Monday 27th April The Coronet Diaries.

Tanya just sent me this link. It is my lunch break and I feel sick in response. I text angrily that I cannot bear more bad news. I was attacking the messenger not my daughter. My heart has leapt into panic and I have not opened the link. My mind strangely leaps back into Tagore, although I don’t want to remember Death later stealing into the lyric.

On the seashore of endless worlds children meet. 
The infinite sky is motionless overhead and the restless water is boisterous. On the seashore of endless worlds the children meet with shouts and dances. 
They build their houses with sand, and they play with empty shells. With withered leaves they weave their boats and smilingly float them on the vast deep. Children have their play on the seashore of worlds.

On another note yesterday I posted a rather confused essay on ‘Psychoanalysis the Impossible Profession’. Someone I trust my ‘pen’ to/ with complained that I was not making proper sense and invisibly, at least to him, my Proustian ‘Fellow’, I blushed a shade of shame. Shrinking into myself, I removed it. I hope he approves my second draft.

Psychoanalysis The Impossible Profession: thoughts on the ethics of publication and the interferences of bureaucracy. (Alongside one of my characteristic digressions into why – post Harold Shipman – we can never exorcise abuse through legislation.)

I keep returning to the fact that psychoanalysis/ therapy cannot be/become a respectable profession.  For many reasons including the factor already referred to that while it can number amongst the most intimate experiences that either the ‘patient’ or therapist may encounter, a crucial component of therapy, is regardless of how intimate it may become, (and why it may become mutually so is a question for another day) one participant is a paying the other for a professional service.

 One of the obstacles to the therapy partnership becoming more transparent is the taboo on confidentiality. That every ‘patient’ must be guaranteed confidentiality is a sine qua non, but that should not be as a consequence of fear, of shame or a social taboo about needing therapy. The shame element has to some extent been transformed by Royal imprimatur. Few mind recommending their cardiologist and some women will even confide the valuable name of their aesthetics practitioner. 

It used to be alleged that the if you were a Civil Servant the very word ‘depression’ was censored and seen as a black mark on your career file. Most things change with time and every Civil Servant I have worked with, (possibly 6 over the years) has described how stress is now the most frequent cause of long-term absenteeism in the teams they manage, Therapy is no longer a dirty word that will hinder promotion.

On this occasion I want to focus on the issues around publication and the therapeutic process. The thorny issue not only of confidentiality but also the fact that historically psychoanalysis and therapy have only entered into the public Zeitgeist, as opposed to the profession, where competing theories would fill the oceans, either through sensational instances of abuse which hit the media, or therapists writing about their work which has been practised ever since Freud published his case histories. The only psychoanalysts and therapists who are well known to the lay public  are those who are also competent writers. The list is large. This can be problematic because having the dual talent of therapist and writer does not for one moment mean that you are a better therapist than your silent colleagues, who may be silent for myriad reasons. It could meant that the privacy, the isolation of the consulting room, challenges latent narcissism and that we scribes want to have our cake and to eat it: to be both in private consultation but also out there in the world. Even those therapists who do not write are inclined to feel a buzz when they are invited to throw a comment into the broad sheets or, even better, are quoted on the BBC. 

Historically, much has been written from the therapist’s exclusive point of view about diagnosis or pathology of patients. With the exception of media complaints of sensational breaches of ethical conduct, we rarely hear any narratives from the patients, the consumers, other than their negative experiences. Whereas first hand narratives or confessionals are becoming more common in life writing, there are few case histories, which are endorsed by both patient and practitioner. 

I happen to have gathered an indelible ‘Google’ reputation for being a therapist who ‘breaks all the rules’ to the extent that I had to warn one editor that if he did not publish an apology I would be seeking litigation for libel. It still surprises me that anyone who is referred to me and consults Google feels able to follow up with an appointment.

It is the case when some new patients consult me they request that a condition of therapy will be that I will never write about them. There is no question that I would write about anybody without permission; but also without collaboration. It is facile, as is often the case, to disguise the subject: change their gender, race or culture to the extent that they may not even recognize themselves and then demonstrate whatever pathology or interpretation suits the clinical example being illustrated.

A few months ago I was invited to participate in a conversation on a BBC program about my experience of practising psychotherapy in which I made reference to some anonymous clinical examples (with permission given.) In the context of explaining when I write about ‘patients/people’ not only do I request written permission, I also asked them to read ‘my’ text, with the opportunity to add their own commentary or difference of opinion to the narrative. It is a second sine qua non that I never write about anybody without sharing editorial rights. 

The example I provided to the interviewer was of the hidden complexities, whenever writing about people, as to whose permission should be requested. This ‘patient’ had given me their written authority to write whatever I wanted about an extraordinary and passionate session when he had invited his father to join us. The ‘patient’ emphasised that although permission was given they did not want to read my account: at least not at the time of publication. They trusted me to record my experience and theirs with as much verisimilitude as I could.  I was about to include the narrative in my book’s manuscript when the thought occurred that although I had been given the patient’s permission, what if one of the grandchildren was subsequently to read the narrative and recognise the participants? Potentially identifying features to another member of the family were intrinsic to my text, which ethically, I now realised I must withdraw. 

I felt this was an important issue that deserved further professional discussion and decided to alert the media section of the United Kingdom Council for Psychotherapy to the interview.Is that yet another example of my innate narcissism raising its prickly head?

The UKCP, who are the non-statutory regulatory body for psychotherapists in the UK have a media link, which their members are invited to alert whenever they are referenced in the media. I have not previously used this link. Surprisingly, the ‘Media Officer’ refused to share the BBC link with the membership. I was informed that as I had used clinical material on air, normal procedures must be bypassed and consultation must now be taken with a higher authority. I withdrew my submission.  Discussion was locked down.

