“Riding the Dragon”: Enhancing Self-Knowledge and Self-Talk in the Health Care Professional

THREE


“Riding the Dragon”


Enhancing Self-Knowledge and Self-Talk in the Health Care Professional


Objectives



The unexamined life is not worth living.


—Aristotle


Dr. Jones was finally completing his documentation at the end of a 12-hour shift. He imagined crashing on one of the cots set up in the doctor’s lounge when the chief resident appeared and silently glared at him for what seemed to be a very long time. Finally, the words began to pour out —clipped and deliberate at first—then rapidly demanding. “We will assume you went to school . . . and that they taught you to read English, at some point! That order is written in English,” he said, angrily pointing to the page. “Now give the patient the medication before he dies!” he shouted as he backed into the elevator.” Embarrassed and angry, Dr. Jones did not respond; he did not have time. He gave the medication, left the unit, and finally crashed in the break room—but he could not sleep.


Enhancing Self-Knowledge and Self-Talk in the Health Care Professional


In a foreword to a book on identifying and avoiding defensive patterns in working with patients, Dame Lesley Southgate wrote, “The missing pieces about the failure of some doctors to incorporate best practice into the consultation may be addressed by paying attention to what the doctor is feeling rather than what he/she knows.”1pviii This advice also applies to identifying and avoiding defensive patterns in working with colleagues no matter your clinical discipline. If acute and chronic secondary stress is to be limited and one’s personal and professional well-being is to be enhanced, self-knowledge and the enlightened behavior that it should give rise to are not a nicety in medical/nursing practice; they must be a given. Personal discipline and self-control are essential in medicine and nursing, as they are for all professionals responsible for the care for others. In the behavioral sciences, this is referred to as “self-regulation.” In a book for psychologists on self-care, Baker writes, “Self-regulation, a term used in both behavioral and dynamic psychology, refers to the conscious and less conscious management of our physical and emotional impulses, drives and anxieties.”2p15 She then goes on to warn:



Managing our affect, stimulation, and energy as we navigate our professional and personal lives, as well as our relationships with self and others, is no easy task. To regulate mood and affect, we must learn how to both proactively, constructively manage dysphoric affect (such as anxiety and depression) and adaptively defuse or “metabolize” intense, charged emotional experiences to lessen the risk of becoming emotionally flooded and overwhelmed.2p15


In the story that opens this chapter, the chief resident and resident were no doubt running on automatic pilot, instead of engaging in any form of conscious self-regulation. However, as Coster and Schwebel point out, if we are to “manage” ourselves or “regulate” our behavior, obviously sound self-awareness must be present.3 Nowhere is this more necessary than in clinical settings.


Self-awareness is especially important for persons working in high-stress settings that require great intelligence and high standards. In such professions, “perfectionism and its associated demon, fear of failure,” as Block recognizes, can be quite dangerous to persons attracted to health care.4pviii He goes on to point out the following:



Health professionals are held, and for the most part hold themselves, to extremely high standards of performance. It is believed that they should always be at the peak of technical proficiency, emotionally available, straightforward, clear, and compassionate. The rewards for this are high status, admiration, and respect. Lapses are in two directions: cynicism and money grubbing, or despair, feelings of failure, and disgrace. This latter triad is often associated with the more frank and overt symptomatic breakdown into addiction and substance abuse.4pix


It is very easy to lose one’s way—even from the very beginning of one’s journey in professional health care. Unfortunately, this problem does not end with graduation and entry into practice. Loss of perspective remains a danger throughout one’s career if time is not taken to reflect on one’s personal and professional lives. The following anecdote on how easy it was for a seasoned neurologist to lose a sense of what was important illustrates this well. He demonstrates, that sometimes even when you are dealing with life and death on a daily basis, it takes someone from your circle of friends or family to shock you into reality and remind you how quickly all of us can blow things out of proportion when we do not take time out to reflect on our feelings, thoughts, beliefs, and behavior.



