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.
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.
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.
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.
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
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.
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.
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.