NICHOLAS STEED October 1 1967


NICHOLAS STEED October 1 1967



talks to


Dr. Murray Wilson is a graduate of the University of Toronto medical school, a former instructor in psychiatry at Johns Hopkins medical school and assistant professor of psychiatry at the University of Ottawa. He is now in private practice in Toronto.

WELL, AS YOU CAN SEE, I’ve got a waiting room — the secretary sits at the end — and a consulting room. It looks less clinical than a general-practitioner’s office. There’s only one door into the consulting room, although many other psychiatrists have two, so patients never see each other. The advantage is, I suppose, that if someone is upset as he leaves, the other patients won’t see. But I feel that two doors encourage a person to believe that he is the only patient, and this isn’t good. 1 don’t have a desk in my consulting room because I don’t like to look at people across a desk. Yes, I’ve got a couch. It’s better for people who are highly sensitive to every movement I make. People forget that I’ve been sitting in this chair for hours, and if 1 shift

my position or scratch my ear they say, “You don’t believe me!”, or, “Is that wrong?”, as il I’ve made some nonverbal comment on what they’ve been saying. With the couch, patients are often less distracted, simply because they don’t have to look at me face-to-face all the time. This enables, some people to speak more freely about their problems.

Why do people come to sec me? Well, the commonest symptoms are depression or anxiety. Depression itself is like a fever; it can be a symptom of many different disorders, and sometimes it’s a malady all on its own. Depressed people lose their appetites for food, sex, life; sometimes they can’t sleep. Anxiety, on the other hand, is a mixed psychological and physical thing. The person has a sensation that something is about to happen; his heart beats faster, or misses beats, or he feels a constriction in his chest.

Do people come because it’s fashionable or in some way “smart” to see a psychiatrist? Good

Help me, doctor,

jLjvery day in Canada, thousands of troubled people class, the psychiatrist has become father-confessor. For fulfill his traditional role. But what about the troubles

people’s troubles? In these two articles, a priest and a agonizing depression, self-doubt and disappointment

for I am


heavens, no. Psychiatrists may have been popularized by magazines and television, but we're still regarded by many people as being on the lunatic fringe of the medical profession. In many ways, we're still scarcely respectable. Most patients don’t want their friends to know that they're seeing a psychiatrist — it’s usually a sign that they're getting pretty desperate. Occasionally. I've appeared in people's dreams as a garbageman; this tends to show you how they think of me. On the other hand. I've also appeared in patients’ dreams as a restaurateur giving a banquet — I guess that shows the other side of the picture. But on the whole, there's certainly nothing fashionable or smart about going to a psychiatrist. For the patient, it's a pretty serious—even desperate — business.

Inevitably, I have more women patients than men; the ratio is about two women for every man. This is partly because it's usually inconvenient for men to come during the day, and partly because it's more difficult for men to admit the “weakness” that is

implicit in seeing a psychiatrist — although in actual fact it takes some strength and guts to make the decision.

Then too, most of the people I see tend to be middle-class. It isn't because poorer people can't afford to see me; with today's medical plans almost everyone can see a private psychiatrist. In fact, if a person is unemployable because of mental difficulties the government will pay entirely for treatment. The main reason my patients tend to be middle-class is that there are problems of communications with uneducated people. For instance, words such as “decision” or “distract” are not used by uneducated people. When I use them with an uneducated person a barrier is created between us. I've got to be able to understand his symbols, both verbal and nonverbal, and the patient's got to be able to understand mine. Naturally, this is easier with someone whose background is roughly familiar, either from study, or simply because it's similar to my own.

But if a person's life is too chaotic, psychotherapy

isn't possible; this is more likely in the disturbed home of a working man. You see. there's a big difference between what I do in my practice and what’s done with severely disturbed people, such as you find in a mental hospital. My patients are out and functioning in the community; they're not so sick they have to be in hospital.

Mostly, people come to me voluntarily, although sometimes I see people who are forced to see me. They're usually adolescents under pressure from parents. They may be silent and unco-operative, in which case 1 might make some remark such as, “Well, it seems you don't want to talk to me today. Could you tell me why?” If that draws a blank I might say. '‘Well, we've got an hour to put in together. Can you think of anything you'd like to talk about — movies or motorcycles or whatever?” If this still doesn’t work I simply say, "Fine. Goodby. I'm around if you need me.”

There’s no point in fighting a silly battle with a patient. By all means let him / continued on pape 45

continued on pape 45

turn to professionals for help. For the affluent middle Canada’s 10 million Catholics, the priest continues to of these men who spend their lives listening to other psychiatrist reveal how they explore and cope with —their own and that of the people they try to help

HELP ME, DOCTOR continued from page 31

continued from page 31

Patients must depend on me —yet learn to be independent

win. Maybe the next time he sees a psychiatrist he’ll be less defensive.

But sometimes, at the other extreme, people are really desperate for help. They tell me so much about themselves at the first interview that I can't refuse to take them into treatment. To tell such people that I’m too busy to see them, that I’ve got too many patients already, would be a gross betrayal after they've poured out all their terrible secrets. If I don’t have any free time, 1 just try to avoid initial interviews with people who sound very disturbed.

But if I do agree to see a person, then I have to make some decisions in the first couple of interviews. The person may require hospitalization — but this 'is rare in my practice. Often a person may just have some specific, conscious problem that he wants to work on. An example of this could be a man who has decided to end a bad marriage; or a girl in her late 20s who’s finally got up enough courage to leave her parents and start a life of her own. All these people may need is sympathy, a neutral sounding board, while they work out their problems themselves. In such cases l try to keep out of the patient's way as much as possible—I stop interpreting things to him, try to create the impression that I’m not working hard. If I talk too much the patient might feel he must start fighting me, too.

