1

RECOLLEC
TIONS:
LISTENING
WITH THE
THIRD EAR
 2

SARAH: Dying With Dignity 5

INTRODUCTION 9
MRS J 12
TODO - Heading missing from this section 19
MRS S 24
MRS. A 26
CHILDREN 27
EDWARD 28
BILLY 36
CHRISTOPHER 42
MONICA 46
ELIZABETH 50
MRS. B 54
LIZZIE 58
TOM 67
AROHA 73
MRS. D; UNIQUELY FEMININE 83
A NON TERMINATION: CAROLINE 92
ANOTHER TERMINATION: LYDIA 94
MARIAH 95
1000 SICKNESS INCIDENTS 100
DONNA 103
 3

AMELIA 109
MR. J. 116
STEVE 118
A LOVEABLE MORPHINE ADDICT: GEORGE 132
TAMATE 145
POST TRAUMATIC STRESS DISORDER 150
DIANE 152
LINDA 158
DORIS 168
MRS. C. 183
ROBERT 187
SIMILES. AND METAPHORS 208
KEN 213
ALBERT 216
SALLY 220
EVE 224
JULIE 228
GRAHAM 231
RHONDA 236
ANNE 239
An Unusual Transference - John 245
STEPHEN 248
 4

BETSY 253
ANDI 257
A RELUCTANT SOLDIER: JACK 261
AARON 271
Moki 279
MRS. A 284
Mr W. 287
Mr Yeong Chan and Dr Ng. 288
ELLEN 290
DONALD 296
David 300
REPRISE 306
 5

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.
 6

“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 talk 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, 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.
 7

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 later in this
book) 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
 8

they would allow me to meet in their private domains and share their
sadnesses and suffering.
 9

INTRODUCTION
Throughout my career as a family doctor, I have been particularly
intrigued by the psychological significance of my patients’ clinical
histories and the life experiences that gave personal meaning to
them.

I was prompted to write this book by my close friend and colleague

Dr Ron Wintrob, who was visiting from the USA. As usual, we
talked shop. 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.
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 up.
By the time I retired, I had numerous stories documented.

Through this book, I wish to share the nature of the joys, stresses,
and occasional pain of being a family doctor, and to show how
patients and I have worked together in the process of healing. To this
process I brought my awareness of my Third Ear and my
understanding of the connection between the mind and body. Thus,
this book presents my patients and our shared experiences.

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
 10

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.

Medicine made huge leaps in during the latter half of the 20th
century. The discovery of antibiotics allowed doctors to control
infections for the first time mastery over infections; vaccinations
almost rid the world of scourges, such as tuberculosis, dDiphtheria,
measles, and 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 simplerified the
management of conditions traditionally beyond the reach of
medicine. Progress in psychiatry has in that time progressed to
havingproduced a number of medications to more effectively treat
depression, psychosis and bipolar disease that which washad
previously been 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, and George Engels in the USA, and Knight
Aldrich in the USA were talking of about psychosomatic diseases,
postulating that the mind had much to do with some illnesses. This
was spoken of astermed ‘“the mind- body concept”.’.
 11

Throughout my career, mMy patients have been my major main

teachers. have been my patients, whoThey have been generous in
their acceptanceing of my efforts to understand the nature of their
dis-eases and in allowing me to to join me them in attempting to help
them in their healing processes. I have also been fortunate in having
received support from a number of mentors at all stages of my
development.

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

When I do this, it is imperative that I consider my patient's the

cultureal background irrespective of whether they are newly arrived
in New Zealand or are New Zealand born. I must of the patient to be
sure not to invade their privacy more than is absolutely necessary,
and as far as possible, reduce the physical and emotional discomfort ,
both physical and emotional, of the experience.

ThereforeI need to recognise 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
testexamination, such as a rectal or pelvic examination, I have a duty
to 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 also need to explain that in advance if the examination is
going to be painful.

The following stories of Mrs X, a refugee, and Mrs J show how I

have exercised these professional obligations.
 12

Mrs X ,A a refugee from Somalia presented with a gynaecological

problem. After inquiring about her symptoms, aA pelvic examination
was indicated., I realised but it occurred to me that I knew little
about Somali culture. Her Mrs X’s English was limited, but I
nevertheless I detected a certain reserve in her., such that I felt
coimpelled to tell her friend, who was present, of about the need for
this intrusive examination. The Her friend gently explained to me
that, within their belief systems, such an examination would be
unacceptable within their belief systems., so Therefore, I referred
this charming, softly-spoken woman to a female colleague.

The important considerations for my actions in this consultation

were that I knew little about Somali culture and I detected some
reserve in Mrs X. 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?
 13

MRS J

Mrs J, a New Zealand-born woman, also came with a gynaecological

problem. Again, a pelvic examination was necessary.

Something, I was not quite sure what, about her manner (I am not
quite sure what), made me ask if she had any reservations with
regard toabout my proposed examination.

Hesitantly, Mrs J told me that, despite being her age – 54 - years old,
she had never been asked to “submit” to this very personal
procedure.

The use of this the word - "submit" alerted me to her sensitivity to

issues of interpersonal power. She let me knowtold me that there was
a strong sense of shame in her family about sexuality, including
genital exposure, based on certain their religious beliefs. , and that
Iin fact, those beliefs had delayed her seeking this appointment.

