Consultation as Ritual


“The third type of consultation is a ritual. Cinderella is an example. Here the power of the theatrical experience depends on encountering what seems to be already known: the content of the story and its denouement. Of course the quality of the performance is important. But actors and audience are celebrating in a relatively safe form, dark forgotten conflicts and hoped for resolutions. Here there is no attempt to find out what is wrong, still less is there an attempt on the part of any of the characters concerned, doctors or patients, to embark on a journey of discovery or self disclosure. The intentions of this sort of consultation are containment, remembrance and denial. Some sort of ritual is being enacted, a prescription repeated again and again; an old complaint rehearsed but unexamined. The acts performed by doctor and patient seem far removed from the rational discourse of modern medicine.

25 years ago, I took part in a study of consultations in general practice, in which little seemed to happen – save the repeated prescription for the same unvaried medication. The research, under the leadership of Michael Balint, was published in a monograph called Treatment or Diagnosis?. What we uncovered surprised us.

Most often these consultations were acted out according to a very tight scenario, with a script which varied little between one performance and the next. These consultations also seemed to be innocent of any sensible component – concerned with our traditional ideas about diagnosis and treatment. They were also devoid of emotional content, of the kind which would allow some insights into motivation and the possibility of change. On the contrary, the intention seems to be to limit intimacy. The doctor here was taking part in a pantomime.

Pantomimes are serious drama. In the consultation as ritual, there appears to be a contract that the communication should remain predictable, replicable and, above, all opaque. In Cinderella, the fairy tale which enchants children in the pantomime obscures the origins of the story, the terrible rivalry between Cinderella and her sisters, the separation of the mother into the good who is dead, and the wicked stepmother who punishes and denies. Still darker is the now forgotten archetype of the fairy tale princess: the dirt-encrusted Aschputel, who can only be saved and transformed by an act which is perhaps most delicately described as ‘fitting the foot into the slipper’. How will you judge communication here? You will look in vain for new information, for problem solving, for empathy, insight, interpretation or even just good old fashioned clarity of instructions. Cinderella is a performance for anthropologists and teachers of communication in medicine, and small children. “

from the essay THE MEDIUM & THE MESSAGE

Marshall Marinker, 22 July 1999, Chicago.