Chapter 4: How Dr Clarke learned about PPD
If you are skeptical about any of the information in the earlier chapters, I can relate. I will share my story about this because you should know a little about the background of anyone who provides health information. It will also provide useful context about how medical clinicians are trained.
Dr. David Clarke sharing his insights on advancing the diagnosis and treatment of stress-induced medical conditions.
In 1982 I was nearing completion of my formal medical training when I was shocked to learn that what you read about in the earlier chapters was possible. Until then I had been doing well. I earned an award for clinical excellence in medical school, I was at a top hospital residency program and passed my National Board exams with flying colors. Then, after over seven years of medical education, I encountered a patient I didn’t know the first thing about treating.
This was a 37-year-old woman who, for two years, had been averaging one bowel movement per month. High doses of four different laxatives didn’t make any difference. Her doctor was baffled and sent her to a university. Their testing found no explanation. So that university sent her to the Gastroenterology Department at Harbor/UCLA medical center where I was in training, doing highly specialized testing on muscle contractions of the bowel. My Department Chair and I were confident this test would reveal the problem because no other explanation was possible. Or so we thought. The test was normal, which perplexed everyone.
I was left to tell the patient she would have to live with her severe constipation. I knew enough to ask her about stress but so had all her other physicians. She said, “No.” Her marriage was good, she loved and enjoyed her children and found her work as a bank manager rewarding. Then I asked about stress earlier in her life, looking for anything that might have triggered her illness two years before. That is when she told me her father had molested her as a girl.
I was completely unprepared to respond. I had never heard anything like that before and had no training in what to say. My first thought was that talking about her sexual abuse might trigger a lot of unhelpful emotions. But she did not appear at all upset so I fell back on my earliest training and asked for the full story. Her father had sexual intercourse with her about once per week from age 4 to age 12. Even today, forty years and 7000+ patients later, this is one of the most severe sexual abuse histories I have heard.
Yet she was calm throughout. Her tone of voice was little different than if she had been reading a grocery list. If you didn’t know better (and I certainly did not), you might assume she had fully processed this trauma and moved on. After all, no one had touched her against her will for 25 years. But she had this terrible medical condition that was completely unexplained. Could the abuse and the shutdown of her bowel be connected? I didn’t think so. It didn’t seem remotely possible. This was my first mistaken assumption, but it would not be the last.
Fortunately, I had heard of psychiatrist Harriet Kaplan MD. She was also certified in Internal Medicine, and I was vaguely aware she had experience with psychological conditions that impacted the body. I arranged for an appointment with the patient, hoping she might learn to live with her condition a little better. But I didn’t believe for a moment that Dr Kaplan could do more than that. I was wrong again.
I ran into Dr Kaplan in an elevator three months later and asked about the patient. “Haven’t seen her in a few weeks, Dave,” Harriet responded. “She’s fine now.” I was shocked. Well into my 8th year of training I had never heard that you could alleviate a serious physical condition merely by talking. Yet my patient was cured after only ten sessions of treatment that today we call Pain Relief Psychotherapy. I will describe this in detail in later chapters.
I had been a Psychology major in college but had no formal training in psychotherapy. Nevertheless, I persuaded Dr Kaplan to sit in during outpatient Gastroenterology Clinic so my colleagues and I could learn her framework for thinking about PPD. I assumed patients like the abused woman with constipation would be rare (wrong again!). I also assumed that, during my future practice, I could find other experts like Dr Kaplan because Pain Relief Psychotherapy must be widely available (wrong again!).
After starting my career in Portland, Oregon in the 1980s, I used Dr Kaplan’s ideas whenever diagnostic tests failed to reveal the cause for pain or illness. This turned out to be 5-6 patients every week (i.e., far from rare). They were suffering from a wide range of psychosocial stresses with adverse childhood experiences (ACEs) of every description prominent among them. I referred many for psychotherapy but, unfortunately, the Cognitive Behavioral Therapy that dominates mental health treatment wasn’t nearly good enough for most of them. They came back to me still suffering from PPD.
I knew these patients could get better. I had seen Dr Kaplan achieve this many times before I completed my training. But I was a beginner in providing treatment. Fortunately, the concepts of Pain Relief Psychotherapy are so effective that my patients were improving even as I climbed the learning curve. Nearly all had made no progress elsewhere in the healthcare system. This was incredibly rewarding personally and professionally and encouraged me to keep going. After 5-6 years (and over 1500 PPD patients), at last I felt reasonably proficient. It was probably not a coincidence that this was when I received the Doctor of the Year Award from a large HMO.
Chapter 4: Videos
Watch Module 1 of 14 of our First Online Course. The course was developed for health professionals, but patients will find the material useful as a recovery resource. For more info, click here.
