Growing Into Medicine

by Ruth Skrine

  I am reminded that Joan Chodorow, talking about dance therapy, found it useful to ‘. . . keep feelers out for the fourfold crisis emotions: grief, fear, anger and contempt/shame. More often than not the first three are named – the fourth is the missing one.’ In my section on symptoms and feelings I dealt with these emotions under different headings. The first, ‘I’m not that sort of girl – or boy’ is the one on shame. The feeling, that one’s own sexual arousal is dirty, can be present from the earliest stages of life. It can also be precipitated by many later events: by marriage, childbirth, disease, especially genital infections, or indeed many other life experiences. I would be most interested to know how big a part this plays in psychosexual medicine now, during the second decade of the twenty-first century. With sexual matters so pervasive and explicit one might expect shame to be a thing of the past. But my hunch is that the roots often lie in very early experiences. If this is true, then changes in social mores are unlikely to have much effect on the feelings of the individual. Indeed, the social ease with which the subject is discussed could make it more difficult to admit one’s own feeling of dirtiness and inadequacy.

  Personally, the messages I had received from my father and mother were very mixed. Their almost blatant exposure of their bodies in their bathroom, and their comfort with bodily functions, contrasted with my mother’s hesitancy about sex. I was introduced to the facts of childbirth by sitting next to our cat as she gave birth to her kittens. My parents covered the mechanics of intercourse and contraception with cool precision. But sexual arousal and pleasure were never a matter for discussion: I would have been deeply embarrassed if they had been.

  I was a virgin when I got married although, even if my mother had believed me, it would not have lessened her abhorrence of my white dress. Ralph was also fairly inexperienced. As my marriage progressed I was lucky to have little difficulty getting in touch with my own sexual feelings. In addition, I learned from Tom Main to feel easier with sexual matters and to value a ‘good enough’ sexual life within marriage. Our discussion and efforts to understand our patients helped me to keep an interest in that side of my life throughout the ups and downs that Ralph and I negotiated during the years. Without this help my passion might well have cooled as happens to so many people. Even to myself I am only able to acknowledge this personal side effect of the work from a safe distance – after more than twenty years of widowhood.

  Much has been written about the effect of childbirth on the sexual life of individuals and couples. In my chapter on the subject I find one of the few tables in the book. What I notice at this point is that the first three feelings identified by Chodorow, grief, fear and anger, are so often inextricably mixed, especially after childbirth. I identified another feeling that seems as important: that of vulnerability. The loss of control during childbirth can be terrifying. Good sex also requires us to ‘let go’, laying us open to feelings of hurt or ridicule.

  Another of my chapters deals with ‘Sex, anger and the couple’. I was well aware of the inhibiting effect of unexpressed anger in my own marriage. I remember a specific night when I could not respond to Ralph’s advances. I found myself thinking, ‘Tomorrow, I will make him listen,’ and my body was freed.

  It is often said that to resolve sexual difficulties both partners must be seen, for the problem may be collusive. In non-consummation a frightened woman is often attracted to a timid man with his own inhibitions. Tom Main believed, with some passion, that when a patient chose to consult a doctor and came alone, we should respect that decision. By the use of a one-to-one interaction, and the opportunity to examine the body, we could reach a deep but restricted area of the psyche. We should not be attempting to help those with more global disturbances of their personality. I hear him asking again, ‘Is this a suitable case for a brief psychosomatic approach?’

  Sending for the absent partner can be seen as a defence against uncomfortable feelings in the doctor, patient or both. Blame is shifted and can be explained by the psychoanalytic idea of projection. I recognise simple examples of this in my own life. One day I was fuming round the house counting the piles of papers Ralph had left about, collecting the dust. Only when I had the sense to count the larger number of my own piles was I able to smile. His piles were a sign of untidiness, mine were work in progress. In the same way, when my mother was living in the granny annexe I found myself standing alone in my kitchen saying, out loud, ‘I must tell my mother not to talk to herself, people will think she is crazy.’ Who was crazy? In our everyday life we frequently project our uncomfortable feelings into others where they can be despised or sometimes tolerated more easily than in ourselves.