Mrs J surprised me by asking me to describe in detailexactly what

exactly was involved in this procedure. and tThen, I thought rather
courageously, she consented to the examination, which was
performed without any noticeable upset to her.
 14

She commented at the end of the consultation that she was glad she
had questioned my intentions, because she felt she had full control of
the event.

A key signal in this consultation was Mrs J’s use of the word
“submit”, which . she then used as a reason to ask for a detailed
description of the examination before she consented to it. My Third
Ear picked up the significance of Mrs J’s use of the word “submit”,
and

Each of usperson is unique. It is the duty behooves of doctors those

of us involved in the necessary intrusion into the bodies and minds of
our patients to try always treat patients with to respect and a sense of
integrity by seeking permission to cross ordinary social boundaries.
A patient's oObvious uncertainty may then be a guide tosignals the
need for caution and further inquiry into the origins and
psychological significance of that uncertainty.

The follow-up to the history taking a patient's history and conducting

an examination is, wherever possible, to formulate a diagnosis that is
understandable to the patient and their family. This naturally
proceeds to clear explanation of the proposed treatment.

When pPatients seek a consultation, they usually pose an unstated

question. which goes something like this:
 15

“Doctorr, 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.

Patients often also need to be validated during consultations. Mr R is

a delightful example of this need for validation.

Mr R, was an intelligent and talkative elderly Englishman, who liked

to tell me that he had previously had a Jungian analysis. He also
enjoyed talking about many subjects. He visited me after he 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. After our usual 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”.

My interest in the Third Ear and the mind-body connection was

aroused by the work of Michael Balint, a psychoanalyst and the
establishment of Balint Group meetings. , During the 19XXs, Dr
Balint wanted to teach general practitioners family doctors in
 16

London, how to practisce psychotherapy. However, tThese doctors

however, had little interest in psychotherapy. Rather they wanted
better to were more interested in getting a better understanding of 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 Ttwo such Balint groups were
established in Christchurch, which have now been meeting for more
than 25 twenty-five years. I was fortunate to have belonged to such a
group.

In theAt each meeting, a doctor one of the group presents a

consultation with a patient.

Mostly Tthe presentation is frequently related has to do withto a

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

In time, the doctors collectively come to a better understanding

better of why the patient has attended sought a consultation –—
often to the presenting doctor’s great surprise.
 17

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.

The eEarly in the life of the Balint group meetings mainly , the
meetings concentrated on the presentation of the medical information
presented in a 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 aAs the group became more experienced and wiser about the
psychological significance of patients’ presenting clinical histories,
the focus of the meetings shifted to the relationship between doctor
and patient.

With fFurther maturation, of the group moved on to resulted in

deeper examinations of the doctor’s feelings and thoughts, and the
group members became increasingly empathic towards each other.

This is seen in the experience of Dr P.

Dr P was, a middle-aged, experienced physician, who opened told us

in opening a case discussion at a meeting. He that he was rather
puzzled by that he hadhis considerable great difficulty treating
middle-aged women with migraine headaches. He said that he had
felt anxious during these consultations and was aware of a
wishwanting to close finish the consultation as soon as possible, to
“get her out of the room.”.
 18

This was so unlike this clever, insightful doctor, that the group also
became highly puzzled. All sorts ofMany questions were asked in a
vain endeavour attempt to understand what triggered such a reaction
in him.

Suddenly, Dr P. exclaimed; , “now 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; . Sshe was a great mother’.”

it was interesting that Iit took twenty twenty-five minutes of the

group session for Dr P to express this insight, suggesting that the
experience had been repressed in his unconscious until the right
moment presented itself and he waited for the right momenthim to
become aware of it and to tell the group.

Having dredged up from his unconscious mind the origin of this

uncomfortable experience from his unconscious mind, Dr. P felt
much more relaxed in the future with middle-aged women presenting
with migraine headaches.

It was not long after I started attending Balint Group meetings that I
became aware that patients were showing me that there are different
ways of listening and tuning in not only to what they are saying, but
also to what they’re not saying, but may be alluding to. These may
be an emotion or apparently unrelated information from their life that
need to be better understood.

MOVED TO THE FRONT OF THE CHAPTER

 19

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 usual, doctors are wont to do, we
were talkinged shop yet again. This time, though, Hhe 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
 20

secretary to type up. By the time I retired, I had a lot ofnumerous

tales documented.

material and this book is intended to present my patients and our

mutual experiences.
 21

BEING AWARE OF THE THIRD EAR ???

TODO - Heading missing from this section

To present the fascinating stories of my patients and our shared

experiences, I have altered the real names of my patients and
changed place names and other material information to make sure
that which may make the persons people I write about cannot be
identifiableidentified. I hope that Ihave written these stories with
sufficient respect and admiration, for the patientsm, and for our
mutual undertakings., In that way, I hope that patients they would
will 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 attemptingWhen
trying to gain relief from both physical and emotional distress we use
language to explain our life experiences.

It is part of the richness of the English language that literal

expressions are often inadequate in conveying that whichwhat needs
to be understood., and wWe are ablehave to use figures of speech,
such as similes or metaphors, to expand understanding.

