Sara K. Schneider's Skin in the Game

Reflections on body, culture, and spiritual practice

A Re-membering Human

Sometimes I look to their bodies for a definitive answer to my ongoing prayer for understanding. I remember how I felt when I touched my grandfather’s scars, those deep imprints left by Cuba: I was a blind child reading the past in Braille, understanding for the first time the vast plantation, the raging river, the cattle, the dark jail, the soldier’s clubs. When I ask my patients to undress, I think of him. … Funny how I never feel [their] pain, though I can often reproduce it in them as I press and poke the indicated region. Pain must be too personal, held too deeply with the body, to be known without actually experiencing it. Though my grandfather’s smile emphasized a certain scar on his forehead, and therefore could feel like a blow to the head, so bitter and full of loss, I never felt the pain he must have known. I can only imagine it.

–Rafael Campo, The Poetry of Healing: A Doctor’s Education in Empathy, Identity, and Desire

Twenty-five years of virtually constant computer use: what do you expect? (Hint: If you’re thinking of something between the fingers and the forearms, you’re getting very, very warm.)

To give them credit, the office staff had mentioned that the diagnostic procedure might be “a little uncomfortable,” but nothing more than the slight shock to the system than one might expect from acupuncture needles. The NCV/EMG test would help us find out whether my carpal tunnel syndrome (so much for the pride of being an early adopter!) had involved any nerves in the neck. “More data”: I’m on board!

For the first portion of this test, the physician sets electrodes along the arms, chest, and neck and administers electric shocks; she wants to time the velocity by which the electric signal is conveyed along the nerve. In the second part, the examiner inserts needles into the muscles, asks the patient to contract her arm, and again tests conduction speed (of the pain impulse!). All I can say is, the speed of the pain impulse was something I understood a whole lot better through experience.

I was lying on the examining table when a white female physician and the medical resident who was shadowing her entered the testing room, the former brusquely and if she were determined not to waste a single motion. I wondered whether the force with which she moved didn’t include some overkill. I noticed my new doctor’s almost aggressive efficiency as she set up her equipment and slapped electrodes onto my chest, neck, and arms. Scarcely speaking to me, she instead directed her words to the medical resident, who I guessed was from South Asia. The language was technical, dealing (I think) with how to read the metrics they were about to extract from my body. The resident’s movement contrasted deeply with the doctor’s: she moved in a more spacious, diffuse way, as if uneasy of her place in the triangulated encounter.

When it came time to test my upper body nerves (so to speak), the doctor applied the shocks at different points as if searching for a stud behind drywall. I was astounded by how quickly I experienced what seemed a projection of inanimacy upon me. My new physician was testing my body as if my self had already left it. I hoped that happenstance was still years off but had to reckon with a moment of uncertainty as to whether I was perhaps the person or the state of consciousness she touched me to be. Fighting my own reactivity, I thought I would try some temperate inquiry, ultimately to try to learn not why the tests were being done, but why she was doing them in such a depersonalizing way.

Do you do these tests every day? I asked her. Pausing and staring past me for an instant, she replied, no, only on one day each week, on Wednesdays. Experience had taught her she couldn’t handle on a daily basis the volume of patient venom that would be directed at her during these tests; one man had even jumped off the table and fled the office, electrodes still on, for good. She offered that it worked better for patients if she administered the shocks quickly, as that would minimize the length of time patients had to experience pain.

Her pain or the patient’s? I wondered. The nerve conduction velocity test was physically arduous; after all, the point of the test is to cause and then study nerve pain! But the physical challenge of the test, I soon realized, was a relatively minor part of what I was feeling on the table, which largely derived from experiencing being touched as if I were not alive.

She didn’t “play me like a violin,” at least not in the seamless melding between player and instrument played, or the kind of unity experienced by the dancer who is also danced. Instead, she played me, as the Italian composers might have said, bruscamente: brusquely, abruptly. Dolores Krieger, the inventor of a bodywork modality called Therapeutic Touch, urges therapists to remember that, as humans, “we don’t stop at our skin.” The brutality of the touch had little to do with its mechanics, much more with with what led to each prick and shock and how that intention sank in.

Physician-author Danielle Ofri writes of the “singular intimacies” between physician and patient, a connection that, though not a romantic one, “is an intimacy nevertheless.” But what of professional boundaries? Aren’t caregivers–particularly those with doctoral degrees–supposed to maintain an appropriate level of professional distance? As the progenitor of bioenergetics, a body-based psychotherapy, Alexander Lowen actually urges that professionals learn how to touch patients as part of both diagnostic and healing processes. I’ve substituted “professional” for “therapist” in sharing Lowen’s thoughts: “A professional’s touch,” he writes, “has to be warm, friendly, dependable and free of any personal interest to inspire confidence in touching. … One should expect a professional to know the quality of a touch, to recognize the difference between a sensual touch and a supportive one, between a firm touch and a hard one, and between touching that is mechanical and that which has feeling.” But the touch has to be with “clean hands”: free of the provider’s own need-seeking.