The following letter, written by a first-year college student to her father during the middle of her second semester, delightfully points (out how easy it is to lose perspective no matter how delicate and important one’s work is). Prior to receiving this note, her father was totally preoccupied with her “success” in college. He was worried because she didn’t do well in her first semester and was concerned, she would fail out during the second semester—and take his money with her! He had forgotten, as many of us parents do, that performance in courses is only a partial measure of learning; moreover, there is much more to the total college experience than just grades.


Despite her youth, this woman knew this better than he, and so taught him an important lesson on perspective. On the front page of her note it said:


Dear Dad,


Everything is going well here at college this semester, so you can stop worrying. I am very, very happy now . . . you would love Ichabod. He is a wonderful, wonderful man and our first three months of marriage have been blissful.


And more good news Dad. The drug rehab program we are both in just told us that the twins that are due soon will not be addicted at birth.


Having read this, her father then turned the page with trepidation. On the other side of the note it said:


Now, Dad, there actually is no Ichabod. I’m not married nor pregnant. And I haven’t ever abused drugs. But I did get a “D” in chemistry, so keep things in perspective!5p115


It is very easy to move through life—even the most service oriented of lives—in such a compulsive, driven way that we feel out of control. When we take out time to reflect on who we are, what we are doing, we often get a glimpse of the roots of our behavior, realizing how “unfree” we have become in so many ways. The bottom line is that you can count on losing perspective and deluding yourself if time is not devoted to reflection on your thoughts, behavior, and affects. But it is not easy to be honest with yourself.


Zen master Shunryu Suzuki once cautioned his students, “When you are fooled by something else, the damage will not be so big. But when you are fooled by yourself, it is fatal” (cited in Chadwick6p308). In health care, this is a particular danger. DeChant and Shannon7 point out that the medical profession does little to emphasize self-care.



This observation can be extended to most medical and nursing professionals.



An interprofessional team of clinicians formed a study group to review research findings on the effectiveness of COVID-19 screening tests for both the virus and for antibodies. The studies’ findings did not offer a clear directive on test accuracy particularly with respect to antibodies. There was much debate on the quality of the studies and the interpretation of the findings. The group decided to proceed with their current protocol and continue to monitor research findings.


This detailed review of research studies is something we applaud and possibly expect of medical and nursing professionals who are taught in their educational programs to review available evidence. However, it is only recently that medical and nursing professional associations and educational programs are attending to the alarming evidence and promoting self-assessment and self-care for health professionals as essential curricular content. Further, the pandemic is confronting health professionals with their lack of self-knowledge, deficiencies in self-care, and fragile resilience.


Attaining self-knowledge, the foundation of self-care, is sometimes elusive, even if one pursues psychotherapy. Donald Brazier reflects this reality in a book advocating the use of an integration of Zen with psychotherapy when he notes,



These days . . . we are apt to seek out a therapist to . . . help us get the dragon back into its cave. Therapists of many schools will oblige in this, and we will thus be returned to what Freud called ‘ordinary unhappiness’ and, temporarily, heave a sigh of relief, our repressions working smoothly once again. Zen, by contrast offers dragon-riding lessons, for the few who are sufficiently intrepid.8p14


Given the personal psychological dangers to medical and nursing practitioners and their patients when they are not self-aware, they must be among those who are “the sufficiently intrepid” with respect to self-awareness. To deal with simple self-mentoring and to learn to “ride the dragon,” approaches using cognitive and psychodynamic psychology are provided here for consideration.


Uniqueness and Self-Knowledge


No matter what approach is used to understand stress—be it weighted in the direction of environment or personality—the individual is always a major factor. This is observable in persons who seek psychiatric or psychological treatment. We have found the following:



A significant turning point in therapy or counseling arrives when the individual seeking help is able to grasp the following, simple, seemingly paradoxical reality: When we truly accept our limits, the opportunity for personal growth and development is almost limitless. Prior to achieving this insight, energy is wasted on running away from the self, or running to another image of self.9pp5–6


Such obviously is the case with most of us. This should not be surprising. Poets, theologians, and great scientists have joined those in the mental health field to warn people to not be unconsciously pulled into trying to be someone you are not. In the words of e.e. cummings, for example, “To be nobody but yourself in a world which is doing its best, night and day, to make you everybody else—means to fight the hardest battle which any human being can fight, and never stop fighting.”10


The point here is that it can be a great struggle to be “simply ourselves” to do what is really best for ourselves especially when we are in a transferential role such as physician, nurse, or physician assistant where patients, colleagues or managers are turning to us as the “designated helpers” in ways they turned to parents and significant figures from the past.


