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One morning in surgery a young woman recovering from depression, expresses anxiety that she may lose her new-found friends because of recurrent internet bullying. When I ask her if she has talked about this with her friends she answers that their response is to invoke violence, they ask: ‘Are you going to bray her or shall I?’ they ask. Their brutal loyalty towards her does not assuage her anxiety and contributes to an everyday violence, which feels endemic when listening to many patients' stories.
Talking about ‘us and them’ with regard to patients and doctors is never a comfortable experience yet there exists an unfathomable distance at times. How do we respond to the unpalatable realities of fractured lives that patients describe?
We invite our patients to share their lived worlds with us and as we co-construct the narrative we seek to give opportunities to explore and articulate emotional reactions to painful life situations. Yet, are we creating a further source of distress? Angst examined from the safety of a secure income and an owner-occupied house looks very different when it is confronted against a backdrop of redundancy and a repossessed house. In areas of multi-generational, institutionalised poverty, where lack of investment has led to a strangulation of aspirations and a paucity of real opportunities, everyday survival predominates. Patients talk of relationships which seem stripped of intimacy and warmth; such as the young man who puzzles over why he has not been able to sustain a long-term relationship with any of the women he has dated, explaining how one girlfriend asked him: ‘Why don't you ever hit me, that's what me other lad did?’.
How are these uncomfortable exchanges to be dealt with? This young man fantasised about leaving the region and working abroad but in the meantime he struggled to understand why sexual violence was considered ‘the norm’ in his community. And so did I. How do our rational discussions about the thoughts and feelings that underpin our behaviour begin to make sense of such destructive human behaviour? And as we listen to patients telling their story what can we add?
There is no easy answer. We must resist the temptation to become nihilistic because it leads to cynicism and the death of compassion, but it remains a huge challenge in primary care to know how best to respond to the ‘everyday violence’ which seems to be an unpalatable truth framing and limiting so many people's lives.