1 Boring Old Man

    early days…

Practicing as an Internist in a Military Hospital back when the world was young, fresh out of a residency training program, I had a period I think of as on-the-job training. I learned that the majority of patients referred to me as an Internist didn’t have medical diseases. They had some kind of symptoms that worried them, but they weren’t from physical diseases. For most, reassurance was all that was required. But for more than I would’ve guessed, it wasn’t enough.

The first thing I learned with those cases was to say what I thought up front before ordering tests to prove the absence of underlying pathology. "I don’t think you have the ___ that you’re worried about, but let’s make sure and do this-and-that". That way, when they returned, I could say "Good news, the tests look okay." If I didn’t do that, they often left feeling, "He couldn’t find it, but worried that it was there but just not found." Those were easy things to learn. What was harder was how to ask, "What’s going on in your life?" to try to look at why they were having symptoms, probably psychosomatic symptoms. The reason it was harder is obvious. Any such questions can be heard as discounting, invalidating, saying "It’s just in your head."

But I learned, and then they started talking. I had no psychotherapy experience, psycho-anything for that matter. I was hearing the narratives behind the stress and the symptoms, but I had no idea what to say or do with what I was hearing. So I just listened. In those days, neither soldiers nor their families would go to go to the mental health clinic because of a fear it would damage the soldier’s careers. So all I had to offer was a sympathetic ear. But a lot of them got better, actually figured things out, solved some problems. I was surprised. It wasn’t from anything I did because I wasn’t doing anything, at least not anything I knew I was doing.

    is the fact that they got better the placebo effect?

Usually, the placebo effect is thought of as sort of a mind trick. Give people something they think might get them better, and they do – an expectations cure. Others attribute it to the mathematical regression to the mean [see in the land of sometimes[4]…]. While I suspect that both things are factors, but the amount of change frequently seen probably rules out a major role for either or both.

    latter days…

As a retiree, I started volunteering at a local charity clinic several times a month. Each time I’m there, I see about twenty patients in five hours [15 min/each]. As it turns out, many are returns for refills and checking in, so I can take more time with new or difficult patients. I obviously can’t do the psychotherapy I practiced. What I can do is use medications rationally, listen attentively, make comments  when I know what to say, and remember the patients when they return.

My presence has been a raging success and people get better, just like the early days. I’m sure I do more now than in my beginning, but not a lot more in the circumstances. So the same question is still appropriate, "is the fact that they get better the placebo effect?"

    or…

I would now say that in those early somewhat clueless days, I was encountering something basic about human psychology that I just didn’t yet understand. Emotions aren’t just internal signals that something’s awry, they are communications to others as well.  Mom knows the minute her child walks in from a bad day at school [and won’t settle for "fine" as the answer to "how’d it go at school today?"]. Years ago, Bibring hypothesized that depression signaled helplessness or powerlessness which remains a useful rule of thumb. And the help sought is often simply having the communication received and the story heard. The act of narrating the situation itself is cathartic. Likewise, in telling such a story, one is forced to put it into language and there may well be elements you hear for the first time yourself. Clarifying comments, questions, or further understanding are in the range of "gravy" on the meat of human contact [I’d better shut up, or I’ll begin to sound like a psychoanalyst].