February 26, 2014 21 Comments
I’ve been reflecting on times when I’ve felt trapped during conversations with patients and their families.
Times when whatever I seemed to say, I tangled myself further into an endlessly looping web of discursive constriction.
I was reminded of R.D. Laing’s book Knots, which is a gleefully brusque collection of various traps of thinking.
Here are some of my own examples.
This one is from my time on the medical wards:
Patient’s family: “We don’t agree with your diagnosis. Do some more tests”
Me: “Did you have any specific alternative diagnoses or additional tests in mind?”
Patient’s family: “Don’t ask us. You’re the doctor!”
If I try to assert my medical opinion I get shot down, but if I try to divest it I get shot down too. An infinite regress of rejection.
A second example, this time from early in my career in psychiatry:
Patient seen in A+E: “Admit me or I’ll kill myself”
Me [after lengthy consultation]: “Ok, let’s admit you”
Patient: “No. I won’t come into hospital”
I had no idea what to do. The opening statement felt more like a threat than a presenting symptom. The patient appeared to have turned up in A+E specifically to pose me a choice and then categorically turn both self-imposed options down. It was checkmate, I was lost.
Both examples can be boiled down to “I want you to help, but I won’t let you help”.
So how do we untangle these knots?
As I have now learnt – from insightful senior colleagues and patients themselves – the key to escape is to recognise why you’re stuck. And talk about it.
What lies beneath the tangle? Defense? Confusion? Weaponry?
The first example is a double bind – damned if you do, damned if you don’t. The fix is to either do or don’t but explain why you’re not damned for it. In the example given above, we explained the diagnosis again as a team – giving the option of disagreement but making it clear that we were firm in our convictions.
The second example, as well as being a double bind of sorts, is also a false choice – there were other options available, like the patient not being admitted but not killing themselves. Fostering some responsibility in the patient and getting them to work with us, not against us was the key to progress in that situation.
I don’t exactly look forward to more knots, but unbinding myself, or watching others unbind me, is an education.