Book Review: Suburban Shaman

Although about the practice of general medicine, Helman describes Suburban Shaman as a 'mosaic of memories' rather than a single story. His aim is to share some of the lessons he has learned from his patients and from different settings about the nature of healing and medical care. There are 24 chapters, arranged in topics such as Medical School, Possession, Boundaries, Healing Time, Shamans, Placebos. Helman is as much if not more concerned with the underlying emotional distress and meanings than with the outward physical ailments he encounters.

A South African, Helman comes from a family of 13 doctors starting with a 'village practitioner' 200 years ago. He grew up and trained in medicine during the apartheid era and he describes some of his experiences in mental health there, such as the Whites Only wards and the different 'culturally appropriate' treatments for Blacks, which led to his belief that diseases are partly a function of time, place and circumstances. For example, Addison's disease, which causes darkening of skin pigmentation, had a particular meaning and set of consequences for 'Mr Pritchard' a White European living in apartheid South Africa.

Helman moved abroad after graduation arriving eventually in London where he worked as a GP. His stories of his encounters with the British public are variously funny, humane and poignant. Like the lonely pensioner whose 'bowel movements are his artwork, his creativity, the daily fruit of his inner self… the greatest source of novelty in a sad and solitary life… "Doctor, I'm still in the toilet. Please come in here. The door's unlocked. I just want to show you something. Something very interesting…"'.

His career includes research at Harvard Medical School, studying anthropology and working in medical aid programmes in the Third World. Along the way he explores his interest in shamans and folk healers and concludes that different types of healer (medical or not) have much in common. He suggests surgical operations can be viewed as allegorical performances where masked actors become heroes confronting the cosmic forces of Disease and Death. He contrasts British folk ideas about 'germs' with traditional ideas about 'spirit possession' - in both cases the patient finds relief in the idea that it is not their fault.

Helman suggests the placebo effect is the weak link in the medical paradigm and declares that most forms of healing are 'theatrical performances designed to enhance this effect'. He believes that to be a good doctor (or healer) you have to be 'a compassionate chameleon, a shape-shifter, a shaman' adapting to the patient's world and working within their system of ideas and beliefs. In the case of an Indian woman who believes her ex-husband has put a curse on her and whose behaviour and beliefs seem bizarre, possibly psychotic, Helman does not diagnose or section her, instead he supports her wish to consult a Vaid and she slowly recovers, although it turns out later the Vaid is a fake, not at all the real thing!

He bewails the gradual demise of the old style family GP, that treated the whole person as well as their disease in the context of their home, family and community, and the rise of what he calls the 'techno doctors' whom he fears have too narrow a focus, too great a faith in technology and a misguided belief in the possibility of ultimate certainty.

He believes medicine is not just about science but also stories, the mingling of narratives among doctors and patients, and the absolute necessity to understand the storyteller as well as the story.

For him medicine is about doubt and ambiguity, ethical dilemmas and the limits of human expertise, and the need to be open to surprises and mystery. Technical skills are necessary but not sufficient. People also want compassion and care, to make sense of what's happened and to be helped to cope. Even where he cannot cure he tries to heal, to restore balance and well being if not health.

Helman was originally attracted to psychiatry because it dealt with non-material aspects of the human condition but he found it was an 'even more secular discipline' offering absolution in chemicals. In disillusionment he came to view it as imposing a medical grid on the human condition, attempting to control its unruly behaviour and emotions. He has read Laing and Szasz and 'other psychiatric heretics', and many ideas familiar to an existential psychotherapist are found in this book.

He takes a sideways look at the hierarchical medical world and its rituals, like the Consultant's 'Grand Rounds' which he views as a weekly mystery play where the Consultant keeps his trainees in suspense while he first elaborates all the dimensions of the mystery and then slowly reveals not only the solution to the (very difficult) puzzle but also his astonishing skill. Helman describes this is as a healing ritual for the doctors themselves, a way of dealing with ambiguity and doubt, where the mystery ends comfortingly in diagnosis and coherence. The meaning of life may still not be clear but at least there is a precise cause of death.

He also records his own experience of being a patient, when he briefly joined the ranks of the 'Trolley People… a new species of centaur: half human, half trolley', and what it's like to be a treated as a collection of organs, 'a Babel of parts' with no person / soul / spirit at the centre, where the 'techno-doctors' have no need to attend carefully to the patient's story because they have their diagnostic machines.

Reflecting on boundary issues in the GP/patient relationship, he describes his own experiences where a folie à deux or collusion can develop, with both participants trying to meet their personal needs through the relationship, where boundaries can become blurred and emotional burnout ensue. He thinks people who are attracted to medicine often have motivations that need exploring if the practitioner is to be good at his/her job and avoid burn-out.

Overall the book is well written and achieves the author's aim of describing and reflecting on a long and varied experience of general practice in the community and the value of remaining open to other ways of healing. It retained my attention because of its existential attitude and acceptance of the value of psychotherapy and many other approaches to healing. In essence it is about integrating modern medicine with the wisdom and insights of traditional healers and aspects beyond the purely physical. The style is succinct, witty and simple but nonetheless an interesting and thought provoking read. Although not an academic book he does include a bibliography with some enticing entries for further reading.

Diana Pringle