  If we ask to see the partner we often end up with two patients. Together with many of my colleagues, I realised that I knew very little about the interaction of couples and had no skills to help them. I had analysed my own practice in 1991 and discovered that I separated couples more often than I sent for the absent partner. Looking at the case histories I used in my chapter about the couple I find that all the patients presented alone. The safe space of the consultation allowed some of them to get in touch with their anger, connect it to their sexual difficulty and then deal with it more directly at home. However, couples still sometimes chose to come together and my feeling of inadequacy led me to attend an introductory term at the Tavistock Institute of Marital Studies (TIMS). My experience gave me some insight into the complicated nature of relationships and subsequently, when a couple came together, I tried to focus on the relationship between them. Only if I suspected there were body fantasies or other fears that could not be expressed in the presence of a third person, would I split them up.

  Soon after publishing my book I wrote an article for the Journal of Sexual and Marital Therapy that I called ‘Emotional contact and containment in psychosexual medicine’. In this article I explored the idea of holding bodily and emotional anxieties together in the safe space of the consultation. When this article was republished in 2001 in a book Brief Encounters With Couples, edited by Francis Grier, I felt I had come of age. I had mastered enough psychotherapeutic ideas to hold my own in the company of some of the exalted staff at TIMS.

  In the final section of my book I try to suggest ways of looking for a theory of our work. It is here that my references become more wide reaching and I could be accused, and accuse myself, not so much of using them defensively as of trying to be ‘clever-clever’ or showing off. Because I am aware of being ignorant in so many areas I get particular pleasure from knowing things. Yet I am not prepared to rubbish the work for that reason. I remember Tom Main saying that most mental health nurses choose their occupation because they need help themselves, but if it were not for them we would have no mental health care. Even if our careers satisfy some need in ourselves, that does not necessarily negate the value of the work.

  Fifteen years later, I find one or two quotations that still seem pertinent. Carl Rogers quotes Lawrence Henderson: ‘The physician must have first, intimate, habitual intuitive familiarity with things; secondly, systematic knowledge of things; thirdly, an effective way of thinking about things.’ Our traditional training had given us the first two of those requirements but Tom, perhaps because the work was so new and exploratory, had actively discouraged us from perusing theory. Now, in his absence, I believed that we needed to strive for ideas with which to think about our work. My book falls far short of providing any answers. It seems that I was groping for a language in which to conceptualise our experience without being pulled sideways into that of psychotherapy or behaviourism.

  Re-reading my work now, I am struck afresh by the idea of therapeutic space and the need to keep it free of too much theory. A quote from Peter Brook, writing about producing plays in his book There Are No Secrets, hovers in my mind: ‘In order for something of quality to take place an empty space has to be created.’ I see now that the idea of keeping both the consultation and the training group free of theory is in opposition to my own search for ideas to exp
lain and further the work. I can only hope that this dichotomy produces a tension from which further understanding can develop. Marshall Marinker, in a lecture to the IPM, said that ‘exciting things happened at the boundary’. I am becoming aware that the space between knowing and not knowing has ever-expanding boundaries.

  Before starting to write this chapter I could not imagine how to comment on the book that was the culmination of my professional life. As I sit at my computer looking out at the garden I think back to those months when I was first alone, with no one here but my naval friends. Re-reading some of the things I have written, I am hopeful that the safe space I am now in will allow new thoughts to emerge that will help me to face my remaining days with fortitude.

  Writing a memoir is an exercise in making oneself vulnerable. For me, this is not about revealing desperate personal traumas, for I have been mercifully free of those, but about exploring the relationship between my personal and professional self. Until now, my training encouraged me to keep these two sides of my life in separate compartments. In order to put them together I am learning to trust that space of unknowing within myself, in the way I learned to trust it in the consultation, and from which (to my great surprise) the next chapter of my life erupted.

