Q & A: Acceptance vs. Judgment

NOTE:  Through a happy coincidence, Michael and I worked on answers for the same question at the same time. The next two posts are in answer to the same question.  We think you’ll find that we’ve taken very different routes to the same conclusion!
~ Mary Koloroutis

QUESTION:
I read in See Me as a Person that [the therapeutic practice of] “wondering…is accepting not judging.” How do we do that when sometimes we’re just flooded with judgment?

ANSWER:
Michael-Trout-150x150Of course we are! We’re human beings with our own experiences (which have led us to create narratives about how the world is supposed to work), our own values, even our own thoughts/dreams/expectations about how people (including ourselves) ought to behave.

So let’s just get this part out of the way:  judgment is natural.  

You won’t be shot for it, and doing it (judging) doesn’t make you a lousy nurse (or doctor or aide or dietary worker or…). Being “flooded” (what a great word you chose!) merely means that your story about the world—or your values—is, at this moment, being sorely challenged, if not violated, by the person in front of you. Something inside is screaming:  “No!  You’re not supposed to act that way!” or “Do you not see how stupid that behavior/point of view/attitude is? My dad taught me that only low-life [or ignorant or thoughtless or unprincipled] people think (or act) like that!”

But it turns out that many of the things we normally do or feel—while completely understandable and quite acceptable in everyday life—are counter-productive in health care. Judging of other folks is one of them.

Our work is a “discipline”; it calls for us to do not what comes naturally, but what is called for in the situation.

The surgeon may like to wear a particular perfume (or dangly jewelry), and does so in everyday life. But she has learned that this may not be in the best interests of the patients she treats. Some may have allergic reactions to the perfume, and there’s always a risk that a piece of jewelry will fall into a body cavity or otherwise get in the way of the surgical work she is called upon to perform today. So she goes against what she wants to do, what she normally does, what is most comfortable for her to do, because the best interests of the patient call for it.

Feeling judgment about the behavior or attitude of a patient or family member comes naturally to us. But we know that when judging begins, wondering stops. And when wondering stops, so stops our discovery of this human being we’re treating. When discovery stops, everything stops: data-collection, catching on to the nuances of the disease, our capacity for empathy. We stop having fun, and we stop having a relationship.

If we want these things, we will begin with accepting ourselves as health care people who, like all other human beings, have the impulse to judge. Then we use a quiet momentary meditation to re-focus ourselves on the task at hand and the person in front of us. We don’t have to like this person,  but we do have to connect with him, because this is the way healing works.

I volunteer at a women’s prison in a program for mothers. These women have done nasty stuff. In the process, they hurt lots of people around them, not the least of which are their own children, who are now without parents, as many of the dads are in prison, too.  Several of them in my group have had babies while they are in prison. Nobody gets out of this unscathed.

But I go there to listen. I go there to see if there’s any way on earth to mitigate the damage to the lost children of these moms. I go there, in other words, for the same reasons you go to work at your hospital or clinic every day: because that’s where the sick people are. They probably know I judge them; after all, they can’t help but notice the big difference between the nice suit I show up in and the crummy prison garb they show up in. As we begin, it seems that the only thing I have to give is wonder. Where did you come from? What’s your greatest fear about what is happening to your kids? Why—no, I mean, really why—do you keep making the same mistakes over and over again? If I ask these things while judging, I get nothing. If I ask them while wondering, I get stories—gut-wrenching, real stories that actually do throw some light on the problem. In the telling of these stories, the prison mothers begin to hear themselves; they begin to discover answers, and they begin to imagine what it would be like to live differently—for the kids, at least, if not for themselves.

I walk away from that place changed, every time. I’ll bet you do too, when you’ve had a day in which wonder replaced judgment, if only for a minute.

~ Michael Trout

Q & A: Acceptance vs. Judgment

QUESTION:
I read in See Me as a Person that [the therapeutic practice of] “wondering…is accepting not judging.” How do I do that when sometimes I’m just flooded with judgment?

