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Hope and salutogensis

Salutogenesis

Four patients in my afternoon surgery were suffering from chronic pain and had spent years being treated by pain specialists, spinal surgeons, psychologists, physiotherapists and complementary therapists. None of this specialist attention had alleviated their pain to any significant degree or provided a satisfactory explanation for their suffering. I have long-since stopped trying to ‘explain pain’, but for people who want explanations there are excellent resources online like ‘Pain is Weird’ by Paul Ingraham on Painscience.com and Tame The Beast by Professor of pain science, Lorimer Moseley.

Two of these patients with chronic pain had suffered child sexual abuse and one had also been a child slave. One had been tortured by the police in his home country and one had been traumatised by having to kill people when he was an army conscript. One of the women who had been abused had been seeing me with her back pain for 13 years and yet I only learned a few weeks ago about how she was sold into child slavery and some of what happened after that.

In nearly 20 years of working as a GP, I have very rarely come across patients with chronic intractable pain, who do not have a history of trauma. It may not be necessary to talk about what has happened, but it is necessary to acknowledge that what has happened long ago can have lasting physical effects,

For patients who have suffered with chronic pain for years, discovering the links between past trauma and present suffering may very often be re-traumatising and bring on symptoms of PTSD, like nightmares and flashbacks, also worsening the pain and fatigue and other symptoms like IBS (irritable bowel syndrome). Even where we are aware of the links, there is a fear that confessing to a history of abuse will mean that fellow pain sufferers – who by this time may make up an important social/ supportive network, along with professionals who have been treating them – will reject them because their pain is somehow less ‘real’. The shame that is inherent with trauma, comes into sharp relief; shame goes with self-blame “I am to blame for the way I feel – emotionally and physically, it’s up to me to fix myself, no-one can help me now”.

Talking about the past may also be overwhelming for clinicians. Doctors exposed to stories of rape and incest, torture, domestic violence, neglect and loss, can suffer from secondary trauma. There are days when I am completely, emotionally overwhelmed. And like most GPs I don’t have a therapist of my own.

My patients and I need to be able to find hope amidst past trauma and present-day suffering, and we are discovering this together by changing our focus of attention away from ‘pathogenesis’ – the science of what makes us ill and the subject of medical education – to ‘salutogenesis’, the science of what makes us well.

At this point I would recommend you watch “What causes wellness?” an amazing talk by Harry Burns, recently chief medical officer for Scotland, in which he gives a brief history of salutogenesis grounded in the reality of trying to improve outcomes for Scotland’s most deprived citizens.

I wanted to be able to share these ideas with my patients, but 20 minutes was too long to spend watching Youtube during my consultations, so I had to find something that summed it up, that people could easily remember. The picture at the start of this piece is on the wall of my consulting room. If you hold out your left hand in front of you, fingers outstretched, looking at the palm and then look at the picture you’ll be able to imagine our conversations. Each area requires care and attention if we are to be well. Salutogenesis requires a balance; neglect one or two areas and you’ll need the others to be robust to compensate, but that’s not sustainable for long.

Beginning with the little finger, ‘Mind’ refers to feelings/ emotions/ memories, thoughts, and interpretations. Shame and anger, depression and fearfulness, heart-ache and grief, confusion, hope and despair. Taking care of your mind depends on how overwhelming (or numbed) your feelings are. For some people a good therapist is essential and the quality of the therapeutic relationship is more important than the type of therapy, but in general, the further back the problems go, the longer the therapy needs to be, and CBT probably won’t delve deep enough for long enough.

Taking care of your body definitely doesn’t require gym-membership or marathon running, many people who have experienced trauma or who suffer with pain, irritable bowels or other chronic physical symptoms have very difficult relationships with their bodies. Taking care of your body means changing those relationships, so that your body isn’t a cause of shame or dread, but something that belongs to you and does what you want it to. Yoga, dance, singing, painting, making music, arranging flowers, or baking bread can be as therapeutic as fell-running or mountain-biking. You and your body are working together, you’re enjoying what you are able to do. And you don’t need to go over painful memories.

Taking care of your biology refers to everything that you consume; food, drink, medication, supplements, alcohol and drugs, even the air that you breathe. I talk about this with patients to put medication into a holistic context – it’s one part of biology which is one finger on the hand of salutogenesis. It’s something, but it’s not, by a long way, the only thing. With a sceptical eye always open to the science of nutrition, I’m pretty confident that so far as diet is concerned, Michael Pollen is right: “Eat [real] food, not too much, mostly plants”. Most people who come to be discussing salutogenesis with me have really strained relationships with food – it’s either a punishment or a reward. Their appetite comes and goes, their weight goes up and down. They’ve been on and off diets and supplements half their lives. Helping vulnerable to stop smoking, cut down on alcohol and reduce their intake of drugs and prescribed medications can always do more to improve their wellbeing than anything new that I can prescribe.