This is particularly true in respect ofin medical consultations. How

does one a patient describe the cramping feeling of a bowel
 22

obstruction? “Iit feels like something is twisting my gut.”, How does

a patient describe the or another cramping feeling – that of angina
pectoris - when the heart is temporary starved of blood?; “Iit feels
like a band around my chest.”.

Understanding our emotions is equally complex. Most people are

aware of the existence of the unconscious mind. It is that ; 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 a person that dreams, thinks and
reasons,, that feels shame and guilt, and - that even punishes us; - all
well away from our conscious understanding and awareness.

It is only in recent times that we have become cognisant aware of the

huge network of connections between every functioning unit of our
bodies, constantly informing and moderating all systems. Some call
it the ‘bBody-- Mind’mind connection‘, implying that these
connections are not hierarchical, that is,where 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 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 a person.
 23

On such occasions, for exampleIt might be, an itch without a rash, a

headache without brain disease or a pelvic pain without pelvic
disease., On such occasions, it is incumbent upon the doctor to ‘hear’
that whichwhat is unsaid and ‘see’ that which what is unseen.

In other words, doctors need to use their intuition, sensitivity and

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

Thus, we have Donna who learnedt that her the “pain in my [her]
face” wais a manifestation of grief for her mother, as she recognises
recognised she must ‘face up to’ her grief and “that is a pain”.

Listening with the The Third Ear picks up messages a patient

unconsciously ‘‘broadcasts’’, by the patient, in such a mannerso that
the listener doctor becomes aware of feeling an emotion, -
commonly sadness - but also other emotions can be involved, which
that do not actually belong to the doctorthem at that moment.

This is an unconscious communication between doctor and patient

which becomes manifest if it grows sufficiently strong. to force its
acknowledgement.

Thus, I picked up on Sarah’s sadness by feeling it in myself, and

with Robert’s unexpressed whose feelings, entirely unacknowledged,
that I felt compelled to address them despite the risk of Robert
rejecting my efforts and even me.
 24

The A doctor, if aware of the Third Ear interprets this emotion as

coming from the patient. They and reveals it this by such comments
as; , “I wonder why I’m feeling so sad at this moment”? This
generally precipitates a realisation in triggers the patient into
realising that they of theare presence of experiencing this emotion
within him/her selfthemselves. and This realisation allows, and,
indeed gives permission for, the patient, to openly express it.

In psychoanalytic language, this is known as ‘pProjective

iIdentification’. , and wWhen it is appropriately processed with the
patient, it can have a profoundly beneficial effect.

I shall endeavour to will illustrate the ways in whichhow patients

have aroused the my awareness of my Third Ear, and how I have
used that information to reveal further elucidate the symbolic
meaning and psychological significance of their symptomatology.

My This book tells the stories of medical consultations in the context

of an everyday family medical practice. By no means are Ddoctors
are far from being uninvolved detached and objective observers.
They We are deeply involved in every moment of the a
contactconsultation and .

Not only involved, either, but also emotionally caught up, in ways
that we often do not know about ourselves. I will tell describe of the
emotional impacts of these interactions upon me personally in these
transactions and what the effect I think believe they have had upon
the outcome of treatment.
 25

As we seek to understand disorders and the systems , we callwhat we

call illness or disease, , we need to try to and hear the quiet
emanations from those those silent unconscious parts of a patient and
translate the signals into understandable communications.

There are ways the A patient can give us these signals inform us
through slips of the tongue (see Aroha, for example, who says
‘“mongrel”’ when consciously she means ‘uncle’ ), and similes (such
as like a “a ‘vise around my head”) ‘ and metaphors (like “I will
fight this disease”). These expressions help the patient to “grapple”
with the disease and will often will help the doctor better to
understand the patient’s story better.
 26

MRS S

Let me describe Mmy first lesson on the existence of the

unconscious happened when . 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 Mrs S 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 appropriate medical
questions but I could not the diagnostic issue was noidentify the
source of the problem nearer a solution. A pPhysical examination
simply confirmed a tender sore neck. An iInquiry into possible
trauma yielded no information of value. I asked her what she had
been doing ion the weekend, thinking of some activity being
responsible for her ” sore neck”. Nothing.

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!”

It was like tThis statement physically felt like it hit me. I was silent
for a moment, then asked her to repeat what she just said. She did
and, then smiled.
 27

, and asked; “Ddid I just find my own answer doctor?”

“I am not sure.” I replied. “What do you think?”?

Mrs S decided that she had what the answer she had come came for –
— to understand , — and would now to let nature take its course.
She declined any further treatment.

Later Sshe told me later that the pain in her neck had gone by the
next day.

Further, Sshe was also 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 everything is not necessarily as

it seems. Mrs S knew at an unconscious level the cause of the
problem at an unconscious level and, with a little help, rapidly made
her own diagnosis, leaving me surprised and a little wiser.

It is experiences like this which that help a doctor to form a close

bond with patients where they , such that they feel understood and
are ready prepared in the future to be more open to questions that
cross social boundaries. My consultation with Mrs A illustrates this.
 28

MRS. A

Mrs. A was 76. She had lost Hher husband had died of to cancer five
years previously.

Three months before this consultation, she mentioned that she was
lived living with a man some years her junior and, that they were
enjoying their companionship and outings.

