Unfinished conversations with Dr David Owen
These are some of the concepts and ideas that have helped me in my work as a holistic doctor. They are arranged around phrases that I’ve said to patients but not always had a chance to fully explain. I have tried to generalise the way the phrases are expressed to make them more accessible but of course in a consultation with a patient they are carefully framed for each person. At times they remain an inner voice to myself if I deem that to express the message at that time would not, on balance, be helpful. Sometimes there are other priorities, at others a broader explanation would be needed for the patient to make use of the concept. Sometimes it’s just not the right time for the person to hear it. I hope that sharing them now will help you make use of those that resonate with you, in helping you work positively to maintain wellbeing. These ideas are some of those that have emerged for me over my professional career and as such they belong not just to patients I have seen as a holistic doctor but, I believe are relevant to a wider audience of not just patients but more generally to the medical profession, the public and all health professionals. The way I express them and indeed if I express them at all to a particular patient, has always been informed by my ‘best guess’, based on where the patient is at in their healing journey and whether these ideas will be helpful. I am sure I have not always got this right, as it is difficult to hold the professional balance between unconditional support and gentle challenge, between servant and expert, listener and adviser, objective observer and subjective participant.
I share them with the caveat that individual journeys cannot always be extrapolated or generalised. If they do not resonate directly with you, then please accept they may describe something others have gone through. The reflections and any insights have emerged from the special place that is created when a patient and doctor sit and travel together into the patient’s past and together glimpse a few steps into the future. When I chose to follow a way of working that allowed these things to be described, I made the assumption that by working in this way any benefits would be self evident, that they would contribute to our shared knowledge of patients suffering in a way that could help others. For many reasons perhaps best articulated as a societal illness, this has not happened. And so, if what you gather here is of value to you, I ask in return that you share it when and where you deem it appropriate. If you have a comment or suggestion on how to build on the message, including if you want to add your experience of any of the points, please email me at firstname.lastname@example.org. David Owen
1. Navigating by feelings – keeping your body in mind
‘How does it feel now, when you are talking about .......’
Talking to a patient in order to understand how a chronic illness has come about is a core part of both the diagnostic and therapeutic process. The conversation needs to include not just current symptoms and details of treatments that have modified symptoms, but detail of what was happening in the ‘patient’s world’ when they became ill, to reveal possible
causation. It also requires a picture of the patient before they ‘became ill’ to understand aspects of their susceptibility and sensitivity. It amazes me how often no one has ever really taken the time to do this with patients. Of the doctor it requires the ability to be present for the patient, not to be distracted by any one symptom, or label or to jump too quickly to a treatment or intervention for a symptom before the full genesis of the illness is understood. Often the diagnosis is a narrative description of what happened, and often this reveals something to the patient that hasn’t fully been attended to. These events that happen around the time the illness started can be thought of as causative. They may be a change in the person’s environment, such as a new perfume or chemical exposure; they may be a physical event such as an injury or change of habit; or they may be psychological such as a particular worry or stress. Of course, often the major life events throw up changes in all three domains (mind, body and environment) and these need gentle unpicking. Doing this well can at times feel like a piece of detective work, while at others it is more like untangling a knot of multiple long pieces of string. Although the same events in someone else might not affect them in the same way at all. Obviously, the timing of events is a strong clue, but the emotional impact of the events is often even more important. Sometimes the feelings come spontaneously bubbling up to a cathartic head, more often the feelings have been suppressed or locked around one small part of the narrative.
So, for example the grief of losing a friend, child, parent or life partner can each affect us deeply. When someone is unable to attend to their grieving, say for example because they need to put a brave face on it for the sake of others, then in my experience, the unresolved grief can be focused on one small area. Here we see the truth of the statement, ‘that what is suppressed in one aspect of life is necessarily expressed in some other way’. For many patients I’ve seen grief and loss are key parts of their psychological pathology. Perhaps holding a romanticised view of how life should be – something I feel our Western values suggesting we all can have a perfect life , is partly why we are unpractised or intolerant of taking or giving time for grieving. Frequently I see patients who give a history of recurrent losses. It can be they interpret the life events we all have through a lens of loss, perhaps becoming susceptible to loss due to an early unfinished grieving process. At other times it really feels that their fate is to keep meeting losses, out of all proportion to their situation. I’m not saying it is easy to attend to our losses, engaging with a grieving process that spirals around us - visiting and revisiting the different emotional stages of grieving one after the other that, depending on the loss, can go on for many years. While many of us must do this well enough, I see a vast number of patients that are stuck in one or more of number of stages or axes of grief. These can include different positions on their loss from denial to over absorbed, supressed to expressed anger, exhausted to obsessive, and fatalistic to deterministic. When appropriate feelings at this stage or on this axis cannot be expressed, it can have a huge impact on health.