ANSWER:

It ain’t what you don’t know that gets you into trouble.
It’s what you know for sure that just ain’t so.
~ Mark Twain

Mary-Koloroutis-150x150I love your question because it lifts up this mammoth challenge for all of us. It is simple to say “be accepting, not judging” but it’s so very hard to do! We are judging creatures; in fact, in a way, our brains are wired to judge (Damasio, 1994, 2003). We have been blessed with the capacity to take in information and use our minds to integrate it, synthesize it, and attach meaning to it. Much of this happens in moments. We see patterns and we perceive and interpret the patterns based on our experiences and our knowledge. We are also social creatures and are prone to connect easily with those who seem similar to us and prone to withdraw from or reject those who seem very different. So the problem with relying too much on our automatic and habitual responses becomes quite clear. If we rely on automatic judgment, we are likely to leap to conclusions and think we know things that “just ain’t so.”

Once we are clear that this phenomenon is automatic in all of us, we are in a better position to activate a more mindful (less automatic) process—one which develops our capacity to recognize and suspend judgments; to consciously be open and curious. This, in turn, facilitates our ability to continue to take in data and information and to learn about the unique person in our care.

I think about this in two parts: first is clarifying why it is important to suspend judgment, and second is how to suspend judgment.

Why it is Important to Suspend Judgment

Most of us have learned in our professional training that we need to be “nonjudgmental” in the care of our patients. This teaching is based on the fact that we will and do care for people from all walks of life—all ethnicities, cultures, socioeconomic backgrounds—people who may be very much like us and people who are very different from us. Some of these people could potentially be our friends—or maybe our enemies. Some of these people may be pleasant and cooperative and grateful, and some may be tenacious and irritable and rude. Some of these people will make “good choices,” follow our instructions, and engage actively with us in their care, and others will seem to be doing everything they can to undermine their own health. There are people who inspire us and people who frustrate and confound us. We have been taught (or at least told) to see them as individuals, accept them where they are, and to suspend judgment. Is this just pie-in-the-sky?—great in theory, but not practical in reality? Is it a reasonable expectation?

Consider these three “whys” as you seek your own answer:

1. Suspending judgment is fundamental to the scientific method. When we leap to judgment, we shut down our ability to take in data and vital information. We become anti-scientific, and we compromise safe care.

2. Suspending one’s own judgment is the only way to understand others on their own terms. Practically speaking, we have too much white noise going on in our minds when we are judging or “think we know” to open and listen and take in what we’re hearing. It is only through understanding and connecting with the other on their own terms that we have a chance to partner with them and help them cope and take ownership for their healing and recovery.

3. Suspending judgment is an inherent responsibility in our role as clinicians. Maria Bellchambers, in the opening chapter of See Me as a Person describes how this teaching was ingrained in her as a young student nurse in war torn Ireland (pp. 25-27). Her teachers prepared her to be able to provide care for the very people who may have tried to hurt members of her own family and who would be disparaging to her, simply because her name is Maria which marked her as a Catholic. Her teachers prepared her to fulfill the sacred trust inherent in her role as a nurse. In order to remain open, she mindfully wrapped herself in a “cloak of dignity.” This cloak symbolized the responsibility for the sacred trust she accepted in becoming a nurse and helped her stay true to her commitment.

These are the “whys” that inform my thinking. I encourage you to reflect on your own compelling reasons to stay out of judgment. It is only when we are anchored in our own values and beliefs about why it is important to suspend judgment that we can develop the discipline to mindfully release our habitual patterns of judgment.

How to Suspend Judgment and Accept Others Where They Are:

The steps to suspending judgment and accepting others are pretty straightforward. They become easier with time and practice.

1. Notice: I appreciate the fact that you describe being “flooded with judgment” at times. When we are flooded, we are much more able to notice and take responsibility for our judgment. (It is when our judging mind is subtle, and more nuanced that it can more easily go unnoticed.) Be easy on yourself when you notice your judgments. Letting go of self-judgment is fundamental to noticing and releasing judgment of others. As you notice, mentally shift your heart and mind to a state of openness.

2. Release: Mindfully let go of the judging thoughts.

3. Make a new Choice: Choose to attune to and wonder about the person in front of you. Remembering that everyone has a back story allows you to stay open to learning what you need to know to care for this unique person. When behaviors are challenging, wondering helps us shift from seeing behaviors as unacceptable (and a reason to judge) to seeing behaviors as a source of information about this unique person and what he or she is going through.

~ Mary Koloroutis

References:
Damasio, A. (1994). Descartes’ error: Emotion, reason and the human brain. New York: Quill.
Damasio, A. (2003). Looking for Spinoza: Joy, sorrow and the feeling brain. Orlando, FL: Harcourt.
Koloroutis, M & Trout, M., (2012). See me as a person: Creating therapeutic relationships with patients and their families. Minneapolis, MN: Creative Health Care Management.

