognised early that Michael Balint’s ‘ticket of entry’
was just that, a flimsy complaint, designed simply to justify the consultation, and of little further use in
the consultation.
Next I would recommend that my young self relax, let his patient lead with further commentary. My
relaxation should include vigilance, such that I can hear the explanation and listen with my Third Ear to
‘hear’ what is not being said but needs to be.
I need to see the unconscious body language that is a pointer to what is being repressed in my patient,
the sadness, the guilt, the shame, so crippling to the soul.
The doctor and the patient are two sentient beings. Both will experience the verbal interchange, and both
will experience emotions, related to the illness, or to people not physically present but representing
powerful parts to the story. I would encourage myself to be self- observant, to try to notice the sudden
emergence of ‘foreign’ feelings for they will be part of the story too.
I would teach myself to answer empathically, to keep my voice gentle, and enquiring, and to answer
questions honestly
I need to be able to think around the available evidence, in order to comment upon connections made by
me or the patient, to expand on those connections, to make sense of our mutual discoveries.
And when it is necessary to ask clarifying questions, I would recommend that these be open- ended,
simple such as” I wonder how you feel about that?” or “is that connected with what you said before
about so and so?”
I would tell myself that psychosomatic illness, depression and anxiety are not due to a broken brain
( more likely a broken heart), they are not madnesses, but human responses to overwhelming
experiences.
Further they are not ‘cases’ but sensitive human beings whose adaptive mechanisms have come under
pressure. They need help and NEVER criticism, spoken or unspoken.
Finally I would say to my younger self that it is OK to feel the patient’s pain, to feel sad, even to show
tears, and acknowledge them, for that is simply joining the other in a mutual task, with a common aim to
understand and gain relief.