by Ruth Skrine
Not long after we arrived, I joined a group at the Cassel hospital, led by Tom Main under the auspices of the Institute of Psychosexual Medicine (IPM). At the time when the majority of family planning services were handed over to the NHS doctors working in marriage guidance clinics run by the FPA felt they needed a special training organisation. They asked Tom Main to be their chairman as he was already running groups to discuss the sexual problems that presented in the clinics. He was a psychoanalyst with a fund of understanding about human beings and a rigorous approach to our study; but he inspired strong feelings of attachment and antagonism. An unsympathetic doctor referred to his acolytes as his ‘lovely ladies’. We were in the main women, because the work started with family planning doctors who were almost exclusively female. In addition, something about the nature of the work might have appealed to us more than to male doctors. Many men found Tom’s personality overbearing. Prue Tunnadine, the training secretary of the IPM for many years and who succeeded Tom as president, described a ‘stags at bay’ scenario that could develop between him and some men.
I travelled to London by train with a colleague, Pat Roberts, a gentle, charming person. I was delighted when Ralph asked her to become a prison visitor. Although we were enjoying our life together in a large house and pleasant garden it was good to have a friend with interests in both our worlds. We talked on the terrace, looking out at a trellis of roses running down one side of a lawn with a pond on the other.
After Pat had gained some experience in the prison she gave a talk to the IPM about her role. She explained that she had not been appointed as a doctor or as a person with training in psychosexual medicine. She was only an interested member of the public who wanted to help in any way she could. She had no powers within the prison and no set agenda, other than to be a friend to the prisoner, within the rules of the service. When she had finished her talk someone asked if she had ever felt frightened in the company of men who had committed murder. She said no, but added, ‘I have to admit to a small frisson when I heard that the charming man who recently offered me one lump or two in my coffee had poisoned two wives.’
In common with most doctors who start training with the IPM, both Pat and I found the seminars frustrating. The acquisition of facts had played such a large part in our previous education. All through my training I had believed that there was a body of knowledge that I must master, either by being told or by studying the recommended books. I could not understand why Tom Main was not teaching me how to help my patients. Doctors are supposed to have the answers and I was not equipping myself with them. The idea that I was learning how NOT to know, to stay in ignorance with the patient, only dawned slowly.
In the world of psychoanalysis and dynamic psychotherapy Tom is probably known best for furthering the idea of the therapeutic community. After serving in the RAMC as a psychiatric advisor he was posted to Northfield hospital to develop group studies in the care of disturbed servicemen. Soon he was appointed medical director of the Cassel hospital where he developed a more dynamic psychosocial role for nurses and where he established a family unit.
Michael Balint had been his analyst and they worked together to develop the group training method for general practitioners which I had experienced briefly in 1958. Some of Tom’s seminal thoughts are captured in The Ailment, a collection of his papers edited by his daughter. The last three chapters that deal with the defences of doctors and the training method of the Institute of Psychosexual Medicine are of vital importance. His most salient ideas have reverberated in my head down the years.
The clues to an individual’s discomfort with his or her sexual feelings or performance lie inside that person. All the doctor can do is to work with the patient to try and discover what these internal feelings might be. Over time I learned that preconceived ideas learned from books or teachers can only muddy the waters. Indeed, Tom was so concerned that his original ideas might be turned into accepted truths that would be passed down and block further thought that his work with us, alas, covers no more than three chapters of the book. But these are of vital importance for psychosexual medicine.
During this time, the mid- to late seventies, the new discipline of Sexual Therapy was developing. Treatment was based on the work of Masters and Johnson who had published their book Human Sexual Inadequacy in 1970. They had studied the physical changes that took place during sexual arousal and orgasm, using human subjects in a laboratory. For many years a behavioural approach was advocated with enthusiasm. Men and women were told how to have sex and given exercises to desensitise their hang-ups. Deeply personal and interpersonal feelings were labelled ‘Sexual Dysfunction’ defined by the frequency and adequacy of sexual performance. A new terminology developed to classify symptoms. Thus impotence became erectile dysfunction, retarded or premature ejaculation. Frigidity was subdivided into dysfunction of the arousal phase or orgasmic failure. Lack of desire was often seen as a hormonal deficiency.
The use of these terms removed the stigma of words like impotence and frigidity, which can imply something about the person rather than a medical condition. Despite this advantage, I disliked the new terminology. The old words were useful and poignant. Frigidity suggests something of the painful sense of being out of touch with one’s feelings. The word also helps us to understand the atmosphere that may develop during a consultation. Tom never referred to the transference or counter-transference, preferring ‘doctor–patient relationship’ and ‘atmosphere’ as being more descriptive of the dynamic whole.
‘Come on,’ he would say. ‘How did the patient look? What was she wearing? How did he enter the room? What was it LIKE to be with this person?’
