A Doctor's Journal
Creative Listening
By MILES HOWARD
MEMBERS of the medical Estab- lishment are sometimes heard to say that 'psychological treat- ment' should be undertaken only by doctors. It is (in their view) a highly skilled and rather hazardous procedure, which the 'trained' practitioner alone can be trusted to manage. On the surface, this looks reasonable; on closer scrutiny, the most cautious observer must admit that: (a) Most doctors have had no training in psychotherapy at all. A very few have been allowed to work with patients over any length of time : for instance, some of the Edinburgh students, under the guidance of Dick Scott. Out of the total number qualifying, this is but a tiny fraction. (b) Much illness in the stress disorder class never gets to the doctor : it is dealt with by the patient himself, perhaps with the aid of a friend, or relative, or one of those who practise 'healing,' in the role of therapist. (c) A proportion of the work of the non-medical staff of hospitals is, in effect,. psychotherapy—although they don't give it that name : but it is work of the highest value to the patient, his doctor and the community.
So I was glad to read, in the current issue of The Almoner, an account by Dr. R. B. Coles of case- work carried out by almoners at the Northamp- ton General Hospital on patients with skin dis- orders. In the year under review, no fewer than 188 patients were referred for case-work, with a wide variety of disorders—eczema, neurodermati- tis, rosacea and many others. Dr. Coles, who is consultant in dermatology to the Hospital, makes it quite clear in his paper how much he is indebted to his colleagues Miss Bate and Miss Williams, and how much help they were able to give 'to his patients. In a word, what the almoners could give was time and 'creative listening'—and time is just what the consultant in a crowded clinic is short of. This paper shows once more that the social worker, with experience and the minimum of supervision, can through the medium of case-work guide many ill people to recovery : and surely this is what an almoner should be doing ! —handing out information and hernia belts is all very well in its way, but I cannot doubt that case-work is more satisfying, and more re- warding, to all concerned.
In trying to understand the meaning of illness, the doctor (quite rightly) tries to get from his patient an account of when it started and how it grew and changed; if he thinks that stress may be a causal factor, he will look back over the patient's early history and childhood experi- ence. This process is called 'taking a history,' and it is a necessary part of the examination. In listening to the stories of illness, recounted al medical meetings, I sometimes wonder whether 'the history' is being over-emphasised at the expense of the Here-and-Now. Whatever may have happened to the patient at the age of six. it is only important in so far as it determines his behaviour now: if, for instance, he was domin- ated by a menacing father, and hasn't managed to 'work through' this experience in life or in therapy, then he may be unduly submissive to 'father-figures' in his current world. This pattern of submissiveness can be read in his day-to-day behaviour—towards the doctor, his employer and other authority-figures. No need (one might argue) to comb over the events of childhood in minute detail : the attitudes and drives the ob- server wants to know about are right there, if he can see them. In hospital, the means by which a patient tries to control, or evade, or flatter, other patients in the ward, and the staff, are a good guide to his habitual reactions towards the rest of the world; his Here-and-Now behaviour maY well speak louder than any history. The past is over, the future may never happen; all we call, deal with is the present, and (in one sense) all .", need for the comprehension of human reactions is contained therein.
, More than 6,000 people die in Great Britain every year as a result of accidents in the home. Of these, some 700 are burns and scalds. No reliable data are available on the incidence of non-fatal accidents, but a rough estimate is that 55,000 people per year need hospital care for 'burning' mishaps occurring at home. Beyond this, there must be many more minor injuries dealt with on the spot—so that the total of all 'accidental' in- juries, in the domestic setting, must be formidable indeed.
The accident-at-home is a serious problem, and it has been exercising the authorities in charge of public health. In some areas an attempt has been made to estimate the number of these accidents treated by the family doctor, through 'notifica- tion,' but such estimates are bound to be pretty rough. Lately, the Ministry of Health issued a notice to family doctors on the prevention of burns. About 80 per cent. of deaths from burns are due to ignition of the victim's clothing, and open, unguarded fires are the main cause here.
MOst fatal domestic accidents due to burns take their toll at the extremes of life: in children, per- haps inadequate supervision; in the aged, reduc- tion in the 'capacity to 'organise' behaviour. The female is at greater risk than the male, probably because of her more wayward dress. Various legis- lative measures exist for the protection of child- ren: for instance, the Children and Young Persons Acts of 1933 and 1952, under which parent or guardian is liable to a fine if a child of twelve is seriously injured or dies from burns caused by an unguarded fire. Plainly, however, the passing of laws cannot, of itself, do more than reduce a little this tremendous volume of avoidable injury—only by education of the citizen can this social 'malady' be tackled: education by the doctor, by the press, and by that instrument with the greatest potential scope of any—the TV.
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