Four years previously she had had successful treatment for breast
cancer.

On Tthis day, she had a minor problem that we dealt with quickly.
Then she reminded me, in a quite a coquettish manner, that she had
told me previously of about 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 asked if she had become
sexually active. Her reply astonished me. “Yes, Dr.octor, we are and
it is great! “ She leaned forward. and said “ we are, …Bbut we are
not using condoms. We trust to luck!”

Banter that crossed social boundaries with Mrs A gave me joy. Such
are the minor joys of family practice.
 29

CHILDREN EDWARD

MOne day my wife gave our much-loved eight- year-old grandson a

discarded T-shirt. The nNext 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 twenty-five years.

I had cared for Edward’s mother, Amanda, throughout her

pregnancy, and had established as commonly happens, a strong
relationship was established with the family.

When I am ready to see a patient, Rather than my staff ushering

patients to my office, I prefer to attend collect them from the waiting
room myself because , in the knowledge that I can gain useful
information is gained by observation observing of thetheir
behaviourbehaviour. of patients whilst waitingWho are they sitting
with in the waiting room? How are they sitting? How do ; that is,
with whom and how they sit, and how we behave towards each other
as we walk down the corridor to my office.
 30

EDWARD

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

Edward was just ten 10 years old when Amanda brought him to see
me. She explained her concernwas concerned that, for some months,
Edward for some months he had been irritable, tearful and, 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 that something important was happening to with her
son, but inquiry of himtalking to him led to tearful, angry, rejections
of her approaches. John, Hhis father John, 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. I knew My knowledge of
this family is that Amanda and John weare deeply committed to each
other, and the boys., and Ccovert activities, such as sexual or other
abuse were highly unlikely.
 31

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 hDid he needed to avoid being openness about
the situationsomething –— perhaps to protect John and Amanda?

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

I told Edward that I was impressed noticed with how unhappy he

looked and that maybeperhaps he could share the problem with me. I
reassured him in the understanding that I would not reveal his
confidenceswhat he told me to his mother without his permission and
only in his presence.

He smiled at this stage., Tthe first positive emotion showns so far

shown., Tthen tearfully, tearfully, he saidbegan to talk.;

“She threw it out.”.

“Threw what out?”

“My box. My powder box.”.

“Your powder box?”?

“Well, Ggrandma’s powder box.”.

 32

I knew Edward’s grandmother, a kindly old woman who died

suddenly some months previously.

“Your grandmother that died?”

“Yes that one.”

The whole family had attended Amanda’s mother’sher funeral. They

all grieved her; she had been a goodloving mother and grandmother.

Edward confided that, for a few days after her death, he had
difficulty sleeping and 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 Ggrandma’s house. and
Edward found his grandmother’s a small, round powder box — of
his grandmother’si. It smelled just like her. - and It was small enough
that he was able tofor him to spirit it away and, keeping it as a secret
and special connection with to Ggrandma.

When he felt miserable in his grief, he would take out this the box,
sniff it and feel better.

Inevitably, Amanda found the box in Edward’s bedroom and

unthinkingly, threw it in the garbagerubbish. Soon afterwards,
Edward sought the solace from his grandmother’s perfume and
discovered it was gone. He felt devastated and, realised what must
 33

have happened. , butHe felt unable to approach talk to his mother

because he felt guilty about keeping this secret memento. as a secret.

He Edward also felt angry towards with his mother, while at the
same timesimultaneously knowing that she couldn’t not
realisticallyly be blamed her, since she had no idea of about the
significance of the power box to Edwardhim. Thus, not only did
Edward not only feel felt a huge loss, but he also felt trapped into
silence.

The relief from liberating the secret was obvious. Initially, as he

talked he looked sad and cried when he talked, but quite quickly in
this half-hour consultation, he brightened up and began to talk of
about happy experiences with his grandmother. I commented to
Edward that he seemed relieved and and added that it was clear his
parents were clearly deeply concernedvery worried about him. I
wondered aloud if it might be a relief forto them to know all about
this, and what Edward he thought about telling his mother.

“She might be mad with me.”

“Why?”

“Cos’ I took grandma’s Grandma’s special box.”

“Well, she might be pleased you got something special of

grandma’sGrandma’s.”

“But I didn’t tell her about it.”

 34

“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 his mother and I

asked her Amanda to return to my office. from the waiting room.
Somewhat haltingly, he told his mother what had happened. Amanda
was shocked, burst into tears and apologised to Edward as she
hugged him.

Edward’s depression vanished!

This family does did not deal in the currency of punishment and
reward. Edward’s feelings of grief, and later depression was caught
up in a confusing situation where his feelings of grief, and later
depression, over- rode h

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 also felt a was also aware of a pressure inside need to unburden
himself. and When he was presented with this opportunity, he 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
 35

that was aware of a sense of loss of his grandmother’s perfume could

(symbolically) relieve his sense of loss. and his ability –
symbolically, through her perfume - to relieve this pain.

This is typical of grief, to Bbeing aware of the a loss and to

experienceing the concomitant associated sadness is typical of
grieving.

However, when the box was discardeddisappeared, he Edward

sensed a loss of himself;, an emptiness , which seemed irrecoverable.
This is typical of depression, aA combination of helplessness and
hopelessness, mixed with anger and sadness, is typical of depression.

