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What Are You Feeling Doctor? Identifying and Avoiding Defensive Patterns in the Consultation • Friends in Low Places • Letters from the Clinic: Letter Writing in Clinical Practice for Mental Health Professionals
  1. G Bolton

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    J Salinsky, P Sackin. Radcliffe Medical Press, 2000, £19.95, pp 174. ISBN 1 85775 407 • J Willis. Radcliffe Medical Press, 2001, £19.95, pp 214. ISBN 1 85775 404 2 • D Steinberg. Routledge, 2000, £15.99, pp 130. ISBN 0 415 20504 2

    `Medicine: only an attempt to rationalise magic.' (Steinberg page 115)

    The doctor or healer has always been regarded as a magician. And still is, despite the attempts of contemporary scientific medicine to shake this off. Wise doctors and health care staff accept this multicoloured mantle, along with the stethoscope of power, the healing touch, and the chronicler's pen.

    These three books celebrate the magic of medicine in general practice and psychiatry. They open doors to understanding the ways feeling, insight, unarticulated judgment based on skill and prior knowledge, understanding of the narrative (or story) nature of medical and therapeutic consultation, politics, and creativity, can enhance technical experience, knowledge, and skill.

    Let's start with feeling—a word boldly placed in Salinsky and Sackin's title. It concerns a group of general practitioners experienced in the Balint method. In “Balint” work, groups of doctors discuss their feelings around specific patients in specific consultations. They focus on what bothers them, not what might bother just any practitioner. The group depicted in this book, however, moves above and beyond traditional “Balint” work, and discusses, and attempts to understand, the personal roots of their anxiety or distress (or anger, hurt, fear . . . .). They steer a course between the Scylla of therapy, and the Charybdis of cosiness. The focus of the group is to understand their own defences better—neither an easy nor a comfortable task. And then they have the courage and public-spiritedness to share their struggles and insights. “Wow”, I hear you mutter. Wow indeed. Read it.

    Doctors are trained to develop defences, many of which are essential. How otherwise could they deal daily with the kinds of situations and issues which hurtle others into post traumatic stress disorder? It wouldn't do to smack a supremely irritating child either, or always cry at a death, or leap onto the couch with a sensual patient. But many defences are far from useful, and prevent the “personal self” of the clinician making contact with the “personal self of the patient”: a contact which is essential to the healing nature of the encounter. “We ignore the personal self at our peril (and that of the patient).” The defences which prevent this contact are often out of proportion to present need. There is always something in the past or present life of the clinician which has created this defensive barrier. John Salinsky, for example, learned that not all old ladies were his mother.

    The level of trust built up in this group enabled them to tackle these issues. They became able, over the five years, to listen to themselves effectively, and to use what they heard to improve their consulting skills: to be able to listen to patients and colleagues more carefully, considerately, deeply, and warmly.

    Of course they used the group metonymically. The defences they displayed within the group were similar to those within their daily practice. They learned through the process that clinicians will be able to listen to others only when they've listened to their own emotions first—with the support of trusted others.

    I could go on and on about this book, telling you: the specific questions the group devised to get them closer to the heart of each situation; their group work processes; their evaluation methods and outcomes, and specific stories they discussed. But you'd be far better buying the book and hearing it from the group themselves.

    James Willis's book says something so essential and vital that it needs to be shouted from skyscrapers. It is, however, also about something as simple as the emperor wearing no clothes. This is that a denial that life-as-it-is-lived is wonderfully, hopelessly, chaotic and complex, is not just doomed to failure, but will inevitably cause untold damage. Our society is attempting not only to deny this, but also to constrain life to become structured, controllable, controlled. There seems to be an insane belief that life can be controlled by ticking boxes, by diligently reading instructions, before doing anything, thinking anything, being anything.

