by JOSHUA BIERER M.D., F.R.C.PSYCH., D.ECON. & SOC.SC. (VIENNA), DIP.INDIV.PSYCH. work of a professional is hard, the responsibility he carries is great and the of success often rather small. Most people do not realise how much a therapist is at the mercy of his patient. He needs the patient’s co-operation, and the more the patient knows this, the greater his chance to use it to get his own way. If the therapist &dquo;gets involved&dquo;, he is likely to be in trouble. If he does not &dquo;involved&dquo; he is unlikely to achieve the relationship or the transference necessary to get therapeutic results. Operating theatres and all the physical paraphernalia of modern scientific medicine are always immediately impressive. The psychiatrist, on the other hand, who &dquo;treats only with words&dquo;, all too often meets with a deprecatory attitude on the part of his patients; and it is true that to deal with the psyche means that one works a priori without a system of fixed rules and has to adapt oneself, one’s relations and one’s treatment from moment to moment. It may well be concluded that one would have to be mad oneself to undertake these thankless tasks. I do indeed incline to a belief that a certain measure of egotism goes into choosing this work, but also the experience of having undergone suffering. Of course it is essential to have overcome difficulties and gained insight into one’s own problems as well as those of others. Many friends have asked me how it is possible that I remain an optimist after having worked in the field of psychiatry and psychotherapy for over fifty years! There are probably many reasons, which I should like to analyse at some other time, but for the moment, may I just tell you what happened an hour ago ? A relative with whom I was spending the weekend said to me: &dquo;Do you know that Paul has become a judge? !&dquo; Paul is a former patient of mine. I felt a glow of happiness and excitement. I am always overjoyed when one of my former patients does well. I do not think it is my humanity or my altruism-it may well be my egocentricity! I am pleased that my optimistic therapeutic outlook has been vindicated that anyone can change for the better. Paul was not a run-of-the-mill patient, easily forgotten. Many years ago a tall, handsome man walked into my consulting room after having made an appointment. He told me that he was brought up in Canada, but had been working in London as a lawyer. It would be more correct to say that he was supposed to be working, as he was out of work, out of money and deserted by his family! He had quarrelled with his mother, who had refused to help him any longer. He felt completely alone in the world and saw no way out. His mother was a hard and undemonstrative woman. She had never been able to show him any love or affection. His father died some years ago and played no role in his life. He had many girl friends, but lost interest as soon as he had &dquo;conquered&dquo; them. He had psychoanalytical treatment for two years, but this had not helped him. After listening to him for some time it was clear to me that he was not much burdened with moral values or an appreciation of such things as law and order. He

THE chance

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220 able to get away with acts that would have got others into trouble with the law their conscience! His mother, unhappily married, had been able to shower him with presents, and financial help in a very generous way. Using his charm, the ne’er-do-well son knew how to exploit his mother’s weakness. Mothers who display contradictory behaviour patterns are many times worse than mothers who show no love and affection but are consistent. With the former type of mother, children feel insecure and anxious, for they do not know from one moment to another what to expect. By hook or by crook, they must be ready to react immediately, without notice. They have no time for moral considerations and develop a sense of cunning, as they are determined to get and make their way. They feel so insecure that they cannot afford to lose. They become extremely ambitious and feel that they must win at any price. The price they pay is their conscience, and the result is what psychiatrists call a &dquo;criminal psychopath&dquo;. Of course politicians, businessmen or even professional men must be ambitious to succeed, but the difference is that &dquo;price&dquo; ; usually they are not prepared to pay, at least not in the &dquo;illegal currency&dquo; of the psychopath. This is the reason why some psychopaths finish in the dock and in prison, whilst others end up in big positions. Often neither intelligence nor ability divide the successful from the failures. Having found out the life-style of this patient I had no time to &dquo;analyse&dquo; him for months or years-he had undergone all that before! Here was a case where the house was burning and a life had to be saved. I rang up a friend (it is important for a Social Psychiatrist to have many friends) and I asked him to help me. He got me an office that had belonged to a solicitor who had died. I took the office for my patient and sent him the first clients. I had no hesitation, as I had convinced myself that my patient was an excellent solicitor. I recommended him to a friend, who sent him many cases. Years later this man told me that my patient, the solicitor, never lost a case for him ! Only much later did I realise why he was so successful. He made a special study of the judges before whom he had to appear. There is no doubt in my mind that British judges are fairer than those in any other country, but they are still human beings and, therefore, have likes, dislikes and prejudices. My solicitor patient had a way (which I had better not disclose) to avoid appearing before a judge whose particular prejudice might be harmful to his client. Ingenious, but was it fair? I sent him a patient who had committed a crime, as I believed he might be able to help this man. He charged him a very large fee, which he insisted on receiving before he was prepared to do any work. This was probably wise, as the client was not very reliable. He then told me that he proposed to collect a similar amount for me. I told him that my fee was much lower, but that I would be indeed obliged if he were to collect it for me. I never received a penny ! After my patient was well-established in his work and earning a very good living, I asked him to represent me in a dispute. He met the man once and sent me a bill in three figures which was quite a lot 20 years ago. The irony was that I had never sent him a bill for my treatments! I never intended to, because when a man comes to me, on the brink of suicide, without means, at the end of his tether, not knowing where to turn, I do not think of money. When he does well afterwards this was or

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221 is better payment and gives me greater pleasure. Some may think I am unusual, if not mad. I probably am, but why may I not be allowed to enjoy myself in my own

way? That a patient whose sanity I have helped save shows no gratitude comes as no surprise to me. My teacher, Professor Alfred Adler, was fond of saying: &dquo;You should prefer a patient who leaves you and says ’To Hell with that old man, he could not help me, I am going to show him what I can do myself’-to a patient who sticks with you for the rest of his life and never changes.&dquo; In the end, I did send Paul a bill for £300, but I never heard from him, not even when he was appointed a judge. He was not a Q.C., and it was an honour which only very few achieve ! I do not tell this story to quibble at his appointment; quite the contrary, I believe he will be an outstanding judge, as he knows crime from both sides of the bar! I am writing this to plead again, not to label people, not to look down on anyone, as everybody is superior and inferior at the same time in different fields in relation to the same people or in the same field in relation to different people or to the same people in different fields at different times. People who always feel superior or inferior need sympathy and/or treatment. However, people who are aware of the fact that they know nothing do not need to worry, as they have our admiration.

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Must we label people?

219 MUST WE LABEL PEOPLE? by JOSHUA BIERER M.D., F.R.C.PSYCH., D.ECON. & SOC.SC. (VIENNA), DIP.INDIV.PSYCH. work of a professional is hard, the resp...
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