Q & A: A Container of Presence and Attunement

QUESTION:
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?

ANSWER:
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

Q & A: Patients with Chronic Pain and Med Intolerance

QUESTION:

For me, the biggest challenge to staying therapeutic is patients with chronic pain who are highly medicated, highly drug-seeking, and have great tolerance to medications—especially patients who rate their pain high at “20 out of 10” and yet are moving around as if they have no pain. I’ve had patients who want meds to sleep, yet they drink coffee all day and into the evening. This is not something that’s going to change among my patient population. What could help me stay therapeutic in these encounters?

ANSWER:

Michael-Trout-150x150I feel my own judgment of your patients rising, even as I review your poignant question. I was raised with the idea that there was nobility in managing one’s suffering, including physical pain. To complain—much less to use drugs to manage discomfort—was to be weak. So much for growing up in rural Indiana, with Depression-era parents!

But the truth is that pain often brings on regression. We want someone to make it better, and we return to earlier developmental stages in our lives: when we cried and cried and no one came; or when we learned that the only way we could arouse attention or empathy from others was if we made a great deal of noise; or when we concluded that no one was reliable (including ourselves) and that drugs provided a way out of the limbo of impotence and passivity (now there’s an irony!).

As clinicians, we have certainly learned that not much teaching actually sinks in when people are in a regressed state. We have seen how little value there is in telling someone who is rating his pain “20 out of 10” that this is impossible; or that it’s a little silly to drink coffee and then demand meds for sleep; or that we think they have had enough of one medication or another.

We have also learned that we’re unlikely to change longstanding personality traits or medication habits—much less addictions, or proneness to complaining—during a brief hospital stay.

So what in the world can we do?

What happens when we return to wondering? Remember: wondering doesn’t mean searching for answers. Sometimes answers come, and sometimes they don’t. The point of wondering is never to solve the problem; it is to alter our own state of mind with respect to the patient and with respect to the issue. Wondering helps us to detach a little, replacing annoyance or judgment with curiosity—replacing a judging mind with an open mind. Just as we would when our own little child declares absolutely that he’s “dying” after falling off his skateboard and scraping the dickens out of his leg, we find ourselves smiling just a little, displaying a tiny bit of empathy, and responding, “You are?! Oh, my. I hope not!” as we go about the task of fixing him up. We don’t argue or judge or even engage, really—except in the detached, but compassionate way that enables us to apply some immediate care.

So what if our response to the “20 out of 10” response to the pain rating inquiry were: “Whoa! That’s a lot of pain!” And that’s it. No judging, no arguing, no didactic lessons, no re-orienting the patient to “reality”—just acknowledging the patient’s relationship to his or her own pain in a way that suggests we are open, curious, not necessarily convinced, and still right there, present and attentive to the person in front of us.

What if our response to excessive or irrational use of—or demand for—pain or sleep meds were simply to sit attentively with the patient and ask for more information—a sort of open-ended curiosity about the patient’s experience of injury and pain. Oddly, since both children and regressed grownups rev up their greatest neediness and demandingness when they think they are going to be denied what they want or need, our very act of open-minded interest may take the edge off the ferocity and irrationality of the patient’s request. Maybe the bottom-line need was merely: “I want someone to know how much this hurts,” or “I need someone to catch on to how scared I am about not being able to sleep…(or about my surgery in the morning).”

Try this, and let us know what happens. Remember: The wondering has to be genuine. The open-mindedness has to be real. Just as our children catch on quickly when we’re faking it (or using a strategy on them), grownups in pain will not respond if we’re just “managing” them.

It would be cool, wouldn’t it, if our jobs got easier and the patient felt better, if we showed genuine understanding of their predicament, while not reacting too much to their declarations and demands about pain.

~ Michael Trout

Q & A: “Beyond the Ability to be Soothed”

QUESTION:

At times I feel as though when a patient or family member expresses anger it is often too late to soothe the situation. Listening can often help, but it’s not always enough. What would a therapeutic relationship even look like when one person is angry beyond the ability to be soothed?

