Two Years Later
Monday January 21, 2008
BACKGROUND:
I am 34 years old now. My childhood was hell. I suffered
physical, sexual, emotional, and psychological abuse. Two
years ago, I wrote to Alice Miller ("the crime of
not giving protection", Dec 04, 2005) because I
couldn't feel the anger toward my parents. Inspired by
Alice's reply, I wrote a letter to my mother, accusing
her of abuse and neglect and expressing my anger for the
first time in my life.
During the two years that passed, my mother has confused
me terribly. Trying to buy my loyalty with empty words
and gestures, she deceived me into believing she has
changed and into discussing my childhood with her. This
repetition of the drama made me sick with confusion
("confused", Aug 6, 2007). In the meantime, my
father has died. In the year that passed since his death,
memories of how he physically and mentally abused me have
surfaced. All the while I tried to stay in some kind of
contact with my now-widowed mother. Gradually I could
feel more and more anger ("anger, my friend",
Dec 09, 2007). Recently, I confronted my mother with the
issue of my father's violence (he hit me especially when
I was a small baby). Again she tried to deceive me with
an insincere "empathic" letter. I wrote to her
again, this time inspired by Barbara Rogers' writings
("Liberation from Guilt", in "Screams of
Childhood"), and determined to cut all contact with
her. I am sending my new letter to my mother (translated
from Hebrew), because I think maybe it can help others.
Please feel free to publish it.
N. P.
======================
LETTER TO "MOTHER":
I want you to know that in the future, I am not going to
read your letters or your mails. Even your most
"understanding" letters, like the last one I
got from you, hurt me too much. And I will not allow it,
I will not allow myself to be hurt again. Not even once.
You write that you "didn't know what father
did" to me and that it "didn't even cross your
mind". That hurts. You are lying to me again. I
don't believe that you didn't know about father's
violence, that you didn't experience this violence
yourself. I simply don't believe it. You knew, you just
couldn't face it, couldn't face questions like "Is
this violent man dangerous to my children?" and
"Should I do something about it?". For your own
reasons, you FAILED. For this failure your children have
almost paid with their lives.
Let me explain what I mean when I speak of emotional and
psychological abuse. Social worker Kieran O'Hagan defines
EMOTIONAL ABUSE as any continuous, repeated, and
inappropriate emotional response to the child's emotional
expression and expressive behaviour (Emotional and
Psychological Abuse of Children, 1993). Examples:
Repeatedly responding with DISREGARD and DERISION to my
expressions of FEAR and DISTRESS in the face of my elder
brother's violence; repeated responses of WEEPING,
ACCUSING, and SELF-PITY to my expressions of ANGER and
DESPAIR - these are just two examples of your emotional
abuse of me and my sister. Your INTENT or AWARENESS at
the time are IRRELEVANT - most abusers are blind to the
severity of their deeds, just like you were. The effect
of this kind of abuse on children is devastating. It
crushes the child's personality and it robs him of the
capacity to feel positive emotions and to ENJOY LIFE. As
a child, I hardly experienced anything but FEAR, ANGER,
and HELPLESSNESS.
PSYCHOLOGICAL ABUSE is any repeated, inappropriate
behaviour that damages, or significantly decreases, the
creative and developmental potential of the child's
mental abilities and processes; including intelligence,
memory, awareness, perception, attention, language, and
moral instinct (O'Hagan). For example: Repeatedly
ACCUSING me and my sister OF LYING OR EXAGGERATION when
we told you THE TRUTH about what happened to us - is
psychological abuse. This behaviour of yours made me
distrust my memory, and I began to think I was lying when
I was telling the truth. At a certain age I didn't
understand what truth is and what a lie is anymore. I
started lying and believing my own lies, and I thought
that my story of abuse was also something I only imagined
or made up. I FORGOT many things that happened to me, and
BLAMED MYSELF for the rest. I misunderstood my life: I
thought it was all MY fault, when in fact it was YOURS. I
couldn't understand what was being done to me. In
summary: my SELF-CONFIDENCE was broken, my PERCEPTION and
UNDERSTANDING were distorted, my MEMORY was
dysfunctional, and my MORAL INSTINCT was damaged. And all
because of what YOU did.