  19

  And Then There Was Fiction

  Once my book was published I had nothing more to say about my work. The sense of emptiness was made worse by my approaching retirement. The local authorities had made it clear that at the age of seventy they would no longer employ me in their clinics. I was only seeing one or two private patients a week. If I continued to work from home the need to clean the mud from under my fingernails, and the cat’s hairs and dead mice from the consulting room, would be a tiresome constraint. I also knew that without a steady stream of patients on whom to spread my concern I would become overanxious.

  Having decided to stop all clinical work I needed to retire from the Institute of Psychosexual Medicine. Although nobody suggested I should do so, I had learnt that training groups work better if all members are prepared to be equally vulnerable. The observer who can criticise, without receiving a reciprocal critique of their own work, alters the balance of power, creating eddies of unnecessary resentment. Without work I would be such an observer. My skills as a leader would diminish if I were not facing the same day-to-day stresses as the members.

  Two years before I retired I was already wondering how to survive without the profession that had, to a large extent, defined the person I was. I had loved the work with patients and colleagues, and imagined their loss would be a bereavement. Aware of my ignorance in the arts, I considered taking an Open University degree. Good fortune led me to mention my dilemma to my friend Elizabeth Forsythe who introduced me to the Open College of the Arts (OCA), an organisation described as ‘a creative arts college that specialises in distance learning’. I chose the Starting to Write course. At the beginning of my folder for the course I find a scrawled note. ‘Having had the course material for two days I feel as if I am in love! Moments of excitement are followed by hollow despair when it seems so difficult and tiring.’

  This introductory course gave me an opportunity to try poetry, prose and script writing. A chapter in the course book introduced each of the six assignments. My work had to be sent off with a covering letter of comment to my tutor Irene Rawnsley. She is a poet who always followed the educational precept of giving praise before offering criticism. Having my work considered seriously by a ‘real writer’ was a heady experience and my excitement is clear from my replies.

  Re-reading those assignments is more problematic. I recognise some of the characters and situations for I have built them into subsequent stories, but I cannot always remember how they have developed or where they have finally come to rest. Some images recur, each time described as if I was seeing them for the first time. The sweet chestnut tree outside my bedroom window that I am gazing at now, the prickly husks swelling each day, the sky behind turning from black to indigo to pale blue, is there in that first folder. I also meet it in my bedside diary, in half-filled notebooks and on scrappy bits of paper. The mind worries at images and ideas as if sucking at a drinking straw, hoping to extract the last drop of liquid from the bottom of the glass. I now see the returning light at the start of each day as holding out the repeated hope that such clarity might dawn in the world of my understanding.

  The following year I embarked on the short story course. Trying to make some sense of the material I have found on my computer is a lengthy process. Most stories have at least two titles and several drafts, for I appear to have re-worked them diligently, the good girl as always, in response to each letter of critique. Names and some situations are half-recognisable from my later novels. I sent a couple out to agents who showed no interest. One, who was looking for commercial stories for women’s magazines, was dogmatic that a couple must never meet over an animal – not a dog, a donkey or even a stick insect.

  The six stories I wrote got longer as the course progressed. Towards the end the tutor suggested that the form might not be suitable for me. I must have taken that comment to heart. By the time I enrolled on the MA course in creative writing at Bath Spa University, two years later, I had the first draft of a novel in my hand.

  The year was 1999. I celebrated my seventieth birthday with a party that I arranged for myself. As well as family and friends I invited a number of medical colleagues in an attempt to ease what I had expected to find a traumatic parting from my professional life. By the time it happened I was so enchanted by the idea of the new writing course that I hardly noticed.