‘Human Relationships’ is usually the most painful area. “Do you have anyone in your life who knows you well, how you love and trust, who loves and trusts you back?” is usually how I phrase the question. Loneliness is one of the worst things that anyone can suffer from. It so frequently accompanies chronic pain and chronic mental illness. Sometimes the people I ask this question say, “Apart from you?” For too many people, the GP is the ‘only normal person they know’. Helping people connect compassionately with themselves and others is almost certainly the most important thing that can be done for salutogenesis according to the Harvard Cohort Study and other research.

Human connection also requires spaces for people to meet and connect with one another. In the next video, Eric Kleinberg explains how death rates in very similar neighbourhoods varied ten-fold during a drought because some places had a lot more places where people would gather, do things together, get to know one another, and in a time of crisis, look after each other.

People for whom the dark shadow of trauma lasts into adulthood were very frequently betrayed by an adult who they trusted, who they expected to care for them. The adult may have abandoned them or abused them, and they may find it very hard to trust other people from then on out of fear of being abandoned or abused. They may blame themselves for what was done to them leading to a sense of shame. To understand shame, a sense of being profoundly un-deserving of love, kindness and respect – I have written a series of blogs – beginning here.

I really like Dr Phil Hammond’s CLANGERS – the first, and most important point is ‘Connect’ – each day I will try to like myself and reach out to others.

The thumb refers to social security, by which I mean security of housing, finance, employment, and safety from violence, intimidation and all forms of abuse. The tip of the thumb touches every other finger, with adequate social security it is so much easier to access therapy, to join a gym or go to classes, to eat healthily and to socialise. Doctors have a duty to act as social advocates and help people access the benefits they are entitled to and draw attention to the health effects of poverty. A decade of austerity and failed welfare reform means that social security has hardly been worse in living memory.

Social prescribing, derided my some GPs but greatly appreciated by others like myself, helps people to connect with other people and to access social security. With awareness of salutogenesis Social Prescribing makes a lot of sense.

Crisis management is written across the wrist because that is where so often I seen cuts that have been inflicted in a time of crisis. When the pain gets too much, self-harm and suicide are ways to bring it to an end. A crisis plan should be written, shared with others, referred to in a crisis and reviewed afterwards. It should include warning signs that a crisis is coming, people to speak to, places to go, things to do. Even if self-harm is not part of what happens in a crisis, people with chronic pain will still have days when it’s too much, when the usual strategies are insufficient. They need a crisis plan or a ‘rescue pack’ for these days.

A few months ago, I faced a woman whose daughter had recently died by suicide. The woman I faced, a patient I knew well, had suffered her own terrible traumatic past and suffered with chronic pain related to connective tissue disease, trauma and grief. She wanted me to prescribe more painkillers. “What kind of pain are we treating?” I asked her, “Is it physical, emotional or grief?” She stared back at me, confrontational, “What. Is. The. Difference?” She demanded. “How can you even tell?”

I can remember the confrontation vividly. She was right. All pain affects, and is affected by physical, biological, emotional, biographical and social systems. You cannot neglect any of these areas if you want to manage pain, but when pain is overwhelming, sometimes it is easier for patients and doctors to go for a prescription, and I gave her some more Oxycodone, “We know it works”, she said, “we both know, it numbs every kind of pain.” But we also know that it’s not enough, it’s not safe and it will soon stop working. Whenever we meet we check in on all the areas on the hand together, MInd, Body, Biology, Relationships, Social Security, crisis plan. In every aspect there is room for improvement, something to be done – and in there lies hope.

“How do you cope with seeing people like me every day?” asked another patient this week. He knows what I know, that the waiting room is full of people who are full of pain and trauma. He has lived around here for 30 years. I had to think before answering and I answered carefully. “It’s true, at the end of the day I am drained. But I’ve been here long enough to have seen people through the worst of times and out the other side. Sometimes that takes weeks and sometimes it takes months or years. So I share in the suffering, but I also get to see people go through the most appalling circumstances and then recover. And that’s priceless and that’s why I’m still here and why I’m going to stay here and stick with you for as long as it takes.”