So how can the doctor navigate through a patient’s often supressed grief? The answer is both easy and hard. The easy bit is they just allow them to feel what they feel when you accompany the patient on their narrative journey through the evolution of their illness. Sometimes the story that often has been rather crystallised over time gets a bit overly objective, as if the patient is talking about someone else. This is where asking them how they feel can reveal something deeper about the patient’s experience. The hard bit is that
often where things are stuck is disguised, Not usually consciously but as a symptom, like the forced expression or dry eyes of a patient who does not want to show sadness or shed a tear. Here the doctor uses the emotional feelings that resonate in them, even if not in the patient, such as the sadness or even being close to tears while the patient describes their history. The feelings may also be expressed as physical symptoms, (as most of us can get in differently charged atmospheres), like a twitch in the eyelid, a heaviness or ache in your body. While there is some overlap between people in how they somatically experience unexpressed feelings, in others it really requires knowing yourself quite well to tune into this and use it to help you navigate in a difficult case. While most of this subjective experience leaves the doctor once the consultation is over, not all of it does and some issues or feelings the doctor is susceptible to need to be managed through regular supervision.
As you can hopefully appreciate from this, the conversation is both diagnostic and therapeutic. The doctor and patient travel together to see and experience something new and this both helps clarify the journey into the illness, and signposts and often initiates a journey back to a healthier place.
2. The importance of creativity
‘I’m pleased to hear you are painting again / joined a choir / taking more photos / meeting more people ...........as often the first sign that a healing process has started is the expression of, or engagement in, something creative’
There are many factors that contribute to a healing process. In the same way there are often many factors that have contributed to a patient’s symptoms. But in the same way that illness in any individual follows a pattern or journey, I also find healing or a move to greater wellbeing also follows a thread. This is important as it gives reassurance that an individual is moving in the right direction, that even as their symptoms are changing that something therapeutic is happening. It’s not uncommon that when symptoms ease a little the first thing those with a chronic illness do is reduce their medication or do a little more. Of course, both of these can make you feel the same or even a bit worse, but there still has been a shift for the better. I don’t think you can stop individuals doing this although sometimes when the patient is especially flat, exhausted or on a carefully balanced drug regime, I try.
So how to know if the patient is really getting better? Sometimes it’s just obvious – they do more, feel better or symptoms drop away. More often it’s a gradual shift and what I have come to recognise as one of the best signs is the patient has found or rediscovered a creative passion. I’m not sure you can fake this – trying to take up a musical instrument or sing if you really don’t want to, but if a patient asks or wants reassurance about their creative expression, I feel it a strong guide that something positive has happened.
3. An aspect of professional responsibility
..... ‘Having heard you describe your experience at the hands of the medical profession, I, as someone who is a member of that profession, would like to apologiese for what you went through.’
This is not something I’ve had to say often, and I wonder at times if I should say it more. Patients with chronic illnesses, that often involve a number of different parts or systems of the body, see a lot of different health professionals. Now and then one of these will have some difficulty communicating with this particular person or be under time pressure, take a short cut – tempted to interpret the patient’s history from the notes- or make assumptions from test results without attending to the patient in front of them. Sometimes I’m sure that happens with me, even with the best of intentions. My experience is when patients courageously mention this to me, I can apologies and explain what was going on and this mostly leads on to a better connection and relationship. I’m sure some doctors don’t like to hear this sort of feedback, but most respond positively to it and it is important to support doctors in how to reflect and learn from this constructive criticism. It is part of the reason I spent ten years as a medical educator. There has been a positive shift in patients’ courage to challenge health professional’s’ poor behaviour and in doctors’ self-reflectiveness that is changing the way medicine is practised for the better. With all United Kingdom doctors now required to disclose any complaints received as part of an annual appraisal, I’d encourage any patient who is unhappy with their treatment and hasn’t been able to discuss this satisfactorily with their doctor, to make a written complaint.