I might find myself becoming very active, chipping away as if at a block of ice with questions and ideas. Yet, somehow, the patient could let out none of the feelings that mattered to her, except the despair of being how she was. ‘I am standing at the sink, he puts his arms round me and I freeze.’ The pain of the moment can be powerful and present in the room.
One of the first things I learned in the seminar was the futility of asking questions. ‘If you ask questions you get answers,’ Tom would say. ‘What use are they? You have no idea if the patient is trying to please you, give you the expected reply or fishing for the answer they want. Your question is dependent on your ideas and may be miles from the patient’s concerns.’
In the scenario described above, questions would have been useless. If the patient had known why she felt this way she could have remedied the situation herself. At that moment, what she longed for was to have her feelings understood. If the doctor makes a guess, based on other patients or what has been written in books, he or she is likely to be wide of the mark. The best response is to recognise the misery. ‘That must be awful for you.’ At least then the relationship with the patient has a chance of developing some warmth.
Another early lesson was the destructive effect of reassurance if it is given too early. Unless one can get near the core of the anxiety, reassurance is felt as denial. I remember once, when I was overcome by despair at my inability to help, I told a patient that she was not the only person to have these feelings, other people suffered in the same way. She leant forward and banged the table. ‘I am not other people, I’m ME.’
Learning to recognise that our own feelings and actions might be a response to the patient, a signpost to his or her difficulty, was the central idea that Tom brought to our work, which he believed was ‘applied psychoanalysis’. At the time I thought it was a ridiculous exaggeration of our skills, but with the passing of time I have come to believe he was talking about an approach so fundamentally different from many forms of counselling and behavioural therapy that he might have been justified.
During training for psychoanalysis and psychodynamic counselling, based on this idea of the relationship, the worker is required to undergo a varying amount of personal therapy with the aim of disentangling emotions produced by the patient/client from those arising from the psyche of t
he professional. Although some of us decided to have our own therapy this has never been a requirement in the IPM. Tom made a deliberate decision to ban discussion of the doctor’s personal feelings in the group. He had no wish to produce some lower species of therapist. His objective was to sensitise and improve our skills during our day-to-day work. (He was always ambivalent about special sessions where I believe important work can be done.) We were to remain, before everything else, doctors. Our personal feelings were not denied, just ignored. Any attempt at self-understanding was to be done outside the training seminar. With hindsight I see that this emphasis acted as a powerful stimulus to keep the consultation focused on the patient. For example, the doctor who admitted he had been angry with a woman in surgery might explain it to himself by saying he was in a bad temper because of an argument with his wife that morning. Tom would point out that he had not lost his temper with the preceding patients, so why this one? After some thought the doctor might say she reminded him of his wife. Instead of wanting to know in what way, Tom would wonder what it was in this patient that led her to ruffle people who were trying to help her.
Much of my professional life had been dominated by my lack of knowledge and by my anxiety that I would make mistakes. The opportunity to concentrate on the patient instead of myself was a new experience and a great relief. For the first time, I was encouraged to think not ‘was that right or wrong?’ but ‘what does that mean in terms of the patient?’ In addition, we were listening to stories of the sexual lives of our patients. It was particularly important that our personal lives were not exposed to the group in any way that we might regret later. Our professional selves were being studied, not our whole persons, allowing a more open and honest critique of our work.
The second tenet of the IPM, the study of what became known as the psychosomatic genital examination, emerged during Tom’s early work with family planning doctors. They noticed that before, during or after that vulnerable moment when people take their clothes off, they might get in touch with feelings they had not been aware of or had not connected with their symptoms. For most of us, when we lie on the couch, we are concerned to detach ourselves from the embarrassment of the exposure, to act unconcerned and sensible. The idea of further exposure, of feelings as well as flesh, is threatening. I was once asked if I obtained the patient’s permission to do such an examination – as if it was some invasive procedure, like an X-ray. It is nothing of the kind, merely an attempt to provide a listening and observing space where feelings can be allowed to emerge if they are pressing to do so. The most one could do to facilitate such exposure would be to comment on tension, sadness or fury evident in the face or body of the patient, or just present in the room.
As I became more confident I began to lecture on various courses. I will never forget being seized by the arm as I stood on an escalator leading to the underground in Stockholm. A young gynaecologist looked earnestly into my face as he asked, ‘Just how exactly do you do this psychosomatic examination?’ With the crowds surging round us, I was silenced by the impossibility of condensing several years of study and experience into a one-minute soundbite.
The next stage in the development of consultation skills was to learn how to step outside my feelings and interpret them to the patient in a meaningful way. Tom suggested that one cannot feel and think at the same time. The activity must be one of going close to feel with empathy, then pulling away to think, the movement one of rapid oscillation. I continued to struggle to develop this art for the rest of my professional life.
