Posted By Margaret Peterson,
Thursday, May 3, 2012
A month or two ago I was accompanied into a consult by a young woman who was training for a new job as a behavioral health consultant at a clinic elsewhere in the city of Philadelphia. The consult was an integrated care visit, which meant that we entered the exam room knowing nothing but the patient’s name and date of birth, and with the agenda being to explore behavioral and psychological factors that might be affecting the patient’s health: diet, exercise, substance use, depression, anxiety, trauma.
The patient was a middle-aged man who turned out to be a rather colorful character—flamboyantly gay, with a long history of polysubstance abuse and a range of other health issues including infection with HIV. He and I were quickly absorbed in conversation about his concerns and his goals for his health, some of which were more conventional (adherence to his medication routine) and some of which were less so (getting back in touch with a "hormone doctor” who had been helpful to him in the past).
the provider arrived and the consult was over. I left the room with the
woman who had been observing me, whose presence I had more or less
forgotten about in my focus on the patient. "Well, that was
interesting,” I remarked. "It certainly was,” she agreed, fervently.
Something in her tone of voice made me realize: she had been a little
startled by this patient. Her reaction shed a sudden light upon my own: I
had responded to this patient as if he were an old friend.
Every patient needs
and deserves welcome and safety, even—perhaps especially—the ones for
whom empathy might not come automatically.
Where did this come from? It came, I realized, from my experiences at the Duke University Infectious Diseases Clinic in the early 1990s. My late husband was a patient there, and practically every other patient was a flamboyantly gay man. This was back in the day when there wasn’t much of a welcome mat anywhere for people who were gay or HIV-positive, and one of the things that distinguished the Duke ID clinic was the absolutely unconditional welcome extended to people who were either or both of these.
I was extraordinarily grateful for the care that my husband and I received at the ID clinic. At the same time, it was unnerving to find myself surrounded by the clinic’s other patients, many of whom were (like my recent patient) very colorful characters with complex psychosocial histories, and (superficially, at least) not at all like me. "What on earth am I doing here?” I would think. "How is it that I belong here, in this place, with these people?” It felt like I was normal and they weren’t, and I wanted out.
What I grasped only dimly at the time was that I was no more or less unique an individual than anyone else at the clinic, and the same unconditional welcome that was extended to everyone else was extended to me. There was no comment and no criticism; only curiosity and empathy and a desire to be of help. And it changed me; and one specific way it changed me was to create in me a deep sense of kinship with individuals who (like my recent patient) remind me of the clinic and its patients.
In a broader sense, I find that experience at the Duke ID clinic informing every aspect of my new work in behavioral health. Behavioral health is all about welcoming; it is about creating a safe space in which the patient feels confident that he or she is cared for, and thus feels free to explore issues that may feel overwhelming or scary, whether those have to do with symptoms ("I’m in pain all the time”) or risk factors ("I know I need to quit smoking”) or relationships ("I’ve had so many losses in my family recently”).
Sometimes creating this safe space seems to happen very easily. The other day I entered an exam room to find a woman in her 30s who a few weeks earlier had come in complaining of severe situational stress and anxiety. The doctor had prescribed an anxiolytic and invited her to come back for a followup visit in a month. She hadn’t taken much of the medication, she reported, but she was feeling much better. "That sounds like a big change,” I said. "How has that happened?”
She wasn’t sure. Externally, things were much the same: the job, the kids, the busyness of life. "But I’m not stressing about everything,” she said. "I just let it go. And I go out with a girlfriend from work, and we go shopping.” "It sounds like the beginning of the change might have been your decision to come to the doctor,” I said. "And then the doctor responded supportively, and that was enough to help you make some different decisions about how to handle your stress.”
"Yes,” the patient said, thoughtfully. "I guess that’s exactly what happened.” As if on cue, the provider entered; I summarized our conversation and left the room. It had been a straightforward and enjoyable consult: the patient was resilient and had already reached out for and received some of what she needed and had made good use of it, she had been ready to relax into the opportunity to explore the sources of her increased well-being, and the connection between provider and patient had been enhanced.
Other times it’s not so easy. Later that same day I saw another patient, a man in his mid-twenties, at the doctor for a routine checkup. He was handsome, personable, and in apparently perfect health. He was also unemployed and uneducated beyond high school. Mostly, he just watched TV and went to the gym. "What would you identify as your primary goal for your life or health?” I asked. "Oh,” he said, "I want to have kids and grandkids, with some kind of check coming in—disability, whatever.”
"What???” I thought (but did not say). "You are smart and strong and 25 years old, and you actively aspire to be on disability? What is wrong with you?” In that moment, I was not feeling empathetic, or welcoming, either. Somehow I managed to stay with him. He wasn’t proud of his lack of ambition or accomplishment, he said; in fact, he was troubled by it. He hadn’t done anything bad with his life, but he hadn’t done anything good, either; years were going by, and he had nothing to show for them.
"If you did have an interest in something, what would it be?” I asked. His eyes lit up. "I love trains!” he said. "Not subway trains. Real trains, big ones.” And then he returned to the subject of his inertia in life. "I need a drill sergeant,” he said, fretfully. "Someone who will tell me what to do and make me do it. My mom made me work in high school, but since then I haven’t had anyone to make me do anything. I think things would be different if I had a drill sergeant.” He paused for a moment. "Or maybe if I had a father.”
All of a sudden I saw before me, not a 25-year-old man, but a six-year-old boy, a boy who loved trains, and who had no father to show him how to be a man. No wonder he had been unable to grow into adult achievements and responsibilities. No wonder he longed to be himself a father and a grandfather, yet had no idea how to integrate those roles with other aspects of an adult identity. What might help him develop into a fuller sense of himself and a greater ability to reach more of his potential?
"Have you ever had any outpatient psychotherapy?” I asked. "Do you know what psychotherapy is?” He hadn’t, and he didn’t. I offered a few words of explanation: "Children need certain things from their parents when they’re growing up, and if they don’t get those things, it can be very difficult for them to move into satisfying adult lives. Psychotherapists work with people who didn’t get what they needed when they were children, and help those individuals grow up and into more of what they want as adults. There are outpatient clinics where psychotherapy is available, and if you were ever interested in this, we would be happy to refer you.”
Before I was half done with this speech, the provider entered the room. She waited while I finished, and then I rose and took my leave. Of course I hope that this patient got some small piece of what he needed in our conversation, and that perhaps some day he will get more of what he needs in the context of some other relationship, perhaps even in therapy. What I got from our conversation, though, was a reminder: every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.
Peterson, PhD, is a student in the master’s program in Marriage and Family
Therapy at La Salle University in Philadelphia. She is doing an internship in
integrated behavioral health at Fairmount Primary Care Center, under the
supervision of Suzanne Daub, LCSW, Director of Behavioral Health for Delaware
Valley Community Health.