4. The Doctor as Counsellor

The Doctor Himself and the Human Condition by Martin Lloyd-Jones

There is a very definite impression in the minds of the lay public that a doctor can be trusted with confidences more than anybody else. It seems to me that they believe that they can trust him, rather than the Christian minister, because he has always been the repository of his patients’ detailed personal matters. And this I think is going to be increasingly the case. Many of the Churches are losing their congregations. It is no longer the custom for people to go to church as they once did. So it is no longer the practice for people to go, with the same frequency as they used to do, to see a Christian minister.

THE FAMILY DOCTOR

Now I am old enough to remember the days when the doctor was a counsellor in a wider sense; and this was especially true of the old type of family doctor. He was almost invariably a friend of the whole family. When he went into the homes he realized that he had brought many of these people into the world, and they had grown up with him. He knew them intimately and they All knew him as ‘guide, counsellor and friend’. People would turn to him for advice; and he was highly successful in this respect. It might be that many such doctors were not Christians at all, but they had developed a kind of general wisdom. They were men who met life in the raw, they were men of experience, and from time to time they were present at crises in the life of these families.

I may be wrong, but I have a distinct impression that this is no longer the case. I hear, very frequently, complaints at the present time about the National Health Service and about the difficulty of getting a doctor to visit a home. This is something that will have to be argued out in the future. I believe it to be a tragic loss – this intimate contact between doctor and the patient and his whole family life. It is a need that will become more prominent, because people will be crying out for it.

Whether there will have to be some new kind of specialization in this respect I am not sure. I would argue that the general practitioner, the man who practices medicine in general rather than a speciality, is still the man who is in a unique position to counsel people. It will be something that will be needed more and more, because we are facing problems of a more acute form at the present time, through the extraordinary technological developments and new factors which have arisen within our own lifetime. For example, I believe that it is correct to say that at the present time somewhere around 45% of the hospital beds are occupied by psychiatric patients of various types. The sheer pressures of life and the pace at which we are all living tends to accentuate the human dilemma.

THE DOCTOR’S PERSONALITY

I believe that the best way of approaching our theme is to take a particular case, to discuss it together and to work it out. There are certain absolute essentials. The first is the doctor himself. We must start here. Counselling is not something outside the personality of the doctor, it is a part of it. There is a sense in which any kind of man can prescribe, let us say, penicillin. It does not matter whether he has a good or bad character. In the case of a straightforward condition such as an infection, it is a question of early diagnosis and – if possible – identifying the infecting organism, and then prescribing. But when we come to counselling, the doctor himself is a vital part of the situation. He is not doing something outside himself. He is giving something of himself and his experience, and there is an exchange taking place between the patient and himself. Hence the most important thing of all in counselling is the character and personality of the counsellor.

THE QUIET MIND

What is the greatest essential in a counsellor? I would say that it is a quiet mind, and that he is at rest in himself. You will remember how our Lord put this on one occasion– ‘Can the blind lead the blind? If the blind lead the blind they will both fall in the ditch.’ In other words, if a man is in trouble within himself, and is restless, he is really in need of counselling himself. How can he give useful counsel to another? The first requisite, therefore, in a counsellor is that he himself is possessed of a quiet mind, a mind that is restful. It is at that point, of course, that the importance of the Christian faith comes in. I am prepared to defend the proposition that no man ultimately can have a quiet mind, a heart at rest, and ‘at leisure from itself’ unless he is a Christian. He needs to know a true peace within – the peace of God which is able to keep ‘both mind and heart’. For the patient comes in an agitated troubled condition, and can detect if there are similar manifestations in the counsellor.

CHRISTIAN DOCTRINE

The second need is an understanding of Christian doctrine. What do I mean? A man can be a Christian and still be very defective in his understanding of Christian doctrine and the basis of Christian peace. When anyone takes up the role of counselling, he is in the sphere of daily living and practice. People will come to him with problems. How is he going to counsel them? He himself may have had a wonderful experience of conversion, but that in itself does not necessarily enable him to be a good counsellor. I have sometimes known it to be a hindrance. For example, when Christians have come suffering from various forms of spiritual depression they have been treated by other Christians to a thumping slap on the back and the suggestion – ‘Pull yourself together, cheer up!’ But that may do more harm than good, because it is the one thing which the poor patient cannot do at the time. I have known problems exaggerated and aggravated by this sheer lack of knowledge of skilled ‘doctoring’. It is not enough to have had the experience yourself. You need to reason with people and to take them on step by step, until you have brought them out of their difficulty. But you can only do that if your answers, and your whole approach, are governed by an understanding of the Christian life as a whole. It is a whole life.