ANSWER:

Michael-Trout-150x150We’ve talked about anger often in this column, and in the book, so I won’t rehash all the principles. Besides, you seem to be saying there are situations when things have escalated so far that it would seem ludicrous to use Wondering, Following or Holding. In fact, it might seem laughable to you, at the moment, for someone to suggest that you pause to wonder in the face of a patient or family member who is threatening or who has resisted all other efforts at calming.

So I’ll just mention one little trick that is sometimes useful when things have gotten quite out of control: affect-matching. We don’t do it as a replacement for wondering, following or holding. It is not an excuse to fail to be present, and it is not an invitation to fail at attunement. Indeed, it may be that this little trick amounts to all of these principles, on steroids!

What is it?

We would all know better than to approach a calm, serene patient going into surgery, and shout instructions to him: “YOU’RE GOING TO BE FINE! JUST LIE THERE QUIETLY AND THE DOCTOR WILL BE HERE SOON, AND THEN WE’LL BEGIN THE CUTTING PART!”

We would all know better than to enter a patient’s room—let’s say there are also four or five family members visiting, all looking somber—with a tutu on, happily dancing and careening around the room. Even when we feel like dancing—even when we think the patient would feel better if he could just rise up out of that bed and do a jig or two—our cute little outfit and truly great moves, don’t quite match the tone of the room.

Ditto when we enter a space with a seriously angry patient or family member. Calmness, sometimes, is as much a mismatch with the tone of the room as a tutu. When we decide to match the affect of the other, we simply decide that the best acknowledgement of their state of mind, at the moment—and, as far as they’re concerned, the best acknowledgement of their problem—is expressed when we match the affect of the loudest person present. “OH MY GOODNESS! I CAN SEE THAT THINGS HAVEN’T BEEN GOING WELL HERE!” may, oddly enough, feel comforting to the angry patient or family member. Somebody gets it. No one is trying that “Calm down” routine on me. This clinician really cares! (And please note, the clinician has consciously followed, rather than contradicting the patient or family member.)

If all the remarkable literature on co-regulation (see See Me as a Person, especially pp. 62-73) is right, then such affect-matching creates the potential for us to eventually turn down the volume and intensity of the other’s anger much more easily. We begin right with them—not trying to get them to calm, but actually matching their state, while remaining in control of both our own emotions and the situation—and then we slowly turn down our own volume and intensity. If we’re lucky, the patient or family member follows.

A caution: We must be in control. We don’t run into the room shouting because we’re triggered. We don’t give anger for anger; we’re matching the person’s affect, not his or her emotional state. We simply respond with empathy and understanding spoken in a way that matches the voice tone and affective intensity of the angry patient or family member. Then we begin turning it down. It’s not done much in polite society. Hospitals, of course, are not “polite society.” People there are in a world of fear and hurt.

~ Michael Trout

Q & A: Engaging the Family: An Inquiry from Brazil

QUESTION:

I am a nurse, and I coordinate the care team of a hospital in the city of São Paulo, Brazil. Last year we had wonderful experiences when you provided the Therapeutic Relationship workshop at our organization. After that we started to hold organized meetings with the families of the patients who were hospitalized in the Intensive Care Unit and clinical/ surgical units. The purpose of these meetings has been to bring these families together with the caregivers in order to take care not only of their health but also to meet their needs and build better relationships. Although it’s not a common practice in our hospitals in Brazil, the results have been excellent, bringing many opportunities, but it is not always so easy to make the families understand our purpose or to get at the point we want. Sometimes the conversations are more superficial.

What could we do to help these families feel safe enough to engage therapeutically?

ANSWER:

Mary-Koloroutis-150x150We’re very excited about the work you’re doing, and we look forward to hearing more about how your meetings with families are impacting care and the overall patient and family experience. Partnering with the family during the rush of daily care can be challenging (though very rewarding). Finding a way to intentionally partner with families in a planned meeting for the purpose of engaging them in a dialogue about what matters most is a brilliant and proactive intervention. We offer the following thoughts and tips in the hopes that they will be useful. Let’s begin by remembering that every therapeutic encounter has a beginning, middle, and end.

The Beginning: Meeting

Paying attention to the beginning is important to set the stage, clarify the purpose, and establish a sense of safety. Some beginning tips include the obvious such as having every member of the team and the family members introduce themselves. You may also want to establish “agreements” that may be helpful to assure safety and freedom of expression. Some examples of agreements are: begin and end on time; protect privacy; honor confidentiality; and prevent unnecessary interruptions. Prepare yourselves to be fully present and attuned. Prepare to listen, see, and give your undivided attention. Remember that for many people, the hospital setting is foreign and even intimidating. Tending to their safety and comfort will facilitate trust and more open expression.