Because the feelings in the consultation were to some extent a product of our own internal worlds, our remarks had to be tentative and patient centred. Not ‘You are making me feel sad’ but ‘I wonder if you are feeling sad’. Or even ‘There seems to be a lot of sadness (anger, fear) around.’ One colleague found herself almost asleep as the patient droned on. Instead of processing the feeling she said, ‘I’m feeling very sleepy.’ The patient replied, ‘Yes, I have that effect on everyone.’ The doctor was immediately interested and fully awake. I cannot decide if her remark was foolhardy or courageous. I would not have been so direct, but in this particular instance the remark freed the patient to let out something real.
Tom Main called the study and use of the doctor–patient relationship the golden road to understanding. He departed from Balint by believing that doctors who were not analysts could learn to lead training seminars. I became a leader and attended the leaders’ seminars. Although we learnt much about groups, the most striking aspect of these meetings was the way Tom always took the discussion back to the patient. As with the basic training, we were taught no theory, for Tom believed passionately that one learnt by doing, his favourite quotation being from Izaak Walton, That art was not to be taught by words, but practice.
I am concerned by a further memory. Tom frequently asked, ‘Is this patient suitable for a brief psychosexual approach?’ I don’t remember asking this in the groups I led and I wonder if I had enough experience of more disturbed people to make that judgement myself. I did refer some patients on for further psychological help so at least I was not trying to cure the world. Tom thought we could help those with a problem in a focused area of their personality. This is not the same as focusing on the sexual problem – that was always secondary to the doctor–patient relationship.
The skills of psychosexual medicine cross the boundaries between the body and the mind. Along with others, I often felt ignorant and ill equipped to help.
‘This work is really difficult,’ I complained to Tom one day.
‘What do you expect? Anything worth doing is difficult. Stick with it.’
That obligation to stay with the here and now of the consultation, to remain in ignorance with the patient, required more courage than I realised at the time.
I have never felt myself to be courageous. Childhood and adolescence were full of frightening things. To my shame, when a gaggle of hissing geese approached, it was my younger sister who intervened to protect me. Since becoming an adult I had been able to avoid doing anything alarming. I only realised how easy it had been to run away from anxious situations when Ralph and I moved our cabin cruiser south from Yorkshire where it had been built. Bringing it by road would have been impossibly expensive, so we found a route via the canals and the tidal Trent. As soon as we passed through the lock into the rushing tide our engine failed. We were pulled back into the calm of the canal and had to wait a whole day while the engine was fixed and the tide reached the required height again.
There was no escape from the wild waters that waited for us. Glad of the pre-exam experience of controlling my nerves, I immersed myself in a novel, walked the dog along the towpath until exhausted, even tried to pray. Ralph read his book of knots, only looking at the engine manual when he thought I would not notice. I was glad he ignored me; we both knew that no words could relieve our anxiety.
When the time came to exit the lock for the second time all went smoothly. I clutched a handrail for support against the movement of our home, now a fragile matchbox in substantial waves. In the late afternoon we passed into the Fossdyke navigation via another lock. Once through to the other side, the scene was transformed. Boats were moored by the bank, motionless in the placid water where moorhens puttered about. Sitting in the still evening sunshine, protected from the fury of a nine-knot tide, made us realise that we knew nothing of the reality of nautical life.
The memory lingers as one of those moments of peace, so often provided for me by a river or canal. Some people long for the sea from which our antecedents, those minuscule creatures, dragged themselves onto the land. Perhaps the expanse of ocean signifies a greater reality into which our beginning and end can merge. For me, the journey is more important than the arrival. From those days on the river Thames with my parents, via our canoe, various punts and then our canal boat, the inland waterways have coursed through my being. Upland brooks still call to me, even though I can no longer walk up the hills to reach them. Rivule
ts join to form small rivers that coalesce and become waterways, on which we humans can journey, becoming a part of the whole. During those years when I was struggling to learn how to consider the body and mind as one entity, these watery experiences shared with Ralph not only continued to hold our marriage together but fed what, in the absence of a better word, I have to call my soul.
14
Body Fantasies
As I write about psychosexual medicine my voice takes on the tone of the lecturer I became, originally as an occasional speaker on family planning courses, then to various other groups of health care professionals. Telling people about the work, or about my life, appears to negate the idea that listening is important. Perhaps the tension between these two opposites can provide ways to approach the truth. Neville Symington, in his book The Analytical Experience, says ‘Truth. . . is a reality that exists between two people seeking it. . . truth can be seen or glimpsed, not possessed.’
The truth of someone’s mental picture of his or her own body is certainly difficult to grasp. The word ‘fantasy’ often describes a pleasurable journey into an imagined world. It has also come to be used for the more florid misconceptions held about the body. These distorted images may underlie the problem of non-consummation.
The inability to have full, penetrative sex is a fascinating example of the interaction of the body and the mind at different levels. There can be no doubt that social attitudes are very important. Good sex education, a more open approach to the body and relationships and the more enlightened upbringing of children must have reduced the incidence, although accurate figures are impossible to obtain. The difficulty is often revealed during a family planning consultation. A woman might feel she needs a cervical smear but is unable to relax enough to allow it to be taken. The matter is intensely private and may only be forced into the open by the desire for children.