What do you want me to do with your apologies and what
use can I make of them now? What's the use of your
"caring" for me, as you write, of your
"appreciation" for my "courage, morality,
honesty, beauty, and intelligence"? I have nothing
to do with them now, for until the day I die, the memory
of the pain I felt for NOT EVER getting this appreciation
from you, when I was so desperate to get it from you and
father - this memory of pain is burnt onto my skin. For
your own reasons, you could not directly EXPRESS this
"appreciation" of yours, you kept it locked
inside or hidden, and I just DIDN'T GET IT. This is again
YOUR FAILURE as a mother, a failure that caused great
damage to my pride and self-esteem.
Do you know how it felt, to be your child? I felt you
never believed me. I felt I had to buy the right to your
attention with total self-denial. I paid for your
attention by wearing a friendly, "good boy"
mask, in the face of your never-ending brutality. To do
that, I had to suffocate my thoughts, my feelings, my
truth, my opinions, everything that was ME. I had to kill
myself, to crush my personality. This was the only
meaning of being your child: to be DEAD, to put up with
living in hell, full of fear, helplessness, pain, and
humiliation, with no complaints. I had to forcefully
silence every emotion that aroused in me. My whole
existence became lifeless, hopeless, and I was haunted by
a strong wish to die, from an early age.
And then there were moments - perhaps a few minutes or
hours, or even a day - when everything looked better.
This made me hope I finally got to you. I was so
desperate, so eager to believe that I was wrong, that you
DID love me - and so I believed it. I was in heaven...
And then, in a flip of a second, you would CHANGE, leave
everything in the middle, and go do something else. You
would then totally ignore my existence, and become
impatient, nervous, and hard-hearted. Every time my whole
world collapsed, in the face of this unexpected hatred,
which I didn't understand why I "deserved".
Another and another disappointment for your heart-broken
child.
This is how I lived, in this hell of ups and downs, in
this cruel roller coaster of yours. I suffered
unimaginably from it. I was exhausted, confused, and
driven to despair. I felt I had no way out of this hell.
No way out. The years passed and the boy I was lived his
life of fear and humiliation, of insults and pain,
without crying, without complaints, not asking questions
and with no hope. This is how I lived, frightened to
death, always expecting the next blow, the body stiff and
aching, afraid of everyone I met, afraid of all the kids,
locked up behind a wall of silence, no friends, no help,
no hope. This was my life as a child.
It is NOT MY FAULT that I cannot forgive you, that I
cannot even speak to you again. It is not my fault. I
have no part in it. No part. These are YOUR failures as
mother, your failures alone. It's not my fault that you
need this relationship with me, that you need me, that
you feel pain for everything that happened to me, as you
say. Your pain is not my fault. I bear no responsibility
for it and I have no part in it. NONE. I am without
guilt.
I don't want you to write to me again, because you hurt
me every time. And I will not waste even one minute of my
time in trying to "fix" it. This is the last
time I'm doing this to myself. All my life, this is
exactly what I tried to do - to "fix" this
distorted relationship. This is the same emotional trap I
was caught in all my childhood. Everything is always too
familiar with you. I can't believe you anymore, because
you betrayed my trust too many times. Too many times I
believed you loved me, and your behaviour proved that the
opposite is true. You disappointed me too many times, and
I have no more trust in you. And this, too, is not my
fault. It is NOT ME who brought about this state of
affairs.
I have MY OWN life now, did you know? More than a third
of my entire life has passed when I was living in a hell
of fear, self-denial, and suicidality. The inner death
you caused tormented me for thirty four years. Now, for
the first time in my life, I am beginning to feel ALIVE,
and I will let NOTHING that can threaten this feeling
come near me. I won't let you destroy this amazing change
I did within myself, this miracle of re-birth, after
years of hell. Now that I start to feel real happiness
and peace for the first time in my life, I will NOT RISK
IT, not for anything in the world. Least of all for you,
after everything you did to me. I can't let you get close
to me and ruin me with your lies. My good life will be my
revenge. I will live good and I will live without you.
For years you were near me, and I was devastated, dead,
erased, devoid of feeling and personality. Never again.
Only when I'm far away from you, I can LIVE. And I'm
going to live GOOD. Goodbye "mother".
AM: Congratulations! Your
letter is strong, true and will encourage others to take
their feelings seriously and not to force themselves to
believe in lies so that the illusions can be saved. Hence
it is exactly because of our illusions that we become
sick. You saved your life, your future.
|
|
British Journal of General Practice Article
Sunday August 12, 2007
Dear Dr Miller,
I thought you might be interested to see a monograph,
which has just been published in five parts in the
British Journal of General Practice. This is a journal
for family doctors. It was written by Dr Gwenda Delany,
who died last year. She was enormously influenced by your
work, and the monograph describes how she used your
insights in her work as a family doctor. I wrote the
appendix at the end in which I attempted to summarise
your thoughts. I do hope you think I have expressed them
reasonably.