However, there are other experiences at the hands of doctors that patients recount, sometimes from many years before, where the patient has been significantly hurt or wounded and not felt this has been redressed. These include rude, aggressive, negligent, even sexually abusive behaviour. Patients often require some acknowledgement of and apology for such things before they can feel safe enough to trust another doctor or break a pattern of responses that stops them moving on. When I offer such an apology it is never lightly or without deep sadness for what the patient has experienced. Sometimes after talking about it the patient is able to raise their concern with the doctor, service or regulator concerned, but at other times this is not possible for the patient to consider.
While in no way excusing such behaviour in individual doctors, I do feel it important that we as a profession take some collective responsibility. It is too convenient to occasionally identify one unprofessional doctor who is vilified in the media without really understanding how they came to be that way. Perhaps there are a few evil people out there and some of them find their way into medicine, and from one perspective its right these are found out and punished, but from another perspective I think, based on my experience, there are a number of individuals that react to their life experience in a way that makes them act inappropriately. I don’t aim to extrapolate this to all wrongdoing but in medicine there are a few things that need attending to. so that we give the best chance to doctors emerging from a training process in a way that they can act appropriately in the wide range of situations they find themselves in. I don’t wish to look at every possible event in a trainee doctor’s life that might have impacted on their ability to act appropriately, but want to give a few examples so there is an understanding of a potential collective responsibility in addition to an individual one.
One of professional concern is on managing boundaries, especially around time. The fact that whole sectors regularly run late, (I understand and am susceptible to the pressures myself), is an indicator of power imbalance and disregard for boundaries. This in one way is a tiny thing, but its prevalence and the impact it has on patients and doctors meeting as equals results in starting each meeting encumbered with the feelings one gets as a patient from being kept waiting and as a doctor from running behind .
The second is around appropriate levels of professional intimacy. Patients need to reveal personal information and have personal examinations, but often the patient and doctor are poorly prepared for this. For patients, an understanding of the need for such information and trust, for example in confidentiality, need to be named as part of what I’d call the doctor patient contract. For doctors their training on intimate conversations and the examining of taboo areas of the body without clear procedures and training that attends to the psychological impact of these things, can set up or leave inappropriate feelings or reactions. I will name just two such experiences I was aware of in my training. Although now unlikely to happen, they will have impacted on doctors of my generation. One, for some medical students the first dead body they saw was the one they were asked to dissect as an 18 or 19 year old first year student. Two, it used to be common practice to do intimate examinations on patients under anaesthetic without explicit consent, including breast, vaginal and rectal examinations. These always had clear educational goals but modelled inappropriate behaviour, inculcated an inappropriate dynamic between patient and doctor and would have had an impact on the trainee’s own intimate experiences.
How do we identify the projection of feelings displaced on to us by patients (transference) and our own projection back to patients of our feelings (countertransference)? In effect our feelings displaced onto patients. (In medicine not only does the countertransference get directed to a patient in response to what they evoked but also it gets stimulated by other patients and possibly whole groups of service users and other team members. This is why we need to consider a collective group of patients and the whole team.) I believe it is one of the indicators that the social (societal) contract between doctors and patients is no longer working. Patients expect something doctors are unable to provide, and doctors expect patients to behave and use their services in a way that no longer fully meets their needs.
4. Somatisation – an enquiry it’s often hard to make directly with patients.
‘Thank you for describing your disabling physical symptoms and the impact they are having on your life, but I still want to know about your psychological and emotional journey as in my experience these are equally important.’
