As I read this book for the third or fourth time I think, ‘I wish we had geniuses like this in medicine now.’ Perhaps we do. But they certainly don’t write books like this. Eric Berne had only been a doctor for 12 years when this masterpiece was published. He was just 37, the same age I am now.
Why is this a masterpiece? Start by taking a look at the contents page: it is breathtakingly simple (‘Chapter Five: Neuroses; Chapter Six: Psychoses …’), but each subsection makes you want to turn to the page right away and start reading:‘Why people act and feel the way they do’, ‘Getting along with people’, and, one of my favourites, ‘What is intuition?’ Berne writes so candidly and with such lucidity that it feels like he is talking to you. Not a word is wasted.
Berne writes about patients, but much of what he writes is germane to us as doctors too. We all had an image of what medicine would be like based, of course, on television and film, but based also on our hopes and our own wishful thinking. So the consultant neurosurgeon, blisteringly skilled and highly qualified, finding his working week increasingly filled with paperwork and meetings, leaves his operating theatre behind to work for an indemnity firm because he’s ‘had enough of all this’.
The GP, reaching the dizzy heights of senior partner, finding his work increasingly distant from his ideals of general practice, becomes burnt out and stressed, retiring earlier than he would have liked. This gap between dream and reality is a large part of what Berne discusses in the section on neuroses: ‘Images are made of stuffs of different flexibility. Some people have brittle images, which stand up against the assaults of reality with no change up to a certain point, and then suddenly crack wide open, causing great anxiety to the individual.’
When you read these pearls of wisdom about human interaction one might think that Berne had it all together. In fact he was divorced three times and barely spoke to his first wife. None of his four children followed him into medicine and he died at 60 from a heart attack. Perhaps he couldn’t put his theories of love and relationships into practice; perhaps his dream of publishing more and more work became too much even for him.
For those in the field, Berne’s name is most strongly associated with transactional analysis and the triumvirate of personae that we all carry: the Parent, the Adult, and the Child. Patients most frequently come to us in the Child ego, so that even an older, wealthier, more successful person than me (say, a barrister) seeks my reassurance (as their Parent) about a spurious blood test result or a worrisome symptom. But I could never get on with Berne’s next book, Games People Play, published in 1964, which describes this fully, even though it’s his more famous work.
We know from Balint that patients haven’t really changed at all and perhaps never will. But we know from our clinical work that things at the front line do change. Hospital doctors are under pressure to work 7 days a week, while GPs are being told they need to merge into federations ‘to survive’.
Doctors feeling that familiar anxiety creeping over them as the goalposts shift once more would do well to heed Berne’s prescient words: ‘One of the most important things in life is to understand reality and to keep changing our images to correspond to it, for it is our images which determine our actions and feelings, and the more accurate they are the easier it will be for us to attain happiness and stay happy in an ever-changing world where happiness depends in large part on other people.’
- © British Journal of General Practice 2017