Best wishes, Judith Burchardt
AM: Thank you so much for
sending us the article and for having written the
excellent Appendix. I hope that some of the GP will open
their ears and check what they have read with their own
patients. But for doing so they should overcome (at least
a bit) their own fear of their childhood pain.
Unfortunately, doctors like this are rare; most of them
think that they have to DO something (prescribe drugs) to
feel powerful and do not to listen. They don't know that
listening gives them much more knowledge, also about
themselves, which means to gain true strength for
themselves instead of playing the powerful one.
*******************************
A Farewell To Heartsink?
by Dr Gwenda Delany
Prefatory note.
This is a testament of 26 years lived in General
Practice. I completed the testament after some years
gestation, when I retired from work at the end of 2005,
with disseminated breast carcinoma and a prognosis of
weeks. The references to my evidence base are therefore
entirely inadequate, though I have indicated the areas
where some may be found. But as this is primarily
narrative medicine, I feel my small testament may stand
as it is, and go, in Beethovens words, from the
heart to the heart; with not a sink in sight.
The word she or he is short for
he or she wherever it crops up in
the text: the writer is a bona fide she who
finds conventions such as s/he obtrusive and
jarring.
Being a doctor myself, I have the incorrigible tendency
in what follows to refer most often to doctors in
connection with heartsink encounters. These are of course
not limited to doctors, or even to medical professionals;
as humans, we all encounter them in our daily lives; we
all get the chance to do something about them, and to
make a difference. The illustrations, which are entirely
fictional, were provided by a non-medical collaborator
who has had much to do with medical professionals in the
course of her life, and hopes in her turn to make a
difference to them.
Is heartsink a term of abuse? I dont
think so: speaker and listener may truly bring a sunk
heart to their meetings. That this is a sign of life and
hope, is what I aim to demonstrate: if anyone comes to
see it in the same light as a result of reading this
monograph, I shall have achieved my aim.
A Farewell to Heartsink?
Chapter 1
Scrolling through this mornings appointment list, I
see A is coming to see me. In a cruder era a few years
ago A might have been labelled a heartsink patient:
a patient whom I just cant seem to help, and who
all too frequently comes to remind me of the fact.
Every consultation with A leaves me aware of a turmoil in
myself out of all proportion to the presenting problem.
Turmoil made up of many feelings on my part: Anger,
misery, irritation, fear, rejection, blame, manipulation,
exploitation, contempt, hopelessness, helplessness,
uselessness, confusion. So much confusion in fact, that I
hardly know where in all of this my feelings towards A
begin or As towards me end.
Its a consultation were all familiar with: we
all know A. Some of us might defend our own negative
feelings towards A as entirely justified; others would
prefer to bundle them hurriedly out of sight, ashamed of
a supposed lack of professionalism and compassion. But we
could adopt a more practical approach, and treat these
difficult feelings as part of the objective history and
examination. They are as present in the consulting room
as any other physical sign might be: a cough say, or
impetigo - or bursting into tears.
Monica asked to be taken on your list 18 months ago,
after misunderstandings with her previous GP,
in a practice on the other side of town. She has tried
everything for recurrent bouts of IBS, which she is
convinced stems from a food allergy; shes even
attempted an exclusion diet a couple of times, but
neither of you felt that it proved anything. She often
responds to your suggestions with a sigh, opening her
eyes very wide; then silence. As she lives on the edge of
your practice area, she has difficulty arriving
punctually for appointments. Its impossible not to
feel irritated yourself by Monicas behaviour; you
are being challenged to discover the secret source of her
irritation, in every sense
Of course, A can be 20, 30, 40 or older; male or female;
of any or of mixed ethnic origin. Dominating all the
feelings A has ushered into the consulting room, there is
a sense of ill-usage, on the part of both patient and
doctor. Both appear to experience the consultation in
terms of: I dont deserve this and
Why are you doing this to me? Where does all
this come from, and what does it mean? Could it literally
be telling us that we are dealing on some level with a
history of ill-usage, of maltreatment - of some kind of
abuse?
What is abuse? The term is generally reserved for harm
inflicted on children by adults or by older children:
inflicted by those in a position of power and/or trust,
on someone more powerless and defenceless than
themselves. The abuse may be overt or may have come in
disguise, as love, as discipline, as protection or good
parenting even.