Many patients come to me after a long road of medical specialities, tests, trial treatments, false reassurance (we can’t find anything wrong) and dismissal (we can support you but there is nothing more we can try). Others come with a neatly wrapped diagnosis (heart disease, cancer, arthritis etc etc) wondering if there is anything more that can be done because treatments so far have only worked so much, are poorly tolerated or have not
worked. The consultation usually starts with the presenting symptoms and mostly these are multiple – rarely less than 3 or 4 and not unusually more than 10 different symptoms. Going through these understandably are the focus, and it often takes some time before we get to the point where I feel I can ask about their emotional journey into their present state. (I say their but the reality is this often extends into their family history There is growing evidence that family history and experience determine active genetic susceptibility and psychological transgenerational factors often reveal sensitivities and patterns that predate the patient’s birth or illness.) It is almost as if the emotional component of the illness has been locked (or crystalized) in the physical symptoms. Sometimes the illness means the patient has been forced to live a life with little emotional engagement or articulateness. These factors and our cultural defence of blandness when it comes to recognising and discussing feelings make it difficult to enquire into. Many patients are defensive when I raise the relevance of emotions to health – as if to say ‘you are another doctor not taking me seriously’, ‘you think it’s all imagined and in my head’, ‘I’ve got a physical illness how can looking at my feelings affect this?’ etc etc.
There are at least three quite different groups of patients where feelings are difficult to get to and that I want to discuss briefly. In each my experience is that the symptoms are only an expression of one part of the illness, there is no sense of the patient consciously (knowingly) suppressing or hiding their feelings. Over time and with sometimes gentle and sometimes provocative enquiry, aspects of a person’s life and feelings can emerge that can lead to a shift in perception of and by the patient. A different and healthier person can then emerge – perhaps changing how they think about their body, their relationships, their environment and even purpose. What can emerge, and I should stress not a high proportion of patients manage this metamorphosis, although many more make a subtle shift, is a revealing and more accepting or motivatedindividual or someone who has a content accommodation with their illness.
Why would this be the case? I’m not sure but I wonder if these patients are carrying a susceptibility that they have to some degree been born into. It’s not all to do with their family, but I have found it helpful to consider the patien’ts distress is not just a symptom for them, but also for their loved ones, who are often pained by the patient’s suffering. For example, a teenager that has taken to their bed or a partner unable to engage in recreation (or sex). Perhaps like those illnesses historically put down to hysteria (and please,I am not saying the suffering is not real) they tell us about the sensitivity of the individual but the pathology belongs to the family, society and culture in which the suffering takes place.
One group, those with a clear physical symptom, will not infrequently give a history of an apparent coincidental emotional or psychological trigger. Sometimes a psychological set of symptoms
accompanies the physical symptoms but in other patients it is as if the physical symptom is the outlet for a supressed or masked psychological state. Some of these are well recognised and described, such as a patient with persistent catarrh leading to mucus building up in the back of their nose dropping into the throat (a post nasal drip) linked in some patients to a suppression of tears, described as crying inside. While it is not always appreciated by patients, a consideration of whether a physical symptom is only part of a symptom picture
that includes psychological symptoms or indeed if the physical expression is linked to a masking of the psychological, can offer one way of working with a number of patients.
Another group of patients in which to consider somatisation are those who have undergone significant lifestyle or body changes. They may have gone off their food, taken up extreme exercise regimes, changed their ‘look’. While these can be healthy adaptions to a change of life stage or environment, they can also be an expression of psychological illness such as a body dysmorphia, anxiety, depression, personality disorder or the autistic spectrum. While the physical changes need to be taken into account, the psychological and environmental factors (including family and friends) also need addressing
A third group of patients are those who present with disabling symptoms but no clear organic disease process. Where the symptoms themselves are severe and can be longstanding and yet the expected psychological impact is hard to get a clear picture of. Some patients with chronic fatigue no doubt have yet to be fully understood environmental, physiological and infective components are important but in addition these patients are often very emotionally and physically sensitive, almost as if that sensitivity is an expression of a wider less personal more disassociated (or abstract) psychological burden.
5. Surrogacy – how might an individual’s illness be an expression of a broader pathology
‘I have heard you talk about your cancer and over several appointments we have looked at treatments you can follow and how to minimise risk factors of a reoccurrence. You are still puzzled about why you and why this cancer and I want to offer you a thought about this although I can’t offer evidence for this. I feel it makes sense of why some people get these serious illnesses that present for the first time only after they have been present or growing for sometime.’
