Monday, 14 March 2016

"Being with and Saying Goodbye"

The art and the Science of Child Psychiatry

(“Being with and Saying Goodbye: Cultivating Therapeutic Attitude in Professional Practice”, Andrew West, 2016, Karnac Books, London.)

At first glance I was puzzled by the title of this book. Perhaps West was challenged by management to say what exactly he did when closeted with his young patients session after session, over a period often extending to months. And West may have eased his annoyance with a deprecatory verbal shrug along the lines of  “Just being there with them!”.  I was further puzzled by Chapter 1. It seemed the first page of the book was missing. We learn about ‘potential space’, the difference between ‘being’ and ‘being with’, between ‘having’ and ‘doing’, the importance of ‘being oneself’, of ‘silence’. But what is this book about? At whom it is directed? What does the author mean by “being with”? The writing is lucid, easy and precise, and the points are subtle; how can he have overlooked these elementary questions? Gradually it dawns on us that West is illustrating his own method; we (the readers) are ourselves constructing the meaning from the ideas strewn in our way. [“..the new…therapeutic ideas…have to be discovered, rather than pushed into the conversation.” p. 55]

There follow two chapters (“The Intrusion of Reality”, “The Nature of Evidence”) in which a torrent of anger is directed against Health Service Managers, commissioners, politicians, and ‘modern life’ in general. Here West inveighs with passion, but his targets are valid and his points well argued. Does the system overvalue numbers? What does ‘in a timely fashion’ mean? Is it better to be ‘timely’ than ‘effective’? Does ‘evidenced-based medicine’ necessarily exclude psychiatry, and the placebo? (In which case, is it excluding too much?) Attention is drawn to the harm of premature diagnosis, of overprescribing, to the value of inaction, to the dehumanising and demotivating effect of uncaring non-clinical managers.  Are we forgetting the value of ”reason, experience, analogy, instinct, and memory?” [p. 53]. West may seem to be doing little more than lamenting, but I ended these chapters feeling that something precious is in danger of being lost, something valuable to the practice of medicine, even something essential to humanity.

A book, West points out, needs two covers; the front cover to attract, the back cover to close, to say “good bye” [p. 156]. In the central chapters we are taken carefully through the entire therapeutic process from the first eye-contact between clinician and patient on their way from waiting room to consulting room, to the solemn “Good bye” that ends the treatment. But this book makes no attempt to be a text-book of clinical practice and the nitty-gritty detail is entirely eschewed. What is examined is the less-easily-seen, the ‘between-the-lines’ stuff, the hard-to-describe stuff. It is this core that makes the book, with its subtle observations and its carefully nuanced writing, valuable and rare (it not unique).

There is, in general, a lightness in the text, and a sense of humour that makes the book enjoyable reading. There are one or two obscurities, and one or two laboured passages. (West, arguing both for and against diagnosis, cannot decide which is going to have the last word.) But there are many lovely points. (The bus driver who turns to his passenger and says “You should never presume a thing”; to illustrate the point that the clinician should not ‘presume’ his duty is to remove the 'presenting symptom’; it may be there because the patient ‘needs’ it. And is it true that the NHS manual of diagnostic codes does not have a code for ‘normal’? Fabulous!)   West clearly enjoys making his readers think. We must distinguish (it seems) between evidence and “evidence”…. “It is a confident uncertainty that needs to be projected at this stage.” And thinking (we are told) does not occur only in heads, but also “in the space between heads”.

This is a creative, inspiring, even an uplifting, book. With luck, the complacent reader will come away from it more aware of his shortcomings and frailties, but at the same time with a vision of perceptiveness and humanity . 

Middleton Cheney,

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