Most of us would have no difficulty in acknowledging the
criminal end of the spectrum where physical or sexual
abuse are concerned, and would expect the victim to be
deeply and lastingly scarred.
Jake is 19, in his first year as an art student, still
living at home; he seems a shy young man, who moves
awkwardly. He has presented quite frequently in the past
few months with headaches and trouble sleeping. None of
the remedies you suggest seem to help much. Examining him
for a shoulder injury, you discover that his arms are
heavily scarred. He has little to say about this, except
I do it when I feel bad. Nobody in his family
is aware that he cuts. When you find time to look back
over his early notes, you see that he was on the At Risk
Register for possible abuse when he was ten; shortly
afterwards, his father spent two years in prison.
Many heart-sink patients will turn out to
have suffered such gross and overt abuse; though feelings
of confusion, intolerable shame and self-blame may still
be preventing them from disclosing, or even from
consciously remembering it.
There are other forms of ill-treatment: as well as less
extreme physical and sexual abuse, there is a whole
spectrum of gross and subtle emotional damage. If, as I
propose, were right in linking heartsink
behaviour in the consulting room to an origin in a major
or minor abusive experience, then A, without
knowing it, has already given us a map to a troubled and
largely unexplored interior. Here be dragons, belonging
to As past, but not of As making.
Geraldine is a woman in her late fifties who relies
heavily on laxatives. She is overweight and, you suspect,
a more than moderate drinker. She claims to have suffered
chronic constipation ever since I was at boarding
school, really, and is reluctant to give details of
her diet. In her presence, you have the sense of things
being held back
from a long way back
All these examples are of patients who cant tell
their stories openly. The origin of their pain is hidden,
even from themselves.
Chapter 2
Emotional abuse is a concept that lays itself wide open
to - well abuse. But perhaps it can really be put
very simply. To have experienced emotional abuse A must
have heard or interpreted words like these early on in
life:
Youre not the way I want you to be.
Its your own fault.
Everybody else knows how.
If you really wanted to, youd do it for me.
Id be a good parent (teacher) if it werent
for a child like you.
Did anyone in As life really say these words - or
consciously imply them? Might they have been
spoken/implied by someone unaware of their power to
annihilate, someone no longer capable of hearing how they
would strike a child? Someone so damaged by their own
childhood that they themselves had never come to realise
how such an attack would strike a child in his self-image
or worth? In emotional abuse, the childs love,
trust and attachment are used to warp the course of the
childs development in the (un)conscious interests
of the adult, who is lashing out with unresolved damage
of her own.
For an 11 year old boy, Russell already has an impressive
accumulation of notes. A very premature baby, his parents
were worried that he might be a slow learner; but by the
time he started school, he seemed to be of average
ability, if a bit small for his age. His mother or
sometimes his grandmother, who lives with the family
turns up with him at the surgery every few weeks,
with suspected ear infections, chest infections or
tonsillitis; demanding antibiotics, and wondering if he
ought to be taking fish oil or extra vitamins? Shouldnt
he be referred to a specialist?
You get the feeling that Russell is an unsatisfactory
child, who needs to be put right; and if only you were a
good doctor, youd see that hes all wrong... a
child like this has to live in an atmosphere of constant
criticism which amounts to emotional abuse.
Emotional abuse inevitably accompanies physical and
sexual abuse and may also occur where there is:
Rigid discipline at home or in school, in
deference to values of past generations and unrelated to
the childs real needs
Harsh or intolerant religious/cultural indoctrination
Excessive demand for achievement
Excessive demand for conformity to questionable standards
Role reversal where the child is expected to be strong or
considerate or self-effacing beyond his years, for the
sake of the fragile adult(s)
Deception surrounding adoption or parental disappearance
Unpredictable and deficient parenting associated with
alcoholism/drug abuse/ untreated mental illness. Etc, etc
- for further examples, we need only consult our
patients.
Mary is fourteen, the eldest girl of a large family, and
a great help at home; her mother says she is a little
saint, the way she looks after the younger ones, making
all their breakfasts before she goes to school. Her
father is away a lot in his job as a drug company rep;
when he is home, he often relieves his stress by going
out drinking, but her mother says that Mary still adores
her Daddy and wont hear a word against him.
However, lately Mary has been having a lot of stomach
upsets and seems to be off her food; after glimpsing her
daughter in the shower, her mother is worried that she is
getting dreadfully thin.
