Introduction
One can easily empathize with the plight of young Alice. She is encountering the unpleasant slap of confrontation, and she does not know where to move next. She is probably wondering if she should rebuff the cantankerous egg or politely retreat, admitting her gaffe. The answer, ironically, is that there is no single correct answer.
During the initial interview, and indeed throughout the course of therapy itself, clinicians will not infrequently encounter such points of disagreement, anger, and confrontation (sometimes revealing themselves in the guise of questions from our patients which are asked “with a certain edge”). Attempts have been made to provide steadfast rules with which to handle these encounters, such as “Always address the underlying process” and “Look for the hidden agenda of the patient.” These principles may provide valuable suggestions for action, but when they become rules, they become traps. These traps are littered with the remains of frustrated interviewers and disengaged interviewees. As opposed to rigidity, it appears that it is the clinician’s use of creativity and flexibility that holds the key for transforming such potential points of disengagement.
In this chapter, the focus is not upon rules. Rather we shall focus upon the development of a clarifying language and a set of simplifying principles. This language and its accompanying principles can help us to transform times of potential disengagement that, if handled improperly, could rapidly degenerate into deadly impasses to communication and healing. Those times in which the potential for disengagement is on the front burner are frequently easy to recognize, for they are vividly framed by the patient’s angry statements and accusations. But not all moments ripe with potential disengagement are statements. Patients sometimes ask awkward questions that challenge the interviewer’s competence or invade his or her sense of privacy such as, “Are you a student?” or “Have you ever had an affair?” As with provocative statements, these questions represent determining moments in the therapeutic alliance. Depending upon the fashion in which they are handled by the clinician (gracefully versus defensively), the interviewee may very well determine whether or not a second appointment is necessary.
In clinical practice, disengagement points are often characterized by four inner phenomena experienced by the interviewer. It is these discordant sensations that make points of disengagement so troubling to interviewers:
1. They frequently appear abruptly, sometimes feeling as if “they have come out of the blue.”
2. They demand an immediate response from the interviewer.
3. The interviewer feels “on the spot” (the clinician’s own defenses are often automatically triggered).
4. Clinicians feel ungrounded and “at a loss,” for they seldom possess a concrete, and well-practiced strategy for comfortably handling such situations.
The generation of these unpleasant inner experiences is one of the reasons, no matter where in the world I present workshops on clinical interviewing, no matter what the disciplines of the professionals attending, and no matter what their levels of experience (from graduate students to clinicians with decades of experience), delineating better methods for effectively handling such situations is one of the most common requests I receive. For this reason alone, it is wise to devote considerable time to such situations.
Indeed, the interest shown in this topic by clinicians across all levels of experience, highlights a paradox of sorts. This skill set (often of great value in the early years of a clinician’s career) is, simultaneously, an advanced skill set (that will still be a focus of professional growth in the last years of a clinician’s career). It is an advanced skill, for its effective implementation requires a great deal of observing ego (Sullivan’s participant observation from Chapter 2) that is hard to come by early in one’s career. The development of an observing ego is partially dependent upon experience and the confidence that comes with it. But the development of an observing ego – and the ability to resolve these difficult therapeutic moments – is also dependent upon the acquisition of a clarifying and practical knowledge base upon how to approach the transformation of these moments. This chapter is designed to provide exactly the type of knowledge that can kick-start the development of this process for the young clinician.
Moreover, arguably, the single most pressing reason for our attention is the tremendous import riding upon the fashion in which the interviewer responds to such potentially disengaging moments. As stated throughout this book, the most important goal of the initial interview is to secure a second interview. Learning to gracefully transform points of potential disengagement is crucial to achieving this goal. Indeed, everything we have discussed up to this point in our book might be for naught if the interviewer does not understand how to effectively navigate points of disengagement.
In the following pages we will explore interview principles, techniques, and strategies that can significantly decrease the discomfort surrounding such potential disengagement points. I should add that our new-found knowledge will not eliminate such discomfort. Over the many years that I have been utilizing the following strategies and techniques I still encounter moments when I feel caught “off-guard” by a patient’s statement or question. On the other hand, over these same years the moments of discomfort have decreased both in frequency and in intensity. Perhaps, more importantly, I respond less defensively, with the result that my patients seem to feel that their concerns have been met in a reasonable and reassuring fashion.
Once clinicians have processed and practiced the principles of this chapter, the four negative sensations mentioned above undergo a reversal of sorts. First – regarding the apparent abruptness in appearance of disengagement points – we will find that there are often harbingers that such disengagement points are on the horizon, so they need not take the clinician by surprise.
