Self Disclosure & Smoking Cessation

I'm not really big on self-disclosure, especially in a patient-practitioner setting for many reasons. For one, I never want to be like this old colleague of mine, who presented transcripts of her sessions with a patient and always left me wanting to raise my hand to ask, "Wait, I'm confused...can you please clarify which one of you is the patient here?" It kind of annoyed the heck out of me to have to listen to her soliloquies at our weekly case conferences. We learn to be professional and to have well-defined roles and boundaries...strong iron clad professional boundaries that is. Clearly, she did not.

For the most part, patients don't direct the conversation towards me or ask me questions about myself. This almost never happens at the hospital where they've come out of thier way for a service, unless of course they are having a bad day and want me to have just as bad of a day as they're having. In such a case, they might berate me and tell me I'm useless...but then they come back the following week without fail, so at least I know it's not really me. Every now a then, I get a, "I'm doing fine, how are you doing?" which always surprises me and I have to take about a second to grab the word "well" from my vocabulary bank followed by a quick "so, what are we working on today?".

I've been doing some smoking cessation work over the last few months here at the VA. Most of the patients have no desire to quit smoking. The conversation usually ends with "I smoke about 2 packs a day and it doesn't really bother me, so I have no intention of quitting at this point...I may sometime down the line, but I'm good for now". We learned that if the patient has no motivation to quit, than we don't push the issue. The reason being that if they're not motivated to quit then we're not motivated to annoy them further because truth be told, checking in on someone about something they don't want you to be checking in on is just really freaking irritating.

And then there are those patients who say they want to quit, "I have all the resources (ie. patch, spray, gum), and I'm just waiting for 9/1/2010 or 10/1/2010 or 11/1/2010 to really stop." We learned that these patients tend to like the idea of quitting, but also are not motivated to really quit so we just treat them the same as the ones who are actually forthcoming with having no intention of quitting.

And then there's Mr. S, a married 48-year-old with 2 children spinal cord injury patient. He's been smoking for over the last 18 years and thought he should look into stopping after he was diagnosed with Chronic Obstructive Pulmonary Disease. Actually, it took a COPD diagnosis and maybe about an additional six 50-min sessions about his PTSD before he even acknowledged the possibility of quitting. "Smoking calms me down, takes the edge off, helps me function better as a husband and father, and helps me not think about my time in the service" he told me when I first met him. "I understand. But you know, smoking caused your COPD and this COPD can potentially kill you." He shrugged. I shrugged. And we never talked about smoking again until this week...

"So, I've decided to quit smoking" he said on Monday over the phone. "In fact, I already quit. I haven't smoked a cigarette in 2 days...I've gone cold turkey." I did some quick motivational interviewing around his decision and then expressed my concern for his going cold turkey so quickly. You see, I've learned that smoking is probably one of the hardest addictions for people to give up mainly because the pain of giving it up deosn't hit immediately, and when it does hit, it hits hard. "I'll be okay," he said, "I just wanted to let you know so we can talk about it on Thursday when I come in."

I guess I wasn't all that surprised this afternoon when he came in angry and somewhat disheveled. We started by talking about the weather and how he had gone to the beach with his family earlier in the week. He then told me that he hadn't slept much in the last few nights and felt consistently on edge snapping at his wife and kids. "I caved and had a few cigarettes yesterday I'm really beginning to wonder if it's all worth it and if I should just forget the quit smoking thing altogether." I told him that I knew it was hard for him, but I could see he was working hard and that he was doing a good job (this is probably the worst thing you can possibly say, but it's the only thing I knew to say). And then it came:

Mr. S: You know? What do you know? Do you smoke? do drugs? Have you gone to war? You look all clean and good, I bet you have no idea how it feels or what I'm going through. I'm in a wheelchair. I can't breathe very well. I don't sleep well, and now I gotta quit this thing that has kept me going for so long. What do you know?

I was completely caught off guard. It's been implied but I'd never been asked outright, the "what do you know?" question. I was quiet for a while wondering what it was that I did know...and then:

Me: Mr. S, you know you're right. I've never been on drugs or even touched a cigarette for that matter. I'm as clean as they come.........but believe it or not, I know what it feels like...I know what it's like to be so deep into something, to be so dependent on it even though I knew it could and would probably kill me. I know what it feels like to try and quit that same thing and feel absolutely crazy and out of my mind in trying to kick it...and I know what it feels like to fail repeatedly at quitting and then to have to start all over again. And you're right, I haven't gone to war and I'm not in a wheelchair...but I do kind of have an idea of what it's like to feel trapped...

He was quiet for a while and then asked me what he should do and what I would do. I didn't really know what to say at that point. I felt like I had already violated every rule in my book of nondisclosure.

Me: You keep trying and you accept that you'll fail a few or even many more times...and that it will hurt each time. And you'll have your good days and your bad days, but you keep trying anyways...because you have to believe that you're meant to be better than where you're at right now...and I believe that about you, that you can be better...and I think you believe that too because otherwise you wouldn't be here...

Thinking a Little on Haiti

My last annual just refused his psychological assessment. The 10 second meeting went something like this:

Me: Hi Mr. M, my name is Grace and I'm from psychology. I just have a few quick questions and you'll be all done

Patient: I don't believe in psychology, I think I'll pass.

Technically, he's not allowed to just pass on psychology. He needs to go through a complete annual evaluation with the Spinal Cord Injury physicians, social work, nursing, physical therapy, and psychology staff in order to continue having the VA pay for his pain medication, but since I don't like forcing anything on anyone, I respected his wishes. I'm not very good at being assertive when it comes to advocating for my own agenda...or in this case, the VA's agenda. Over the last few years, I've seen lots of people and somehow I've managed not to take anything personally and instead just shrug it off as "whatever, you do what you want".