I remember being told as a medical student that children lack the

capacity to grieve. This certainly fitted my own personal experience.
However,, but successive encounters with children, who have
suffered loss and had been able adequately to grieve adequately,
have demolished this belief. Rather, it seems that previous
generations have denied children the opportunity to grieve, by
various social manoeuvres, such as not allowing them to n-
attendance at funerals, refusal refusing to talk of about the losses of
loved ones, and denial denying 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 realised in an unarticulated way that the

apparent lack of a cause for Edward’s depression did not mean that
there was no cause; only that it was not obvious. and Tthough she
did not verbalise it, she understood intuitively that Edward needed a
more disinterested impartial person to expose the cause.
 36

There is also a lesson also in thishere for those of us who

endeavourpeople who try 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., However, if we are to understand the reasons, wyet we
must consider them them within the personal cultural context of thate
individualcontext of the personal culture of the individual and
attempt to put aside our any prejudices about what is ‘“right’.” in the
service of understanding.

I remember feeling a deep sense of satisfaction with this whole

scenariocase. I felt very privileged to be 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 about the his fond memories he has of his grandmother.

In Doctors in family practice mostly see , as contrasted with the

specialties such as psychotherapy and psychiatry, patients who
mostly have not been referred and have. Rather, they arrive without a
no professional diagnosis. Thus Patients present we are frequently
offered the raw material of symptoms and the doctor it is our
challenge tomust synthesise arrive at a diagnosis that satisfactorily
explains the discomfort presented. He does this through a process of
inquiry, examination, investigation, and the ever important empathy,
a diagnosis which satisfactorily explains the discomfort presented.

This An iinquiry is based on many factors, including history, that is

equally coloured by the patient’s and doctor’s patient’s past
experiences and culture, as well as nd equally coloured by the
doctor’s past experience, culture, and medical beliefs.
 37

Any interview examined in retrospect demonstrates identifies what

one writer refers to as “nodal points”, at which. At these points, the
direction of inquiry may follow several possible pathways. The
arrival of at these a crossroads crossroad may be signalled in obvious
or in subtle ways as demonstrated by Billy’s case.
 38

BILLY

Billy was a cheerful 10-year-old with sparkling eyes and quick

intelligence. He lived with his younger brother Shane, two years his
junior, and his father, Robert., They had been in his 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’s father had was taken him in
the evening to the After after-Hours hours Medical medical sService
with a severe attack of urticaria (h hives). This was appropriately
diagnosed and he was given an anti-histamine 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 thought to be acute an allergy. ,

butHowever, I believe I have my doubts.that i It seems is more likely
to me that urticaria is an fine example of the body –—- mind
connection at playplaying 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 gotten under
the skin”. This is the itch, which in urticaria can be quite intense. The
redness consequent uponfrom scratching the itch is a further
reminder of the problem.
 39

I asked Billy what he had been doing on this particular e day he had
developed the itch. , and hHe 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
timewhen the urticaria first appeared. and hHe replied, somewhat
dismissively, that he had just been watching a video.

However, something in his manner made me ask him to supply give

me more some information about the video. My Third Ear leaped
into action, detectinged Billy lowering his head, looking pensive and
pausing thoughtfully. I felt a sense of sadness.

I mentioned told Billy that I my suddenly feeling felt of sadness., and

tThen, slowly, he told me that it was a horror movie about , the
underlying theme of which had to do with a mother being unkind to
her children. He burst into tears, and with encouragement, talked
about sensing of a sense he had that his mother didn’t like him, and
she had rejected him. The feelings intensified in the session, Billy
described his and Shane’s stay with his mother during the school
holidays after her promise to spend equal time with them both. The
feelings of sadness intensified during 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.

When he arrived at his mother’s home, hHe 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 to the
back of the behind the door in the bathroom door.
 40

This seemed to epitomise typify the his experience of this the

holiday, as he found himself increasingly left alone while his mother
devoted time to his brother. At this point, his father interposed
mentioned that, every time the boys had mother made contact with
their boysmother, they would be upset for about two weeks
afterwards, and this would show in with attacks of crying, sadness
and anger.

It seems that at no time has contact with their mother never provided
a sense of nurturance.

As Billy talked, he suddenly remarked that he was feeling quite

itchy. and tTo our surprise, the urticaria appeared in partson places
of his body it had not before.

This boy Billy had been booked for an ordinary quarter of an

hourfifteen-minute appointment. However,, 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 and it was not possible to stop after fifteen
minutes..

When I suggested to Billy that this experience had “gotten under his
skin”, his smile through his tears showed that he understood exactly
what I meant and accepted the my interpretation. I invited suggested
that he him to return the next week, which Billy and Robert was
accepted byagreed to Billy and Robert.
 41

We met for two further sessions, which . On those occasions Billy’s

brother Shane also attended. He Shane too also acknowledged that
he seemed to be the favourite of his mother’s favourite son. , but that
Hhe 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 by the Robert and Shane’s show of
empathy demonstrated by Robert and Shane tofor 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 hisHis father reported that he had progressed
well in school and social activities.

