Iatrosedation by Dr Nathan Friedman

Another indirect cue that must be “heard” and understood is the word “gag” or “gagger”. Gagging frequently is a panic response, related to a feeling that some threat to breathing or swallowing is about to occur. This feeling has its roots in the past, similar to the cue discussed in the previous history, due to an experience of actual or anticipated suffocation, a traumatic surgical experience involving the threat or a choking incident.

In the following iatrosedative interview, this type of cue arises. The “what” questions are used to track down the specificity and origin of the fears, but in addition, the cues are facilitated by the use of reflection.

“Reflection” is a major method of facilitating cues. The word or phrase is reflected or repeated, either exactly as stated or in a similar form. This echoing or repeating the patient’s word or words acts as an invitation to continue talking about that subject. It is the most economical and productive facilitating tactic in the repertoire.

In the exchange that follows, the key words (cues) are underlined as are the reflective responses of the doctor. In addition, the “what” questions are underlined.

Doctor: “Good morning, Mrs. Caswell. How are you?”

Mrs. C: “Good morning, Doctor. I’m fine, thank you.”

Doctor: “Tell me, are you having any difficulties?”

Mrs. C: “Well, yes. I’m a terrible coward about anything to do with my teeth.”

Doctor: “You are? In what way are you a coward?

Mrs. C: “I’m terrified. I guess that sums it up. I really get very jittery.”

Doctor: “Have you had any idea what happened to terrify you?

Mrs. C: “Yes, well, I … when I was a little girl I had very bad baby teeth I guess, and the dentist I went to see was kind of mean. … and also … I’m a gagger … those two things… when I was 18, I made about 3 appointments, showed up and then ran out.”

Reflecting the words “coward” and “terrified” accomplished several objectives swiftly. The doctor communicated his recognition of the patient’s fear and invited her to tell him more about it. Simultaneously, he moved from the general statement of fear toward the specific fear. The past doctor’s behavior was stated in a general way (“he was mean”) and an indirect cue was sprung (“gagger”). The doctor then combined a “what” question with the reflected word “mean” to continue the facilitation.

Doctor: “In what way was he mean?”

Mrs. C: “I have a horrible memory of the nurse grabbing me and holding me while the doctor worked on me… and not being able to get my breath.”

The vivid image of the behaviors of the doctor and his assistant, though briefly stated, expresses the patient’s feelings about that behavior. In addition, an important indirect clue is uncovered: the “not being able to get my breath”.

Gagging is the physical expression of panic; in this case, the panic associated with “not being able to get my breath”. This is the specific fear. If the interviewing doctor did not “hear” the cues “not being able to get my breath” and “gagger”, and if he did not know that there was an important relationship between them, he probably would have gone off on a time-consuming and unproductive tangent. Instead, he moved straight to the target of determining the origin:

Doctor: “Did you ever have an experience where you were not able to get your breath?”

Mrs. C: “That’s a very interesting question, Doctor. I’ll tell you why. When I was a child I had diphtheria. I remember fighting trying to get my breath, and the memory of a band of fire around my throat… and faces coming very close to me. I remember my breath, you know… they were trying to decide whether or not to give me a tracheotomy… my grandmother told me. They didn’t, but I do remember all those faces and even now, if anyone gets too close to my face, I feel like my breath is being cut off. It’s the memory of that fear and the distrust of my first dentist.”

The specific fear apparently stems from this experience – it’s generalized so that any doctor coming close in a therapeutic situation triggers the associated feeling of panic. This presumably is what occurred with her first dentist. Using this as a basis for initiating a relearning process, reducing the anxiety and offering support, the doctor at this point switches from gathering information to giving information he interprets and explains past events and suggests change can follow.

Doctor: “Yes, the heads coming close to your face became associated in your mind with the choking and the panic you felt when you were gasping for air. When your first dentist approached you, you panicked. He ignored this, had you held down and intensified your fear. But this can be changed. What we have to cope with is the present.”

Mrs. C: “You sound very psychologically oriented.”

The doctor accepts this recognition of expertise and uses it to expand on his interpretation of suggestion, finally leading to commitment:

Doctor: “I am, and for an important reason. What we have to deal with here, the dominant issue, is your fear, not the condition of your teeth. If I cannot assure you that I will take care of you as a person, then you’ll run away from me in the same way you did from other dentists. And you’ll not get what you want and need.”

Mrs. C: “Yes, that’s right … and as you pointed out, I would not really be reacting to the fear here… the reality of the situation… but rather to the earlier fear rooted in my childhood.”

Doctor: “Exactly. Just as your mind can record and retain a vivid image of something that happened thirty years ago, so it has the capacity to relearn. And that’s what we’re going to talk about now. You are not that child, you do not have diphtheria, you are not going to choke. I will keep you informed in advance at all times what I plan to do and what you may expect in the way of discomfort or lack of it. I will ask for feedback from you as to how you feel about it. In short, you will have a great deal of control over the situation. I believe that my approaching you will not set off the panic button and we will be able to accomplish what you want. Just remember, I will keep in mind at all times how you feel.”

Mrs. C: “All right. Thank you, Doctor, I do feel better now.”

This statement by the patient infers that she feels less anxious. It remains for the clinical iatrosedative encounter to determine this and to continue the fear reduction process.

The concept of determining the specific fear, its origin, interpretation, explanation, suggestion and commitment is a general one. It is used here in a particular manner. Each individual will use it in a way peculiar to himself. The principles are sound. The manner of implementing them is individualistic.