no laughing matter…

Posted on Tuesday 9 July 2013

One of my most frequently told stories [maybe already told here before but I can’t find it] came from my days running the psychiatric emergency room at Grady Hospital – Atlanta’s inner city charity hospital. I was recently graduated myself and supervising a resident – a "city boy" with tons of education. He had been referred a case:
    The patient was a thirty something year old African·American man who had grown up in rural Alabama with his grandmother living at the end of a dirt road on a large farm. He had been to school "some" but was only semi-literate. When his grandmother died, he set off for Atlanta. He got a job in a furniture factory and lived in an apartment. He’d come to the Grady ER complaining, "My nerves is bad." He was given some medication and was referred to the clinic.

    The resident took a history and began to explore his life and situation. He said the man answered his questions, but didn’t seem very engaged, often looking at him oddly. He often repeated, "Doctor, my nerves is bad."

    After a few visits, the resident reported that the man had seemed frustrated, but then blurted out, "You think my nerves has something to do with my life!"

    The resident was a little taken aback, and responded, "Yes," and started to explain, but the patient interrupted him. "Why didn’t you say that?" he asked.

In case it’s not apparent, this story is about two people with a cultural gap as wide as the Atlantic Ocean even though they were from the same region, a gap even wider when this happened nearly forty years ago. I’ll have to admit that at the time, I could hardly keep a straight face listening. And I couldn’t hold my smile in when the resident reported the next session. Fortunately, he smiled too:
    "Doctor, I think you was right. I went home and threw out that no count woman living with me spending all my money on beer for her no count friends. And I told that no count boss of mine I wasn’t working no more seven days a week. And I feel a whole lot better. Thanks."
A grateful patient, but an even a greater teacher. So many lessons. Start where the patient is. Make no assumptions. etc. etc. This story is from a long time ago – before the DSM-III. I’ve always told it as an example of basic things that some people don’t know – in this case how emotions are complex signals, guides we all use in negotiating life. This man didn’t know that, something inconceivable to this urban, educated resident with a college degree in the humanities. This patient literally thought he had something wrong with his nerves – like they were broken things.

But the story means something different to me now. What brought it to mind was a comment on the last post. I doubt that anyone would argue with the idea that a system as complex as emotions are there for a reason – no matter how you think we arrived at our current design. "Emotional problems" refers to times when the emotions don’t function as they should – times when we’re anxious when there’s no apparent danger. But if you could be a fly on the wall in the offices of a lot of physicians, even psychiatrists, I’m not sure you’d think that the usual function of emotions is much recognized – by patients or doctors. Often, you’d notice that the doctor doesn’t say the obvious thing when a person complains about how they feel, something like, "What’s going on?" And even if that question gets asked, the patient goes on to describe the unwanted feeling in more detail, rather than talking about what’s "going on" in his or her life and times.

Working in a rural clinic, it always jars me a bit when the patients persist in talking about their uncomfortable emotions in isolation. I’m not used to that. But I wouldn’t be, practicing as a psychotherapy type seeing only referrals in a sophisticated part of the world. When I first came to the woods, I thought that was it – a different group of people. But I actually doubt that’s all of it. I think some of it is iatrogenic – something these patients are used to after seeing GPs or PAs out here in the southern wild. I’ve taken to saying things that I once would’ve felt funny saying in the past.
    "I know you want to tell me about your bad feeling, and I want to hear about that. But feelings are part of the package, and they’re supposed to tell us something about our reaction to things. So first, let me hear something about your life, and the stuff that might not be going so well."
I made that up, but I expect you get the gist. I’d like to report that they immediately open up and reveal their innermost secrets, but alas, this is the real world. It’s harder than that, because in the course of what follows, you’ve got to help the person see that you’re not just being nosy or indicting, and that’s a different pathway every time.

I’m not talking about Freudian "resistance," veering away from painful topics. That’s the same in Appalachia as it is on Harley Street, 5th Avenue, or Peachtree Road. I’m talking about people who are used to getting a pill for what feels bad – often an un-needed pill, or even the wrong pill, or worse, yet another pill. I think that’s in part a byproduct of the current era and reflex prescribing. And when I ask about current medications, I hear way too often, "he was in a hurry" ["he" being the GP or PA].

So in former times, the resident and I smiled together as our patient learned the most basic lesson there is to learn about emotions and their function. However, it’s no laughing matter at all to think that so many physicians are acting as if they don’t know it either…
    July 9, 2013 | 3:04 PM

    Do you have health coverage? Do you see a physician regularly? When was the last time you had a check-up?

    Do you know if you have or have had allergies, hypoglycemia, back pain, headaches, iron deficieny, B-12 deficiency, thyroid problems…? Do have any of these conditions that are untreated and unmanaged?

    Are you getting adequate sleep?

    Since poor and working person’s idea of “adequate” is often based on the minimum that they can get by with, rather than what is healthy or optimal, a mini-brief on quality sleep might be very edifying. The poor and the working poor often don’t feel entitled to what humans need. Merely giving permission, in a manner of speaking, and presenting getting adequate restful sleep as a medical and psychological necessity might help some people make that as much of a priority as they can.

    Shift-work and rotating shift-work can be so hard on a person that it’s a threat to bodily and mental functioning. Personally, after doing rotating shift-work in the military, my sleep patterns were never the same again. At the time, my mind and body were in utter confusion. I didn’t know when to sleep, when to eat, it was like having one illness round the clock— sleepiness, appetite, all the signals and cues of normal functioning were kaput. It was disturbing. I never did rotating shift-work again. It’s not even an option. I’ve seen suggestions that shift-work it can cause long-lasting damage and shorten lives a little.

    When was the last time you had a vacation?

    Never is indicative of a lifestyle beset by demands that interfere with self-care. For a working person who has worked without even two consecutive days off with no responsibilities for years or always the concept of vacation may have been forgotten. At least, understanding that vacations are a human need would help some people get off their own backs somewhat, so that they might try to find ways to give themselves mini-breaks here and there. And so they can learn the distinction between burn-out and depression.

    Are you taking any pharmaceutical drugs like contraceptive pills, anti-histamines… — even over-the-counter drugs can have an effect your emotions, moods, thinking, concentration, and sleep, react with other drugs, etc.

    Do you drink/eat, take __________ ? These drugs and foods can react to pharmaceutical medicines by…?

    Are you being bullied? At work? At home? Is anyone in your home threatening toward you or behaving violently toward you? Is anyone being emotionally abusive toward you?

    Does it seem to you that you are alone too much? Does it seem to you that you need some solitude?

    Do you experience hunger frequently? Do you diet habitually?

    What and who are you responsible for? Do you feel like you managing your duties competently? Do you get overwhelmed by the demands? Do you feel like you know what is expected of you from the people in your life?

    July 9, 2013 | 9:34 PM

    At a meeting today, I think someone summed it up fairly succinctly, with noting how Facebook basically is the social agenda of culture.

    So, people just want to come into the office and just have us hold up pictures of medications so they can “LIKE” the choice.

    “Like” it or not, our culture is so stupid and vain and without effort, I think people should just google “Jim Jones and Guyana” and realize it is quicker and more effective to drink the Kool Aid.

    Wait for it, history repeats itself like the daily bowel movement, someone will copy it once again. Ever read Doonesbury, time for the Summer Daydream…

    July 10, 2013 | 1:34 PM

    Dr. Mickey, truer words were never typed.

    This is what comes of defining certain emotions as illnesses.

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