How can a pathology remain hidden for 70 to 90 percent of its lifecycle (a typical breast cancer is only of a size that is palpable when it’s been through 70% of its lifetime cell divisions)? We can just think of it as one of those things – cells are small. But many other pathologies present as a physiological disturbance before physical / organic pathology emerges. One way of thinking of this is that the disturbance including lifestyle trends and psychopathology are shared within society and so the behaviour, although normalised, is still pathological.
Before going on, I should say that I only say this to a handful of patients who ‘need’ to understand why they have suddenly developed a serious illness. And I do not offer it as an alternative to the best possible treatment of the individual and their illness. However, for some patients it really helps to see their illness as an expression of something out of balance in wider society. Asking patients to think about this and share with me what they feel might being expressed for others by their illness has left me feeling this is an important aspect of societal or public health that is being neglected. I don’t have the answers but believe the questions it raises are important enough to raise for others, especially those suffering from these illnesses, to think about.
So, what might this be for cancer, the theme that seems to come up is around an over developed sense of responsibility and duty. In some ways western society has been driven by these feelings and maybe it is those who are most susceptible who are the ones getting ill from it. Are patients getting cancer a symptom of a societal health problem and if so, what does society need to do about it? –Perhaps patients can offer us advice on this as well as needing our support. If there is something to this, we might expect the most common cancers to represent this linked in some way to what this part of the body represents. This was poignantly brought to mind working with several patients with breast cancer. Where they not just asked of themselves what they were doing with their own strong sense of duty and responsibility,ut they also reflected on how the female breast is a figure of so much projection in relation to attractiveness, pornography, motherhood. Not all of this projection is willingly received – does this create or leave a shared psychological vulnerability that some susceptible individuals will express through breast pathology? If so, is there perhaps a way of society hearing the experiencing of these women to address the uninvited transference onto the breast?
Obviously, there are many other ways that life puts different part of our body under particular scrutiny. From culturally driven diet fads, to habits like alcohol and smoking, to medication regimes such as hormones for contraception or menopause. Many of these are known about. but we often don’t explore for the individual patient what this feels like. Yet naming this is not just cathartic but can, in my experience, lead to significant change in the relationship a patient has to their cancer.
While something similar can be considered for other apparently deep-seated illnesses that come on suddenly, I want to consider only one of these here. This is chosen because of its huge prevalence that seems to say to me ‘take notice’ and attend to our shared susceptibility that includes both a physical and psychological ‘risk’. Treating one without the other is attending to only part of the illness.
We all know of the big public health drive to reduce cholesterol for cardiac health based on a correlation between these two. But for many patients with cardiac problems that seemingly come out of the blue, I notice they often have relationship issues that are unresolved, Perhaps we all have these, but it doesn’t make it healthy. One way to enquire about this that I learnt from a patient who had a sudden onset of a heart arrythmia, is to make a list of every word that is linked to the word heart and to think about what this means to the patient. (One person’s list is given below). I’ve found a number of patients doing this have triggered feelings about unresolved relationships – its obviously not the only factor contributing to a susceptibility or causation, but at the personal level patients have felt better for articulating their feelings with me or someone else, and at times even with the person they have felt ‘heart’ linked unresolved feelings towards. While helpful for some individuals the reason I have put it here is more of a concern for what the prevalence of heart disease says about our collective societal attitude towards relationships. How at a cultural level we see superficial and transient relationships being promoted as the free and easy way of being. I wonder how this portrayal, even if not a personally shared experience, can impact on some individuals in society. Are these the very ‘big hearted’ individuals that find this pathologizing tendency gets acted out on and through them, even if their own relationships are relatively well attended to.