Second – concerning the apparent need for an immediate response – this fact remains unchanged. The clinician must still respond quickly. But what becomes different is the inner sensation of the time available for the response. There is a common phenomenon in American football that is completely analogous. The speed of this sport is remarkable, especially for National Football League (NFL) quarterbacks who essentially run the team on the field. All quarterbacks who move into the professional ranks from college comment on how much faster the game is at the professional level secondary to the uniformly great athleticism of all the players on the field. Because of this fact, few quarterbacks from college succeed in the pros. But quarterbacks who do succeed often make comments such as the following, regarding a phenomenon they find quite odd yet whose presence they feel is a great gift, “There is a point in my development as a professional quarterback when suddenly everything after the snap of the football seemed to slow up. And when I am at the very top of my game, it almost seems like the play is unfolding in slow motion around me. It is remarkable how much time I seem to have to think.”
This radical change in time perception has a scientific basis. It results from the fact that the successful quarterbacks have learned new principles and techniques for handling the action of the play (some of which felt quite awkward at first). But with repeated practice these new and more effective methods became second nature – essentially intuitive – so that the quarterbacks feel as if they have more time to make their decisions, even though the time with which the plays unfold is, in actuality, unchanged. So it is with the handling of angry disengagement points for clinical interviewers. Once the numerous and flexible principles of this chapter have been learned and practiced, they become progressively intuitive and more rapidly accessible. The bottom line is, the time needed to respond to disengagement points will feel remarkably longer (although, in essence, there has been no change in their length).
The third uncomfortable inner experience for the interviewer – the clinician feels “on the spot” because his or her own defenses are often triggered – this phenomenon remains present, but it too will be experienced differently. As opposed to a problem, triggering an immediate sense of discomfort or even panic, the clinician feels a certain excitement about these moments of potential disengagement, for they sometimes represent moments of insight for both participants. The clinician realizes that such points herald two things: the patient’s defenses are near the surface and the clinician’s defenses are near the surface. In this sense, few areas of the initial interview provide a better window into the psyche of the clinician than watching the clinician’s natural responses to angry patient comments or provocative questions that challenge the clinician’s competence or invade the clinician’s personal history. As Harry Stack Sullivan has suggested, the self-system of the therapist quickly comes to the fore, staunchly defending the therapist from the affronts cast by the patient.
These moments are pregnant with potential growth for both participants. Handled in a non-defensive fashion, the clinician will be able to help the patient overcome a problematic hurdle to healing and may very well learn something about his or her own defenses on the way. Not always, but often, these disengagement points become “win–win” opportunities for both members of the interviewing dyad. If the clinician attends to these moments with sensitivity, they can provide unexpected gateways to both a deeper understanding of the patient and of the clinician’s self-system.
Pertaining to the fourth uncomfortable inner sensation – the clinician feels ungrounded and unsure of the correct way to transform the moment – this inner tension will gradually ease as the reader learns that there is no “correct method,” as noted with Alice and her Egg problem above. There is no pressure to “do it right.” In fact, a variety of well-tested strategies exist, and can be practiced, for transforming such moments. Each disengagement point represents an opportunity to creatively discover the most effective approach for this particular patient at this particular impasse in the initial interview.
Moreover, the language we are about to develop will provide these four shifts in inner experience in two distinct timeframes, one retrograde and one anterograde. First, such a language can help a clinician to review a recently completed problematic interview with the hope of figuring out what went wrong, while discovering methods of handling the situation differently the next time it presents itself. Second, perhaps even more importantly, a more sophisticated understanding can allow a clinician, during the interview itself, to recognize possible courses of action that may transform the anger of the patient before irreparable harm has occurred to the therapeutic alliance. Indeed, a seasoned clinician eventually recognizes such interludes not as demons but as odd allies of a sort, offering opportunities for insight.
This point brings us back to Alice, who has clearly been insulted by Mr. Dumpty. The rest of this chapter will attempt to show that Alice has a variety of viable pathways to follow, any one of which may help her to both engage and understand her would-be antagonist. Even for Alice, innocence and good intentions are not enough. Our task is to master these pathways.
In order to accomplish this task, the chapter is divided into three parts. In Part 1, we shall define basic terms regarding potential disengagement points. In Part 2, we shall delineate a language for understanding the principles that allow a clinician to more deftly navigate these daunting points. In Part 3, we shall translate these newfound principles into concrete interviewing techniques that address a variety of potential disengagement points that appear in everyday clinical practice.
Part 1: Points of Disengagement – Core Definitions
The Nature of the Beast
It is normal for clinicians to view disengagement points with appropriate hesitation. Because of the uncomfortable inner experiences they create, they are frequently experienced with some trepidation, and, on occasion, even fear. If handled inappropriately, and with the wrong person at the wrong time (a patient who is intoxicated or in a manic state), they can even lead to violence. These challenging moments represent clinical gremlins or beasts that can do great damage to the newly emerging therapeutic alliance between the patient and the clinician. It is of value to understand their nature better, for they are complex, nuanced, and not always what they seem.
Broadly speaking, there are two types of disengagement points: (1) moments characterized by angry disengagement and (2) provocative questions that can lead to disengagement depending upon the fashion in which the clinician handles them.
