Saturday, February 03, 2007

Common Countries

I just finished reading Charles Barber's Songs from the Black Chair, the book I mentioned in yesterday's post. It's a lovely memoir about Barber's OCD, and how his own history of mental illness has informed his work with mentally ill social-service clients in New York City. At one point in the book, he describes how tempted he was to tell many of his clients -- especially a man named Michael Jasny, to whom he felt particularly close -- about his psychiatric diagnosis. He ultimately chose not to, partly because he didn't want his supervisors to know about his history. He recognized, however, that his own illness was what made him good at his work:
I responded to my clients, and they responded to me. I may have some natural abilities in reaching clients, but at the very heart of my rapport was my own experience with obsessive compulsive disorder. While I never revealed the diagnosis to the clients, and am thankful I did not, it informed everything I did with them and allowed me to understand their craziness. I related to their madness -- I could see how someone as rational and intelligent as Michael Jasny could be completely taken over by an irrational universe. I had lived in their country. (138)
This passage struck me for several reasons. One was that I responded to the metaphor of the common country; as I've said here before, I find travel metaphors more fitting in many medical situations than the far more prevalent military ones. Barber's description also resonated for me because my favorite patients at the hospital are very often depressed or alcoholic, if not both; both conditions run in my family, and as I've shared here very freely, I have depression myself. (I'm not alcoholic, but only because I don't drink; I don't drink because I probably would be alcoholic if I did). Like Barber, I relate well to certain patients because I've lived in their country.

But the passage also made me uneasy; I self-disclose quite freely with a number of patients (always being careful to make sure that the visit is still about them, not about me), and Barber's reluctance to do so made me wonder if my own practice is somehow wrong or harmful.

I offer small pieces of my own history to patients when I sense that self-disclosure will make them feel less isolated and ashamed. Several times, when female patients around my age have said, "I have depression and anxiety," I've answered, "Yeah, I do too." In all of these cases that I can remember, the response has been a wide-eyed smile and a semi-incredulous, "You do? Really?" In all cases, the patients seemed happy that I'd told them. I suspect that patients find it helpful to see someone who's functioning with the same condition they have, and who's willing to talk about it instead of being ashamed of it. Establishing common citizenship may be especially important because I'm a volunteer chaplain, an ambassador from a God many people fear will only love them if they're flawless. Knowing that the chaplain isn't flawless either (as if!) may make patients feel more comfortable with God. (These are very old ideas in Christian pastoral-care circles, going back to Henri Nouwen's The Wounded Healer.)

At least, that's what I hope is going on.

When I talk to alcoholics who've despaired of ever being able to stop drinking, I often tell them the story of how my mother got sober; they've always seemed moved by the story, and often newly hopeful. When I talk to people facing gallbladder surgery, I often say, "Oh, I felt so much better after I had mine out!" When I talk to cancer patients, I sometimes share very small snippets of my mother's experience with breast cancer and lung cancer. In general, when I talk to patients with chronic invisible illness, I try to empathize with how difficult that situation is, even though most of the time, I don't tell them I have depression.

In all of these cases, patients have seemed to appreciate the empathy, and often the assurance that happy endings are possible. My job, after all, is to help proclaim Good News, in all its forms. I'd never questioned this specific form of proclaiming Good News until I read Barber's book.

Granted, there are some significant differences between us. When Barber had this particular job, he didn't want his bosses to know about his own history. I'm comfortable with people knowing mine: partly because depression's not as stigmatized as it once was, and partly because any stigma that remains will only go away if people who have the condition talk about it. Barber also had much longer continuing relationships with his clients than I do with most of the patients I see (a few frequent fliers excepted); that might have made him feel a greater need for personal boundaries.

And I suspect that the protocols for paid social-service providers are different than they are for hospital volunteers. Of his impulse to share his history with Michael Jasny, Barber says:
It would have been extraneous: it was my understanding, and his, that I was there to do a job, not to be his friend or intimate, and playing with those roles might have confused him. (137)
This makes sense for Barber. But I'm a volunteer chaplain, and that means that my job is (at least in many instances) to be a friend, if only for a few minutes.

And, of course, Barber has now openly and lucidly shared his history with the world, by writing his book.

Perhaps I'm rationalizing in all this, and I'd be interested in hearing different perspectives. But after pondering the subject, I still think my own self-disclosures have been appropriate and helpful. For me, it all comes down to the Great Commandment of the Golden Rule. If I were in an emergency room, dealing with an exhausting and stigmatized condition, I'd be grateful for a visit from someone willing to say, "I've lived in that country."


  1. I know in social work we have to be worried about "professional boundaries". And self-disclosure is sometimes good, sometimes not so good. But I think you're doing the right thing in this instance.

    To be perfectly blunt, if I were in the E.D. with something wrong, I'd want real comfort, not something I have to think hard on to embrace the symbolism in, or strain to comprehend. Knowing that the chaplain who's talking to me gets the whole deal with chronic illness, or understands where I'm coming from on a more personal level would be most comforting. I think E.D. staff have to keep somewhat of a professional distance so they aren't swallowed up in all of the tragedy they see. They're often worried about the emergent physical needs. Having someone who is more personal helps.

    The other thing I'd say is that you're not doing psychotherapy with the patients. The image of the Wounded Healer is a good one. Your goal isn't to fix the ailment as much as it is to help the person spiritually. I think spirituality demands a more human face, and demands a sharing of the spirit. It doesn't demand the "professional distance" that psychotherapy (which is generally more long-term) does. And, like I said, self-disclosure is used in social work.

    Also, the term professional distance sounds wrong to me, because I believe you have as much validity and professionalism for being in the E.D. as a paid social worker or other paid professional would. Also, if any of this doesn't make sense, feel free to ask me to clarify; I'm not the most quoherrent right now...

  2. Ah yes, depression and anxiety--I know the two well. In my experience, I think that most patients feel reassured when a professional can relate to their experience---because then they don't feel so "alone". But I do realize that one must take care to keep professional "boundaries" at an appropriate level.

  3. There are two doctors practicing at the family-practice clinic my husband use, as well as a couple of nurse-practitioners. One of the doctors has always been a favorite with us, and we've chosen him when possible. But since my husband had heart bypass surgery, we chose the other doctor for him because he has had a heart attack. We felt he would be more vigilant and knowledgeable. Silly? probably. But I feel good about the decision.

  4. i suppose sharing ur own experiences, enables patients to see their doctors as human. it eases the professional air a bit.

  5. Shauna8:41 AM

    The admitting nurse at the hospital came to see me where I was waiting with my parents after just getting a diagnosis of MS. She saw my chart and asked how long I'd had MS...I told her "About an hour and a half" after looking at my watch. She laughed and said she'd had it for 5 years. I was able to smile and look at my mother, without saying, "see, I'm going to be fine" thanks to that nurse's disclosure.


  6. Oh, I share all the time. I KNOW what it is like to have a hemorrhaging ruptured ovarian cyst. I know what that feels like. Sometimes I have to describe that to a male physician who has no clue.

    I've looked at patients when I ask if they are taking a certain med for depression and said "Depression sucks, doesn't it!" I know what a migraine feels like, I know about the nausea and photosensitivity.

    I don't go into big detail when I disclose that I've visited that particular "country", and sometimes I don't verbalize it but it most certainly helps me understand what that patient might be feeling at the time.

    So, I think sharing on occasion when appropriate is perfectly fine!

  7. Hi, I found you from Grand Rounds. I really liked this post. I always hesitate to disclose, but I think medicine would be much better if we didn't have so many walls between doctors and patients, if we could all acknowledge that, more or less, we're living in the same world, with the same pains and uncertainties.


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