Dr Austin O’Carroll, a GP who works with homeless patients in Dublin describes this commitment and continuity to patients as ‘high fidelity’.

And in a time of professional burnout, it is important for doctors and other health professionals to think about their own salutogenesis. We are prone to burying the bits of our past that we are ashamed of, we neglect our emotional health, eat badly (especially when on call), drink too much alcohol and lose touch with our non-medical friends and family, even though we are fortunate enough to be more socially secure than most people. We are prone to over-compensate when feeling stressed, by putting all our efforts into exercise, dieting or therapy, when what we need is a balance.

I hope that the image of the hand will help me, my patients and my colleagues to focus on what we need to be well, and will give us reasons for optimism, especially for those of us working in areas of deprivation. We can always find areas where positive changes, no matter how small, are possible.

Reflections on medical culture and the Bawa Garba case

For a background to the case – see this excellent BBC report by Dr Deborah Cohen

I have been a doctor for over 20 years, 5 in hospital and 15 in general practice. I have been on the receiving end of medical errors and have made complaints about my own care, and the care of family members, who are not doctors and have lacked the confidence to complain, even when complaints are clearly justified. I have also been on the receiving end of serious complaints from patients, I have been successfully sued and had cases against me investigated by the Parliamentary Health Ombudsman.

Any doctor who has practised more than a few years will know that the vast majority of medical errors are not noticed, ignored or covered up – and though the majority of these don’t cause any serious harm, a minority do. Any doctor who has practiced as long as I have, will, like me, have personally contributed to a patient’s death. Doctors are aware that most patients and their families do not complain even when they are aware that there has been an error and when they have had very reasonable grounds to complain. I have had to make complaints on my patients’ behalf because they were afraid or insufficiently literate/ articulate to do so themselves. I know that most of the time, complaints are dismissed. When patients do complain, clinicians know that the majority of complaints are not about issues involving patient harm or clinical decisions, but about problems where patients and their families feel more confident, for example; lost dentures or professional attitudes, cancelled clinics, lost results or other organisational issues. Doctors know that the worst of their colleagues seem to be immune to the complaints they deserve, while the most conscientious are prone to the most vexatious.

Dr Bawa Garba was forced, under stress to write down everything she could think of that she personally had done wrong. The person who forced her to do this wasn’t a prosecuting lawyer, but her clinical supervisor, the consultant who should have been supporting her on the day that Jack Adcock died. He did not help her think through what had happened in a place and at a time suited for reflective thinking. He made her write a list of everything that she had done wrong in a hospital canteen. He then made her upload the list as a ‘reflection’ in her educational eportfolio. This is not medical education as I or any other medical educator would practice it, but too many doctors’ experience of ‘reflection’ in medical education is shallow, critical, unsupportive and frankly, unreflective. If anyone in this case was ‘truly, exceptionally bad’ it was this doctor, Dr Stephen O’Riordan.

To make matters even worse, the media is a menace – fanning the flames of fear, pitting doctors and families against one-another and baying for vengeance and then moving on to the next story before the dust has settled.

In very little time at all doctors learn from experience that complaints are no measure of a doctor’s moral character or clinical competence. Doctors and patients learn that justice is rarely achieved.

Consequently, many doctors grow cynical, hateful of the GMC and the tabloid media and suspicious of patients. And a growing number of patients are losing trust in medical professionals.

These are problems of culture and psychology far more than they are technical and legal.

The solution must therefore involve an honest acknowledgement of the cultural milieu that doctors and patients inhabit. Doctors live in fear of patients discovering the mistakes they make and patients live in fear of being harmed. Both have good reason to think that the system is unjust. The solution must bring patients and clinicians together to have honest conversations that bring about what Richard Lehman has described as the ‘shared understanding of medicine’. It must include much greater transparency including shared medical records, patient safety reports, transparency about organisational pressures and what the NHS can afford. Patients and clinicians do need safe spaces where they can learn from mistakes apart from one another, but this should not and need not reduce the requirement to have shared learning as well. Only by making alliances with patients (contra pharma/ commercial healthcare) and by treating patients as expert partners in care (and part of the solution) rather than a burden / problem, can we change. Medical educators and supervisors must take reflection seriously and learn how to use it as a force to challenge and change medical culture for the better. Finally – as Dr JulianTudor Hart has argued, ‘Accountability must require that doctors insist that they have time to do their work properly’.