Clarifying your purpose is important to engage the family and to ease any anxiety. If the goal of the interaction is to better meet their needs, you might state it as, “We’re here to learn more from you about how we can support you during this difficult time.” Then express your sincere interest in what they’re going through.

The Middle: Connecting

The conversation with the family is facilitated by wondering through open-ended questions:

• What has your experience here been like so far?
• What worries you most about your loved one’s condition?
• What is on your mind right now about your loved one’s care?
• In what way has your loved one’s illness affected your life?

You want to convey the message: “We want to understand your experience better so that together we can partner to be as proactive as possible.” However, this message is best conveyed by demonstrating genuine interest rather than stating it as an objective.

Once the answers start flowing (even if the flow is more like a trickle) your job is to follow what you are being told. Following is the act of hooking into the last thing the person says (or sometimes doesn’t say) and making your next question or comment follow what the family member is teaching you about his or her experience. When following, you find yourself interested in learning all you can about the other’s experience. Your focus is on the person, and your curiosity and openness encourage the family to let you know honestly what is on their minds. In this way, we honor and respect what the family is teaching us by making it quite literally the most important information that anyone in the room is able to provide. This therapeutic focus empowers the family to truly make a difference in the patient’s experience and in their own. It is a contrast to the very normal feelings of helplessness that are a common human response for the family members of people facing illness and injury.

Following can be verbal or non-verbal. Sometimes the best following is the act of letting the emotion expressed by the other register on your own face, or uttering an empathetic sound, or simply offering your quiet, attuned presence as you wait and listen for the person to continue. Here is some language that may help you follow:

• Tell me more about…
• When you said…, I wondered…
• What else will help us understand how your loved one cope’s with …
• Is there more about…that you’d like us to know?
• OR simply convey nonverbally and by quiet waiting that you are here to listen further

The End: Transitioning

The ending provides a structured way to clarify understanding, receive feedback, identify any next steps, and determine if there is anything further required before ending the encounter. An effective way to close the time is to ask everyone present, “What one or two things have you learned or are you taking away as a result of our time together?” “Checking out” in this way assures that every voice is heard, and in particular, that the family members know they have been heard and that any necessary actions are clearly articulated and implemented.

If you create a structure (beginning, middle, and end), stay attuned and present, and consciously practice wondering and following, the family members will feel respected, safe, and held in your care. When your deepest intention is to build relationships with family members and to learn from them so that you can provide better care for their loved one, your deep intention creates the space for true partnership. This kind of relationship, one built on respect and proactive engagement, will assure that the patient and the family receive extraordinary and compassionate care.

~ Mary Koloroutis

Q & A: Nurse Sometimes Feels Like He’s Acting

QUESTION:

We’re working on creating therapeutic relationships with each patient. One nurse noted that he feels like he’s “acting” with some patients, so that he can best communicate with them. This is a problem when he has two patients in the same room, because he’s afraid that they will sense his different behaviors with them. How do you develop authentic relationships in this circumstance?

ANSWER:
Michael-Trout-150x150We love this question! I surmise several things about the nurse on the floor, as well as the person who poses the question, all of them noble (so disabuse me of my fantasies, if I’m wrong!):

• If this nurse is worried about “acting,” then it must matter to him to not appear so. This suggests to me that authenticity is important to him. He must be highly sensitive to his patients’ perceptions, since he wouldn’t know the difference, if he were not.

• If you and the nurse you describe are concerned about two patients who are sharing a room noticing different interactive behavior between him and each of them, this suggests that his behavior is different with each, which implies that this nurse’s behavior is actually being guided by each individual patient. Hurrah! This is the natural result of attunement and following which are, by definition, highly individualized acts.

I wonder if the nurse’s worries about “acting” arise in part from inexperience with such intensely individual interactions that are based exclusively on the needs of the other. In a sense, the sort of interactions that characterize a therapeutic relationship are unnatural. They are not social, so they don’t feel like how we talk to a friend or someone at church. The therapeutic relationship is like no other. It serves only the other person. The words out of the clinician’s mouth are guided by—indeed, formed in response to—the last thing the patient did or said. Such a relationship is intense, but not intimate in ways already known to us. Where else in life do we get to practice this unusual way of connecting with another human being?

