I am wondering what your thoughts are on the following scenario: A patient comes to us with medical issues, but is also suffering from alcoholism. He has been hospitalized many times in the past for medical issues, most related to his chronic alcoholism. The patient has gone through detoxification many times at our facility, and when he is discharged he begins drinking again. The patient becomes combative during detoxification and is very verbally abusive toward the team caring for him. How do we ensure that we are not becoming angry and judgmental of this man and instead remain compassionate and caring for this human being who has entrusted us to care for him?
This is a tough one. You may be vomited upon, swung at, cursed at by a (momentarily, at least) raving lunatic. You don’t deserve this sort of treatment. The patient is being his own worst enemy. He is not participating in or cooperating with his own treatment. It’s maddening. How easy is it to have compassion for people whose own chronic behavior is the cause of their suffering and the suffering of countless others? In these instances, for many of us, judgment comes far more easily.
It may or may not help to know this, but each time you try to engage with this patient you join a very large group of friends, partners, and family members who have nearly caused themselves head injury from ramming into this same wall, over and over.
You have already taken an enormously important first step, in naming the problem. You didn’t name it “disrespect” or “rudeness,” even though those labels seem to apply. You named the problem alcoholism, and as soon as you used that word, answers began to emerge. Whether we like it or not (and certainly alcoholics don’t like it, and routinely deny it), alcoholics tend to have a few characteristics in common:
- They drink. (Hmmm….)
- They say they don’t drink. (or at least not excessively)
- When they have been drinking, they treat most people around them (including those they love) with utter disregard for human courtesy, much less love or respect.
- They neglect their health, eat badly, forget to eat or to take certain meds, yell, neglect many of their responsibilities, and act badly even toward people they really love.
- They manage to avoid seeing the writing on the wall.
- They drink. (Did we already say that?)
We mentioned “they drink” twice because it turns out that an obvious-but-elusive truth is contained therein. Quite naturally (but irrationally, as it turns out), we sometimes expect people to not be who they are. In an Al-Anon meeting, it is commonplace for new members to go on about the drinking and drinking-related behaviors of their partners. Usually everyone is quiet for a while, until finally one of the more seasoned members states the obvious: “Yup, drunks drink.”
For some, this is truly a revelation: not that their partners do indeed drink, but that the person living with this behavior is everlastingly surprised and reactive to the fact. Sometimes this is a moment of genuine healing, when a person decides to stop being surprised. This is not a moment of condoning the drinking (or the ensuing vomiting, missing work, or yelling), but a moment of deciding to stop being surprised and stop reacting.
We in health care are not spared this challenge. Alcoholism tends to come with certain features in addition to the drinking itself (see list above). Those features are as inevitable (and resistant to rational discourse, or health care education, impatience, irritation, or demand) as the drinking itself. These folks are going to be resistant, depressed, and withdrawn, and they’re going to be Olympic gold medal champs at denial. And, as if we needed this to be more confusing and confounding, they will also occasionally be incredibly charming, compliant, and articulate. At these moments, we are at great risk of imagining that the other characteristics we saw just a few hours ago are not inherent and therefore may not return. We think: This person can be all of the things we want him to be! At that moment, we just fell into the trap that the patient’s partner, family member, or friend has likely fallen into a hundred times.
So what’s the answer for the clinician caring for this person? Acceptance of our inability to make the patient behave better is a terrific first step. This can happen when we stop to wonder: Why is my patient acting this way? And then it dawns on us: She’s acting this way because that’s the nature of the illness she has. Hemophiliacs bleed. Alcoholics drink (and deny and argue and neglect their responsibilities and resist our care). At that moment of acceptance, we stop feeling obligated to take on the impossible work of changing the person’s behavior, and our frustration can ease.
From there, it gets easier. We’re less triggered, and we can focus on the few things we can do: to be attuned and compassionate, to hold, and to show genuine interest. We can accept this person for exactly who he is—a person suffering from alcoholism—rather than who we want or need him to be.
This doesn’t mean we start liking the behaviors being exhibited, and we may still find ourselves susceptible to irritation, dismay, and even disgust. But there’s an opening now, through which compassion might find its way into your heart and to your patient’s experience of you. While this won’t cure him, it might make you both able to cope just a little better and open the possibility of genuine human connection.
~ Michael Trout