As a culture, we tend to give greater emphasis to outward transgressions of touch boundaries with vulnerable populations–violations of children’s sexual integrity by some clergy, the potential for sexual exploitation of students by teachers or college faculty–than we do to the opportunities for healing that are lost to professionals’ unwillingness to examine how their own needs may inhibit healing. The withdrawal or withholding of a touch that had an opportunity to heal can also be traumatizing.

Some argue that it is in the very nature of Western medical training to objectify the patient in order simply to be able to handle the constant onslaught of human suffering a professional faces every day, that the desensitization is a unavoidable and concomitant in the work. But how encompassing must this be to allow the health-care worker to provide healing to the patient before her and to maintain her own sanctity and integrity to serve future patients well?

Practitioners in many fields–teaching and spiritual guidance come to mind as readily as does health-care–might consider trying the practice following, allowing you to consider the healing power of your own professional touch–given, misgiven, and withheld.

How have you experienced the “singular intimacies” of the care given you by health-care, spiritual, or educational professionals? How have you known when and whether their touch, given or withheld, has helped or harmed you?

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing | Leave a comment

A Practice on Professional Touch

I once asked a massage therapist if she’d ever had a client she was loath to touch. Only one, she replied, in all the years she’d been giving massages. Though she had a hard time pinning down just what about the client had provoked her aversion, she experienced something about him as “evil.” She struggled through the massage, but required several days to recover and clear.

In this practice, you’ll pay attention to your reactivity to the people with whom you must engage in your professional life, especially those for whom you carry some professional responsibility for the well-being of their minds, bodies, and spirits.

Investigate:

  • To whom do you notice you want to get closer? With whom do you have some inchoate aversion?
  • How would you label what in them is “making” you react in the way you are? Is it something about their physical person? Is it something harder to define, something in their “energy,” whatever that may mean? How close can you get to labeling it?

Now, turn your attention to yourself:

  • How are you experiencing your desire to reach out to them, to offer them healing touch, acknowledging that it is not just they but you too who have a body? Why do you want either to touch them or not to?
  • What would happen if you thoughtfully, respectfully envisioned doing the opposite of your initial inclination –touching them compassionately if your inclination is to avoid, keeping at a mindful distance if you’re drawn to connect?
  • What might be impact on them, on you, of making this different choice–an impact that stems more from the how of what you do than from the what?

What did you find out?

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing, Insight Practices | Leave a comment

Anne Fadiman’s The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures

The Spirit Catches You and You Fall Down

Although not a new book, Anne Fadiman’s The Spirit Catches You and You Fall Down (1997) classically highlights a life-and-death crisis that devolves from Western medical professionals’ living out an ethnocentric self-assurance and a hermetic professional worldview. Fadiman became intrigued by what she’d heard about the clash between the Western medical establishment of Merced, California and the concentrated group of Hmong refugees from Laos who had begun settling there in the 1970s, escaping persecution by the Vietnamese after their little-known contribution as guerrillas to the American cause.

The Hmong were involuntary migrants, not given to adopting American ways any more than necessary to survive. Some feared going to doctors whom they thought might rather study them than help them. To the Hmong, Western doctors engaged in hazardous practices. They extracted large volumes of blood from their patients. They opened the body in surgery and in autopsies, and inevitably and irreparably damaged the integrity of the person, not only for this lifetime but for future incarnations. They announced the probability of death. The Hmong mistrusted Western medications and took fractions of what had been prescribed, putting the physicians in the untenable position of trying to “game” how much they might have to prescribe to end up with a Hmong patient’s actually ending up taking the desired dose.

Fadiman began fieldwork with a particular Hmong family, whose six-year-old daughter Lia had been in and out of the Western medical machine since she was a baby because of her epileptic seizures. She inquired equally into the perspectives of the entourage of doctors who treated her and who attempted, to varying degrees, to communicate effectively with her parents.

Lia’s parents fundamentally disagreed with the doctors about the origin of Lia’s problem and about the impact of the medications that had been prescribed for her. To Lia’s parents, the troubles began when her soul was frightened out of her body when her sister slammed a door, and her seizures would be instigated by a spirit “catching” her. The cure would be perhaps a very short course of medicines, but ultimately would be carried by Hmong shamanism, animal sacrifices, and herbs.