Relationship centred care Dr Jonathon Tomlinson blog

Defining Patient Centred care New England Journal of Medicine

A New Kind of Doctor: Professional Accountability. Dr Julian Tudor Hart

Managing the threat to reflective writing. Dr John Launer

Book list

A list of books about medicine, society and more – posted here from one of my medical education wikispaces. Please send other suggestions! My intention is to keep adding to it.
Most of these books i’ve read. Many of them are old. Although I’ve linked them to Amazon for your convenience, i’d recommend you try your library (if you still have one), your local independent bookshop or second-hand from abebooks

General:
Henry E. Sigerist: Medical Historian and Social Visionary

  • All of his books are very highly recommended, especially Medicine and Human Welfare
  • His book ‘Man and Medicine’ was written for medical students.

Medicine and society:

Medicine and science in the media:

The media:

Hoxton history:

General practice:

Doctors and patients:

Medicine and politics:

Markets

Pregnancy and childbirth:

An examination of who controls childbirth and who controls doctors

Food, politics and health:

Health promotion

Poverty and medicine:

Pain: history and culture:

Pharma

Medicalisation

Dying

Mental health:

Medical ethics

Medicine and History

Misc

Dr Jonathan Tomlinson Law And Justice Interview – SoundCloud

An interview with Jane Mulcahy about the ways childhood trauma manifests in adults who present to healthcare and criminal justice

Listen to Dr Jonathan Tomlinson Law And Justice Interview by Jane Mulcahy #np on #SoundCloud

The Adverse Childhood Experiences evidence base–a wake up call to radically redesign Children’s Mental Health Services.

For any readers based in Hackney where I work, I’m reposting this in response to Saturday’s SAFAPLACE conference at Stoke Newington Secondary School. What was an excellent conference was notable for there being no discussion about the impact of adverse childhood experiences. I’m very grateful to discover Elizabeth’s work

We need to talk about Children's Mental Health

Throughout my twenty year career as a psychologist working in Specialist Children’s Mental Health Services (SCAMHS) two frequently repeated mantras have been amongst the biggest sources of  frustration for me:

“It’s a social problem, not a mental disorder” and  “the child needs to be stable to access therapy”; the latter often responded to with the helpless reply  “but the child need’s therapy in order to be stable”. Indeed, much of the tension between Health and Social Care can be boiled down to these two themes.

I understand, of course, that service design and a splitting of health and social care lies at the root of this; along with a scarcity of resources and a need to carve the work up somehow. However, as  a psychologist employed by health, I see a child’s context and life experiences as fundamental to their mental health and emotional wellbeing. Ironically, when it comes down to individual…

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What happens to empathy in medical education?

An unhappy patient comes to a doctor to offer him an illness – in the hope that this part of him, at least (the illness) may be recognizable. His proper self he believes to be unknowable. In the light of the world he is nobody: by his own lights the world is nothing”

But if the man can begin to feel recognised and such recognition may begin to include aspects of his character which he has not yet recognised himself, then the hopeless nature of his unhappiness may have been changed; he may even have the chance of being happy.

John Berger, A Fortunate Man

“One of the greatest diseases is to be nobody to anybody”

Mother Teresa

After a few weeks of watching second year medical students talk with patients I have been wondering about where, when and how empathy is lost during medical education and clinical practice.

The students enjoy talking to patients and listening to their accounts of living with diseases such as Parkinson’s disease, fibromyalgia, depression, heart disease, and diabetes. They are moved by suffering and curious about patients’ lives and their life histories. By so doing, they show natural affective and cognitive empathy.

My patients enjoy coming in – they don’t have the pressure of a 10-minute appointment within which they have to condense their symptoms into a problem to be solved for a stressed doctor who is running late. They have up to an hour of conversation without a goal in mind. They are under no pressure to impress their doctor with their weight loss or better medication compliance. Seeing the students looking more anxious and even less sure of what to say than they are themselves, they enjoy a levelling of the usual differences in power and confidence and take the opportunity to guide and reassure the students. We call them ‘patient-educators’ in recognition of their role.

Epistemic justice in healthcare is when patients have sufficient opportunity to give an account of themselves and their symptoms and the meaning and significance that they ascribe to them. We see this in the patient student encounters and encourage it.

Cognitive empathy is the ability to understand another person’s life and experiences. Affective empathy is the capacity to be emotionally moved by another person’s experiences.

With time and experience of these kinds of conversations, students learn that often patients need doctors to ask ‘the questions whose answers need to be told’. Patients won’t just volunteer information unless they can trust them. Trust can be gained by the student proving, by the questions that they ask, that they are aware that certain illnesses are associated with symptoms that might be embarrassing, experiences that may be hard to talk about, feelings that might be shameful, social stigma, prejudice and alienation. My students, my patients and I learn this together.

