Once upon a time in the 1990s, a medical student was going to meet his first real patient. While he had taken patients' medical histories many times before, this was something completely different. Now he would be going into depth, and for the first time he would use therapeutic dialogue as a healing instrument.
That student was me. I was filled with nervous anticipation. My supervisor allowed me to read the referral. It was for a middle-aged woman, on a disability pension due to fibromyalgia and fatigue. She had been struggling psychologically after her husband had not danced with her at a party.
I was extremely disappointed. What was this? Fibromyalgia – a disease we scoffed at? A patient who 'struggled psychologically' because she was not asked to dance? It sounded ridiculous! After all, I only got this one chance. This was my only opportunity to get training in therapy. How unlucky! Damned bad luck to get a patient like this!
She came to our first session. I would have probably written in her medical records: 'Appears significantly older than her age'. We sat down, and the patient began to talk. She laid out her life, almost as if I were not there. She talked incessantly, with her eyes closed the entire time. I could have made grimaces without her noticing it, and I was tempted to do so. She talked about the pain throughout her body, about poor sleep, about fatigue, about tiredness. About her children who were now adults, but who continued to use her like a 'service station', about how she had maintained the household and taken care of them for years without a single thank-you, about her husband who went to work, came home, ate dinner, sat on the sofa, watched TV, and went to bed. She talked about how no one noticed what she did in the house, that once she had tried not doing the dishes, and that no one noticed, as if it made no difference
Good grief. How trivial! My thoughts began to wander from what she was saying. It was difficult to stay focused on her. I was thinking how I could have got a psychotic, depressed or manic patient, someone relevant to my exams, but here I sat, listening to empty talk, to no avail. I felt really sorry for myself. I felt a wave of self-pity. My thoughts wandered further and landed where they generally landed at that time: my own heartbreak. I had just ended a turbulent, two-year relationship with extreme highs and lows. I felt a kind of relief, but mostly sorrow. I felt lonely and doubted the choice I had made. Freedom had turned out to be painful. In my dark moments, I wondered if life would ever be good again. I knew that she had already found a new love – it was difficult to admit, but it hurt me deeply. I kept all of this to myself, I felt ashamed, I was the cause of my own misfortune, after all.
If I say goodnight to my husband, he answers goodnight. If I don't say goodnight, he says nothing
Our first session was nearly over. It felt like a waste of time. I heard that the other students had got very exciting cases, conditions discussed in our textbooks. Poor me! I was already dreading our next meeting. The patient had taken a break, but still sat with her eyes closed. Then she began again. She talked about the party. Her husband had danced with a lot of women that evening, but he had not asked her to dance. She was clearly upset about this. I thought: It was certainly not very nice of him, but is it possible to dwell on such a trivial matter, even go to therapy for it?
Suddenly the patient became silent. She opened her eyes. She looked at me, for the first time. She said nothing; she just looked at me. I felt a kind of panic: Should I say something? What should I say? What could I tell her? The distance felt insurmountable. It was clear that she expected me to speak. My heart was pounding. I had no idea what to say. She sighed and said quietly: 'If I say goodnight to my husband, he answers goodnight. If I don't say goodnight, he says nothing.' Then she was silent again.
There I was, the therapist, leaning against her, crying, helpless, until I was exhausted and had no tears left, still at a loss for words
Almost nothing had happened during the therapy up to that point. Now, suddenly, everything was happening very quickly, in a few seconds. And it was happening inside of me, the therapist. I was unprepared for it, and it was powerful, frightening. My patient had been trying to reach me for over an hour. She had talked about her life in strong, clear words, and I had taken nothing in. I had been totally untouched. But the sentence she had just spoken seemed like a poem, like quiet poetry: 'If I say goodnight, he answers goodnight. If I don't say goodnight, he says nothing.' This sentence I understood. It pierced me like a sharp arrow and struck an inner nerve, which now quivered. Suddenly I recognised that she and I were alike. She was suffering from the same sadness and loneliness that I was. I also understood that her entire life was like this, that no one saw her, that she was invisible. My sense of our shared experience intensified my own loss. I had to admit to myself that I was just like this person I had been looking down on, as if she were a pathetic creature. A grey-haired woman with fibromyalgia and I were in the same boat! Could I fall any lower?
Guilt was the next feeling that overwhelmed me. I had scorned and despised this person. Yet, she was like me. A wave of bad conscience flowed through me. It was unbearable. I could not take any more. I was lost. Tears began to well up, and a few seconds after she had spoken the sentence that revealed everything to me, I broke down in tears, intense and convulsive.
I realised that the key to understanding others is to understand oneself
This must have been incomprehensible for the patient. But she was an experienced mother. She moved her chair, sat down next to me, put her arm around me and leaned into me. There I was, the therapist, leaning against her, crying, helpless, until I was exhausted and had no tears left, still at a loss for words.
What a therapy session!
What a pathetic therapist!
What misery, what a disaster!
Now, when I look back on this experience a quarter of a century later, I know that it was not a catastrophe. It was a gift. The woman gave me a treasure chest. Like treasure chests in fairy tales, this one is inexhaustible. All my life I have been taking pearls from it, shining pearls of wisdom. I learned that patients must be allowed to tell their stories – to the end (1). I understood that listening is more than hearing words. It is participating, sensing, living, understanding. I saw the significance of a glance during a conversation (2–4), that words can be less important than body language (5, 6). I learned that a meeting between people can contain magical moments. That small, cautious and vague words in a conversation can have an explosive effect that breaks down barriers and opens up completely new perspectives (7–11). I learned that I am a human being, even when I am wearing a white coat, and that my mind and heart are a part of the therapy. What is seemingly about another person may actually be about oneself. I realised that the key to understanding others is to understand oneself (12). I learned that I have prejudices and can wrong others with my disdain. That I, as a doctor, must treat the patient as a person like myself (13). I learned that women's lives are different from men's. That life histories take root in the body, that listening can alleviate pain, that we all have our stories and battles in life. That pain arises in a context, in a life with all its facets. That illness is more than biology. I learned that words can heal. That the little things in daily life are what life is all about and that no pain is as great as everyday pain. That a 'goodnight' at bedtime can mean the difference between being seen and not being seen, between a life with and without pain.
I found that the darkest defeats can turn into something good, without anything falling apart. I learned that we can play host to angels without knowing it (14). I learned, as the emperor Marcus Aurelius said, that 'universal nature has made rational creatures for the sake of one another, to the end that they should do one another good' (15).
So this was truly a therapeutic session.