It is too easy, as Freud has demonstrated on many published occasions, to portray a subjective view of a patient’s pathology without consulting the patient. Freud was the progenitor of Psychoanalysis and not subject to its ethics. He is congratulated for his famous case histories of ‘Anna O’ and the ‘Wolf Man’, et al but we shall never know whether either ‘Anna’ or’ Wolf’ would have recognised themself, let alone agreed to publication … 

We do know that Emma Eckstein, the subject of another, now infamous, case history would have vehemently protested about Freud and her ENT surgeon, Dr. Fliess’s collaboration and their verdict of Anna’s ‘Nasal-genital Reflex Neurosis’. It is a hideous account of vanity and crass misdiagnosis whereby Emma almost bled to death: › wiki › Emma Eckstein

Psychotherapy is not and cannot be a respectable profession because it can never be successfully scrutinised which is true of any of the few examples where a health care practitioner and their patient are still allowed to be in consultation without being chaperoned. Its ethical practice depends on the integrity, wisdom, kindness, intelligence and ears of the practitioner. Every therapy grows into an unique experience, whether creative or destructive. It is also important to hold in mind that therapists and doctors are capable of being psychologically abused by their patients. The applicants for professions like gynecology and obstetrics fall each year due to the risks of irrational complaint and litigation.  Wherever there is disappointment the possibility for misunderstandings also occurs. 

By its very nature, as Janet Malcolm brilliantly observed in 1986, Psychotherapy is an impossible and opaque, sometimes even wild profession which cannot, despite the years spent in training, be controlled or regulated by bureaucratic scrutiny, inspections, higher powers, or the academe. It is neither science nor ‘art’ and yet its creative practice requires knowledge of both the brain and the invisible Self.

The medical profession is subject to even greater scrutiny and control, which has accelerated since Harold Shipman was convicted of murdering several patients. Unlike therapy, the medical profession can prove its competence through objective examinations, apprenticeship and appraisal of clinical techniques, which are not, like therapy, carried out in obscurity and shadow, but on wards or in shared consulting rooms. It too is suffering as a result of the increase in time-wasting bureaucratic procedures – which the therapy world now imitates in its quest for respectability – whose unceasing and time consuming demands drive many medics to distraction and increasingly to early retirement. 

Post the Harold Shipman arrest and conviction, the Quality Care Commission, theindependent regulator of all health and state regulated social care services in England, (therapists remain unregulated) has brought in the most exhausting and time wasting annual hurdles that every medical practitioner, or their NHS trust has to finance and to survive the recurring inspections, which can go on for days, in order to qualify for re-registration. 

Shipman, as it happens, was a brilliant academic, a brilliant and dedicated diagnostic physician and a scrupulous case-note keeper as well as being a psychopath. He was respected by his colleagues and, it is alleged, loved by the majority of his patients. A doctor who would have passed any routine QCC inspection with flying colours

As a result of his prosecution medical bureaucracy has run amok and many laws and procedures regarding drug control, in particular the use of morphine, have been changed in ways that prevent even the most experienced doctors from applying their judgment or discretion, which have had negative outcomes both for palliative, hospice care and general pain control in general practice in acute emergencies. Many people have reported witnessing unspeakable experiences with members of their families dying in hospices when there have been insufficient medical staff available to provide sedation on request. These legislations and restrictions of a senior doctor’s autonomy and professional opinion are now proving to have unspeakable consequences in relation to the challenges of treating COVID-19. Unlike pneumonia palliative and hospice care in reality often have a much better PR than is evidenced by the patients’ and their relatives’ experiences.

There are now urgent calls, in relation to COVID, to relax the UK’s laws on palliative drug control. Several reports have emerged that some Covid-19 patients are waiting hours, even days for pain and anxiety-relieving medication such as morphine. Professor Martin Marshall, chair of the Royal College of General Practitioners, has stated that the college was applying urgent pressure on the government to relax the rules on the access to medicines like morphine used to control pain or symptoms such as breathlessness at the end of people’s lives. 

It has been alleged that the combination of local supply shortages and the draconian legal requirements that every patient has an individually named prescription is leading to unacceptable delays in releasing and administering drugs in cases where COVID symptoms develop in a distressing manner with rapidity and often in an matter of hours. 

Prior to the ‘Shipman enquiry’ in 2006 and changes in legislation, every senior doctor was trusted to carry morphine in his ‘bag’, to use it discretionally whether seeing his patients in their homes or in an institution. 

Psychotherapists have not yet come under such bureaucratic scrutiny as the medics but that day is not far away. The question of how you monitor anyone’s internal sense of integrity and responsibility first to do no harm, whether a therapist or medic has not been solved. 

Rules, regulations, bureaucracy, managerial jobs, officers and officialdom prosper. There does need to be scrutiny in all of the caring professions but such measures will sadly never wipe out abuse that is intrinsically linked to why it is tragically perpetuated both silently and invisibly.  The cost is too high to police practitioners, whether they be medics or therapists, with reams of paperwork and time consuming reappraisals. These inspections are not being carried out by senior consultant colleagues, but by teams of inspectors who, too often are themselves mediocre, and may turn out to be those failed practitioners who prefer to sit in judgment on others. 

Whether physician, therapist or parent, the first commandment has to be, to try to do no harm. The second is to remember that for the ancient Greeks the most serious offence to society was hamartia, which translates as – the occurrence of a fatal flaw (often inflation) that leads to the tragic downfall of an individual. Currently, we are all conspirators in an universal fatal flaw of neglecting, at our peril, our collective social integrity. 

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