- Heart throb
- Heart in mouth
- Heart ache
- Heart rending
- Heart of the matter
- Heart sick
- My heart missed a beat
- Heart sinking
- Good hearted
- In good heart
- Bad heart
- Black hearted
- Heart stoppingly
- My heart stopped
- Heavy heart
- Heart broken
- Heart break
- Heart attack
- Heart failure (maybe not a metaphor) - Brave heart
- Faint hearted
- Hand on heart
- My heart turned over
- Heart in my boots
- Big hearted
- Touches the heart
- The beating heart of the city - My heart's not in it
- With hope in my heart - Sacred heart
- Bleeding hearts
- Heart felt
- Wooden heart
- Cold hearted
- Warm hearted
- Heart to heart talk
- Hearts and minds
- Lion hearted
- Heart and home
- Put heart and soul into it
- From the bottom of my heart
- His heart was pounding
- He hardened his heart
- The heart has its reasons that reason knows not
- The inarticulate speech of the heart (Van Morrison) - Heart of oak
- Heart and Soul
6. Making a choice about how we live
‘I’m not here to make you better, rather I’m here to help you make yourself better’
This has become a central principle about how I see my role as a doctor. It doesn’t mean I won’t assist if the patient is unable to – what it does mean is I believe it’s my role to help the patient take as much responsibility for their health as they can. This will evolve as they engage in their healing journey and as they become enabled to make changes in their life. I’ll sometimes say, ‘responsibility is dependent on your ability to respond’. My experience is that individuals can do a great deal to help their recovery. Indeed, recovery implies a return to a previous state from which the patient got ill. so perhaps it’d be better to call the healing a process of ‘discovery’. Where the patient moves to a new state without returning to an old one (see transformation), I use the analogy below to explore a patient’s choices about how they can lead their life in the best of health. Starting from them telling me when and where they feel better and what factors make them worse, I invite them to think of themselves as if they are in a boat bobbing along through life. Each vessel has a shape and design, like our constitution, that suits different environments. It also has a crew that can look after the boat, make modifications within limits and navigate to the environment in which it is most likely they can operate most efficiently Think of this as your resistance, immunity or vitality). The integrity of the boat and safety of the crew depend in part on choosing the right environment, the right conditions. If you like, imagine getting ill as the boat filling up and starting to sink in a hostile environment. This hostility might be environmental toxins, wrong foods, disturbed sleep, a problematic relation or one of many destabilising factors. Some of these are bad enough to ‘sink any boat’, others can be detrimental to some but not others. When we find ourselves in this situation, we mustcrew the boat carefully, including where we can make repairs and modifications to our boat. Ultimately though we need to balance three things: we need to choose the environment where we can function effectively, to use our skill to adapt to our environment and cope as best we can in the circumstancesin which we find ourselves. This sums up the journey most patients want to make to feel they have completed their healing journey. Many only get so far. Their constitution feels relatively fixed, their capacity to make change has been depleted and their environment feels out of their control.
While this feels like the truth of the situation for the vast majority of patients, this is not all that getting well in a responsible way entails or offers. Many who make this journey recognise a few small changes that they have made could help others. I remember a rather ‘burnt out’ accountant surviving on multiple coffees a day realising the coffee was part of his pattern of over stimulation then collapse. Once feeling better, he’d not only cut his coffee intake down hugely, but he had introduced the option of decaffeinated coffee into his offices.
One of the great pleasures is seeing how parents can engage in working through their own health issues, often involving habits and patterns set up in them from their own childhood, emerging with a modified lifestyle and insights that really benefit their own children. Seeing how the wellbeing or perhaps we should say rebalancing of one person can resonate
through a family, a team or organisation is a testament to how we are each connected. Perhaps this is why I have found the way I work with individuals translates so well into a very similar way of working with families, teams and organisations.
In a small number of patients their personal health journey is transformational, not just in how they live their life, but in how they engage with and shift the environment we all live in. Patients may go on to campaign for healthy food, demand a change in food labelling or use of additives, highlight and politicise pollution, raise concerns about outdated or unsafe practices, set up support groups. All of this I have seen, and I like to think in a small way this is a counter point to the harm that an unhealthy environment causes to those living in the environment. While these individuals are right to champion these causes based on their own journey, I wonder at the extent it is possible to change others without they themselves going through some form of reflection and insight enabling different choices - people shape their environment to match their needs and if those needs are out of balance or unhealthy then they are likely to default to an unhealthy lifestyle or environment. I’m left feeling that we need both – we to change our environment to change ourselves and we need to change ourselves in order to change our environment.
7. Choosing between Health, fitness and beauty
“Can you help me lose weight / get rid of this spot / improve my race time / de stress / make me more tolerant?”
‘Well yes possibly, but we need to think of these things in the context of your health and wellbeing’
Health, fitness and beauty are each important to patients. Often, they overlap and working with one impacts on the others. In an ideal world all three would be aligned but this often isn’t the case and the gap between them can be part of the problem. This in itself needs addressing so the primary focus for the doctor and patient can be clarified and that explicit and implicit agreement can be reached on what the patient wants and the doctor can offer. It is, I suspect, one of the major reasons for so much litigation in medicine that fundamentally the ‘contract’ between doctor and patient isn’t agreed before treatment is started.