Often the major information about the course cause of distress lies
within the a patient. and mMy task is to uncover that information by
appropriate inquiry. Of course, I might have taken different
pathways may have been taken, yetbut I the same destination
reached the same destination. I believe that the cause of Billy’s
urticaria lay in his relationship with his mother and, while the key to
the uncovering of this information lay in the questions about 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 myself
were so intense such that it is undeniable that Billy’s the experience
of hurt and rejection of Billy was extremely painful for him.
 42

In Billy’s case, as for many others, I note here, as I have experienced

many times, the development of an emotion which is was not in tune
with my general feelings on that day. Even iIf 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 have cried at that
moment. My experience tells me to believe in that these feelings and
to use it them on behalf of my patients.

Even if the relationship between urticaria and psychological factors

were was purely coincidental, it seems to me that Billy’s willingness
to talk freely about that it in an empathic atmospheresetting, had a
powerful healing effect.

Children, just Llike adults, children have many ways of expressing

misery and, not all of themsome of them are indirect. This is
especially so when a child does not sense in situations where the
special empathy required needed for the feelings to be heard and
accepted. the feelings is not perceived by the child to be available.

I have noticed that, when I make an interpretation like in this story,

like “Something has gotten under your skin”, as in Billy’s story, the
responsechanges in the symptoms is are quite rapid, as if it isthey are
not needed any more., and This makes the shift to emphasis focusing
on the psychological factors is logical and easy.

Many stories from family practice have uncertain endings. I cannot

be sure Billy’s symptoms were caused by from the loss of his
mother, but I am sure he changed from a miserable boy to an
ordinary boy -, and with that I have to be satisfied.
 43

CHRISTOPHER

This Christopher was a 10-year-old 10 y.o. boy, who came with his
father, Tom, who was a single parent.

The problem was a bright red rash on each side of Chis hristopher’s
face, over the cheekbones and, extending down to the corners of his
mouth. He was carrying a wet cloth, which he kept dabbing onto this
these bright red areas. 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 aboutsaid the
origin of the rash appeared a week previously.

I observed that Christopher’s dabbing was rhythmical;, three times

on one side of his face 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 doing with the wet cloth. Apart from this, said father,
nothing unusual had 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.”.
 44

Christopher‘s father had Iin the past three months, Christopher‘s

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

I asked him what was the problem was about Jane,, the father‘s new
friend, and again he surprised me by saying; , “Ggoing to her place is
great and she treats me really well, but if dad 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
Tom’s eyes lit up with understanding. Tom 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, she and wanted to get married again and get rid of Christopher.
The father’sTom’s response to this was to take Christopher with him
to live with him. , and eEvidently, Christopher was terrified that the
same rejection would happen again with the his father’s new partner.
, Jane.

Further inquiry revealed that, though Tom cared for Christopher in

the physical sense, he was somewhat uninvolved in Christopher’s
daily activities. I suggested that they may might do more things
togetherbecome more involved. Tom told mesaid that he had
suspected something was wrong emotionally with Christopher and
he had tried to talking to Christopher, suspecting something was
wrong emotionally,him but Christopher he was uncommunicative.
They both reacted favourably to the idea that a 10-year-old might
 45

speak about the problems better when they two of them were doing a
mutual project together, rather than Christopher being sat down, and
Tom talked talking to him and and questioneding him.

I arranged for them to return a week later for a half-hour session. and
wWhen they did soarrived, it was obvious both of them 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 by chance inat a shop. He told me that Christopher has had
not resumed the rituals, and that he and Jane were soon to be
married. Christopher was to going to be the BBest MMan and was
very excited about the prospect.

It is a matter of pure speculation to try to understand Tthe meaning

of the ritual that Christopher performed is pure speculation. That it
arose from separation anxiety It seems abundantly clear that it arose
from separation anxiety. 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 have been of interesting to know why the next last
appointment was cancelled, but an explanation would do little more
than satisfy my own curiosity.
 46

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
Tthat father and son achieved an improved understanding of each
other may be seen as a bonus. We did not discover the meaning of
Christopher’s ritual, but by then that was purely academic.
 47

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.”

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!
 48

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.
 49

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.
 50

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
 51

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”.

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.
 52

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.
 53

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.

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.
 54

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
 55

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 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 about everywhere but after the interview, she found
calm water and accepted her near-death situation.
 56

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.
 57

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 were 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.
 58

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 medical practice.

I have 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 Lizzie would
become hysterically upset and the other said that Lizzie 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 nor 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
 59

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.

 60

“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.
 61

“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.

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 Lizzie and her sisters’ 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
 62

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
 63

medication. Lizzie agreed to have radiotherapy simply to control the

umbilical tumour without expectations of a cure and this was
successful.

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 have 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.
 64

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”.
 65

“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?“

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.
 66

“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.
 67

Tom‘s response to treatment was dramatic. Two weeks after the

consultation, 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.

Generally, 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.

I am not certain that the dramatic change in Tom was due to the
antidepressants, certainly the timing fitted with that conclusion, but ,
on the other hand Tom had for the first time felt understood and that
may have been sufficient to account for his greater sense of well-
being.

Fortunately, Tom was already having counselling, so I was able to be

more ‘doctorly,’ and concentrate on the effectiveness of the
medication.

