A Doctor's Journal
Manager's Disease
ISEE that 150 of the BBC senior staff are to get regular medical examinations. This, the paper said, is part of the policy of the Director- General, and its intention is to combat the stress that their work puts on them. Naturally, the top executives of any large concern—and the BBC is large enough, heaven knows—are under stress. It is a nice point whether it is the directors, the intermediate management, or the rank and file who suffer most in this way. There have been few comprehensive inquiries in this field, though Avery Jones wrote about duodenal ulcer (a stress disorder) that it is a disease of the managerial class—the argument being, I think, that the manager is ground between the upper and the nether millstone.
What struck me especially about the BBC health checks was the statement of their purpose. An official of the London Clinic was quoted as saying, 'The purpose of these examinations is to detect as early as possible any trouble that might be creeping up on these unfortunate people. The stresses of their work lead to occupational diseases.' I read that twice to get the full flavour of its meaning. It means, surely, that nothing is to be done about the work situation, and the conditions within it, that produce stress; the policy is to examine the people every 'now and then to find if they have already got an established dis- order—when, of course, it is rather late in the day.
It is as though you had some valuable property in a house, but didn't keep a watchman there. Instead, you sent round a policeman twice a year to see if the house had been burgled. I hope that someone will think again about this policy.
Ernest Jones was a distinguished pioneer in the field of psychoanalysis, one of the small group which formed around Freud himself in the first beginnings and worked with him over the years. Jones wrote many papers for the technical jour- nals, but his greatest single achievement was the biography of Freud, a thoughtful, impartial and brilliantly written book. In it he describes in a vivid way the bitter opposition which the Freudian ideas excited in the first two decades of the century. The greater part of this, as Jones says, could not find its way into print—it was simply unprintable. The outbursts of anger and contempt from intellectual circles in Germany and else- where were, of course, a cover for the panicky emotions that agitated them; psychoanalytic theories had a profoundly disturbing effect on the minds of many orthodox physicians.
Since that time, the nature of the hostility to Freudian doctrines has changed, and this change, oddly enough, is largely due to an acceptance of the doctrines. 'If nowadays it were said of a prominent person that he was "obsessed with sex," that he had the habit of reading the most repulsive aspects of sexuality into every little happening or act, most people would think it rather queer on his part, but would still judge him on other grounds, whether he was personally agreeable, or whether he did valuable work. He would not be regarded as essentially evil-minded and wicked, an enemy of society. Yet that is just what such a stigma would have meant forty or fifty years ago. The moral loathing thus aroused might find its counterpart nowadays in the attitude, general in many countries, that an apparently respectable citizen was really a Communist.'
In our day the most vehement opposition to Freud's ideas comes from those who deem them- selves 'scientists'; their own work, when we examine it, often turns out to be a vast inverted pyramid of statistics on a flimsy foundation. Of course it is true, and every honest practitioner of psychiatry will admit it, that there has been a great deal of loose thinking in the psychoanalytic writings, and the results of analysis as therapy have not been well enough checked and con- trolled. But as a guide to what happens within a personal relationship, and in the disorders of relationship that lead td illness, the body of con- cepts which had its origin in the work of Freud has no equal. In any discussion of stress disorder, the relation of doctor and patient, or the 'dynamics of illness,' the experienced analyst is an indispensable contributor and an excellent stimulus.
The late John Rickman exemplified this very well. I recall a brief comment he once made at a professional meeting. He said that when the Health Service first came in, many doctors found themselves overloaded, and could spare little time for their patients; the true therapist was then, Rickman said, the apothecary, for the patients, not being able to say what they had to say to the doctor, told it to the chemist as they waited for the prescription to be made up. The emotional release which properly belonged to the consulting- room took place in the chemist's shop. I imagine we shall in time see in this country what has already happened , in America : many, or most, psychiatric physicians will, in the course of their training, have some analytic experience, without necessarily becoming members of the Institute, or accepting all of the doctrine.
If I were to give a prize for the 1957 Sentence of the Year, I would give it without any hesita- tion at all to Michael Balint, in The Doctor, his Patient and the Illness (Pitman, 1957): 'By far the most frequently used drug in general practice is the doctor himself'; that is, what matters is not only the bottle of medicine, or the box of pills, but the way that they are given and the faith of the patient in the doctor who prescribes. That sentence will echo and reverberate in the minds of everyone who thinks about medicine (in particular general practice) and influence their attitude and actions for years to come.
MILES HOWARD
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