Consider the following case:



These situations are common, but in terms of our own sense of self, we must be aware that this perception of “health care professional as perennial helper” is based on the needs and personality of the other, on our own faulty self-images and not on our abilities or objective reality. Being “extraordinary” is not being a super-person who attends to all requests, even hints, and meets all needs as some (including, unfortunately, some of our colleagues) want us to believe. Instead, it is being self-aware and in tune with the way our talents and the needs of those with whom we work in health care act in synchronicity. Accomplished inventor and global citizen R. Buckminster Fuller phrased it this way in terms of his own life and the dangerous lures he met during his life:



The only important thing about me is that I am an average healthy human being. All the things I’ve been able to do, any human being, or anyone, or you, could do equally or better. I was able to accomplish what I did by refusing to be hooked on a game of life that had nothing to do with the way the universe was going. I was just a throwaway who was willing to commit myself to what needed to be done. (cited in Wicks11p6)


Resonating with Fuller’s view takes a degree of humility. Yet, with such humility, health care professionals can avoid the unnecessary stress that comes from living as if the transferences put on them by patients, colleagues, and managers are in fact a reality. Further, health professional students, who seasoned practitioners are called to guide, also benefit. In his discussion of humility among medical educators, Pfifferling, rightly indicates,



Humility and its connection with emotional sensitivity on the part of medical and nursing professionals therefore is not a sign of weakness. Instead, humility is a sign of balance, self-awareness, and maturity that raises the quality of interactions between patient and caregiver and between caregiver and colleagues. Coombs and Fawzy’s insights on medical education extends to the education of all health professionals in that such education usually emphasizes only the “hands” (technique) and the “head” (knowledge) and fails to explore the role of the “heart” (emotional sensitivity), which also includes an acceptance of one’s failures.12 Thus, it diminishes not only the quality of the clinician’s own life but also the quality of patient care and the mentoring of new practitioners.12p14


Full self-awareness that includes an appreciation of our emotional sensitivity or lack of it is very elusive. In the words of poet Henry David Thoreau, “it is as hard to see oneself as to look backwards without turning round” (cited in Auden13pix). Yet, every effort must be made to increase self-understanding—not just to curb our errors but also to increase our self-respect because as Leech aptly notes, “ “You do not want to know someone whom you despise, even if, especially if, that someone is you.”14pp43–44 Self-awareness and self-respect feed each other and form a positive circle. Self-respect is true self-awareness.


To become clearer about ourselves, there is a need to expend energy, but it obviously helps to know the most productive and efficient way to do this. To best accomplish a sense of clarity about our feelings, beliefs, and actions, appreciating the value of discipline, noting inconsistencies and exaggerated emotions, and avoiding vagueness (a sign that the defense of unconscious repression is at work) would be helpful and can be a lifelong process. A nurse’s personal approach to this process is described in Box 3.1.





Box 3.1 A Nurse’s Musings on Seeking Self Knowledge


Self-reflection, self-assessment, and self-critique can be difficult processes. Working with patients with mental disorders as well as with health professionals in stress management workshops, necessitated my own periodic trips to the well of self-understanding. To overcome the resistances we all experience in working on the self, I engaged in a variety of psychotherapeutic modalities to facilitate my own development. For example, I have been through didactic group therapy twice which is a process by which one gleans not only the rationale and meanings of one’s group behavior but the overall dynamics of how groups form and operate. I then moved to psychodrama where a Moreno-trained psychodrama leader facilitated the group in selecting a life drama from each of the participants, overseeing the selection of protagonists and antagonists for the drama, directing the drama and then conducting the de-briefing in which each group member offered their own interpretations and self-insights. In one session, I was chosen as the only meaningful figure in the life of a person who struggled mightily with isolation and loneliness. I was selected to be her beloved dog and spent the duration of the drama, lying at her feet. I learned so much about the dynamics of loneliness and about staying silently supportive.


