As a patient, a psychotherapist and as a clinical supervisor of other health care professionals I have often noted that the language many of us in the health care professions use could be experienced as critical by patients/clients and, thus, not conducive to healing. How we use language and what language we use can result in symptoms which are iatrogenic in origin. Iatrogenic refers, as many of my readers know, to the illness caused by the treatment. Most frequently it may be used to describes the side affects of medication or other treatment.
Psychologist, therapists, physicians, nurses and others who practice the health care profession have, in recent years, often been reminded to be more culturally sensitive. There is often mention of the fact that a word, phase, or action may not mean the same thing in all cultures. We need to know who the patient/client is culturally which then affects how we approach and treat them. Yet, often the same material which is attempting to educate the health care professional about cultural sensitivity, uses language which continues to blame the patient/client for their illness or for a treatment plan not working.
Recently I moved to a different state and, in the process of getting licensed as a mental health professional and certified as a professional addiction counselor have been reviewing material which is designed to help those of us who may have to retake professional exams.
Sadly I have found much of the language to be critical and very disrespectful of clients/patients.
My belief is that despite what motivates a client/patient to walk into the office of a health care professional he/she deserves to have the best possible treatment we are able to provide or the best possible referral when we, ourselves, are not able to provide that help either because of the lack of a particular skill or because we do not believe that what the client/patient is asking for is a treatment we can ethically or legally provide. For example, if a person with a drug addiction wants a physician to prescribe a medication which is going to merely temporarily feed their addiction or which the addict can sell on the street to get the drugs he or she needs to starve off withdrawal, it is not ethical or legal to prescribe that drug. On the other hand, we can all have empathy for the person who believes that his/her only hope of feeling decent is having a particular drug. Despite what we may tell ourselves, we have all, if we are honest, wanted or believed that we needed something that may not have been healthy for us long term. Addictions comes in many forms – power, drugs (including alcohol) the corner office, a new car, larger muscles, food, cigarettes, a date with a certain person, sex, parenthood, or whatever. Not all addictions are, as we know, as immediately dangerous or illegal.
Yet, in order to avoid being honest with ourselves or in order to convince ourselves that we are not like “those people” we will distance ourselves from some of our patients/clients.
Language is a big help in distancing us from the pain that we often see and which often mirrors some pain in our internal file drawer. I was just looking over some counseling exam preparation material this morning. Some of the words used to describe patients/clients or their behavior included:
Non-compliant
Resistant
Hostile,
Oppositional defiant
Sullen
Oppositional
Belligerent
Irritable
Inappropriate
What, one might ask, is wrong with these words. On one level they may be very accurate. For example, if a physician prescribes a medication and the patient does not take it or if a therapist recommends an addict attend a 12 step meeting and he or she does not attend, one might accurately say that the patient/client was non-compliant. Asking whether or not they were compliant is not helpful. We want to know why they did not take the medication or attend the meeting. A prime example of this was in the eighties when the AIDS epidemic was at its height. Initially the only treatment which was available was AZT which had to be taken every two hours. A study was done which involved giving AZT to homeless people in a major city. The patients were non-compliant. This was accurate. They did not take the AZR as prescribed. They also did not have watches, a timer, water always available or any the supports which makes it easy to follow such a regimen. The problem was that the treatment plan was unrealistic. It was around that time that some health care professionals begin to suggest that words such as compliant or non-compliant no longer be used. The terms has been used in such a negative, punishing manner that it was easier to adopt the use of the term adherence. Adherence came to be defined as whether or not a treatment plan was working. The presupposition was that health care provider and patient/client would together formulate a treatment plan which was considered an educated guess of what might work. If it worked that was great. If it did not work then the health care provider and the patient/client simply put their heads together and formulated another plan. There was no blaming of the patient/client or the health care provider.
Let us consider another term: resistant. The client/patient is resistant to treatment. Surely the patient/client should recognize that we have their best interest in mind, that we are the expert and if they truly want to get well they will agree and follow our plan. If they do not they clearly are not motivated to get well and we may tell them to come back when they are ready. This is one version of the truth. Another version may be that we have not found a way to instill a sense of trust or hope in the patient/client; a belief that doing what we suggest is going to make any difference. A good example of this is that I just recommended to a client who is a recovering addict and who recently relapsed, that he should get a sponsor. He may not be convinced that he needs the help of another person or he may believe that no matter what he does he is going to continue to relapse or he may believe that he can occasionally use and not do anything destructive to himself or anyone else or…… The bottom line is that I think it could help him and I want to see him successful in his recovery. I think it is dangerous, given his addictive history, to try for the 50th or 60th time to try to do recovery on his own, but the client is not convinced and it is his decision. It is also true that, for some reason, he continues to communicate with me and to ask for advice. I will certainly give him my best advice and will work with him to formulate a plan which works for him. I will not tell him or put in the chart that he is resistant; that he is a bad or unmotivated client who does not want to get well.
