A Therapeutic Sighting: “What do I need to know about you as a person to give you the best care possible?”

Canadian palliative care experts increase empathy in caregivers by instructing them to ask one simple question—what they call the PDQ, or Patient Dignity Question—that helps them see each patient as a unique individual. Clearly it’s an idea whose time has come: Knowing who our patients are as people is fundamental to our ability to care for them…as people.

Enjoy this beautiful article:

PDQ photo

Q & A: A Container of Presence and Attunement

I see that you use the phrase “container of presence and attunement” but find no related definitions of the words/concepts used here on the website. Perhaps these are unpacked and even fully defined in the book—though their usage doesn’t seem to aim at proper definition but, rather, function, or reference to related concepts. Is there a specific discussion of this written somewhere, or are all therapeutic practices simply considered as ensconced within these overarching principles?

Michael-Trout-150x150You’re entirely right. We do use these terms in functional ways, leaving the reader without a clear definition of terms. Maybe I can help.

Perhaps you were blessed—as I was—to go to a small-town grade school that featured roll call each morning. On the face of it, it was merely an exercise in seeing who showed up. But smart teachers knew that this was actually a rich question, the child’s answer to which would help the teacher to know what sort of day each kid was going to have: Who is here? Who is present?

So she went down the list of students from her secret book, and each student was obligated to respond: “Here!” or “Present!” (Those who were not there were not obligated to respond at all.)

This was the first community act of the day, and the best teachers retrieved huge amounts of information from the children’s one-word responses. She paid attention to intonation, eye contact, posture, attitude, timing—even slumping shoulders. She wanted to know: Who is really here today? Is Bobby present? Or is he distracted with thoughts of his parent’s screaming at each other this morning at breakfast? Is he so hungry he can’t bring his body up to speed so he can be fully present? Is he ready to work, to engage, to be with his peers and with me?

This is what we mean by Presence: the act of bringing one’s full attention to the present moment.

Presence is often noted in behavioral terms: eye contact, attention, en face positioning, alertness. But one can be present in the absence of one or more of these typical behaviors because presence, at its core, is a state of mind with respect to another. Lovers can describe when the other is present, even when they are not directly attending to one another. (Lovers also know it when the other is not there.) A mother may be, from time to time, fully present with a baby still inside her, unseen (technically), but deeply seen (energetically, spiritually).

It turns out that we each change when another being is present with us. In laboratory experiments, toddlers perform much better at problem-solving tasks when a parent is in the room and attending than when a parent is absent or is in the room and reading a newspaper. (Take a look around any restaurant and notice the behavior of children whose parents are utterly non-present, preoccupied with their cell phones.) Adolescents dare us parents to be present with them, while not talking too much, asking too much, or interfering. Adults report more optimism and are more creative in their own problem-solving and self-management when they experience that another is present with them.

Attunement—a word we often use in conjunction with Presence—is something quite different. While presence is nearly always a prerequisite to attunement, they are not the same thing. Attunement is a step forward: a conscious act of aligning with another, getting ourselves out of the way, attending to the nuances of the other’s affect and speech, “catching on” to what the other may be saying (even when they’re not saying anything, with speech).

A heart cell on a microscope slide does it when it begins to match the rhythm of the heart cell of another placed on the same slide. Premature twins in the NICU do it when they are placed beside one another in the same isolette, while each begins to calm and their respirations move into synchrony. Human brains do it during a conversation in which one person feels uniquely understood by the other, when they “click.” And we do it with our patients (or with their family members) when we move ourselves into a physical and mental position to be able to catch on to their state of mind. Empathy is the usual result for us, and an experience of joyful connection is the usual result for the patient.

Perhaps the best definition of all can be found by looking at your own experience. Do you know when someone is present with you and when they’re not? Have you had an experience in which someone was exquisitely attuned to you?

Let’s keep this conversation going. Perhaps other readers will contribute their own definitions of these two terms that have found their way into our lexicon of caregiving.

~ Michael Trout