My most intensive and long-term self-care experience was 10 years of psychotherapy with a phenomenological psychoanalyst, every week for one hour and I never missed a session. I entered this process at the urging of my adolescent daughter who believed I would benefit, “because, Mom, you are nuttier than I am.” And so, I took the dare and the timing was impeccable since I struggled with leaving a leadership position that I had held for 17 years. Unfortunately, my new employer landed in bankruptcy a year after I arrived. It was the most stressful time in my career not knowing if the University and the School that I was leading would even survive—but we did and then I had to contend with the stressors of merging into a new university culture. I do not think I would have fared as well as without those weekly psychotherapy sessions. There is nothing quite like having the undivided attention of someone who listens deeply, questions supportively and challenges with care. I learned so much about myself; especially my proverbial buttons and what pushes them. I also search in books to give me perspective. Over the past decades I have gravitated to the Eastern literature particularly Zen Buddhist and Tao writings. There are certain books I keep close to my desk like The Mind of Clover by Robert Aitken and No Mud, No Lotus by Thich Nhat Hanh. One of my most important learnings from Zen is that you cannot prevent adversity in your life but you can shape your reactions to it and enrich your perspective and ways of responding to the next stressful life event—which is guaranteed to happen.


Embarking on a Disciplined Search


Self-awareness is an ongoing, dynamic undertaking that requires daily attention. With such a process in place, we can become more attuned to the rhythms of our personality and have our “psychological fingers” on the pulse of where we are emotionally with respect to an issue, a person, a challenge, or the general thrust of where our life is moving.


To accomplish this, we need to be aware of the ebb and flow of our reactions so we can become more sensitive to the subtle inconsistencies in our affect (i.e., experiences of sadness, depression, happiness, etc.), cognitions (ways of thinking, perceiving, and understanding), and bodily responses to potential stress and actions. This awareness provides us with a link to some of the motivations and mental agendas that lie just beyond our awareness—what some would refer to as our “preconscious.” To be in a position for such an appreciation of ourselves, time must be taken to identify anything in the way we live that is incongruent so we can seek to understand the reason for the difference.


Instead, what often happens when we do, think, or feel something that is generally out of character for us is that we dismiss it as irrelevant or excuse it (“I was just tired, just having a bad day”). However, when we do not seek to accomplish a creative synthesis in understanding all parts of ourselves, we miss the normally buried treasures in our psyche that we might draw upon when living through difficult situations.


Elements of Clarity


One of the constants present when health care professionals seek help to avoid or limit the sources and symptoms of secondary stress is the temporary lack of clarity they are experiencing. In mentoring, the goal is to help them to clarify, to discern different approaches, and to problem-solve, to find solutions to their inner and external stresses. To accomplish this, time must be taken to focus on the specifics of their reactions. This helps the person to move through conscious (suppression) and unconscious/preconscious (repression) avoidance or forgetting. By limiting vagueness and a tendency to generalize or gloss over details and feelings, information that lies just beyond our sense of awareness becomes available. So, rather than turning away from the seemingly unacceptable feelings, cognitions, impulses, and reactions, we face the resultant anxieties as a price for learning more about ourselves. The benefit, of course, is greater self-knowledge and, in turn, more personal freedom. Rather than being limited by our blind spots in self-awareness and the waste of energy on defensiveness, by focusing on our daily interactions we seek to become sensitive to all of our reactions—even the seemingly incongruous ones—as a way to deepen self-knowledge.