Having worked for some years in an adolescent psychiatric unit, I

often met with children diagnosed with ADHD. The general
 68

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.
 69

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
 70

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.

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.”
 71

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 was
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.
 72

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“.

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
 73

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.

 74

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 a 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.

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.
 75

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.
 76

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.”

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,
 77

but it is not cheap and in this case included 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.

 78

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.
 79

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
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
 80

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.
 81

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”.

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.

 82

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“.

 83

“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.

“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“.
 84

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.
 85

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.
 86

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 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
 87

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.
 88

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!
 89

MARIAH

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.
 90

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.

 91

I thought it was time too 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.

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
 92

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.
 93

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 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
 94

thing producing antibodies, white cells and hormones attack

invading organisms - and repair of minor damage occurs.

The remaining group of 250 people recognised 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.
 95

Most primary care physicians will acknowledge that from the very
beginning of a consultation they are forming hypotheses from the
patient’s communications.They 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.
 96

DONNA

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.“
 97

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?“

 98

“Yes; their treatments never did any good“

Just like the doctors treating your pain?“

“The same“

“And then she died?“

Donna cried bitterly.

“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 import of those two words,“pain” and “face“ and she said; “I
 99

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
 100

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.

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’.
 101

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.
 102

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 develop

in a part of the body 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
 103

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.
 104

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.

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.
 105

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.
 106

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.
 107

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.

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 blood flow.
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.
 108

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.
 109

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.

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
 110

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.
 111

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 private 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.

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“.
 112

“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.“
 113

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?“

 114

“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
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
 115

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?”
 116

“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 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.
 117

“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.“
 118

“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? 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?

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
 119

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
 120

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.
 121

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

were not 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.

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
 122

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
 123

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 pain.

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.

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!
 124

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 in 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 have never
had a patient say so.
 125

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.

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 anti-anxiety
medication ) in small doses.

In our weekly meetings, George regaled me with stories from the

minor crime world; which. Whilst interesting, gave me a feeling that
 126

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
that 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.
 127

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.”

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
 128

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.
 129

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.

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!”
 130

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 $100.00 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 $100.00 “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.
 131

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.
 132

TAMATE

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 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.

 133

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?”
 134

“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”

“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 learned this unfamiliar way of looking at the
other person, so Tamate was emboldened to look more directly at
me.

We parted much warmer towards 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.
 135

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.
 136

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.
 137

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.
 138

“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.
 139

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.

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.
 140

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.
 141

The antidepressants seemed to be 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.

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.

I learned some years after I retired that Diane had died- of natural
causes. I felt quite grief- stricken as if so long as she was alive, help
could be given but her death meant that I could never attempt to help
her again.
 142

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.
 143

“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.
Anencephaly is the term describing the failure of development of the
head, including the brain. Such a child is grotesque in appearance
when born.
 144

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“
 145

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.

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.
 146

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.
 147

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.
 148

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.
 149

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 of 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.
 150

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.
 151

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.In retrospect the rise in her blood
pressure was probably related to her sense of stress.

( I believe that hypertension is frequently caused by repressed anger.

It is known that in acute stress the blood pressure rises and it makes
sense to me that chronic abuse can lead to chronic anger.)

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.
 152

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.

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?“
 153

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
 154

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”

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.
 155

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
 156

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.

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.”
 157

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.
 158

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.

It was evident that Doris felt rejected by her daughter’s move and
she suffered some recapitulation of her desperate loneliness.
 159

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 his 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.“
 160

“I sleep right through, never waking up, no longer thinking of my

mother or brother.

I just wished 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
 161

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.

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 to 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.
 162

“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.
 163

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.
 164

MRS. C.

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
 165

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 another
country, 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.
 166

However, after three months, Mr and Mrs C decided to return to

New Zealand because she was too frightened to stay in their adopted
country.

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”

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, 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’,
 167

compared with a specialist appointment, and the ‘ticket of entry’ can

be anything the patient chooses.
 168

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.
 169

“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?“

“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.”
 170

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?”
 171

“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?“
 172

“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”.

“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.
 173

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“
 174

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, to 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.

( 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.
 175

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?“)

It is a delicate point of judgement weather 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“
 176

“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?“

 177

“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.

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“
 178

“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.
 179

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!
 180

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.

 181

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-
 182

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!

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 led 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.
 183

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
 184

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 of 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“

“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“
 185

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 misdemeanour, 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.
 186

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 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.
 187

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 from 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.
 188

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.

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
 189

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 too 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’, ( page. )is a fine example of this; in

which the symptom somehow promotes the denial of the underlying
 190

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.
 191

KEN

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”.
 192

“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
 193

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.
 194

ALBERT

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.
 195

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.
 196

Albert said that his son was terrified of the surgery.

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
 197

wish to be available for his son and his wife in a time of stress. The
problem was quite literally getting under his skin.
 198

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 bed with another
woman .
 199

She was shocked, but elected not to tell her mother, who found out
anyway.

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
 200

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.

In addition Sally was able to wear her ring on her finger within
weeks - sufficient proof that the problem was not one of allergy.
 201

Generally once a person has become allergic to something the

allergic reaction is easily provoked by exposure to the allergen.

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.
 202

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”.
 203

“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 simile 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.
 204

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. The itchy rash settled without
further treatment.
 205

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
 206

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.