    Willis quotes a wonderful piece of research which found that people are half as good at remembering a face in a photograph, if they've tried to describe it when they first see it: if we merely trust our innate and wordless ability to remember a face, we are twice as likely to remember it—a metaphor for general practice. Doctors are being constrained not to rely on their hard won experience, knowledge and skill, their unarticulated sense of what needs to be done, but instead always to use their conscious brain function to work out a solution—thus quite possibly reducing their effectiveness by half.

    I would say that evidence based medicine goes wrong when it stops trying to help, and starts trying to control. In other words, when it stops being a tool, and starts to become a master.(page 105)

    There is also an insistence on a narrow model of what constitutes “evidence”. “Proof” is required (in randomised controlled trial terms) that writing poetry can be healing. The fact that poets have known not just for generations, but for millennia (Apollo not being god of poetry and healing for nothing!) that writing poetry helps you understand your feelings, thoughts, and behaviours better, is not considered “proof”.

    We are trapped in a culture in search of certainty, seeking even to abolish uncertainty. We are in a culture which attempts to deny and abolish the wonder and glory of chaos and serendipity and chance—in the education of children, in the care of the sick. We are trained by the media, by our masters, to have zero tolerance of risk owing to a belief that the end of uncertainty is in sight. This leads to the horror expressed by our masters that half of all doctors are of below average performance, and to their instruction that everyone and everything must show excellence. We need a few lessons in the use and abuse of the English language.

    I would add: we are a culture which has lost its spiritual base, and is therefore trying to construct one out of shaky models. Those in control make models. They then constrain us to live and work within those models. The model becomes the master. Oh dear, I'm getting as worked up as Willis does himself.

    Willis writes in an inimitable everyday style, in keeping with his thesis. He embeds his arguments in stories of daily life: patients, colleagues, wife Lesley, encounters at conferences, when sailing. The reader is made to feel part of the inductive process which led to his arguments. It's so obvious: that if you control and constrain anything beyond the straightforward, it will be prevented from functioning properly. Especially the mystery of the human brain and the magic of medicine.

    Derek Steinberg's text is ostensibly about a clinician (psychiatrist) writing effective letters—to patients and colleagues. But it's really about the power of writing to convey something speech cannot, to help people to “step outside the frame”. It's about the way clinicians construct stories about patients, about the way clinicians can support patients to create stronger, more healthful stories about their lives. A patient might walk into a therapeutic encounter feeling they are the victim within their own story, or the villain. They might—hopefully, will—walk out with the knowledge they are the heroine (or handsome prince).

    Steinberg sees the letter as a “gift” from writer to addressee. As such, a letter should be constructed thoughtfully, even if it merely alters an appointment date. A letter is a static object, unlike a consultation which can more resemble a rollercoaster ride. Although a letter can contain narrative and change, it's an unchanging object itself once written. It can therefore be used by a clinician to communicate with patients (or colleagues) differently from spoken discourse. A letter can move the situation forward dynamically: “In the negotiated misunderstanding that is psychotherapy and much of treatment generally, a letter—something in writing—provides a fixed point”. (page 114)

    The bulk of the book consists in fictional examples of letters and the cases around them. Steinberg discusses each letter—its faults and successes—offering alternatives and suggestions. He also lists wise advice for their construction: from the way the recipient is addressed, to the elegance of the letterhead, and the content.

    This is a wise, eminently readable text. I fear it will miss some of its rightful readers, however, owing to the dull cover and title which belie the dynamism and insight of the contents. It will inevitably force the clinician who dashes off a letter into a dictaphone—and instructs their secretary to “pp”' for them—to think again. The jam for me lies in the discursive beginning and end. A sticky sort of sandwich with the bread in the middle, but then that goes with Steinberg's humorous, approachable tone.

    How do I conclude this “review”? I put “review” in quotation marks because it feels more like a diatribe, or an excited jumping up and down at what these three writers are so differently saying—as I sit here in the sun with my pencil and secondhand paper late on a Friday afternoon. What more can I say? Read them. Rethink your practice as a result.