Often, just being there at the appointed time is itself important. Patients come to rely on their hour with me. They’ll come in and say, “Whew! You're here.” By just being there I’m fulfilling a promise to them, and that’s important. Up to now they may have been badly let down by people who made promises to them. This dependence by the patient on the psychiatrist is necessary for psychotherapy — but it's frightening in a way, too. It means the patient is once again vulnerable to grievous hurt at the hands of a significant person in his or her life.

Because of this, some people are quite rightly wary of psychiatrists and psychiatric hospitals. Also, many people think seeing a psychiatrist involves being encouraged to do and say anything you want. The prospective patient senses in this an invitation to regress — to get worse — and so he rightly resists the temptation by staying away. All such people really need is to learn to control themselves. If they can without tackling the root cause of their neuroses, all the better.

This idea of finding The Problem, the underlying cause of disturbance, originated with Freud and Breuer in the late 19th century. They found that symptoms disappeared once the unconscious problem was uncovered. But by the turn of the century Freud discovered that this wasn't the whole answer, although sloshing around in the unconscious remained the preoccupation of psychiatrists for a long while; it still does for some. Of course, when people tell you what’s bothering them it’s often something trivial, such as a minor physical deformity, or a tendency to blush. These symptoms do have an unconscious

meaning. But the really important thing is why they should continue to bother the person when consciously he knows it to be ridiculous.

Today the shift in treatment emphasis is away from getting at the content of the unconscious and toward getting people to control their problems and urges so they can live

with them. Antisocial urges are always with us. It is what we do with them that becomes the focus. Sometimes therapy could take place without delving into the problem at all. For instance, I might just talk with a patient on some neutral subject, some common interest such as sports cars or bird watching. But it'd be un-

likely you could sustain this for a year or more; the patient is primarily interested in himself, and so he becomes the topic of conversation.

Possibly the trickiest problem of all is dependence. Patients inevitably come to depend on me, and much of my work is taken up with trying to get them to stand on their own two feet again. Dependence shows itself in many ways: patients in long-term

therapy tell me the most appalling things about themselves hut they can't

point out that I pick my fingers, a trait that may have annoyed them for months. The patient is afraid of alienating me, of losing the one person in the world who is helping him. When the patient finally begins to be able to criticize me it’s usually a sign that he’s getting better. For instance, a patient could walk in one day and say, “That’s an awful picture you’ve got on your wall” — and I’d feel he is getting stronger psychologically, abler to stand on his own feet.

Much of my work is helping people feel secure without being obnoxious. But with some people the mental damage is so great that they’ll never be independent. If you recognize this, it's wise to avoid an intense emotional attachment that might cripple them even more. But something more casual, monthly visits for example, could he of real help to such a person over the years.

As for the psychiatrist himself, inevitably he becomes emotionally com-

mitted to the patient, but at the same time he's got to try to remain detached. You see, if it becomes too obvious that you really want a patient to get better, you may make it more difficult for him to improve. This is because he becomes aware of this desire on your part and in a deeply hostile way he can’t permit you this pleasure.

Another trap the psychiatrist must strive to avoid is the mistake of being one-up. The psychiatrist is in the per-

fect position to be the one-up man and it’s an easy habit to acquire. For instance, a patient may casually mention something about sculpture. This happens to be a hobby of mine and I might instinctively correct him if he got the name of a sculptor wrong. This is the sort of thing one does without thinking. You kick yourse’f afterward, but it’s difficult to avoid.

The sort of office psychiatry that I'm talking about is to a large extent intuitive. You don’t have to be bright to be a psychiatrist, but you’ve got to be intuitive, and you’ve got to be reliable and have self-discipline. Naturally. some days I do better than on others. Some days I hear well what's being said; other days 1 hear almost nothing. It's a bad idea n have a hangover, but occasionally I find I’m working well with a patient even though I've got one. It’s difficult to predict how you’re going to do. I did my best work with schizophrenics as a young resident. I was intrigued with them then. Now I don’t think I'd have the patience.

Does therapy do any good? Most studies show one third of people "treated” improve, one third remain the same, and one third get u'orse. It’s heen suggested that just being on the waiting list of a clinic gives the same results as actual treatment. One shouldn’t think, though, that no treatment has actually been given. The patient on the waiting list may have been sustained over a crucial episode by hope, which may have been all the clinic could have given him anyway, along with a few pills. I think therapy dees help, perhaps even in the proportions I mentioned — a third, a third and a third. It's hard to assess. If a person’s objectives are infantile, such as to be brilliant and beloved, then therapy won’t help. Sometimes I haven’t got the slightest idea of what actually has taken place in a patient who conspicuously improves. 1 just don’t know.

Are psychiatrists normal? At a psychiatric meeting they look surprisingly normal — they could almost be any not particularly boisterous whitecollar group. But the rate of suicide is higher among psychiatrists than among other medical men, and it’s higher among doctors than in the general population. My impression is that these suicides occur among younger psychiatrists. Perhaps they failed to find the answers to dicir own personal problems. Sometimes myself, when my own life was restricted, when I was studying all the time, or not getting out socially much, I found myself living vicariously through my patients. I even envied them the messes they got themselves into! This, of course, is wrong — you have to develop your own life to make it as full as possible.

What’s it like socially to be a psychiatrist? Well, people peck a lot. They assume you've set yourself up as an oracle on behavior, and when you behave foolishly they note it. When I’m with strangers I often say I'm a physician, or a teacher, and then try to dodge further questions. It can make life a lot simpler, because when people start analyzing me it's rarely for my own good, and over cocktails I might start analyzing them, which wouldn’t be good for them either. ★