Fitness is the ability to perform optimally in a set or limited situation. For example, a sports person may perform very well in a particular sport, but not in a different one. Fitness helps you “fit into” a particular environment or situation. You can be fit intellectually or emotionally when you are in a particular intellectual or emotional situation, but this doesn’t necessarily mean you will cope if the physical, intellectual or emotional situation changes significantly. You can be physically fit but have problems dealing with things like changes in career, ageing, or bereavements. Many patients want fitness but don’t always appreciate the cost or implications. John enjoyed running. It helped him cope with stress. However, he started to get pain in his right knee, which he treated with an anti-inflammatory. His knee deteriorated until he required surgery. At that time, he was unable to exercise, and found he was unable to cope with the stress of his job. He was diagnosed as depressed and started on anti-depressants.
When the emphasis is on getting fit this involves the doctor and patient being clear about fit for what while being aware this may make them less able to function in a different task or respond to other priorities.
Health is the ability and potential to maintain wellbeing in a changing environment. While much research into treatments look at the ability of an individual to perform or operate in a particular fixed set of circumstances over a set, often brief, timeframe. They often look at a single or limited outcome reasonably pointing toward fitness, but not always looking at longer term health. To concentrate on health the patient and doctor need to think not just about recovering a previous state, but also the changing environment and expectations of the patient. Of course, illness itself comes about in part because of a miss match between these.
Beauty is based on how your appearance or an object’s appearance is viewed by others. For people this is often related to how you want others to react. Sometimes this is linked to functionality but more often it is communicating something more subjective. While a beautiful complexion or attractive body may correlate to something that is fit or healthy this isn’t always the case. I’ve seen a number of patients who aspire to an appearance for how it makes others see them rather than how they feel. Perhaps this is a societal trend but when what is desired is divergent from or confused with the pursuit or expression of fitness or health, there are real concerns that those with influence and power will take advantage of those with less.
Fitness is something that you can train and practise for in a given environment, whereas health is more difficult to prepare for, although you can anticipate some of the likely changes that will affect you, for example, as you age. Beauty changes with fashion and with the expectations (projections) of those around you and your need to ‘fit in’. When the medical profession offers cosmetic procedures or focuses on short term unidirectional benefits without considering the broader and longer term health implications, then it must reflect on whether it is only interested in how it looks to others or more in terms of short term status and renumeration that the social responsibility as champions of wellbeing.
8. Abuse – especially sexual abuse is one of the commonest psychological pathologies that I see in women
“Thank you for telling me about your earlier life. It seems you’ve not really been well since then. Sometimes the things that are most difficult to talk about are the most important. Is there anything you need to ask me or check out to make this a really safe place to talk. I notice when you talk about ................ you tense your jaw / hold your throat / smile a lot even though it sounds difficult/ look near tears. When I hear you say this, I feel really sad/ I notice I don’t know what to say. Thank you for telling me that, it sounds really important / had a big impact. How does it feel talking about this / have you talked about this with anyone else / are you ok talking to me about this?”
Of course, there is nothing like a standard script or normal way this emerges. The conversation might develop in the first appointment or only after several appointments or even years. Sometimes, I’d say in about half of those patients where this comes out, I am the first person they have told. For others they may have told a friend, a partner or had counselling for it. The difference with me is this comes as part of a consultation for a physical or psychological symptom. Sometimes it initially appears a surprise for the patient but mostly they rapidly see the link chronologically or even directly to their symptoms. At other times, it’s as if the issue is ripe to talk about and they may even have been running through in their head what it will be like to talk about it. Where this goes is so individual and personal that I find it difficult to write about – perhaps mirroring the difficulty patients understandably have to talk about it. What comes up is anger, betrayal, vulnerability, shame and guilt. Each of these might need exploring and especially if the abuse first happened as a child, then the patient needs to be helped to sit with and explore the feelings of her inner child as from a child’s perspective they often feel that in some way they are to blame. Sometimes these memories come back or the illness presents around the time the patient has children of the age they were when the abuse happened. And not just for abuse but for all trauma experienced as a child, it can be reactivated in relation to a child age, an anniversary or other tangentially related event. I often use the idea of the three positions we can all take in relation to events, child, parent and adult (ref transactional analysis). It is often helpful to explore the events through these three lenses and not just in relation to the abuse and abuser but also in relation to others around at the time, including those not involved directly in the abuse. This can be the start of an important and very personal therapeutic journey. This will often benefit from the involvement of a skilled therapist although often patients feel a sense of disappointment or even rejection if they can’t stay working with the person they first disclosed the abuse to.
