Growing Into Medicine (28 page)

In the
Journal of Psychoanalytic Psychotherapy
the reviewer points out that I retreat from lists as soon as I have made them, being more interested in the uniqueness of the individual. When Heather asked me to co-edit her book
Psychosexual Medicine, An Introduction
, published in 2001, I tried to ignore my dislike of boxes and tables. I realised that an up-to-date book, written in a modern style, was needed. But I was not the person to do it and should have declined her invitation. In my heart I do not believe one learns skills from lists and bullet points. Possibly a case history can shed some light, but my
own insights have been gained from experience with patients and well-directed discussions with colleagues.

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 explain 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.