Monday, January 23, 2012

A Matter of Perspective

Often, when two people can't get along, it seems like the issue is one of communication.  People say things that are ill-phrased, or the person hearing a statement assumes an intention that is not meant to be.  Sometimes, a well-worded conversation fixes the problem, often with words such as, "I'm sorry that upset you.  I never meant it to come off that way and I meant to say X."  A misunderstanding, it happens all the time.  I sometimes suggest that people read the book Difficult Conversations by members of the Harvard Negotiation Project.  The book talks about the value of feeling heard, and how it is important to understand the intentions of the other party.  You can't imagine how often I hear stories about people that sound a little off, and when I ask why someone would say or do those things, I hear theories of how the other party is jealous, or just enjoys watching my patient suffer, or is manipulative, or sometimes the stories have quite complex theories dating back to an event that occurred long ago and doesn't seem that memorable.  Now the theories could be right, people are jealous, or manipulative, or sadistic, but often I can think of alternative explanations that would explain the same story, and I do think that it may be valuable to ask someone their intentions when things go wrong.

Sometimes, people hit a place where nothing can be said that is right by either party.  There are irreconcilable differences.  One person may talk of their heart-wrenching distress and weep their story, while the other hears it as "there he goes again trying to get my attention with his tears," and the crying party feels like their honest and sincere attempts are useless on someone with a hard heart. You can find your own variations on this theme, I'm sure.

I've started to wonder if I have perhaps come to this place with our Shrink Rap commenters.  I feel like I say something and the response indicates that my comments were misinterpreted.   I try to clarify, it just gets worse, and our comment streams now end with readers insulting the blog, me (apparently I'm someone's nightmare shrink and jail would be preferable--which leads me to wonder why such a person would read our blog), and my choice of topics to discuss.  If I talk about an observation I've made, people get angry because of a scenario they've extrapolated that to, which was never what I meant in the first place.  Attempts to clarify seem to be futile.  I don't feel heard, and clearly, some of the commenters don't either. 

And sometimes I feel like readers don't want a discussion at all.  A story is written in, and I often sympathize with the story because our readers write in about very touching, and often tragic, difficulties.   They also sometimes seem to feel that it is the Shrink Rappers' obligation, job, or destiny to right the wrongs they see in psychiatric practice and I do believe we've let these readers down.  Sometimes, I feel terribly bad for the person who has been victimized, but I'm also aware that I've heard only one side of the story, and I may talk about what the other side might be.  And while I don't believe people should suffer, I do sometimes feel that it's helpful to see other perspectives.  It enables a search for a solution to occur with a more thoughtful dialogue.  But it also means that I sometimes sound unsympathetic in that my answers are read as "Yes, but..."  From my point of view, that's part of the discussion, and if you want to say something and want us to respond with absolute sympathy, having heard half of a story that often demonizes our profession, and you don't want to know how the other side might look at it, then I don't think Shrink Rap is the place to come.   I am not likely to write a post about how psychiatrists are all evil and manipulative control freaks who want only to incarcerate, abuse, and poison their patients.  And it's not that I don't believe there may be evil shrinks out there, or stories of abuse, or nasty and disrespectful nurses, and I certainly do believe there are psychiatrists who practice quick, uncaring psychiatry for the sake of a bigger paycheck, but sometimes I want to consider other possible explanations.

Let me give an example from recent posts.  I put up an article from USA Today on how involuntary commitment is so unpleasant and that if it were more humane, it might not be so awful.  I put it up because I agree with it.  People wrote in to talk about the abuses they've suffered, and that is fine, it's what I expected.  But several people complained about being searched, and how it was offensive and insulting and given their past histories and diagnosis, this was inappropriate.  I understand their pain and humiliation, but what doesn't get mentioned is the perspective of others when things go wrong.  The patients are new to the unit, the staff has no idea who is dangerous and who is not, and psych units can be very unpredictable places.  Some of the policies are made as reactions to bad things that have happened, and often patients have assaulted other patients, or the staff, and suicide attempts (and completions) are not that uncommon.   A patient might be insulted at being searched, but is he also insulted when searching is not done and he's stabbed by another patient who came in with a knife taped to his leg?  Wouldn't that lead to the same "unbelievable" cry?  And to read our blog, one would think that no psychiatric patient might ever care about the safety of the hospital staff or their right to be concerned about it.   It's not that I don't empathize with commenters' suffering, it's that I'd rather there was just a token nod to why it may be necessary.  Why does a four-year-old have to remove and x-ray her flip-flops to get on a plane.  Do we really think she's going to blow it up?  No, but perhaps we think that if they stopped x-raying children's flip-flops, then a terrorist might then use them as a vehicle for a bomb.  Or maybe it's all ridiculous and we should be a little bit more thoughtful about our security procedures.

One commenter was distressed about being strip-searched and made the statement that other hospitals don't all do this.  Not my field of expertise, but it does seem to me that if one can say "I understand why it's done, I want you to understand how damaging it is," and then go on to say that other institutions don't do this and propose other, less damaging means of addressing the same issue (?metal detectors, drug dogs, pat downs, body scanners, whatever) perhaps there is some power to this.  Maybe you get people looking and they say Wow, the institutions that don't strip search patients actually have a lower violence rate (I don't know this, but we do think it's possible that there would be less violence if patients aren't enraged).  But someone is going to read my comments about staff and patients being in danger as meaning that I think it's fine to violently rip people's clothes off them, and for the record, I don't.  

Another commenter asked if I do this to my patients, this 'yes, but' thing.  Sometimes I do.  If a patient is telling me a story about an interaction with another person that sounds unlikely to me, I may ask the patient why he thinks he got the reaction he did.  Would it be honest to sit there and listen to something that doesn't sound right without challenging someone to think about it in new ways, or to propose some other possible explanations?  Let me give an example from a recent Shrink Rap topic.  If a man talks about how his adult son has estranged him and he has no idea why and he presents theories that sound unlikely (my son wants to control me, he's jealous, he always favored his mama,  you name it), and I have a sense of what might be part of the issue from other things he's told me, I might ask, "Do you think the fact that you don't approve of his wife and the way that they are raising their children might be making him uncomfortable?"  Or I might ask if the son may have found it difficult to get his approval when he was younger, or if how the father used to treat him before he stopped drinking might be a part of this.    But it a patient doesn't want to hear this, if they need me to be all in their court, and if they insist I'm wrong (and after all, I wasn't there, so my theories may well be inferior theories), I back off.   The truth is that no matter how troublesome the patient's behavior is or has been, they are my patient, they are the one I am obliged to help, and sometimes I feel around for the best way to do this.  No, I don't always get it right. 

I don't know if this helps, but I suspect it will inflame things.  Commenters may say I'm getting defensive again, and they'd be right.  I read some of the comments and think, "You'd say this in my living room?" Because if you're someone who might behave in this manner, there is no way you'd be invited in to my living room.