“Shahina” comes in with a contracture of the fingers of one hand. Another consultant recommends a botulinum injection. Bingo! The contracture releases instantly. Shahina is cured! Now, usually you take your therapeutic victories where you can get them. But O’Sullivan presses on. She tells Shahina that normally the botulinum works only after a day or two. “The speed at which your hand responded to the toxin makes me wonder if there is a chance that the spasm in your hand might have had a psychological rather than a physical cause.”
Shahina responds, “You think I’m mad?” No, of course not but…
This is actually a model of what not to do: throw patients into confusion with the relentless urge to enlighten them about their supposed psychological problems.
For other patients, as I have argued above, the psychiatrist is held out as the solution of choice. This is a problematic idea, and it is dismaying to see it propagated so vehemently in these pages. Psychiatrists tend to be baffled by such referrals. “This is a patient whose chief complaint is chest pain? C’mon!”
The general internist, the rheumatologist, or another neurologist should be the physicians of reference, because only they are able to build the necessary therapeutic alliance, to keep the myth of organicity semi-intact. It is this myth that patients require to retain their self-respect, while the real therapy takes places in the context of the doctor-patient relationship. What actually works is spending a lot of time with these patients and letting them tell and, if necessary, retell their stories. This is cathartic. But it is advice that is most unwelcome to many clinicians because it takes so much time.
It is not really fair for me to second-guess Dr O’Sullivan from the comfort of my armchair thousands of miles away. Physicians on the front line of medicine, at Queen’s Square and elsewhere, have to cope as best they can – and with relatives that make Himmler seem like Santa Claus. (O’Sullivan’s patience in dealing with these furies is remarkable.)