Although there may be some drawbacks to my approach, except in rare instances when the patient/client is so out of touch with reality that they are not able to view their illness from a distance yet, I share my initial several page assessment and my clinical notes with clients. If working with a treatment team, I also share them with the treatment team members. Thus, I am very aware that whatever language I use will be read by the client or other treatment team members. My goal is to be as accurate as possible, but also to write in a way which shares the responsibility for the success or non-success of a treatment approach. I am not going to use language which is non-complimentary to a client. At the same time I am going to be as honest as possible.
A good example was a high school teacher I was seeing. She was teaching in a very small community where she frequently saw her students outside of the school setting. When she came to my office she was usually dressed for school in a very short skirt, a very form fitting top and high heels. Ironically one of the reasons she was coming to see me was because she felt that men treated her as a sexual object. Her dress was, I thought, very provocatively sexual. I talked to my female colleagues about how to address the issues with her. I finally said to her that she was so traditionally attractive that, unless she dressed down a bit , high school boys and men she might associate with would only see her as a sexual object. I further explained to her that we men could be very sexist and shallow when it came to our relationships with women; that many of us learned to view women first as sexual objects. What I told her was honest and not critical. Now, my initial thought might have been: “Goodness, look at the way you dress.” But saying that would have been heard as critical and would made her feel worse about herself.
In recent years a lot of health care professionals have been exposed to an approach which is being called motivational interviewing. In my mind this is another way of stressing that we need to treat the client with love and respect. One way of doing that is to keep putting ourselves in the shoes of the client/patient and to remind ourselves that we will also be a client/patient and we want to treated with love and respect.
No matter how careful we are we may use a term or a word which is particularly hurtful to a client/patient. We need, I think, to be appreciative of that fact and to be quick to apologize. I once used the word big to refer to a client’s big heart. This was intended as a compliment. She was a significantly sized woman who was very shameful about her size/weight. All she heard was the word “big” which was very insulting. She was very hurt and never returned to therapy despite my apology and my attempt to explain that I had used the word big to refer to her heart.
In the end it does not matter what we intend. It matters what the other person hears. The client/patient may already be thinking of themselves as the sick person and the health care person as the well person. When we begin to label them, they are in danger of hearing that they are the labels rather than a sacred person who is presenting with certain symptoms or issues for which they are seeking help. Even words such as depressed can have a very negative connotation. If a person “hears” that they are a depressed person, they are not necessarily going to feel like this strong, good person who, through no fault of their own, is having symptoms which we label as depression.
I do not think that any health care professional enters the field because they think that they want to just make money. I do think that we have designed a health care system in which there is a lot of pressure for the health care professional to perform: to “cure” people quickly, and always be concerned about lawsuits. This is an enormous amount of pressure. Many doctors and therapists I know who entered the field because they genuinely care about people end up feeling as it they are expected to perform like a machine and do not have time to connect with their patient/clients as individuals. I think we need to be very intentional about treating each other with as much respect and love as we want to treat patient/clients. I have often been in the position of teaching or clinically supervising other health care professionals. I have to remind myself to be as patient with my colleagues as I am recommending that we are with our patients/clients. The same applies to myself. I may find it easy to be patient with a client, but very difficult to be patient with myself.
Perhaps it is important to remind ourselves that life is very short and, if not careful, we get so focused on a goal that we forget to be present to ourselves and others; we forget that healing is not about living forever, but about living with as much quality as we can. We may need to remind ourselves that in the original Greek the term physician meant healer. If we were lucky enough to have a parent who kissed our new hurt and held us in their lap, we know what healing feels like. They did not make the injury go away but we felt much better. Perhaps that is a laudable goal for we health care professionals; to do not harm and to do all we can to enhance the quality of life for the client/patient and for ourselves when we are seeing them. They may not always satisfy our employer or the health insurance company but we and our patients will feel much better.
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