Resistance to achieving clarity in life is often a function of limiting our focus on the roles and behavior of others (e.g., patients, their families, or our colleagues), and denying our own actions. We also must examine our own behavior, cognitions, and affect. Clarity is a process by which we must be willing explore how we might be denying, minimizing, rationalizing, or hiding things from ourselves. Although we may believe that we desire to see ourselves and our situation as they truly are, conflict can arise when this happens because the responsibility then falls on us to



Awareness of Our Agendas


Thinking that we do things for only one reason is naïve. In most cases, there are numerous reasons—some immature, some mature—that we do things. Because the reasons we do not like to acknowledge often remain beyond our awareness, clarity calls us to embrace all of them. In this way, the immature reasons can atrophy, and the mature ones can grow and deepen. However, to accomplish this goal, we must first accept that we are all defensive in some unique way. Such an admission is an excellent first beginning because it does not put us in the position of asking, “Are we, or aren’t we?” Instead, it moves it out of the black-and-white situation to the gray areas where most of us live psychologically. When we look at all the reasons why we reacted to a situation in the way we did, we can begin to appreciate why people react to us in the way that they do. Otherwise, we remain puzzled, feel misunderstood, and project the blame outward so as never to learn what are the dynamics and how to unravel them in any given situation.


For instance, if colleagues do not like to work with us in stressful situations, it would be helpful for us to know what they are seeing so that we can work on adjusting or changing our behavior. A candidate applying for an administrative position asked her future supervisor, the department chair, during the interview, “Do you know how human resources is billing the main challenge of working with you?” Surprised—in considering how there could be any challenge in working with him? The department chair responded, “No, I don’t.” To which she noted with a smile, “They are billing you as a perfectionist who gives vague instructions and gets upset when they are not followed exactly.” The department chair continued with the interview.


Impatience, anger, and other reactions on our part do not increase efficiency when we are working with colleagues in a difficult health care emergency. Blaming our reactions solely on other people’s incompetence provides very limited information for improving the situation by changing our own behavior. Even if the others were not as prepared as they should have been to handle, for example, a patient care situation, reacting emotionally or blaming others in a way that makes the situation deteriorate further, certainly does not improve things.


Clarity calls us to recognize our agendas, face our own fears, understand the games we play with others, lessen our defensiveness, develop new coping skills, and create alternative ways to deal with stressful situations. As Aitken points out, “it is only when we can generously acknowledge our own dark side and the shining side of the other, that you can be said to be truly on the path.”15p76 Yet, to do this, we need to be honest. We must appreciate that this honesty can have a positive domino effect in our life as a way of moving through the resistances we have to growth and change. When we start focusing on understanding individual interactions, larger questions open up as to whether we are getting enough rest or leisure, the right balance of time alone and with good friends, and how and when we are setting limits in all aspects of our life. It is important to recognize that the self is a limited entity that can be depleted if we do not involve ourselves seriously in a process of self-care.


Awareness of the Body’s Responses


The Buddhist teacher Thich Nhat Hanh reminds us, “If we get in touch with our body, then we can also get in touch with our feelings.”16 The tendency, however, is to experience a negative event which prompts bodily signals that we often ignore. We then think, even ruminate about what happened creating a second painful perspective which Hanh refers to as the second arrow.



Attuning to body signals can be helpful in assessing our true responses to situations and in developing responses that match the situation. Table 3.1 lists typical body responses to stressful situations that you may experience. You may be surprised, even concerned, about how long you had to think before deciding on the items to check. You may be aware of only global feelings but focusing on the specific signal will lead to a realization of just how the body’s response influences your behavior.




Once we begin to link body signals to the feelings experienced in negative reactions, we are better able to accept the signal, interpret it, and perhaps reinterpret to our advantage and devote energy to responding more effectively. Your body is a mind-reader, but your mind can generate new meanings to experiences that can ultimately change your body’s responses. This body–mind cycle can be enormously productive in the quest for self-knowledge.


Appropriate Intimacy


Healthy intimacy with others is a wonderful antidote to unnecessary stress and an effective inoculation against the destructive impact of the necessary pressures of health care work. Unfortunately, distancing from others or overinvolvement or inappropriate involvement with others can add to our problems in work and at home.


