Unconscious Demons

Julie was a 50 year old woman who had worked briefly in healthcare as a young woman before she was involved in a car accident which left her paralyzed from the waist down.  She was tiny, severely malnourished, with enormous decubitus ulcers on both hip bones as well as her sacrum.  She had done well for many years after the accident, living independently, and taking a new job working in ministry.  Then her fortunes changed again with a severe illness that left her on life support followed by a difficult prolonged “recovery.”  Her pressure ulcers and chronic infection of her sacral bone were some of those complications and they were difficult to look at.  There was no position she could lay in to keep the pressure off all of them.  Our palliative care team was consulted to “discuss hospice” with Julie but Julie had different ideas.  She was bright, expansive, appreciative, and determined to get better.  She told us how grateful she was for our visit, how happy she was to have the opportunity to meet us.  I was impressed with her spirit, her joy for life, and her determination to appreciate everyone who cared for her.  She went on to tell us how much she loved her job, that she wanted to get back to “ministering to others”, especially “those with sexual immorality- the homosexuals.”  My entire body tensed, and I felt something in me shift.  A wall went up.  I didn’t really want to talk to her anymore and, luckily, her goals were clear, giving me the perfect out.  I signed off.

Only a few days later we were asked to re-engage to help manage Julie’s pain.  I somewhat reluctantly stopped by that morning.  Julie told me that the changes that had been made over the weekend by the physician on call were helping and declined any further adjustments.  I was relieved that I could again justify disconnecting.  But only a few hours later I received a call that Julie wanted me to come back.  She had more questions.  “What questions?” I asked.  No one knew.  “She just wants to talk to you again.”  Great, I thought.  She’s going to try and tell me more about how she’s saving the homosexuals from their sexual immorality.  I felt a sense of irritation and then anger.  It was inconvenient to have to go back.  Julie was a talker.  I worried I would be in there for quite some time.  When I stopped by, she was in the middle of getting her dressings changed.  I offered to come back later but she insisted I come in the room.  She was lying on her side, tearful and in emotional distress due to the pain of the dressing changes.  I had only seen pictures of her wounds before but seeing her uncovered with her rectal tube, urinary catheter, and horrific ulcers wide open was nearly overwhelming.  I stayed for a while, admiring how calm and compassionate her nurse was with her, and failing to find the same in myself.  I noticed how full of appreciation Julie was for everything the nurse was doing for her despite her tremendous pain.  I noticed how her face lit up when anyone came into her room.  I wanted to stay there with her, to kneel down and take her hand and just breathe with her through the pain.  I’d like to tell you that’s what I did, but it wasn’t.  The smells in the room – the smell of rotting flesh, infection, death- overwhelmed me.   In that moment I struggled to feel anything but an intense urge to get out.  I told her I would adjust her morphine and her hydrocodone.  I knew this was inadequate.  Not only would it likely do little to help with the intense pain of dressing changes it wouldn’t address her emotional suffering at all.  I ensured she had received her IV pain medication, and then I fled the room.

Linda Kohanov defines emotional heroism as the ability to stay present when under attack, holding space without fighting back or fleeing.  This applies to the ability to stay present during intense suffering without getting swallowed up in it.  The need to fix runs deep for many of us in healthcare, and when we can’t fix suffering, we feel threatened.  Our fight, flight, freeze response kicks in.  I think I experienced all three during that encounter; anger/irritation at being asked to re-engage (fight), dissociation from her pain/suffering (freeze), and an intense urge to get out of the room (flight).

That weekend, I couldn’t stop thinking about Julie and my response to her deep suffering.  I was embarrassed and disappointed in myself.  I wondered if my judgments of her had contributed to my inability to be present during her suffering.  I recognized an internal tension.  My desire to disconnect, separate, and see her one dimensionally was at odds with the truth- she was actually incredibly likeable and embodied many qualities that I deeply admired.  Her gratitude despite all she had been through and all she would continue to endure was inspiring.  I suddenly realized the irony of my behavior- I was judging her for judging others.

With that realization came another- that my intense disagreement with her point of view did not make her less worthy of my compassion. In that moment I was able to create enough space to notice that, as with all of us including me, her beliefs were based on the experiences and influences of others in her life.  Her beliefs were what they were in this moment, nothing more.  They did not define her.  She was so much more.

I returned to Julie’s room early in the morning on Monday, relieved to find she hadn’t discharged over the weekend.  I sat down beside her and told her how much I admired her ability to live her life full of gratitude despite the tremendous suffering she endured on a daily basis.  I told her what a difference it made to us as healthcare workers to know that we were appreciated.  I told her how much I appreciated her and the opportunity to be part of her care.

My experience with Julie was one of my gratitudes for that day.  Caring for her made me aware of demons that previously lay beneath my awareness, helping me grow just a little bit further in my ability to judge less, and love more.

Dealing with Bad Behavior

I love this quote from Anna Blake, horse advocate, author, speaker, and clinician. “The gift that comes with bad behavior is a chance for positive leadership. It’s a chance to reward his vulnerability and honesty with compassion rather than punishment. Lots of us didn’t grow up in homes that ran by these rules and the help we give our horses heals us a bit as well.”

Learning to see behavior as communication is a game changer. Pausing and creating space for a different response than our often ego-driven reactive patterns takes time and compassion for ourselves when we stumble along the way.  We probably won’t get it right all the time, but just noticing a response we aren’t happy with is the first step toward choosing something different in the future.