Frequently there is a pattern of recurrent situations where the person has been abused and it may take time for the full extent of the abuse to be revealed. These are often events that will evoke feelings of distress, wanting to care for a vulnerable individual.
So what is the unfinished conversation here? Really it’s two fold. On the one hand, it’s to name the frequency and level of distress and suffering that is caused by failure to maintain appropriate personal boundaries, especially around those with less power. Secondly, ’ts to share something that I have found really useful in understanding and supporting those that have been abused. That is the drama triangle. Others have explained it in great detail, and I have used and explained it to a number of patients. The triangle is made up of victims, perpetrators and rescuers. The patient identifies with the victim and indeed can appear to almost draw perpetrators to them. This axis is often the primary one to be explored. There maybe a number of people or circumstances that hold something of the rescuer and while we all need rescuing, at times it’s dangerous if this is always located outside of ourselves. To be free of being stuck in the victim mode they patient needs to get to a place where they have the agency of the perpetrator, but don’t need to inappropriately or harmfully exercise it, equally they need to find their rescuer – not necessarily to rescue others (although I have seen many victims of use only manage by being active in rape crises or refuge services). So, the three positions of the drama triangle need to be held internally in balance. While for
many who have not experienced sitting in the extreme of one position it happens naturally and unconsciously, for the victim this is often a long and dynamic road to hold the three positions well. It is a one of the medical profession’s great mysteries as to why some patients make a recovery while others don’t. We really don’t know why but I have seen a number of patients recover in a remarkably way once they have articulated and worked through their abuse issues.
One other consideration to name is the importance for the doctor of having a safe place to go to confidentially debrief on what these discussions evoke. Of course, the doctor takes the role of rescuer initially but the vulnerability of the victim and displaced feelings onto the perpetrator need to be managed. And then just like for the patient the internal interplay of the three positions need to be held / contained. This is one reason why all of those engaging in this work need regular supervision.
9. Neglect – on the same spectrum as abuse.
‘It was all fairly ordinary, my parents had their own things to sort out, they did their best sending me away to school / hiring a nanny / putting me up for adoption. I guess I just felt different. I had to do my best to get any acknowledgement. Nothing was good enough’
While apparently less common than abuse as a single trigger, there are many patients where rather less dramatically neglect seems to play a part. Both in terms of the patient’s sensitivity and in terms of what they unconsciously carry for those that neglected them. When neglected by a parent, family or school it forces the individual back into themselves. They become hypersensitive to comments, compliments come with caveats and criticisms are hyper charged. The persecutor and rescuer become free floating and the victim hood feels normal and often isn’t recognised as a psychopathological state. This makes it harder to identify and recognise. For this reason, and the fact it’s rather less recognised in our current environment, it often runs deeper and is harder to draw out and work through even than abuse. It commonly shows itself as a patient who struggles to reveal themselves, they are quite hidden and often the only way to encourage an opening is a mixture of time and self-disclosure. Our meaningful work happens consciously in that part of our relationship where both the patient and doctor are prepared to reveal and be seen. (ref Johari window). In some cases where neglect is part of the picture, (and this is quite common), then aspects of the patient won’t be revealed. Picking up on when this happens can help to name it and enable the patient to disclose through dreams, disassociation or metaphor. It’s surprising how often these ‘blind spots’ drive a person’s cinematic, literary or other tastes, as if they are seeking to assimilate something through this vicarious experience. Asking about and inviting reflection on this vicarious world can help bridge a gap. Of course, just the focussed caring and compassionate attention of the doctor can enable a deep reflection and revelation that is often a therapeutic step in its own right.