THE APPROACH TO A PATIENT

Coming now to the actual handling of the patient, the first basic requisite is patience. This is, of course, a manifestation of the quiet mind. If you are not able to exercise such patience you will be a very bad counsellor. If you appear to be only half-listening, and give the impression that your mind is somewhere else, and that you think that the interview is a waste of time, you will do no good at all. You must be ready to give yourself to listening. Above everything else you must listen to what the patient says. It is astonishing to note the way in which people are helped merely by having someone who will listen to them.

Let me illustrate. One day Sir Thomas, later Lord, Horder, physician to St. Bartholomew’s Hospital, was asked to see a very distinguished patient – a Duchess. The local practitioner had written a letter of introduction and had told him that he was sure that there was nothing really wrong with her, though she thought there was. She had been to see most of the distinguished consultants in Harley Street, as well as on the Continent. But she felt no better, and somebody had suggested Horder. As it happened, the previous consultation before the arrival of the Duchess, had been a most interesting medical problem in differential diagnosis at which Horder excelled. This particular patient had been misdiagnosed and Horder had discovered what was really the matter with him, and could see that he could be cured.

On the arrival of the Duchess, Horder simply said, ‘Please tell me about your symptoms and experience. I will ask you a question now and again. But just take your time and tell me.’ So she began. While she was talking he was busy writing a letter to the doctor of the previous patient. Now and again he would stop and put a question to her. Then he would go on writing to the doctor concerned with the previous case, and the Duchess went on speaking. This continued until he had finished writing the letter to the previous doctor, giving him the diagnosis, his reasons for it and the suggested treatment. Then he told the Duchess to go on a bit longer and added, ‘Well, now, this is most interesting.’ He then proceeded to examine her chest and to take other steps to exclude the presence of what might be lurking signs of any serious condition. At the end of the consultation she said, ‘You know, Sir Thomas, I am sure that you are going to cure me.’ ‘Oh,’ he said, ‘How do you know that?’ She replied, ‘You are the first doctor who has taken the trouble to listen to me!’ (In one sense this is not a good illustration of what I want to say; for Horder was not really listening, but in that particular case there was nothing to listen to!) But he had won her confidence in a way which no one else had, and he was able to deal successfully with her hypochondria.

He had acted on the assumption that there was nothing seriously wrong with her, yet there was obviously something wrong, otherwise she would not be bothering all these doctors. He was able to help, because she received the impression that he was patiently following her explanations. I cannot emphasize this point too strongly. It takes us well on the road to solving one of the common conditions which is so widespread today.

GENUINE SYMPATHY

The attitude required also includes an element of sympathy. You must not be impatient with people, even when you are reasonably sure that they are neurotic, for the symptoms are very real to them. To you it may be nonsense, but you should be careful because you may one day have subjective symptoms yourself! When I was still practising medicine, for some reason a considerable number of ministers and clergy would come to consult me. I arrived at the conclusion that they were mostly neurotic because of their complaining of the same symptoms – vague indigestion, headaches and inability to sleep, and so on. I began to think that these preachers were ‘a pack of neurotics’. But I had not been more than nine months in the ministry when I began to notice the similar symptoms in myself. I had become a ‘neurotic’! In other words there are tensions in the ministry – the very nature of the work tends to produce them. So learn not to be impatient with the person consulting you. It is all very real to him in his daily experience and in his efforts to overcome the debilitating effects of the type of life which he has to lead. I seriously question whether anyone has a right to be practising clinical medicine who has no real concern for persons and for people.

HUMILITY

My next point is a negative one. Unfortunately it is necessary to add it. Do not cultivate an air of great knowledge! I have known a good deal of damage to come from this failing in a young practitioner. A patient comes to him under the impression that he or she has some serious condition. He soon satisfies himself that this fear is unwarranted. But the well-informed new sage – ostensibly with the best motives – begins to discuss points of differential diagnosis with the patient, and to give a great display of knowledge in the process. The steps are anxiously followed by the patient. The genius goes on, ‘Oh, no, it isn’t A, though it might have been B, or even C. But it isn’t that!’ Do you know to what this kind of behaviour leads? The poor patient begins to imagine that he or she may be suffering from every single one of these possibilities! The doctor has simply introduced new problems to the patient. I heard the other day of a small child who had fallen from a pram, and a little later a small haematoma had appeared. The anxious mother informally consulted a doctor, who as it happened was a pathologist. He should not have answered her questions, but he did. While assuring the mother that he thought that there was nothing seriously wrong, he went on to say that it might be this or that or develop into this or that. When the swelling changed colour and the child proved a bit fractious, the mother was beside herself with anxiety concerning the ‘fracture’, ‘internal haemorrhage’, ‘thrombosis’ and all the possibilities.