How, why and when is this empathy lost?

Understanding grows with experience, but opportunities for informed, compassionate, curious questioning can be squeezed out by pressures of time and the demands of specialism.

Students are expected to ‘take a structured medical history’. Conversations which once followed cues, in an attempt to understand and make sense of experiences are gradually replaced by structured interrogations guided by computer templates.

When they qualify the consultation will be less about understanding than gathering data for the health-service they are working in – because information that can be coded as data can be used for performance management, quality improvement and financial remuneration. The fruits of empathy – stories about meaning, context and experience that are unique by virtue of their subjectivity will be buried in the electronic record as ‘free-text’ – only available to those who know where to look. To satisfy the need for data, symptoms are defined as disease – headaches become migraines, dry skin – eczema, joint pains – osteoarthritis, back pain – ‘lumbar disc degeneration’, grief – depression, destitution is coded as ‘generalised anxiety’ and people who have suffered abuse are labelled with ‘personality disorders’.

In trying to visualise these different demands on a consultation, the pressure of time, the structure of a medical history, diagnostic coding, and data surveillance, I imagine a pie-chart being divided into ever smaller slices – and am reminded that over time, the patient has been squeezed out. Epistemic injustice takes over.

In time, students will become doctors who have learned to distinguish illness and diseases they can treat from those they cannot. And this, rather than the nature and degree of suffering will be their chief concern.

Affective empathy is lost when clinicians become hardened to suffering. The first patient they meet with depression or a terminal illness can be an intensely moving experience, but over time, especially if they are exhausted and hurried, and unable to attend to their own emotions or reflect with their colleagues, threatened in an unforgiving culture, they may lose their capacity to be moved.

In conclusion.

I think that empathy is lost in medical education and clinical practice. Perhaps one reason is because we don’t value the empathy our students have to begin with and don’t do enough to nurture it.

If we pay more attention to this as well as the factors that undermine it, we could do more to help it flourish.

Trauma and the self

Up until June 14th 2004 Joe was a consultant anaesthetist at a London teaching hospital. That day at work, during an operation he had a panic attack. He froze and as if in a trance, walked out of the operating theatre. The patient suffered serious harm and Joe was suspended from work and struck off the medical register. He hasn’t worked since. After he was struck off, he was referred to a psychiatrist for assessment who diagnosed Generalised Anxiety Disorder and Obsessive Compulsive Disorder and started him on the first of what was to be, over the next few years, many different psychotropic medications. He was referred for CBT (Cognitive Behavioral Therapy) and psychotherapy, which uncovered the extent of his anxiety, but did nothing to relieve his symptoms. On the day he walked out of the operating theatre, his life changed, from being outgoing and popular, he became reclusive and paranoid. His wife, a consultant surgeon continued to support the family, but they had to move to a smaller house and take their children out of private school.

I have been Joe’s GP since he left work and we meet about 3-4 times a year. Usually our meetings are quite brief. He always begins by gesturing to the waiting room and apologising for wasting my time, because there are people ‘out there’ who are much sicker than him, and I reciprocate by doing my best to assure him that I’m very glad to see him, and he is in no way wasting my time. Gradually we have established trust and a good rapport. I’ve not delved too deeply into his past before, partly because I’ve assumed that it’s something he’s been going over in therapy, and partly because our consultations are usually preoccupied with his present circumstances and working out issues with his latest drug treatment. At present he is taking two antipsychotics, two sleeping tablets, and an antidepressant. This makes me anxious and appears to have done little for his anxiety.

Unlike the transient anxiousness that naturally follows a traumatic event, when the symptoms are severe and enduring there is always a back story, but discovering it can take a very long time. The acute symptoms need to be tolerable and trust needs to be established. In writer/ editor Scott Stossell’s account of anxiety, My Age of Anxiety he asks ‘where has my anxiety come from?’ and explores, in detail, the complex aetiology which includes family history, early life experiences, human biology, social, environmental and political factors. All play a part. Psychiatrist Linda Gask asks the same question about her depression in her book, The Other Side of Silence and comes to the same conclusion. I have a strong family history of PTSD, so I have a personal interest.

I recently asked Joe where he thought his anxiety came from. “You know”, he said, referring to the panic attack in 2004. “That’s when my life changed, I was fine up until then”.