I wonder if an exercise would clarify things a bit. What if you asked him to make note of two things about each of his patients (just for a few days) that he has noticed and to which he is responding when he cares for them? These two things, in his mind, may be helping him to distinguish his patients, one from another, but he may not have thought about what they are exactly, and how they might be shaping his behavior with each patient. Then ask him to verbalize in two sentences about how he interacts uniquely with each of those patients based on their distinguishing characteristics.

This exercise might offer him much greater clarity about how his interactions came to be, and why his own behavior with each patient is what it is. What may have felt like “acting” may actually be his sensitive following, which is guiding him to behave in specific, nuanced ways that, of course, don’t feel exactly “natural.” The patient in the other bed, listening to such personal, nuanced interchanges may indeed wonder why the nurse didn’t say the same things to her, but I don’t think this feeling will last. (Just such an experience will, by the way, inevitably evoke old feelings in our patients about fairness in the patient’s family of origin, as well as her perceived position in the family, whether there were obvious favorites, how attention was acquired, etc.) A sibling may have an initial reaction (“That’s unfair!”) when he hears Mom saying/doing/giving something to a brother or sister, only to be most surprised and pleased when Mom says/does/gives something to him that’s not the same, but is better, because it’s personal. Mom thought about him. Her gift was to know him.

My guess is that this earnest nurse is tapping right into the spirit of attunement and the mysteries of following. He just needs a little more experience in getting comfortable with a non-scripted, highly-personal, nuanced mode of interacting with his patients. It’s quite possible that he’s heading in exactly the right direction.

~Michael Trout

Q & A: How Can I Have Better Relationships with the Techs on my Unit?

QUESTION:

When RN’s and techs work together, the tech inevitably feels indignant no matter how you treat them. Can you think of anything I can do to make these relationships better?

ANSWER:

Michael-Trout-150x150We have a notion that the indignation about which you speak is a direct reflection of the tech’s response to the perceived hierarchy. This doesn’t mean the RNs are doing anything wrong. It may be that the techs in your organization believe themselves to be undervalued—perhaps because of the pay structure, the way hours are set, who gets invited to certain meetings, or old (deeply-rooted, historical) traditions or attitudes about techs in your community or in your organization. It may mean only that you happen to have a couple of techs with anger about what they perceive as class privilege or about opportunities they didn’t have (or didn’t take). As you wonder about these possibilities, remember that the circumstances in your culture to which they are reacting with indignation do not have to be apparent to you—indeed, they don’t even have to be real—in order for some of your techs to feel them, to perceive them.

It may, however, be none of these. The simple fact is that people usually behave indignantly when they feel unseen. This is an irony, as indignant people often appear as if they already know everything, which could lead one to assume that such people have too much self-esteem—that they are, if anything, overly cocky and resistant to cooperation.

But appearances may be deceiving.

If a patient or family member behaved indignantly (pretending he/she was superior to you, needed to learn nothing from you, etc.), you would quickly know the reason: The patient was likely feeling vulnerable and afraid and was covering both troublesome feelings by behaving conversely. You would not react to the indignant behavior, and you would not arm-wrestle the patient for control and authority. You would bring your calm presence to the bedside and quietly wrap your caregiving arms around the frightened and vulnerable person. And you would do whatever you could to increase the patient’s (or family member’s) felt sense of authority over whatever was happening. For example, you might ask the patient or family member for information about what their experience had been with the situation at hand, and then remark on how helpful whatever they contributed will be to their care.

Ditto with the indignant techs.

You might wonder on their behalf as to whether they are frightened about making a mistake, worried about being up to the task, jittery about taking on responsibility. You might wonder whether they have gotten an earful from a demanding parent or an unsupportive teacher and are steeling themselves against getting the same from you. Surprise them with your inquiry about what their experience has been with a particular issue (or a particular type of patient), and then find something in their response you can compliment. Let them know you will be working together and that you are grateful for their partnership. In other words, let them know what you want your patients to know: that you consider their welfare essential—never secondary—to the operation of the unit, and you have their back.

Write us back about what you discover really was the cause, and how your strategy worked!

~ Michael Trout

Q & A: Working with a “Disengaged” Colleague

QUESTION:

What are your thoughts concerning health care workers who are detached from the reality of what our patients require when in our care? We have staff members who just seem to want to get done and sit down. They are consistently negative and do not realize how it affects patients and their families.