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.

 207

GRAHAM

I was in the next building, consulting our secretary, 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.
 208

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”.

“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.”
 209

“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?”
 210

“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.
 211

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.She also had an itchy
rash on her back. The concern was about medical issues to do with
her mother, 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.
 212

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.

She had always felt ambivalent about her mother’s gesture but had
never said so, believing that it was not her business to object.

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
 213

dissect the body and took out organs for further examination, and
that the bodies were unrecognisable.

Rhonda seemed very relieved after this talk.

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.

Her rash settled within a few days without treatment.

 214

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.
 215

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.

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.
 216

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.
 217

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 give 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
 218

talking with them briefly, but never spending time with the whole
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.
 219

An Unusual Transference - John

Some years ago, I looked after a delightful man who was on a

dialysis machine four times a week for diabetes- based kidney
failure.Since he was confined to his home our contact was through
home visits, varying from one to three times a week.I liked him a lot,
and we had many discussions about all kinds of subjects including
his dialysis.

I noticed that he increasingly made disparaging remarks about his

machine-“ that bloody machine” as he called it.This was unlike him
because he was a gentle, kindly man, and very intelligent.

I realised he had taken to treating his machine as a person- he had

anthropomorphised the machine.

I suggested to him that the machine had some other significance than
simply its function and gradually over a number of ‘chats’ he
revealed his intense ambivalence towards it - he both hated and
loved it. The hatred was because it was so unresponsive, yet
demanding, as contrasted with his realisation that it was life- giving.

Over the course of several weeks of ‘chats’ he began to analyse his

undoubted transference to the machine.His mother had been
reserved, not specially nurturant, and he thought the negative side of
the transference represented his relationship with her role as a
 220

caretaker rather than a ‘ ‘good enough mother’. He inherited his

diabetes from his mother.

He described his father as strong, caring, nurturant and humorous.-“

The man who gave me my life in so many ways.”

Later he was able in a guarded fashion to recognise his ambivalence

towards me “ the man who did so little and yet so much”

I found this fascinating-that his transference was to a machine and to

him it manifested characteristics that were quite human. It was
implacable towards him-simply demanded that he be beholden to the
machine for his very life, to lie in his bed, much of the time without
human companionship, while the machine emitted its characteristic
noises, mainly a hum as the blood circulated, without the chance of
being able to talk to it, relieve the sense of dependency, even yell at
it, express his growing hostility.He was literally tied to the machine
with no hope of escape. To me the wonder was in his Herculean
efforts to remain sane despite the provocation of this cold,
unempathic ‘being’ that was at the same time his lifeline.

His response to our ‘chats’ was dramatic, and as his variable moods
settled he became much less demanding of his family-a wife and two
young girls.

Regrettably, John was unable to have a transplant. He died a few

years later, at only 46.
 221

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 arranged 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.
 222

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.

 223

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.
 224

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.

Stephen did not return with activation of his phobia. He said that in
retrospect he had constantly been worried about getting
staphylococcal pneumonia again but since he had talked about it and
received reassurance it was no longer an important factor in his life.
 225

BETSY

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.

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, dressed in her dressing gown and weeping.

“He’s gone Dr”

 226

“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”
 227

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
 228

thought, with some humour, that that was the quickest I had ever
cured a stroke victim.

This was the first time I had to treat I had to treat a ‘stroke’ by
climbing a tree!

Betsy and I remained good friends until she died peacefully a year or
two later.
 229

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
 230

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.
Additionally, mother had some loss of recent memory.

The family took their mother to a psychiatrist.

At this point in the tale and 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.
 231

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.

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!
 232

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.
 233

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.

 234

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.

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!
 235

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; he felt 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.
 236

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”.

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.
 237

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.
 238

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 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”.

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?
 239

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?
 240

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 acknowledged their admiration of him.

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.

 241

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.
 242

AARON

Aaron was a stocky 20 year-old, whom I had known most of his life.

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.
 243

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.å

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.
 244

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.

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
 245

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.
 246

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.

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.
 247

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 postpartum 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.
 248

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.
 249

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
 250

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.
 251

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 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, and 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.
 252

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.
 253

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.
 254

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.

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.
 255

Mr W.

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.
 256

Mr Yeong Chan and Dr Ng.

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.

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.
 257

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 19th century.
 258

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.
 259

“You are a victim who wants to change?”

“Yes, I can’t stand going on like this.”

I then asked her about ‘the children’.

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?”
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“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.

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“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.

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.
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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.
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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?”

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“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.?”

“I was lying in bed unable to sleep, and I had this vision of my

parents in their coffin.I knew they couldn’t breathe”

Then 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.

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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 completely.

I was too aware of his vulnerability to insist upon him facing 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.

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David

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.
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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 psychosomatic 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
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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 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
Epstein in Family Therapy. This was to stand me in good stead for
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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 de Lance 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 was performed some years ago, in which a group of patients

with the diagnosis of ‘Idiopathic Depression’ (Depression of
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unknown origin) were re-interviewed 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.

The term ‘Idiopathic’ used in this sense implies no causative

emotional events.

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 abuse.
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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.
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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.
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Finally I would say to my younger self that it is okay 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.