‘What would your Auntie say?’ I throw out for a response. My trainee rocks back, hoping I’ll stop being so stupid and ask something like, ‘What are the muscarinic side effects of quadracyclic antidepressants?’
‘You know,’ I continue, ‘The Auntie who smells of mint imperials and talc and always says the right thing, always leaves you feeling better when you leave.’
We are revisiting another of those situations where, after a long pause looking at his feet, a tearful patient has just mumbled something like, ‘I just don’t think I can go on’.
This was rightly parried in usual trained fashion by my ST1 (isn’t that a disease?) with:
‘Have you been thinking of harming yourself?’
‘Excellent,’ I hear my trainer voice say. Both she and I have had some psychiatric training and we both know that the assessment should move on at this point to something like, ‘Have you got any plans?’ Maybe not in so many words, but that sort of thing. We are well schooled in not creating dependency. We’ve read dusty copies of To Heal and to Harm and dozed through a few lectures about personality disorder.
I rehearse it in my head again and it’s all starting to sound wrong. ‘Have you got any plans?’That’s the sort of question I might ask a friend about their summer break, or the colour of their new kitchen. It’s a sort of, ‘Go ahead, grand idea, how interesting!’type of question. What sort of subliminal spiritual message does that carry?
I have been thinking and talking about the spiritual values embedded in my dialogue with patients these last few months. What is the hidden language of my statements and, in particular, of my questions? What do these tell a patient, on a barely conscious level, about what I think and feel about them? About my deepest beliefs in the nature of their humanity?
‘Got any plans?’is starting to look like a mean thing to say to someone who has just opened the skeleton door to their darkest thoughts. Auntie wouldn’t say that, not ever.
In the film of the book The Diving Bell and the Butterfly, the main character — author Jean Dominique Bauby, the chief editor of Elle magazine — is rendered unable to do anything but blink by a massive stroke. Painstakingly, a young physiotherapist teaches him to spell out letters with a series of blinks. His first sentence is, ‘I want to die’.The physiotherapist’s eyes fill with tears.
‘That’s a terrible thing to say! Think of all the people who care for you.’She blurts out ‘I’ve only just met you and already I care for you,’as she exits the room. Later she comes back and apologises. The message is clear however: Don’t do that. Don’t even think that. You are valuable; we care for you.
‘Well, your Auntie?’I prod a little further as my mind re-enters the room. ‘What would she say if you were sat on her couch saying you were so low you were thinking of killing yourself?’I think through again what I have been saying to patients all these years. It’s me in the dock really, not the trainee. She has locked onto my eyes:
‘Well, something like: “Please don’t do that!”’she offers.
‘And then what?’
‘I care about you. We all do.’
‘Why not start with that then?’I venture. ‘Oh, sure, it’s got to be a full psychiatric assessment. But give it something of the smell of Auntie’s talc.’
I offer a bag of mints.
- © British Journal of General Practice 2012
