Clinical Reflections

Seeing Ourselves as Our Patients See Us

I was cleaning out my garage, sorting through old boxes when I came across a piece of paper and a humorous, somewhat metaphorical, somewhat stylized account from a patient from over a quarter of a century ago. He had spontaneously produced it, and it was typical of his characteristic humour and its reliance on exaggeration and muted shock value. I had met hm in 1995 and had made a brief reference to him in a 1998 paper detailing the abuse histories and phenomenology of 62 patients with Dissociative Identity Disorder (Middleton & Butler, 1998). He was someone who had presented with substantial amnesia for much of his childhood. I described him as I had met him over a quarter of a century ago as:

 “a 50-year-old man who reported extreme physical and emotional abuse in his home prior to running away as an adolescent, never to return. While believing that he was sexually abused, he had no definite memory of it happening. School records were obtained for this highly intelligent and articulate man, revealing that during the period of abuse his IQ had been assessed as 87 (Middleton & Butler, 1998, p 801).”

As I was to learn, he had done the schoolboy IQ test in rural Canada, in a very flat and unengaged identity state I got to know as “Mr Dead”.

As I read again what he had written, memories of his humorous versatility and his accomplished deadpan delivery style drifted back to me. I recalled how in 1996, when I was attending a conference in New Zealand, he had somehow tracked me down to a hotel, where the phone beside my bed rang sometime after midnight. His voice came down the line, “You awake Doc?”, followed by laughter…

So, to his first appointment, in his words…

Well, here we go again, another referral, another Dr. So, what’s madness? Well, it’s spending 15 years looking for a doctor who will verify you really are whacko! I mean, let’s face it; this is crazy. Who in his right mind would do this?

So, I get into a fight, someone comes out of my head and kicks ass. Not good, I was supposed to lose. Not only does he come out of my head, but he brings his own voice with him.

So, I get another referral, phone to make an appointment… Can it really hurt? His secretary tells me he isn’t taking any new patients. Fine, this has happened before. Nothing to worry about, so I say to her, ‘I thought he treats Multiples’. Bingo! She says, ‘He will see you.’ Now something doesn’t seem right here. I mean maybe this joker’s looking for someone to do weird experiments on, or maybe he’s trying to get deregistered so he can avoid paying the tax he’s been cheating on anyway.

So, like the sick puppy I am, I wait the five weeks. Well, I bet he gets $200 an hour to compare his craziness with mine. I thought robbing banks was good business, but these jokers really do have it together… They fuck the government, and sometimes their patients, for which when caught, they are forced into honest work. No wonder they have a high suicide rate.

So, I arrive for the appointment on time. All I can see is an older woman behind a glass partition. She reminds me of a middle-aged bookkeeper from Oliver Twist. I know she’s alive because she moved a few minutes ago. This place is drab, the office looks like it was cut from solid rock, would you believe a dungeon, it really was downstairs… My watch says ‘5:00pm’. I guess he’s not late until over half an hour past the appointment time. After all, he is a specialist. The last time I saw a specialist, she was forty minutes late. I was sure she stayed home to get an extra cuddle, but when she arrived and I saw her, I knew that was not possible. She says, ‘Good morning. I’m Dr so-and-so.’ And, so I say, ‘Did your watch break?’ Boy! Was she rough on me after that – like a gloved vet checking a cow. At least I didn’t have an enlarged prostate when I left. As a matter of fact, I’m not sure I had one anymore. Some people are lucky with doctors – not me.

So, I sit and wait, until a bearded derelict in St Vincent’s attire, walks slowly by. I know instinctively, he’s on work-release from another drunk charge. What I don’t see is his mop. I guess he didn’t know that it takes a mop to wash a floor. He must be an arrogant Son-Of-A-Bitch. He walked into the Doctor’s office without even knocking. I know about these things. He probably wants to hit the Doctor up for a loan to get a bit of the grape. Now, he’s coming towards me, his hands outstretched. Look out there goes my watch! ‘Hello. I am Dr ——–.’

He takes me into the office. I’m sitting there waiting for the boys in white coats to come and get him… Just the same, I feel comfortable. It’s nice to be sitting with another crazy. I waited and they didn’t come. Guess what?

I appreciated his humour and this led me to reflect on the role of humour in therapy and relationships in general. I have written on this topic previously and make the conclusion:

My office since January 1995

The practice of psychotherapy is enhanced by the therapist who maintains a sense of humour, who appreciates its development in his/her patients, and who respectfully uses it to assist in building the therapeutic alliance. Therapy is not so serious that laughter need be excluded from it (Middleton, 2007, p. 148)

As a trauma therapist, I am not alone in valuing careful use of humor. Colin Ross, who after decades working with trauma continues to make ongoing important contributions to the trauma and dissociation field, in 2000 stated,

‘‘I joke around a lot in therapy. I do so to take care of myself, and to provide comic relief from the tragedy. Humour helps form a treatment alliance, disrupts negative transference, has an antidepressant effect and may even benefit the immune system’’ (p. 340).

Of course we need to be careful with humour and indeed our own misunderstandings of another’s culture and language can be both a pitfall in therapy, but also a cause of humour in itself. I reflected in 2007:-

“Shaped by cultural heritage and particular shared adversities, the humour of particular societies or ethnic groups is one of their most defining features, the subtleties of which can be overlooked by the well-meaning but ignorant exponent of the values of another society. When John F. Kennedy in his famous speech in West Berlin on 26th June 1963 announced ‘Ich bin ein Berliner’ (‘I am a Berliner’) (p. 77, Sherrin,1995), to tumultuous excitement from his massive German audience, the response was not so much to the message of brotherhood but one of hilarity in that ‘ein Berliner’ was the name given in Germany to a doughnut (pp. 153-154).”

For further not overly serious discussion of the role of humour in psychotherapy, see Middleton (2007) Gunfire, Humour and Psychotherapy.


  • Middleton, W. & Butler, J. (1998). Dissociative identity disorder: An Australian series. Australian and New Zealand Journal of Psychiatry, 32(6), 794–804.
  • Ross, C. A. (2000). The trauma model: A solution to the problem of comorbidity in psychiatry. Richardson, Texas: Manitou Communications.
  • Sherrin, N. (1995). The Oxford Dictionary of humourous quotations. Midsomer Norton, Somerset: Oxford Dictionary Press.
  • Middleton, W.  (2007). Gunfire, humour and psychotherapy. Australasian Psychiatry, 15:2, 148-155.