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Untold Stories

Posted By Margaret K. Peterson, Tuesday, November 29, 2011
Updated: Saturday, December 17, 2011

When after a dozen years as a college professor I went back to school to get a master’s degree in marriage and family therapy, a primary motivation was my desire to spend more time listening to other people’s stories, and to do a better job of responding to those stories in healing and helpful ways. Now, a couple of months into my internship in integrated behavioral health, I’m listening to lots of stories, and I hope I’m responding helpfully, at least some of the time. But the impression I take away from many of these encounters has less to do with the stories I hear than with the ones I don’t.

One day a few weeks ago I knocked on an exam-room door and entered to find a pleasant middle-aged woman who, it came out, suffers from chronic pain related to osteoarthritis and exacerbated by obesity. Our conversation centered on her ongoing efforts to exercise and to lose weight. After our visit I pulled up her chart and found a note from a previous behavioral health consult, detailing the patient’s insomnia and the relaxation techniques that had been suggested to her, along with a recommendation that behavioral health follow up on this at the patient’s next medical visit. I had failed to ask this patient about her sleep, and as a result had heard nothing about it.

The next visit of the day was with another middle-aged woman, a hostile one this time. She didn’t want to talk, she said; she just wanted her meds. Before I could leave she changed her mind: "What do you want to know?” I listened as she told me about her hopelessness, the granddaughter who constitutes her primary reason to want to live, her opinion of the antidepressants she had been prescribed in the past (Seroquel worked okay; Zoloft was "like candy”) and the marijuana she uses to stimulate her appetite (it "doesn’t count as a drug”). After our visit I pulled up her chart: "Cocaine abuse disorder—chronic.” I hadn’t asked; she hadn’t told.

The next visit was with a man, irritable from pain, who gradually became more animated as he detailed his complex medical problems and his regimens for dealing with them. He seemed a little odd, but nice enough. Also oddly, he seemed to share various of his problems with someone else: "We have insomnia,” he informed me. "We have sleep apnea.” After our visit I pulled up his chart: "Patient seems somewhat grandiose,” read the note from a past behavioral health consult. "Refers to himself in the first person plural.” Note to self: when patient seems odd, consider asking more questions.

But then there are the stories I don’t hear, not because I don’t think to ask, but because behavioral health’s focus on function (rather than, say, history) requires that I not ask. There was the woman who, when I inquired about her use of alcohol or drugs, said, "I gave all that up when I went into the shelter.” That turned out to have been ten years ago, and we ended up talking about how she had managed to stay clean and sober for ten years (no small achievement for anyone). But I longed to know more about the shelter, and what had happened ten years ago that had required that she go into it. But there wasn’t time; I didn’t ask.

Another woman had gained a great deal of weight during an unhappy period in her life, but was now in a better place and was gradually losing the weight. Toward the end of the consult, almost in passing, she mentioned the recent deaths of two sisters. There were now ten surviving children in the family; there had been twenty, "all from the same mother and father. I’m the baby girl, and I’ve got a younger brother.” It was all I could do not to turn over my behavioral health questionnaire and start drawing a genogram. What were the ages of all these siblings? Had there been sets of multiples? What about her parents? What were their stories? Of course there wasn’t time. I didn’t ask.

And then there was the man, twitchy with anxiety, beset with suicidal thoughts, homeless, wanting a referral to a psychiatrist so he could get restarted on his psych meds. Until recently he had been in prison for an assault on a relative; now no one in his family would speak to him. I assessed his suicidality, conferred with my supervisor and the clinic social worker and his physician, got him his referral and some medication to tide him over. But what I really wanted to know was, how had this man been elected to be his family’s scapegoat? How had he ended up as the crazy one, the violent one, the extruded one? Of course there wasn’t time. I didn’t ask.

            The reality is that in integrated behavioral health (as in primary care more generally) there are two time frames in view. The first is that of the individual visit, which is almost always short. The second is that of the patient’s lifetime, which one hopes will be long. Ideally, integrated behavioral health providers see patients periodically over the course of their lives. But in any individual visit, time is limited. It’s like opening a book and reading one page, or at most two. You don’t get to read the whole book—there’s not time. You talk with the patient about his or her story as you’ve glimpsed it, and you hope to hear more at some future time.

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