THE PATIENT’S CONSCIENCE

Another point will become more relevant in present conditions. The counsellor needs to be very careful that his primary concern is not his own conscience. This may at first sound strange, and contradictory of Christian standards. It is, of course, a particular difficulty for Christian doctors and counsellors. Increasingly, the patients will come with moral problems and their accompaniments – contraception, abortion and the like. Here lurks a danger. I am prepared to argue that, if your main concern is the preservation of your own conscience you are likely to be a very bad counsellor! The reason is that the man who is afraid of giving the wrong advice, or advice which he may feel is not Christian for himself (with an eye on his own conscience) tends to be legalistic. He also becomes cold and mechanical. Anyone who is legalistic in attitude forfeits his value as a trusted counsellor. What is needed is great patience and sympathy, and the power to put oneself in the patient’s situation. The adviser must not hold to his own rigid position otherwise the patient will simply become a tangent to a closed circle. The adviser may end by feeling that he has taken the ‘Christian stand’ and said all that was right. He may feel happy; but he may by this very fact have left the patient in extreme misery. This is obviously bad counselling.
The point is that we must be very careful not to foist our opinions on others. The counsellor is not a dictator, he is simply there to give help. While he may give his views and, with care, put them quite strongly if asked, yet all that is put to the patient must be in a spirit of real sympathy, love and understanding. As counsellors we must never be in the position of dictating to another person’s conscience. We have no right to imagine ourselves as ‘the conscience’ of another! We are there to share with those who consult us experience, knowledge, wisdom and suggestions concerning the way of cure. There are, unfortunately, Christians who feel it their duty to impose their own legalistic views on others. Our business, however, is to persuade, never to force. We must always be careful to avoid condemnation– especially in the case of a sick or agitated person. If the plain truth of the situation comes home to the patient that is one thing; but it is not our place to condemn.

THE DIAGNOSIS

The above points are mostly concerned with background attitudes, but they are all very important. Without them, indeed, what follows would be out of perspective. Having ensured that the approach has been right, we come to the actual diagnosis. If you cannot make a diagnosis you cannot finally help your patient. Here again, lies the importance of an accurate knowledge of the facts, the facts of life and the spiritual facts. They all come together here. To me the thing that is needed above everything else at the present time is an accurate textbook which deals with the borderland where the spiritual, the psychological and the psychiatric meet. This is the most difficult sphere of all in the practice of medicine and in Christian pastoral work. I have thought about it for some 45 years. For ministers have been in the habit of sending people to me, and explaining, ‘I don’t know what to think of this case, is it a spiritual or a psychological one?’ There is really no adequate textbook on this problem; and it is very important from every standpoint. Much time will be lost if you cannot differentiate. You will be unhelpful to the person who is confronting you, and perhaps even harmful.

The following may illustrate what I mean. When I arrived at Westminster Chapel one Sunday afternoon about 5 o’clock, two senior church members came in to my vestry. I could see by their faces that they were troubled. I asked, ‘Well, what is the matter with you two?’ They explained that they had been talking to a man for some three hours about his spiritual difficulties; and they had virtually exhausted themselves, but to no effect. On enquiring the name, I found that the man to whom they had been talking in spiritual terms was a poor fellow who had had electric shock treatment three times! He was a case of manic-depression in one of his typical phases. They had fallen into the well-known trap. Because he had come to the Chapel and had asked spiritual questions, they had assumed that he was a spiritual case.

One of the first things one learns in practice in relation to these borderline areas, is to make a broad general diagnosis of the category into which the patient falls. Then one can begin to apply the particular line of treatment. This is not as easy as it may sound. The patient’s reactions to what you are seeking to do is sometimes surprising, because his mind has not been trained into the approach of the doctor.

INFORMING THE PATIENT

Normally the patient should not be told too much in detail. ‘A little learning is a dangerous thing.’ It is good for doctor and patient when the new practitioner beginning his life’s work has passed through this stage. I remember very well how, when I began working as a medical clerk in the wards and was beginning to learn clinical medicine, I developed acute pleurisy after reading a textbook. Of course I had not got it. But I had all the symptoms, and they were all very real to me! Now if this was so with a medical student (who presumably was intelligent!) how much worse may this be with the public in general? The point is that you must either say very little, or you must say everything! Since the patient cannot be given everything – and time alone forbids this – I maintain that the less you say in detail the better. The older type of practitioners were men of few words, but they mostly satisfied their patients at these points. You may say that there was a good deal of ‘mystique’ about the old doctor. But all patients are human, and a little mystique now and again is necessary.

NOTE

[1] From Guidelines No. 24.
Part of an address to clinical medical students at B.M.A. House on Thursday, February 3rd 1972.

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