Anyways, so since I have some extra time, I thought I'd take some time to write about my trip to Haiti. I've been back a little over and week and life has been pretty crazy since I got back last Monday and still continues to be. To be honest, I really miss Haiti...more than I thought I would which kind of surprises me. I'm not completely sure what I miss about it since I haven't really had time to process the whole experience. I mean it was hot...really hot and I didn't have much of an appetite the entire trip. Nevertheless, I really miss it. It was nice to not have to think about yourself all the time for a change. Part of me kind of wants to forgo the whole processing part because to be honest, I'm not really very good at feeling certain things. I've become better than I used to be, but the case still remains that I'm really good at thinking about things but not so much at feeling them. It seems I've become really good at not letting devastating things devastate me. In fact, I can't really recall when my heart was last wrecked by something.

So on the subject of being wrecked, I remember being really wrecked when I went to Bangkok in 2004 at an AIDS hospice where I got to hold a dying 3 year old girl in my arms. She was just about 1/2 dead and I don't think I could really handle whatever it was I was trying to handle. I remember having a really hard time with poverty in general even after I returned to the US, to the point where I had to look away whenever I passed a homeless person on the street. It was a conscious decision. I chose to look away and I feel like I've chosen to not let things wreck me anymore. In my early adulthood, I've come to realize that the middle road may just take a lifetime for me to find. It's safer to sit on one side and just think about the other...in depth and detail, but no matter how long or hard I let my mind wander over there, its still just a thought.

I like to think I've developed the skill to maintain a healthy distance from the pain I face on a daily basis, but I'm not really sure if it's skill, or just my unwillingness to really let myself feel involved. I'll admit that I wasn't all that involved emotionally while I was in Haiti. I was there to help and to serve and that's just what I did. I couldn't really speak with the natives and while I really wanted to hear each person's story, the language barrier and the numerous patients that needed to be triaged just didn't quite allow for it. Well, regardless I still miss it and kind of want to go back...

Resilience

In my four years of training...that's 4/5 with only 20% left , I've had the privilege of working with all different types of people. I've sat afloat in the home of a hoarder, accompanied an agoraphobic elder to the dentist, suited up in gown, gloves, and mask to assess the psychological functioning of a cancer patient in isolation, celebrated the 60th birthday of a transgendered man with paranoid schizophrenia & stage 4 metastatic breast cancer, waited alongside a diabetic 10-year old before sending him through a world class MRI machine. I've watched 3 people slowly fade and then disappear. The culprits: Cancer, COPD, and Cholecystitis.

"The work we do is hard", a colleague of mine once stated as she shared how she finds it difficult to refrain from becoming too attached. She asked me how I manage to remain uninvolved. I told her I didn't know, but that I did notice I have this uncanny ability to leave what I see, do, and say in the place I did it and only pick it back up when I return. I told her I thought it was what might make this profession perfect for me...that I could be passionate about but at the same time stay uninvolved and continue living my life at day's end. Slowly, I'm learning there's a fine line, the one that helps you maintain a balance between being professional and being human, the one that makes you a good psychologist and a great psychologist.

I've been working with Spinal Cord Injury patients at the Veteran's Hospital. I loved it from day 1. I loved everything about it: the interdisciplinary approach to care, being able to learn on my feet, the neurosurgery rounds...everything. I was still uninvolved, yet I felt like a true growing professional...until this week.

Mr. M came in for his annual evaluation at the SCI clinic on Tuesday. He was my last annual evaluation of the day. He had a diagnosis of MS w/cerebellar atrophy (which I had no idea what that was). I went in w/my clipboard and neuropsychological testing screens. The notes indicated he had expressed some problems w/his memory the previous year. I thought it might be helpful to get a better understanding of his possible cognitive decline. He was a pleasant looking man who was cooperative and smiled a lot. I shook his hand and introduced myself... and then he spoke. "HWWE---LLLLLO", he said slowly, exerting all his energy to greet me. I realized he had dysarthria.

In lieu of the pain in his lower body, the MS, the braces on his legs, the inability to manage his own bowel & bladder care, the fact that he had no living family members, he told me in long drawn out words that his only complaint was wishing people would take the time to listen to him while he worked his hardest to get his words out and that all he wanted was to have a conversation. I was speechless for a moment. I had an agenda that needed to be completed. I made a quick decision and in that moment, I put down my clipboard, boxed up my neuro testing kit, and decided to have a real conversation. The social worker came and went and I stayed w/Mr. M. I had a hard time understanding his words but 2o minutes into the conversation, I felt I could understand what he was saying. He was 85 and most of his good friends had passed. He said he was okay though. He liked to visit Walmart and wheeled into town almost everyday. He grew up in Washington state, but loved living in CA. He misses his parents dearly and wonders when it will be his turn to pass. I stayed with him for a while. He asked me if I had anywhere to be as the clinic closed at 4 and it was just about 5. I told him I didn't need to be anywhere important and in that moment I realized that I had crossed the line. Resilience is powerful thing. It's what keeps Mr. M positive through all the crap and puts me to shame when I catch myself thinking about what I wish was different in my own life. It's what gets me involved and what makes this work difficult for me. Resilience.

We talked a while longer and then the paratransit came. I walked him out to the van and said goodbye."Thank you for working w/vets", he said. 'Thank you for serving our country", I said.