CHAPTER 5
Investigations and management
Examining feelings of past abuse is intensely painful for the sufferer, a pain matched only by that of keeping feelings repressed by heartsink strategies. But there is no true healing without uncovering the past. The patient has to set the pace, must never be forced, and must be allowed to remain stuck if that's all she's ready for at the time. The listener is in no position to disapprove of her for this, and can remain therapeutic simply by being aware that this is the stuff of old trauma; by accepting the patient's verdict on how far (if at all) to go with any exploring; and by remaining solidly on the patient's side while genuinely being undaunted by the re-enactment that's going on. The re-enactment is not a personal attack on the listener, no matter how much it feels like one.
Julie has turned up quite a lot recently, with suspected cystitis and problems with discharge; all tests have proved negative. She is a plump, pretty girl in her late teens; she wears tight strappy shoes and clothes that always look too small for her, while her scraped-back hair and heavily plucked eyebrows give her a pained expression. She offers giggly anecdotes about her numerous boyfriends and nights out drinking with the girls, and lately has been hinting at recreational drug use too. When you ask whether she thinks her lifestyle might be causing some of her health problems, she comes right out and tells you, ‘Sometimes you sound just like my Mum!’.
It may be hard for the overworked health professional to feel liking for Julie, who doesn't really like herself much and isn't having as much fun as she wants you both to believe. But she does keep coming to see you. What is she trying to show you, if it's not the succession of elusive sexually transmitted infections? Is there any way of getting in touch with her insecurity and unease about herself? Every professional working with heartsink patients will have his own successful approach based on temperament and experience, and will sense how to adapt this to every individual patient's needs. If we can accept our own discomfort when presented with the riddle of the patient's heartsink behaviour, and if we can signal that this behaviour doesn't throw us but keeps us interested and happy to try and help, then we have no need for an ‘expert’ to spell out to us ‘how to do it’.
But it may be useful to consider some of the therapeutic tools:
Liking (aka ‘unconditional positive regard’, in the phrase coined by Carl Rogers) is one of them: it comes easily when we remember that the patient's feelings and behaviour are appropriate responses to hidden (repressed) stimuli, and that the patient is a survivor of experiences that would have defeated many of us.
Face-saving: we can apply the ancient Chinese wisdom of helping one's interlocutor to maintain his dignity (as we would all wish our own vulnerability to be respected) by welcoming the patient's suggestions, explanations, and self-diagnosis, and by exploring them together in discussion; if necessary, concluding together, for the time being, that the patient's tentative interpretations don't quite seem to fit the picture, don't quite seem to get us there, and that the mystery remains as yet unsolved (even if we feel sure that we ourselves have hit upon the explanation long before the patient is ready to do so, and even if we are bursting with impatience to tell them all about it. Better not, better if the patient is given the space to find the answer for himself.)
Transference: the patient's heartsink treatment of the listener may be used to form hypotheses about the patient's treatment of, and by, other significant figures in his life, especially during childhood/development. These hypotheses may be put, cautiously and with an open mind, to the patient for confirmation/rejection, or may simply be filed away by the listener as useful ideas to be checked out at a later stage when it feels more helpful to do so.
Transparency: All the above has to be a genuine exploration, by two equals, of uncharted territory. The listener has no tricks up his sleeve, no answers ready to pounce with, no directions to give. There is no technique, only a willingness for the doctor to be shown how it is and how it was for the patient.
Conclusion
The care of the ‘sinking heart’ patient is easy if we let it be. In fact, until the patient himself gives us the go-ahead, we don't need to do anything about it. We don't need to come up with advice, recommendations, or treatment. We can afford to admit our ignorance. The patient has the answers, all we can do is wait for them in an atmosphere of optimism and confidence, knowing the answers are there, even if we don't know what they are. There is, as yet, a limited, but growing, evidence base. Meanwhile, a qualitative/narrative approach, empirical experience, and intuitive assent constitute a provisional one rich enough to be getting on with.
Further reading
I am totally indebted to the writings of Alice Miller, which helped me to make sense of heartsink consultations, and to formulate the ideas summarised in this monograph. Her books are highly recommended, especially:
The Drama Of Being A Child
For Your Own Good
Thou Shalt Not Be Aware
Similar conclusions, in an educational rather than a therapeutic setting, are reached and set out in A S Neill's The New Summerhill.
How Babies Think: The Science of Childhood by Alison Gopnik, Andrew Meltzoff, and Patricia Kuhl describes experimental evidence concerning the development of children's minds.
Dibs In Search Of Self by Virginia Axline describes one way that theory may be put into practice.