Marys developing anorexia is telling us something
about the unacknowledged problems in her family. Seeing
her mother struggling with a difficult marriage and an
impossible workload, Mary has found a way of fending off
the demands of womanhood; she goes on being the good girl
who is loved and approved of sustaining, even if it
kills her, the apparently vital illusion that all is
well.
What these parents have in common is that they provide an
insecure environment for the developing child, where she
learns not to trust herself or others; where she is
expected to strive after goals which entail giving up
much of her own spontaneity and creativity to others
demands. This is likely to leave its lasting mark in
depriving her of self-esteem and self-confidence, and
leave her with feelings of anger and outrage she may not
even be aware of. All the same, they are painfully eating
away at her, and are making her feel worthless; even if
she is busy establishing what appears to be a fulfilling
life, with a successful career and happy family. Unknown
to her, inside him, a cry has been waiting to be heard
since childhood.
I am that I am
I love you T-H-I-S much
I know I dont give you what you want
I keep trying to because I love you
I cant help myself
Im mad at you, I hate you
I hate myself
You made me the way I am but I cant face it that
you did this terrible thing to me
When I grow up Im going to be depressed no-
workaholic or
Im going to get my own back and become a delinquent
addicted paedophile serial killing suicide bombing
heartsink patient - and and and - youll
be SORRY
Simple as that. King Lear said it first:
- I will do such things -
What they are yet I know not, but they shall be
The terrors of the earth.
As for an example, do we need to look very far? In our
own hearts?
Chapter 3
So lets say then for the sake of argument that A,
our heartsink patient, may well have
experienced some form of abuse - physical, sexual or
emotional - early in life. Why take it out on us, in our
consultations? Or even in our myriad social, familial and
domestic encounters?
With the best will in the world, there is a power
imbalance between patient and doctor in a medical
consultation: one that easily recalls the original power
imbalance between child and adult, the emotions that went
with it and the expectations that follow from it. If
these involved abuse of any kind, then on some level,
however unconsciously, the patient may see the doctor,
the figure of power in charge of the
consultation, as abuser; and the doctors offers of
help may then be seen as deceit, seduction or attack; or
grossly wanting in some other way. This state of affairs
in turn will require the once bitten, twice shy patient
to be ready with tactics and strategies for repulsing and
outwitting the hapless doctor; to go on the defensive, or
on a pre-emptive offensive. Often both: the
patient/victim gives in and appears to comply, prompted
by old fears of powerful parent figures - only later to
give way to old anger by rejecting or rubbishing the help
that is offered.
Jennifer, in her late forties, wants you to help her lose
weight. She is a chatty, sociable woman who copes alone
with a disabled son and a part-time job; but all those
girls nights out, which she says cheer her up, have
contributed to a weight problem thats making her
breathless and uncomfortable. There is a very good group
run by the practice nurse, but Jennifer is adamant; only
you will do. At first all goes well, and she rapidly
loses a stone; you praise her efforts; but then the
lapses begin. When you have to tell her gently that she
is gaining again, she bursts into tears; its all
right for you, isnt it youve obviously
never been tempted by a chocolate biscuit in your life!
You started off as the good parent, helping her to deny
herself for her own good; and now youve become the
bad parent, critical and hostile, depriving her of
everything that gives her life sweetness.
And thats just for starters. As natural and
unmet needs for a good relationship with a generous and
protective figure of power may lead her to
place impossible expectations and demands on someone who
asks, professionally: What can I do for you?
When that someone who asks is us (us, for heavens
sake!) she is bound to be disappointed
. Impossible,
unconscious dreams of undoing the traumas of the past
come up against the shortcomings of adult reality in our
consulting rooms. For the patient, this is a disillusion
too far: likely at first to reinforce her heartsink
defences and behaviour towards the idealised
parent-figure of the doctor who once again has let her
down and made light of her hopes.
The good news is: its nothing personal. Nothing to
do with us. All we have to remember is that we are
dealing with a simple case of mistaken identity. The
patient in our presence, without consciously realising
it, is relating to and confronting her abuser, the
sometimes hated, often loved, and always powerful figure
whose influence still rules her life. (Reminder: I am not
necessarily talking of major, criminal, abuse here, but
of any degree of more subtle abuse.) The patients
heartsink behaviour tells us with great
accuracy how that relationship was in emotional terms,
how she felt and feels about it, how she copes with it
and covers it up; even as she goes on telling another
story, one of (not so) passive aggression,
attention-seeking or clowning; of mental illness,
alcoholism or addiction. Right here in our consulting
room.