In medical and nursing programs, little is taught on the topic of transference. Transference occurs when a person views someone in the present as if he or she were a significant person from the past. It is a normal phenomenon that we experience often. For instance, when we see a police officer, clergyperson, or someone in authority, we may have a response that has nothing to do with the individual person but has all to do with what they represent to us. Patients and coworkers will often transfer positive and negative feelings onto medical and nursing health care professionals. Being aware of this so as not to absorb the negative transferences or believe and act on the positive ones by violating boundaries is essential.


When one is doing the best that can be done for a patient or is trying to be as supportive as possible to a colleague, it is very hard to recognize negative transference for what it is, but it is important that we do so as not to react negatively in kind. When feeling under great stress at work and/or feeling underappreciated or misunderstood at home, there is also a danger that one would become inappropriately involved with a patient or colleague who is transferring their positive feelings from the past onto us because we are in a caregiving role at a time of great vulnerability and need for them.


Some deal with this not by trying to be aware of what is occurring and discussing it with a trusted senior colleague or mentor but instead by distancing themselves from patients and colleagues alike. Doing this can be dangerous to our welfare and the good of the patients and our colleagues on several levels. First, being very distant can lead to callousness. When this happens, we become impervious to the feelings and needs of others. Also, with respect to our colleagues, deep non-sexual, intimate relationships help one to understand oneself and to open oneself to others in ways that foster mutual support and friendship. In turn, these relationships provide a basis from which we can reach out to patients and colleagues in need.


Learning From Our Negative Emotions


Negative emotions are psychological red lights indicating that we are dealing with situations with which we are unhappy or uncomfortable. It is helpful to more fully understand how contact with people who are depressed, angry, sarcastic, or dismissive of us can affect us. Otherwise, we will respond negatively, passive aggressively, or with “chronic niceness” because of the misguided belief that absorbing patient and colleague anger is part of our job description. As Wicks previously indicated, such an attitude is both dangerous and unnecessary:



This leads to ulcers, unnecessary stress, depression, and outbursts of anger when all the “swallowing” of anger becomes too much. Negative emotions are like alcohol; they can be used or abused.


With respect to anger, it needs to be recognized and addressed directly. In addition, if one sees or experiences depression, it too must be named and the source of it questioned. Hiding, belittling, or running away from such emotions because they are unpalatable is only postponing the problem until it gets worse for the other person or the [caregivers] themselves.


Many . . . say: “I just don’t know how to deal with angry people.” To face such a fear of others’ anger or the inexperience one might have in dealing with it, two steps usually are of help to get one started in confronting it.


The first step is imagery. To image oneself dealing with an angry person and to see oneself responding with a sense of poise is a good exercise to practice in the privacy of one’s own room. Another useful step when one is holding back from expressing anger in a constructive way is to ask one-self: “What is the worst thing that can happen if I confront someone?”


[Surprisingly more often than you would think] . . . there is a deep fear that the person will beat us up physically. In those instances, I say . . . “If this person is not bigger or tougher than you, it won’t happen; if the person is, have someone outside the confrontation area to help you if need be.”


We must face our deepest fears about rejection, being beaten up or having our image stained, so we can face the blackmail we have set up in our own belief system. This belief system has been developed over a period and needs to be addressed so we don’t have to continue to run from others’ actual or perceived negative emotions.17pp254–255


Through self-questioning, we can arrive at a better recognition of both direct and indirect expressions of anger. It is also possible through self-questioning (Box 3.2) that we will see our motivations, fears, and interpersonal style more clearly. The more this is accomplished, the more we will be withdrawing our projections, taking control of our lives, and, in the process, reducing unnecessary stress.




Box 3.2 Questions Regarding Our Experiences of Anger


Mar 13, 2021 | Posted by in NURSING | Comments Off on “Riding the Dragon”: Enhancing Self-Knowledge and Self-Talk in the Health Care Professional
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