Gwynnedd Somerville and Charlotte Paul
What are you here for, if not to treat difficult patients?”
“How to take a history from and examine a sick person would seem an unusual starting point to create a philosophy of life … but that did not deter Keith”, writes psychiatrist Sandy Macleod in The Next Patient in the Waiting Room, a book of essays about his father, which we have edited. Keith Macleod joined the Department of Medicine at the University of Otago in 1951 and became a neurologist at Dunedin Hospital. Following his interest in the borderland between neurological and psychiatric disorders, he later became a neuro-psychiatric consultant at Ashburn Hall, retiring in 1983. He was also a philosopher, poet and great talker. The essays in the book explore Keith’s philosophy of life from the point of view of colleagues, family, patients, students, and friends. Here we take the title of the volume to touch on some of his maddeningly difficult ideas.
Why The Next Patient in the Waiting Room? The clinician’s willingness to treat the ill person and find the willingness to be treated within that person was an essential part of Keith Macleod’s ‘clinical method’. No matter who the next patient in the waiting room was, whether Hitler or Mother Teresa (his examples), it was his view that every person’s suffering and madness mattered and the least likeable the person the more thoroughly they mattered. As he said to a colleague, “What are you here for, if not to treat difficult patients?”
For him, one essential task for the clinician was to help reveal a larger context for suffering, thus freeing the patient’s responses to it.
He prescribed various drugs over the months to try to reduce the frequency of migraines. None worked. He recommended books on values, myths and philosophy. He challenged me on my ideas. Ultimately he made me realise I could live with my migraines. As a bonus he opened up for me a world of ideas and ways of thinking.” – Kelley Gardner, a patient in Keith’s migraine clinic.
In this way Keith Macleod brought the whole world to the clinical encounter. The encounter also became a metaphor for imaginative human connection in general. As the migraine example shows, when conventional methods didn’t work, he didn’t give up on the patient but helped them find imaginative ways to relate to their predicament. This is a part of his central philosophy, The Concept of the Clinical.
He believed that clinical problems could be clarified by taking them back to basic principles, usually extreme positions or opposites, and working from them back to the problem in the daily life of the individual. Basic opposites – Death/Life, Sanity/Madness – would be turned on their head, as would our reliance on the idea of forward-going time. In so doing he helped free up the imagination and widen the experience of the self. He would suggest that we think of human life not as a sequence from birth to death with some hope of leaving something by which we can be remembered, but rather as if we may be ‘dying back’ from our death through to our birth, trying to return to oblivion, to never have existed.
One of his central ideas was the necessity of choice. His patients at Ashburn Hall (a private rehabilitation clinic in Dunedin, New Zealand) who were there under pressure, from peers or medics for example, had to choose to be there for themselves before he would work with them. For himself, he took this notion of choice further: that it would lead to the ultimate choice to die to himself when the time of death arrived.
Keith Macleod’s ideas ranged across philosophy, theology, psychoanalysis, quantum physics, linguistics – anything that might be useful in a clinical situation. Roberta Highton, a friend and colleague, writes:
Behind and beyond the desire to relieve unbearable situations was the passionate dedication to exploring the mysteries of meaning and the universe – to understand”.
The clinical encounter was at the core. He said of himself, “I am a failed poet, a failed scientist and a working clinician”. One of his great strengths as a clinician comes through in this volume. He understood the essential mutuality of the relationship between patient and clinician: mutual healing, shared damage and experience. He never presumed to ‘know’ and would wait to learn from the patient with empathy. The encounter would evolve in a pattern of reversals between patient and doctor, subjectivity and objectivity, until the patient felt heard and the doctor felt able to understand and make a therapeutic intervention. As Gwynnedd Somerville says, “I like to think that in the consulting room he felt most real, focused and steady in that shared space where inner and outer reality meet.”
Keith Macleod died in 2006, never having written down his ideas. The Next Patient in the Waiting Room is both an attempt to capture some of their essence and to pay tribute to an extraordinary thinker.
Gwynnedd Somerville worked as a psychoanalytic psychotherapist in London. Now retired, she looks after a small garden in London and a large garden on the Otago Peninsula.
Charlotte Paul worked in the Department of Preventive and Social Medicine at the University of Otago until she retired in 2013. Keith Macleod’s attention and care through her husband’s illness helped sustain both their lives.