John is 29, a tall, burly young man who is obviously
emotionally disturbed. He sits in the waiting room with
arms folded, muttering under his breath, and there are
always empty seats on either side. What he has to show
you are injuries: he dropped a hammer on his foot, he
burnt his hand on the electric ring. Once he turned up
with horrific bite marks; hed been in a fight, hadnt
he? He speaks angrily and tends to thrust the injured
limb in your face, but so far, youve never actually
had to reach for the panic button.
Somewhere in Johns early life, he learnt to be
afraid; now, for a change, he can do the frightening, and
you can find out what its like to be the one who
fears.
Of course, we are not As abuser, all the while hes
treating us as if we were, and giving us whopping great
insights into his life. But he and his emotions are so
powerful that we are in danger of forgetting, and of
actually here and now turning into his abuser: we may end
up punishing him for the difficult feelings he presents
us with, by becoming angry, rejecting or self-righteous
just like his original parents or authority
figures so helping to perpetuate a vicious circle
of abuse that seems beyond anyones control.
But if we remember, and stay with our realisation, that
the patient is undermining someone we merely stand for,
an old figure of power rather than our hapless personal
self, we find we can stay unfazed with very little
effort. We are freed up to note the anger and defeat we
feel in the presence of this patient, without being in
danger of taking our own sense of inadequacy out on her.
We can remain firmly on her side, welcoming her
communication with interest and respect, experiencing no
need to deflect it or to control it in self-defence. We
become open to his real and sad history, one we wouldnt
wish on our worst enemy; and in our efforts to improve
our relationship with him, we start to become supported
by the admiration we develop for his grit in enduring and
surviving appalling times. The question arises: in his
place, would we have come out so well?
Chapter 4
To sum up what went before: I would like to suggest that
the heart-sink patients behaviour and
attitude begin to make sense, and are entirely
appropriate and consistent, if we bear in mind the strong
possibility of a past history of abuse, in the widest
sense of the term: emotional, physical, sexual. We could
decide to see the heartsink patient as
someone for whom things went seriously wrong early on in
life: in a relationship of trust, at a vulnerable stage
in development.
Our hearts sink for the best of reasons. Feelings are
always true and always rational, i.e. they are always
appropriate and proportional to their original cause.
They can therefore be trusted even when it may be
impossible to link them to anything in the patients
present circumstances; and even though their original
cause remains undiscovered during all our consultations
together. Our difficulty in getting the picture
may indicate we are dealing with a patients
repressed experience, re-enacted in exact but obscure
ways, using the listener/doctor as a ready-to-hand and
convenient figure of transference.
Such terms may be of little help for some doctors, or may
actively put them off; and perhaps they are not
essential. But they are a map, a theoretical ground-plan
of where the action is at: I offer them in that light,
with examples that may be of use.
Repression occurs whenever an experience during childhood
and development gives rise to feelings that are not fully
lived through and assimilated: because these feelings are
forbidden/too painful/too confusing for the child, and
because there is no-one more experienced available to
help the child identify and deal with them. Today more
experimental evidence is becoming available that supports
this hypothesis; e.g. in accessible books on the overlap
of child psychology and neurophysiology, such as How
babies think. A child without adequate support is
unable to cope with such intense conflict as: I
love my parents/ carers but they injure me, physically/
sexually/ emotionally. (This applies to the concept
of abuse in the widest sense of the word, from the
limited to the life-threatening) Having got off to a
faulty start in life with such an unmanageable and
unassimilated experience, the grown-up child is then
disabled from handling feelings aroused by similar
abusive situations that come her way in adult life. She
will lack empathy or understanding for herself or for
others (often her own children) who have been or who are
being abused in similar ways. At the same time the mental
energy needed to keep the old chaotic and unwanted
feelings safely repressed and unconscious, is not
available to the patient for more creative purposes and
leaves her feeling drained, inadequate and bad. The
sufferer feels non-specifically unwell all the time, and
may decide to consult someone about her elusive health
problems: someone who may then feel drained, inadequate
and bad, at the end of a dysfunctional consultation
US!
Peter has not had a job for more than ten years, and as
his thirties are slipping by, he is beginning to feel
desperate. His problem is that he cant leave the
house without checking several times that all the doors
and windows are secure, and all appliances switched off.