“Yes, I mean, is anxiety a family trait, were your parents, grandparents, siblings and so on anxious? Could there be an anxious gene?” Joe’s posture shifted, he folded his arms, his shoulders became more tense, his hands clenched. “No, not really, my sister perhaps, but we’re not really close”. I knew that Joe grew up in Leeds, he was the first doctor in his family and the first to go to university. I knew his sister had suffered with depression and had tried to commit suicide, but little else.

“What about your parents?”

“Not really. My dad was a bastard though. He would slap my mum about and smash the house up. My sister and I hated him”. Joe’s posture became more tense, he gritted his teeth and crossed his legs. “I remember this holiday when I was fourteen – we were going to Blackpool and I refused to go, I locked myself in my room and refused to leave. My dad tried to batter the door down, but couldn’t so he just said, ‘Fuck it, we’re going without you’. And they went without me for a week.”

Joe and I sat in silence for a while. He was curled up on the chair, trembling. Just as we imagined him as a 14 year old boy, this 50 year old anaesthetist besides me.

More came out. He has always been anxious, but was able to hide it, he threw himself into his studies and spent time his evenings in the library to avoid confronting his dad, and got into medical school where he did very well. After he qualified the anxiety became more of a problem with the pressure of work, especially when he met with emotionally distressed and traumatised patients. Anaesthetics seemed to be suited for him, but as he got older, especially, once his children began to grow up, his anxiety became harder to contain. Rather than risk being labelled he avoided going to a doctor and started using drugs from work. Soon this escalated and he was using Fentanyl (a strong opiate) until he realised he was addicted. He was trying to wean himself off and had almost succeeded, when he had the panic attack, probably due to the withdrawal effects.

“Nothing the psychiatrist has prescribed worked as well as the Fentanyl”, he said. “I was fine on that, never missed a day at work, never made a mistake. You won’t write this down, will you? I’ve never told anyone about it before.” “Didn’t they test you?” I asked. “No, and I would probably have been OK, because I was basically already doing cold turkey that day. If you could prescribe me Fentanyl now I’d stop all this other stuff, because it was the only thing that ever worked. But I know you can’t do that”.

Fentanyl like a lot of other drugs, especially opiates, psychotropics, neuroleptics and anti-depressants, for example heroin, naltrexone, Quetiapine, Pregabalin, Amitriptyline and so on, as well as alcohol – all help patients to dissociate. Dissociation is like the outer-body experience that a frightened child can achieve naturally and spontaneously as a defense. As we grow older our brains become less flexible and it becomes harder and harder to dissociate and so we use exercise, or work to cope. It is one reason why there is often a gap of decades between trauma and its aftermath. With time, it becomes harder still and strategies become addictions. For Joe, Fentanyl kept the frightened child separate from the competent anaesthetist. Nothing he has been prescribed since has been as effective.

Trauma fragments the self – a brilliant, short graphic novel.

The child that was terrified of their dad is despised for being afraid and is shameful. The high achieving child that went to university and became a successful anaesthetist is the self that is socially and personally acceptable. We all have different selves, doctor and dad, cyclist and mother and so on, but the traumatised self is despised and a source of shame and so the split is extreme and has to be maintained by any possible means of dissociation to fend off the intense anxiety that it brings.

Too much of the time I think we are content to continue to prescribe drugs to patients under the illusion that they are treating a disease rather than helping them dissociate. In some instances what we prescribe can help keep the symptoms at bay, but most of the time the anxiety persists, no matter what we prescribe.

Drugs probably do have a place in treatment, but so do top down (psychotherapeutic) and bottom up (physical) therapies that enable patients to reconnect with the traumatised self through their body and mind. We could both see how Joe’s traumatised self was inhabiting his tense and hunched body, it wasn’t just in his head. For him to recover he needs to identify the traumatised child and accept him as a part of himself. After a lifetime of shame and dissociation this is no easy task.


I’m not sure why this kind of understanding is missing from so much of medicine. Perhaps because it means shining a light on ourselves as well as our patients, and recognising that we’re not so different after all. Perhaps it’s a post-Freudian backlash and an obsession with biology and objectivity that is blind to subjectivity and experiences. Perhaps it is because financial incentives are constraining clinical curiosity – demanding that every patient narrative is recorded as a clinical code. Perhaps it is a fear of judging parents or others who are not around. Probably it is all of this and more.

One thing I am sure, is that some of the kindness and compassion that is so often missing in healthcare, in the ways we treat ourselves, our colleagues and our patients, could be recovered if we were more attentive to what makes us who we are.