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The couple sitting in front of me on the bus were canoodling—there is no other word for it. They were an oddly matched pair. He was in his twenties, swarthy and Mediterranean, wearing a baseball cap and a fashionably thin beard. He looked a bit of a lad. She was oriental—Thai, perhaps, or Chinese. She seemed quite a lot older than him, and was dressed more elegantly, in a clinging black number. As they intertwined, I wondered for a moment if it was a coincidence that human embraces so closely resemble chromosomal crossover. The three of us were almost alone on the top deck. They cast me the odd backward glance in their pauses between one peak of desire and the next. I tried to pretend I was unaware of them, but their passion was theatrical, and it was hard not to watch.
Considering their difference in ages and culture, I weighed up in my mind what the chances might be that they would still be an item in one month’s time, let alone a year. Perhaps each of them expected only a brief encounter and were perfectly happy with the prospect. Possibly at least one of them—more likely the woman—was hoping this would lead to a more enduring liaison. I foresaw her misery as the new boyfriend got bored with his exotic conquest, and moved on to someone else, or turned out to have multiple partners.
Maybe we see too much as doctors, or see too much that is sad or goes wrong. I found myself imagining an even worse range of outcomes from their encounter: a sexually transmitted disease, an unwanted pregnancy, accusations, violence, a lifelong sense of regret. Then I set myself right. We sometimes see better relationships too. Against all the odds, it was still possible that they might go on a different trajectory instead: a period of excitement and delight, a gradual letting go of idealisation, and then the hard-won love of two people who know and understand each other. I hoped that I had made too hasty a judgement, and that their story might turn out to be a better one than I feared.
I got off the bus, leaving the couple to an unknown future. I thought about how much of our work consists of witnessing disappointment and its consequences. I do quite a lot of work with children who are in distress or have physical symptoms following their parents’ separation or divorce. The mother and father may once have met in a bar or on a beach, have gone on to make a family, and then stayed together for a few years before they became disaffected. Once they have split up, they sometimes develop such hatred for each other that they won’t even meet together in the same room. I have to see them each individually before they can even bring themselves to speak together about the children they have brought into the world. In time, when things go well, they may accept that the person whom they once loved so intensely and now despise wasn’t ever the person they imagined. They may forgive each other for this, and go their separate directions in peace or even friendship. If so, the children always benefit. But acknowledging disappointment and letting go of blame is rarely easy.
Sometimes couples simply can’t achieve this. They carry on with mutual recrimination, or they repeat the same pattern over and over again with other, newer partners and further children. Sometimes, of course, they never separate or divorce in the first place. Instead, they stay together in an acrimonious stand-off, seeing each other reluctantly into old age. I have seen couples in their eighties or even their nineties who could not get on with each other—nor without each other.
Unrealistic expectations are bound up with relationships, but they also surround health. Alongside the stories of love at first sight and undying romance that surround us all the time in the media, we are also bombarded by portrayals of absurdly fit and flawless bodies. Cumulatively, they have the same effect. Illness and chronic disease are as much of a shock to most people as betrayal, abandonment, separation and divorce. As doctors, we spend a lot of our time persuading people that they cannot expect to stay lithe and young for ever, any more than they can pursue a life of uninterrupted and endless sexual ecstasy. Dealing with disappointment is our stock in trade in medicine too.
Working as a GP, I see how different people manage their relationships with their ailing bodies. It isn’t so different from working with couples. With some patients, it is easy to mediate between them and their diseases. They accept their swollen joints or wheezy chests philosophically in the same way that they have learnt to live with their spouses: as familiar friends whom they can rub along with. Others rage bitterly against their failing organs, or against the professionals who cannot restore these to a perfect state. Sometimes the same people are at war with their ailments and their spouses in equal measure. No-one has ever warned them that life is not like a colour supplement, and they have never quite worked this out for themselves either. It can be as difficult to reconcile them to failing health as it can be to get them to settle their marital differences.
A friend of mine who works in clinical psychology sometimes describes himself as a “disappointment-ologist”. He sees the essence of his work as helping people to come to terms with who they are, rather than pretending that he can transform them into something different. In a similar vein, Lionel Blue—a rabbi, writer and radio personality—has spoken about what he calls Jewish archery. This involves firing an arrow at a very large fence, and then painting an archery target around the point where it lands. It is a nice metaphor for accepting whatever happens, and whoever you turn out to be. Possibly we should use such ideas in medicine too. It might help us to resist pressures from patients, from media images, and from within ourselves to pretend that we can turn life into one long canoodle.
Competing interests: None.