On bad days, it can take him two hours just to get out of
the front door. When hes anywhere away from home,
he worries constantly about needing the toilet. He is
quite willing to talk about his background; he was
brought up in a strict but loving home, and
though Peter himself kept his nose clean, as he puts it,
his brother Martin was a right little devil
who was always in trouble, and was beaten by his father
for his bad behaviour.
What do these compulsions actually do for the sufferer?
When hes observed all his self-imposed, rigid rules
about locking things up, there must be at least the
relief of having done something right, of having warded
off the anger and rejection that were always threatened
in his early life, if he failed at being good; at the
same time, their irrationality and his insistence on them
is just provocative enough to the normal
observer to express some of the natural resentment he was
never allowed to feel. And what about Martin? Does Peter
envy his brothers courage, which enabled him to
avoid the burden of Obsessive Compulsive Disorder? Or
does he feel that he should have done more to protect
him?
Repetition compulsion: repressed experiences are stronger
than reason or argument or cognitive therapy; willy-nilly
they are enacted again and again in many different ways
and in many different settings throughout the patients
life, unless and until the intolerable repressed feelings
and their triggering events have been identified and
consciously experienced and reacted to (with sadness,
anger or indignation) by the sufferer. The only way this
can be done is for the patient to revisit them: if all
else fails, alone; but lets hope she can do so in
the company of someone willing to listen, during some
form of talking therapy: which fortunately
may be as informal and ad hoc as an encounter in our
surgeries.
Michael works as a chef in a local restaurant. He is a
good-looking young man. asthmatic, slightly built, with a
wistful expression. His father seems to have been a
violent and unpredictable man who threw him out when he
was eighteen, on discovering that he was gay. Since then
Michael has had a succession of partners, who appear at
first to be the answer to all his needs; but the
relationships always turn out badly. He tells you about
Derek, whos just moved in with him; a bit rough,
but hes a great bloke built like a gorilla,
Michael says proudly, he used to be a bouncer in a
nightclub! Next time he comes for his medication, you
notice a bruise on Michaels cheekbone; maybe Dereks
roughness isnt just a lack of social skills.
So why is Michael attracted to the kind of man his father
was? A gentle, sympathetic partner wouldnt satisfy
him; he has to keep going back to the first man-to-man
relationship in his life, hoping that this time at last
he can find a way to placate his anger and win love.
Transference: as part of this unresolved repetition
compulsion the patients behaviour towards the
listener, and the feelings that arise in the
consultation, tell us the patients story in code
and give invaluable clues about how the patient related
to important figures in his development: parents,
relatives, teachers, people in authority,
helpers even nurses or doctors - who
have confused and mistreated him, in any sense of the
term, while he was very young and dependent on them.
During this unconscious re-enactment in the consultation,
the patient imposes, or transfers, a past situation or
relationship on to the present one. In any given
consultation he may allocate the role of the child to
himself, casting the listener as the unsatisfactory
adult; or the patient may keep the role of the
all-powerful adult for himself: and relieve his old
feelings of pain, humiliation and incomprehension by
attempting to inflict them on the listener, so that the
doctor is cast as the former child. The listeners
feelings, of anger, irritation etc, elicited in response
to such a consultation, are the feelings the patient may
have experienced in a long-past but crucial relationship
or situation.
Clares high blood pressure came to light during an
MOT with her company doctor in the city; she makes it
clear that what she wants from you is a quick solution,
but unfortunately everything youve tried so far is
unsatisfactory in one way or another ineffective,
or the sideeffects are unacceptable. She is a tall,
smartly dressed woman who dislikes being kept waiting,
and receives apologies in silence. Your attempts to make
light conversation while checking her BP are not
welcomed; she has a way of raising one eyebrow which can
be disconcerting. Occasionally she offers a comment about
the waiting room facilities, or asks a question about
your appearance Tell me, where do you get
your hair done?
Clare makes you sink along with your heart- to the
level of the 3-year old whose mother finds fault with
everything she does. For reasons that originate in her
own childhood, a mother like this cant give her
daughter support and encouragement; instead, she is in
competition with her, and wins every time. Fifty years
on, Clare is still under pressure to succeed; perhaps if
she can make everybody else look small..
Is all this plausible but imaginary? There is a simple,
additional thought experiment we can conduct on
ourselves, that may satisfy the most exacting enquirer
after truth. It concerns the dialogue in our heads; the
often inaudible running commentary we have playing
non-stop in the background of our lives. Sometimes it
comes intrusively and almost paralysingly to the fore;
more often it is muted, though any minor incident may
suddenly turn up the volume.