Fadiman’s book sides neither with the native medical cosmology of the Hmong nor with the self-justifying medical culture of the West, situating Lia’s tragic decline in the very gaps between the two. If there was any fault, it lay in the failure of the Western physicians to give credence to the Hmong worldview or to incorporate it into a realistic treatment plan. Fadiman writes of the caricature–just an extreme of the actual–of the M.D., who is an “all-head-no-heart formalist who, when presented with a problem, would rather medicate it, scan it, suture it, splint it, excise it, anesthetize it, or autopsy it than communicate with it.”

While Fadiman concludes that “American medicine had both preserved [Lia’s] life and compromised it,” she wonders whether saving the body, as much of Western medicine is geared to do, or preserving the soul, as was part of the Hmong concern, could not both be considered.

Reading The Spirit Catches You and You Fall Down, I am reminded of the lyrics of “Walking in Space” from the rock musical Hair. Set against the backdrop of the Vietnam War–which the Hmong referred to as the American War–the song extols the visions possible under hallucinogenics:

In this dive
We rediscover sensation
In this dive
We rediscover sensation

Walking in space
We find the purpose of peace
The beauty of life
You can no longer hide

Our eyes are open
Our eyes are open
Our eyes are open
Our eyes are open
Wide wide wide!

It’s not that the singers saw nothing taking the hallucinogenics. The irony of the song is that they thought they saw everything–while only seeing some thing.

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Body Culture in the U.S., Books, Health, Medical Practice, and Healing | Leave a comment

Clinical Empathy in Extremis

As has long been known in the field of undercover law enforcement, some information is easier to gather secretly than overtly.

In late 2008, three psychiatric nurses had themselves admitted as “pseudopatients” to a Dutch psychiatric hospital. In collaboration with an acting coach and a psychotherapist, they developed fictive biographies for their characters–“back stories”–much as do undercover cops. One of the players was admitted to the psychiatric hospital by his “brother” after a suicide attempt that was part of his back story; a history of aggressiveness was also part of his backstopping. Family members, played by professional actors, came to visit them while they lived in the psychiatric hospital as a patient would. Following the lead of a famous covert investigation of the patient experience by David Rosenhan in 1973–“Being Sane in Insane Places”–these undercover investigators were trying to understand the conditions under which psychiatric patients experience their illnesses.

Medical student Kristen Murphy living in a nursing home.

Medical student Kristen Murphy living in a nursing home.

Understanding the patient experience from the inside has become part of some medical schools’ training programs. The University of New England medical school sent (young) medical students in geriatrics for two-week stints as “patients” in regional nursing homes where they could experience the anomie, the longing for human contact, and the challenge of navigating often insensitively designed environments: what their patients live every day. While it was of course impossible to be in any way in deep cover at 50 years younger than the target population, there was still much for participant-observers to learn. Shower bars, for example, were too high for people in wheelchairs.

How far does a doctor have to go in feeling or experience to treat her patient effectively? And, practically, how close can a doctor get to experiencing what her patient feels without running the risk of being sucked into the morass of the patient’s suffering? Isn’t there also a peril of projecting her own experience of suffering upon her patient and blinding herself to the suffering that is truly the patient’s own?

All this is at the middle of an ongoing debate in medical practice and training–at least in the places where patient experience is considered part of the clinical picture. Some say, just recognizing, identifying, being able to label the experience the patient is “presenting” is enough to treat an illness well. Others demand that, in addition to the awareness of the patient’s state, the health-care provider’s being able to respond in the moment, with real emotional savvy, is what constitutes true clinical empathy. They posit that, not only are so-called clinical outcomes better when doctors and nurses experience and convey clinical empathy, but their own satisfaction in their work rises when they allow themselves to be moved by patients.

Some concerned with these issues have been using theatre training to improve physicians’ observational and receptive skills, helping them to listen for subtext, values, and strengths, and their performance skills, coaching them to express themselves fully and clearly through their voices and bodies and to use eye contact, breathing rhythms, and body positions to foster rapport with their patients. They distinguish between a surface-level and a “deep” acting, in which these skills have been internalized and become more automatic.

Yet the bodies of others are not only relational and physical, they are also cultural, and there’s evidence that physicians who fold all these elements into a treatment plan see better outcomes. Just as in On Killing, the book featured in Skin in the Game’s January issue that examines the conditions that make it easier for soldiers to kill, it is harder for doctors to feel empathy for those whom they perceive as being different from themselves-whose bodies and selves they perceive as “other.” The next phase of development in the humanization of the medical professions so that they become professions of healing is the encompassing of how the perspective of someone one may initially perceive as foreign, other–and, thus, inevitably “less than”–can transform into a collaborative relationship of inquiry, with two body-selves linked in a common humanity.

The Bodies of “Others”: Compassionate Care in the Health Professions will be presented at the American Holistic Nurses Association conference June 3 in Colorado Springs. Please contact Sara to schedule this workshop for your health-care organization.

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing | Leave a comment