  Helen would have liked to organise a party for me but because I insisted on arranging it for myself she substituted a mystery tour the next day. I thought we might be going to France for the night but she said I did not need a passport. At the end of the party, my brother Arthur and his wife Ruth left – I thought for their own home in Cheshire. I imagined we would drive north and meet them somewhere between our two houses. When we turned south I was mystified but hid my disappointment. Biz had come from America and was with us in Helen’s car so at least I had one sibling by my side. At lunchtime we had reached Devon and turned into the car park of The Nobody Inn. To belie its name, three of the other most important people in my life were sitting outside: Arthur, his wife and my beloved cousin Jenny. After the meal I discovered that Helen had arranged for us all to go on to a luxurious hotel on Dartmoor where I was greeted by flowers fit for a bride, more champagne, a sumptuous dinner and much loving banter.

  It is for the people gathered at that dinner, and especially for Helen and her family, that I try to be as independent and happy as possible. An idea from the novel by R C Hutchinson, Testament, has reverberated in my mind for many years; that one has a duty to be happy – for one cannot make others happy if one is not happy oneself. I was born with a reasonably contented nature, a ‘glass half full’ sort of person. The effort needed to be content is not so great – indeed, my relative happiness can be a matter of smug self-congratulation. I have to remind myself that the difficulty of judging the struggle another person has to find contentment is as great as trying to assess the degree of someone else’s pain.

  Before the MA in creative writing started, I stayed for five days at Lumb Bank, one of the residential Arvon centres for creative writing. The eighteenth-century house once belonged to Ted Hughes and is at the top of a steep lane with wide views over the Yorkshire countryside. The tutor who influenced me most was the poet Michael Laskey. When he visited Bath recently I was touched and amazed that he remembered a hate poem I wrote about my mother. I spent some time trying to write poetry but surprised myself on the MA by choosing prose modules. I probably realised that I had not read enough poetry to be much good in that form.

  By the time the course started I had became addicted to the discipline of writing. If I do not write for a few days I get itchy inside, as if I am deprived of a necessary antihistamine to soothe an urticarial rash. Despite constant battles
with my poor spelling, my lack of dexterity with words provides a challenge as well as moments of intense pleasure. Apart from giving birth to a baby, the course was the most exciting thing that has happened to me in my life. I was at least twenty years older than most of the others in the year, but because we had a common goal the generational differences did not seem to matter. I spent my time rewriting the novel and trying some more short stories.

  After the MA course ended I enrolled on a third OCA course, this time in poetry. My tutor, Robert Drake, reminded me of my father. Robert’s first collection of poems, A Line on Stone, moved me greatly, for it drew on his experiences with stone and included building the dry stone walls that my father strove to perfect.

  At the same time I found myself writing a second novel. I sent the two novels out to agents. Their negative responses did not deter me and during the first decade of the new century I wrote five novels in all. I was lucky to have the help of Lindsay Clarke’s tutorial group during some of this time. He was the most demanding of all the teachers I have met in my struggle to become a writer. I am greatly in his debt. Leaving the group after four years was hard. I was influenced by Tom Main’s idea, that after three or four years doctors in psychosexual training needed to forgo the support of the group and go out into the world to practise what they had learned. He believed they were professionally independent people who had to be responsible for their own work. He encouraged them to re-join a group later for a ‘top-up’, in order to unpick bad habits, like mistakes in a knitted garment, and to halt the tendency to backslide into more traditional forms of doctoring. The same dangers may lie in waiting for the aspiring writer.

  The seeds from which my fictions germinated were most often psychosexual problems. Heather says there is nothing interesting or exciting about sex gone wrong. I disagree. Sex is a central part of the human condition and no one can divorce themselves from its drives and complications. The problem is to find good enough ways to write about it. I am surprised and hurt when told that my characters do not come alive or feel real, for I believe that professionally I have touched ‘reality’ in the depths of many people. I would like to blame Tom for my inability to flesh them out. His training, concerned as it was with ‘deep penetration on a narrow front’, probably blinded me to many aspects of a character. But the reason is more likely to be my own underdeveloped writing and imaginative skills. My need to rationalise and control my material might be even more of a handicap. Lindsay told me on more than one occasion, ‘Put down your pen and close your eyes. Go back into the scene and see it better, in all its details.’