ANSWER:

Mary-Koloroutis-150x150This is a question we hear often. It’s obvious that care environments include people with varying levels of commitment, and when we see an individual who appears to have a low level of commitment, it’s important to spend time wondering about that rather than automatically opposing it. Just as we recommend wondering in the face of a patient’s or family member’s unexpected or seemingly inappropriate behavior (rather than judging it), we recommend wondering about team members who aren’t engaging in the ways we would like them to. Might these colleagues be suffering from significant burn-out that has taken place over time and is quite possibly permanent? Are these colleagues experiencing temporary compassion fatigue, in which case some support and encouragement may help them restore their connection with themselves, their team, and the patients? Or are these colleagues in the wrong field entirely?

The point is that until you spend some time wondering about the person, you’re not adequately prepared to address the person’s way of being or behavior.

Whether this person is your supervisor, your peer, or your direct report, think for a moment about what a positive outcome with this person could look like. Would you like this person to feel a sense of belonging as a valuable member of the team? Would you like this person to be fully connected with the mission of providing humane and compassionate care? Would you like this person to take the time to be fully present with each patient and family member?

It might help you to look at how to resolve this by asking three questions:

• What can I do as an individual?
• What responsibility do we as a care team have to the disengaged colleague as well as to the patient entrusted to our care?
• What responsibility does the formal unit leader have to assure that all members of our team are contributing fully and meeting our standards for humane, compassionate, and competent care?

What Can I Do as an Individual?

What is the compassionate thing to do in this situation? The companionate thing to do for all involved is to “name the elephant in the room.” Often there are conversations happening about these disengaged team members in the conference room, at breaks, in the hallway—essentially everywhere except with the person in question. The motives for avoiding direct conversation with the person are usually to avoid conflict or hurting the other person’s feelings, but it’s actually less loving to isolate the person in this way. The compassionate thing to do is to hold the conversation. Decide to invite this person into your vision for a compassionate culture in which all relationships matter: “This is what I’m noticing, and we really want you as part of the team. Can I work with you? Can I help?” It’s a courageous and respectful thing to do, and it may be one of the keys to bringing all team members into the culture you envision

What can we do as a Team?

As a team you create the norms and culture for how individuals function. If disengaged behavior is ignored or worked around, you will get disengaged behavior. The team’s responsibility is to a culture in which all individuals feel like they belong, are held to high standards, and share a common pride and commitment in the work.

What is the Responsibility of the Formal Unit Leader?

The formal leader sets the standards and vision for excellence. The leader cultivates the environment in which individuals thrive and in which every person is 100% responsible for their own work.

There is no question that the willingness and ability of our team members to interact authentically with patients are a minimum standard. Just as it would never be thought acceptable that a clinician would fail to be technically proficient, it can never be thought acceptable that a clinician be permitted to lack relational proficiency. (Koloroutis & Trout, 2012, p. 28)

Caregivers, by virtue of accepting responsibility to care for patients, have an ethical imperative to fulfill the trust inherent in their position. When that responsibility and trust are not being fulfilled, formal leaders cannot simply ignore that fact and expect others to work around and compensate for this individual. The leader needs to work with the individual and together identify specific areas for improvement and create a plan for what it will take to get there. The leader is not punitive in her coaching, but is respectful and encouraging, conveying that the true goal is the individual’s success. Success will only be possible, however, if the person accepts full responsibility and fully engages in working the plan and correcting the problem.

Some leaders struggle with how to reconcile being caring and compassionate with their team and taking strong action that could even result in terminating the employment of an individual. It is important to remember that caring leaders are courageous leaders who understand that their ultimate responsibility is to safeguard high quality patient care and to tend to the well-being of their whole group. These responsibilities are met by hiring and developing talented and committed individuals and inspiring high performing teams. When an individual is not meeting his responsibilities it is caring and respectful for all concerned to take action immediately.

~ Mary Koloroutis

Koloroutis, M. & Trout, M. (2012). See me as a person. Minneapolis, MN: Creative Health Care Management.

Q & A: Staying Compassionate with Patients Suffering from Medical Issues Related to Alcoholism

QUESTION:

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?

ANSWER:

Michael-Trout-150x150This 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

If you have a question about how to stay therapeutic in difficult circumstances, click here or go to the navigation bar and send it our way!