I have trouble staying therapeutic when a patient is passive and his or her family member is aggressive and controlling. I find myself advocating for the patient, becoming a little defensive of my patient, and even subtly positioned against the family member.
It might be helpful to remember that you have probably just entered a family dynamic that has been operational for some time. You’re not going to be able to change it, and in the short time you interact with the family system, you may not even come to understand it. But it may help you keep frustration and/or aggravation low to hold in mind that you are probably witnessing a version of how things have been for your patient for many years. It is the right thing to attend to your patient, even to advocate for your patient. But don’t set as a goal straightening all of these people out before discharge!
Use wondering to see what you can pick up about this family dynamic into which you have just walked. Replace judgment or aggravation with curiosity about it. What makes it work? Who are the key players, and what are their roles? Is the patient always this passive, or is there something about the patient’s illness or the patient’s state (vulnerability, for example) that brings out those characteristics of passivity? Does this dynamic arise out of an unspoken—but very clear—agreement between the patient and family member about who gets to be in charge or who gets taken care of or who controls the “gate” into the family? Is the family member always this assertive, controlling, or intrusive? What function might such behavior serve for the family? As you wonder, remember that your aim is not to figure out the answers to these questions. Wondering is about wondering; it’s not about finding answers or reaching conclusions. Just stay curious.
Use following to knock the edge off the family member’s edginess (and your own, perhaps) by mirroring what the family member says. Use following to create a thoughtful question or statement: “I see that you’re very worried about whether I’ll be able to care for Pat. Tell me about your best experience in Pat’s previous care? Tell me about your worst experience! Oh, my. I see why you might be watching so closely.” Or: “I see why you might be worried that Pat couldn’t speak up well for himself.” Or: “I see why you would feel protective.”
Then use holding to reassure, to show respect, to show that you have “caught on” to the family member’s concern. If the family member is over-advocating, perhaps answering for the patient when the patient could answer for herself, use holding to state clearly why you need to speak directly to the patient or hear directly from the patient. As with other examples of using the therapeutic relationship, none of the above needs to take even a moment of extra time. It’s done while you’re doing other things in the room. It’s not done as add-on behavior, but as the center of everything else you’re doing with the patient.
~ Mary Koloroutis & Michael Trout
Wondering is a state of mind characterized by curiosity, openness, and acceptance—a joyful not-knowing and an intentional elimination of our own agenda. Wondering is supported by the actions of
- becoming empty,
- using wide eyes (ongoing assessment rather than resting on early conclusions),
- listening and watching with curiosity, and
- purposefully eliminating all barriers to the above.
Wondering happens when we have a devotion to the principle that the patient always has something to teach us, without which we cannot really do our jobs.
Followingis a series of intentional acts of devotion to being lead and taught by the patient and family. Following is supported by the actions of
- listening to, respecting, and acting on what we learn from our patients about who they are and what they want and need,
- paying attention not only to the patient’s words, but also to voice tone, body language, facial expression, and gaze (including eye contact or lack thereof), and
- continually adjusting our next caregiving act to align with what we are learning from the patient.
When we practice following, the patient experiences him- or herself not on a production line, but in the hands of people who are interested in learning how to provide specific care for each individual patient according to his or her needs and desires.
Holding is a conscious decision to lift up, affirm, and dignify that which the patient or family member has taught us, resulting in intense focus on the patient or family member, while treasuring both the information and the person. It means creating a “safe haven” for healing; one in which the person feels accepted and held with dignity and respect. Holding is supported by the actions of
- keeping confidences as needed and appropriate,
- remembering in specific acts of care, that which has been learned about the patient, the family, the culture, and the history,
- speaking of and writing about the patient and family—at change of shift report, in the hall, in notes—with dignity and an eagerness to transmit treasured information, and
- being a steady and nonjudgmental presence even in the face of strong emotional responses.
Each of the therapeutic practices, when practiced within a container of presence and attunement with the patient and family, creates the therapeutic relationship. Where we find presence, attunement, wondering, following and holding, we find authentic human connection. Where clinicians connect authentically with patients and their families, we have therapeutic relationships.
We are honored that you are participating in this vital work!
The See Me as a Person Web site exists to provide guidance to clinicians in all disciplines in creating, nurturing, and deepening their therapeutic relationships. Mary Koloroutis and Michael Trout, authors of the book See Me as a Person, mentor site visitors in the practical therapeutic arts of wondering, following, and holding on behalf of patients and their families—all within a container of presence and attunement.
We invite you to share your questions and challenges with us as you strive daily to bring authenticity and deep connection to the relationships you create with the patients and families you serve, even within today’s highly technical, fast-paced, time-constrained, and frequently chaotic health care environments.
“May I see in all who suffer only the fellow human being.” Oath of Maimonides