‘Escape with Honour’: The Need for Face-Saving

This paper focuses on one aspect of psychotherapeutic work, the need for face-saving, as experienced with 19 children on a paediatric ward.1 We have found over several years that a hospital setting is often the best place to bring about effective results in cases of persistent physical pain of nonorganic origin, particularly if the symptom has been of long standing. We are not dealing with conditions which are commonly designated psychosomatic, such as asthma and eczema, in which somatic expression of mental conflict may have become an established pattern. Our group suffered from a variety of functional disorders which were various labelled ‘somatization’, ‘hysterical’ and even ‘malingering’. Many challenging technical problems arose in trying to overcome the resistances of these patients, who came to hospital convinced that they were physically ill and expecting further medical investigations. Instead they were exposed to psychiatric interventions which they associated with madness.

Our series contained nine boys and ten girls. The common presenting symptom was pain. Five children suffered from abdominal pain, two from lumbar pain and three from headaches; six had motor and postural disorders including paralysis of a limb, two had convulsions, and one presented with non-organic visual-field defect with artefacted bleeding from one eye. In all cases the presenting symptom was sufficiently severe to cause alarm, sometimes leading to hospital admission as an acute emergency. Most of the patients had had at least one previous admission elsewhere; some had experienced frequent hospitalization. All had been subjected to extensive physical investigation and some had undergone surgery. A high proportion were only children and the majority were pubertal or in early adolescence. This is not surprising in view of the adolescent conflicts relating to their emerging sexuality and concomitant somatic preoccupations.

Although in many cases it was clear from the start of