My little arabian colt Tru started biting when he was about 8 months old.  I noticed this behavior was most pronounced when I was up near his head and when I tried to halter him.  When attempting to put his halter on, he would swing his head around, grab it with his teeth, bite at the air, or if I was close enough, bite at me.  I worked hard to approach this behavior with curiosity and respond productively rather than reactively.  I suspected that his biting was actually an expression of anxiety.  I tried giving him a little more room, stepping back by his shoulder instead of up by his head.  I practiced breathing and waiting.  I worked on my patience.  When he took the halter in his mouth and held it, I said, “Ok, we can’t go out to the others if you won’t let me halter you.”  I left for a while and then came back and tried again.  I went slowly, paying attention to his signals that he was ready, or not ready, offering him a choice.  Slowly he became less reactive, less anxious and it was easier and easier to halter him.

He doesn’t bite anymore.  He is easy to halter and will often show me when he wants to come in by finding me and trying to put his head in the halter. Most of that change came because I worked on myself- responding with curiosity, compassion, and clarity.  Of course, it’s not ok to let a horse or a human walk all over us or push us around and depending on the situation, we may need to respond differently or more assertively.  But getting angry and reactive, going into “punishment mode”, ultimately damages the relationship, causing more harm than good.  We can keep ourselves safe by setting firm boundaries or creating and respecting a need for space while working to understand and ultimately change the behavior.  With Tru, I suspected the root cause of his “bad” behavior was actually anxiety.  By stepping back and giving him more physical space and time, he learned to calm his nervous system and we continued to build a relationship based on trust and mutual respect.

I have a colleague who set a beautiful example of seeing behavior as communication and responding to an angry colleague in a calm and productive way.  When a physician of a patient she had seen called her on the phone, raging out at her about some perceived infraction, she calmly said “Where are you?” and then went to talk with him in person.  She recognized his behavior may be expressing many things- a boundary violation she had committed unintentionally, a long stressful day, a lack of sleep, or perhaps even frustration with himself or the patient.  She showed up, listened intently with compassion, held her ground, explained her actions without getting reactive or angry in return.  The situation diffused, and I believe he respected her more after that beautiful example of true strength.

We are all capable of creating new ways of thinking and new patterns of behavior to become positive leaders for others in our lives.  Here’s to the long, hard, frustrating, and beautifully rewarding journey that is worth all of it.

Seeing Behavior as Information

As healthcare providers do you struggle with finding patience for your patients?  Do you find yourself increasingly frustrated with patients who don’t follow your advice?

Seeing Behavior as Information

From the middle of the round pen, I watched Blitz, a 28 year-old warmblood relatively new to my herd, frantically pacing back and forth, calling out to Monarch, “his” mare who was in the pasture just across the gravel drive, less than 20 feet away.  I had hoped to work with him on some simple exercises he would need to know to work with clients.  So far, I couldn’t even get his attention.  Two years ago, I would have let his anxiety spill over me, making me anxious, frustrated, disappointed, or worse, angry that we weren’t accomplishing the goal.  I would have easily gone to those dark places.  “Why can’t he just focus?”  “He shouldn’t be ignoring me!” “He’s not good enough…. I’m not good enough.”  But on this day, after a lot of work on myself, I was able to see things differently.  OK, he’s anxious, I realized.  I thought about vulnerability and the concept of vulnerability thresholds.  Pushing a little bit out of our comfort zone is necessary for growth- maybe a 4-7 on a 1-10 scale.  Pushing out too far – 8…9…10 – elicits panic.  Ahhh, I thought.  This is too much.  I’ve thrown him into the deep end of the water thinking we were in the wading pool.  Alright.  He’s not comfortable being 20 feet away from Monarch.  Ok. No problem.  We’ll have to build up to this.

Before taking him back to her, I decided to take just a few seconds to try a new breathing technique I had learned.  I grounded myself and made my breaths even and regular.   With every in-breath I imagined drawing in joy, love, and gratitude.  With every out-breath I imagined sending joy, love, and gratitude to Blitz.  I let go of expectations.  Blitz stopped pacing.  Slowly, he swung his giant head around to look at me.  I kept breathing.  He swung his body around so that he was facing me.  I kept breathing.  He took 3 steps toward me and stopped.  I kept breathing, my face in a huge smile.  He took a few more steps toward me until he was about 5 feet in front of me.  Ahhhh.  YES.  Good boy.  That’s enough.  You are enough.  I am enough.  This moment of connection with you is more than enough.

As a physician, I wonder what would happen if we took this same approach with our patients? What if, instead of focusing on the outcome- the hemoglobin A1C, the blood pressure, the cholesterol, changing code status- what if we instead focused on the process, the conversation, the relationship with the patient or family, and trusted that the rest would follow?  What if we simply saw behavior as information?

My patient is acting out angrily.  Did I or someone else in the healthcare system cross a boundary? Or Is this existential angst (anger at God, the universe, fate) and not about me at all?  

My patient seems anxious.  Is what I’m asking too much for her right now?  What effect does it have if I ask for something less or perhaps offer additional support?  What if I focused on being completely present with her in this moment, silently sharing a sense of calm support?

By approaching behavior with curiosity, perhaps we can avoid going down that rabbit hole of self-righteousness “they’re not good enough”, or conversely, self-loathing “I’m not good enough” because what WE wanted or expected for that patient wasn’t what we were getting in that moment.

By valuing the process over the goal – connection over perfection- we may even achieve the goals more often, with patients who feel engaged, empowered, and supported.

Of course, there will be patients who won’t meet us half way despite our best efforts.  Patients who are “non-compliant” and seem hell bent on destroying themselves no matter what we say or do.  But, what if we could simply stay present with them, see their behavior as information, and stay compassionate and curious rather than self-righteous and judgmental? As with Blitz, long histories, experiences, and relationships that we know nothing about are influencing their behavior in this moment.

What if we didn’t make it all about us?