What I Know By Heart

Knowing things by heart usually means having them memorized, at your fingertips. Song lyrics, birthdays, phone numbers, the poem I learned in second grade.

These days, for me, knowing by heart is a different exercise. What I know by rote, what I remember, are the dosages of medications, their side effects, and illnesses that can mimic or interact with various behavioral conditions. Hypothyroidism can look like depression; palpitations aren’t always panic attacks. I have medical knowledge, learned in school and accumulated over many years.

What I know by heart, though, is different. It’s a way of knowing that I increasingly learned to trust as I did this odd work I do—a way of being fully present with another person: their pain, their wounds, their transformations. It’s a heart-to-heart experience. It’s I “heart” you.

It means seeing the increased light in another’s face as an antidepressant begins to work, even before they themselves are fully aware of a change. Feeling the sadness in a story someone relates, even before they’re aware of their own pain. Using my heart, and the connection between us, to help open theirs. Too often, this way of knowing is not taught in medical training.

For three decades, I provided live supervision to fourth-year psychiatry residents who were learning to do couples and family therapy. As I watched through a one-way mirror, they treated families struggling with conflict, loss, illness and parenting or marital issues. I could call in suggestions to the residents, give feedback and at times go in and model interventions and interactions.

One trainee needing intervention was Amber—tall, with long strawberry-blonde hair and a kind, open face. Raised in a small town in Tennessee, she’d grown up on the family farm and was the first in her family to attend college and medical school. She was rooted in her community and planned to return to Tennessee after her residency.

At the yearly graduation dinner held at a downtown hotel, her father, the farmer, came in his blue denim overalls. I remember watching him with curiosity as he stood among the women in dresses and heels, the men in button-downs and chinos. He was quiet, yet didn’t seem to feel out of place; comfortable in his own skin.

After the dinner and presentations, I shook his hand and offered my congratulations: “Amber is such a wonderful doctor. She is gifted and grounded. You must be so proud.”

He nodded, smiled and said softly, “We are.”

Amber had an enormous heart. In our discussions of the family she was treating—parents who were suffering greatly after the loss of a child—she had been generous and intuitive. Yet during their initial sessions, I noticed that she was holding back. After greeting them warmly, she would become stiff, her face almost blank, saying “um” and nodding as they described their pain. I couldn’t understand how there could be such dissonance between who she was personally and how she was working with the couple.

After one session, I said gently, “You have such an expressive face. What if you allowed yourself to look sad when they do, perhaps leaning forward in your chair to hold them in a circle of compassion? You don’t even have to speak—just create a safe moment of closeness to hold their grief.”

She looked doubtful.

At their next meeting, she looked frozen as the couple sat there stiffly. Afterwards, I spoke more forcefully.

“Amber, what in the world is going on? You are so kind—yet in there, you’re acting like a robot. I know you have so much more to give!”

She gave me a strained look, then finally spoke.

“Dr. Oshrain,” she said, “My other supervisor, in individual psychodynamic therapy, told me always to sit back in my chair, never to change my facial expression and especially not to lean forward. You’re telling me the exact opposite, and I don’t know what to do.”

I realized that she’d been receiving guidance from one of the supervisors who believed that we, as psychiatrists, should be blank screens to our patients. Their belief was that staying neutral allowed patients to experience all their thoughts and feelings, without interruption or judgment. When I was in training, decades earlier, they had given me the same advice.

Having good boundaries is essential, to be sure. But years of practice had taught me other ways to provide that space: listening deeply and with compassion, knowing when to speak and when to be quiet, sensing when to hold back, when to lean in and how to explore and deepen an emotional experience.

During my time as a trainee in this same clinic, I had found my face reflecting my patients’ expressions; when they wept, my own eyes teared up. My supervisors supported this, suggesting that I also monitor my patients’ bodily positions. One encouraged me to mimic my patients as a way of “joining” in the emotional experience; I remember the suggestion “When he crosses his legs a different way, you could, too.”

I was taught to carefully gauge my own actions and responses, to stay acutely aware of the emotional dynamics in the room and to incorporate body language and facial expression, both mine and my patients, into the constant relational interplay of therapy. Many years later, when I learned about the discovery of mirror neurons and of their possible role in empathy, this approach made even more sense.

After our talk, Amber grew more comfortable in sessions. The couple, feeling safer, relaxed into an ability to grieve deeply while being held with care and compassion.

Watching behind the one-way mirror as Amber gracefully provided for their emotional needs, I felt the tension leave my body. By showing up as herself, she’d allowed a burden once carried alone to be shared.

I felt delighted and grateful watching Amber embrace the same lesson that I had learned in my decades as a therapist. Knowing by heart creates a security that enables patients to explore and express their feelings. Over and over, I learned that my most useful tool was not the newest alphabet soup of technique but rather my capacity to stay fully present emotionally, with my whole heart, as the other person sat with their unique and exquisite pain.

Some losses, some traumatic events, can never fully heal. I learned that although I can’t do anything to fix a loss, I can be fully present, showing up with my body and face. I can travel alongside my patients on their path of suffering.

Our brains may hold the knowledge we need, but our hearts and bodies hold the wisdom, the intuitive emotional grounding, that we need to heal.