******
Throughout our lives, we are all pursued by critical
voices, reinforcing the sense of inferiority that is
there as soon as we realise how small and helpless we
are, compared with the grown-ups. From playgroup to focus
group, the criticisms never stop:
Yes, but youve drawn the horse bigger than the
house, havent you! And youve gone over the
lines where youve coloured it in..
Sarah has made little progress with her piano playing
this term. She will never improve unless she spends at
least two hours a day practising her scales.
Well, I taught your kid brother to drive, and I must say
he was a natural compared to you. You dont want to
change gears like that youre not meant to be
fighting it! And just think what youre doing to my
gearbox!
Im not interested what time your childminder turned
up. Your job is to get here punctually in the mornings
and I dont care how you do it is that clear?
Before we close the meeting I feel I must mention
something thats been brought to my attention.
Apparently a customer rang just after closing time
yesterday and was brushed off quite rudely by one of our
reception staff. It was you who took the call, wasnt
it, Karen?
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 thats all shes
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 patients verdict on how
far (if at all) to go with any exploring; and by
remaining solidly on the patients side while
genuinely being undaunted by the re-enactment thats
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 doesnt really like
herself much and isnt 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 its 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 patients needs. If we can
accept our own discomfort when presented with the riddle
of the patients heartsink behaviour, and if we can
signal that this behaviour doesnt 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 patients
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 ones interlocutor to maintain his dignity
(as we would all wish our own vulnerability to be
respected): by welcoming the patients suggestions,
explanations, self-diagnosis etc., and by exploring them
together in discussion if necessary, concluding
together for the time being that the patients
tentative interpretations dont quite seem to fit
the picture, dont 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 him all about it: better
not, better if the patient is given the space to find the
answer for himself.)
Transference: the patients heart-sink
treatment of the listener may be used to form hypotheses
about the patients 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 herself gives
us the go-ahead, we dont need to do anything about
it. We dont 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 dont
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 Neills
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
childrens minds.
Dibs In Search Of Self by Virginia Axline describes one
way that theory may be put into practice.
Dr Gwenda Delany
**********************************
Appendix: The Psychological Thought Of Alice Miller
Alice Miller is a psychotherapist. She is interested in
the importance of emotions in understanding seemingly
irrational behaviour. Her thesis is that our emotional
life governs our behaviour. Seemingly irrational
behaviour becomes explicable once one understands a
persons emotional life.
Miller believes that our emotions are formed in early
childhood. If we have happy childhoods then our emotions
develop naturally and we behave in a rational way. If
however our childhoods have been unhappy, as a result of
physical, sexual or emotional abuse, our emotional world
is damaged. Emotionally damaged adults may harm
themselves or others or suffer with psychosomatic
illness. Why is this?
Children who are being abused are in a frightening and
dangerous situation. Children need to believe that their
parents love them. If they react in a natural way to the
abuse, by showing their anger and outrage, they risk
further abuse from their parents or carers. The abused
child, A, represses her anger and outrage and does not
feel it consciously. This is a healthy response to
abusive parents as it optimises As wellbeing while
she is dependent on them. By repressing her anger and
convincing herself that everything is OK really, A does
not antagonize her parents and so maximises the chance
that they will continue to give her the good things they
can, such as food, shelter and a home. She also helps
herself to cope with an intolerable situation.
When A grows up the situation changes. The repression of
her anger is no longer necessary and is in fact
counter-productive for As wellbeing. Sadly, because
A is herself unconscious of the anger it will probably
remain repressed. She lives with the unconscious anger
inside her and is compelled to express it in some way.
The anger may be expressed towards herself (as in
depression, self-harm or psychosomatic illness), her
children (as child abuse) or towards others over whom she
has power (as in violence or bullying). Conversely she
may re-experience her own anger by developing
relationships with other people who will abuse her.
This unconscious anger is usually maladaptive in adult
life. It causes harm to A, her children and other people.
It no longer plays any useful function. If A is able to
consciously recognize her anger and express it directly
then she may be able to free herself from the compulsion
to harm herself and others. Miller believes that people
like A can be helped by communicating with people who
understand her experience. This is the aim of
psychotherapy.
General practitioners meet many patients who have
suffered some form of abuse and express this in the form
of depression, self-harm or psychosomatic illness. A may
make our heart sink if we try to understand her behaviour
on a superficial rational level. However if we are able
to sense the emotional experiences lying behind As
behaviour then this may be therapeutic.
Dr Judith Burchardt
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