For the sake of conciseness, we shall refer to moments of angry disengagement with a simplifying acronym that will suitably remind us of the problem at hand: MADs. MADs in turn can appear in three guises, each with a distinctive flavor: (1) confrontational disagreements, (2) oppositional behaviors, and (3) passive-aggressive attitudes. As the acronym implies, the one common denominator of all MADs is the presence of anger. As we shall discover below, what is different is how the anger manifests itself.
The second type of disengagement point occurs when the patient asks the clinician a question that catches the clinician “off-guard.” We shall refer, once again for the sake of clarity and conciseness, to such potentially disengaging questions as PDQs. PDQs can be every bit as hostile and nasty as MADS (as with “Why do you kill people with your awful drugs?”) but they need not be so.
Points of Disengagement: Type 1 – Moments of Angry Disengagement (MADS)
The Family of MADS: Three Siblings
1. Confrontational Disagreements
Deconstructing Disagreement: The Significance of a Fallen Log Upon a Road
Before we examine confrontational disagreements, it is of value to acknowledge a simple fact of human nature: People disagree.
It is the nature of the human organism. Couples disagree, employers and employees disagree, politicians seem to endlessly disagree, and nations go to war because they ferociously disagree. Although often nasty in nature, sometimes even violent, disagreement is not always bad. Indeed, when – from the very beginning and throughout the process – the two parties proceed in a reasonably calm and collaborative fashion, disagreements (whether between members of a couple or peoples of a nation) can result in growth, new ideas, fresh energies, and improved communication channels. The beneficial dialectics of the philosopher Hegel and their therapeutic adaptation by Marsha Linnehan (dialectical behavior therapy) immediately come to mind.
In addition, disagreements that begin with anger yet end with a genuinely joint approval serve a valuable role in human relations. It is this exact type of resolved anger that, paradoxically, often results in a deepening intimacy in a relationship. Humans like it when they begin to trust that the person across a negotiation table or across a bed in a boudoir can be reasoned with and counted upon to “ride out” the fleeting moments of antagonism that are inherent in all enduring relationships. And, as we have emphasized in the previous pages of this book, the therapeutic alliance is a most nuanced and complicated human relationship. Thus our goal in interviewing is not to remove all moments of disagreement. It is to learn how to make use of them when they arise.
In this light, one of the most common questions about any disagreement is, “Who is to blame?” If you are a participant in the disagreement, the answer is always a simple one – the other guy. If, instead, you are a bystander, the answer may be a good deal more difficult to discern. Occasionally the answer is both parties. Occasionally it is neither party. On rare occasions it is the bystander who started the whole damn thing, but has wisely stepped out of the struggle (think triangulation).
Rephrased, as it has been enshrined in everyday wisdom for as long as the first cave-people disputed who gets to eat the last piece of the mastodon, the answer to this question is, “It depends who you ask.” Disagreements, obviously, have two sides to them. It is no different with disagreements arising in the clinical relationship.
It is certainly true that in many MADs, the anger is first expressed by the patient and often arises from maladaptive processes – indeed, sometimes psychopathological processes (such as psychosis, narcissistic entitlement, borderline rage, and acute intoxication). But there is no monopoly on inappropriate expectations and anger in a clinical setting. All clinicians, including myself, can be the first to bring irritation, frustrated affect, and anger to the interviewing dyad. These disruptive emotions are created by complex processes such as the clinician’s unfinished psychological business, unrecognized cultural biases, or episodes of “burnout.”
With these caveats in mind, perhaps the best way to view clinical moments in which disagreement arises is to view them as communication impasses. Like a roadblock, such as a fallen tree on a highway, the roadblock creates an impasse to people moving in both directions. Neither party is necessarily wrong, regardless of the direction they intend to go, but both parties are thwarted by the fallen tree in the road. Especially during moments when anger has entered the disagreement between the clinician and patient, the roadblock can represent a threat to the therapeutic alliance, and, ultimately, to the healing process itself. Assigning blame is not the issue. Removing the tree is.
Not All Disagreements Are Bad
Disagreements seem to naturally fall upon a continuum. At one end of the continuum is a friendly type of disagreement, at the other end, a not so friendly one. We shall call the first type a “collaborative disagreement” and the second a “confrontational disagreement.” It is the latter type that interests us in this chapter, but let us examine the former briefly first.
Collaborative disagreements are common in everyday relationships, at home, at work, and even at play. They arise when two people have a distinct difference of opinion. Collaborative disagreements are belief based, and, if they are to remain collaborative, are not prone to marked influxes of anger. As the name suggests, they are characterized by a generally calm and collaborative tone, which is set and maintained by the participants both verbally and nonverbally. Intense anger is not present, nor is angry affect generally demonstrated, other than perhaps mild irritation. Each party in a collaborative disagreement is busily trying to change the beliefs of the other party, but does not have war paint on as part of the process.
In this chapter, we are interested in those moments when a disagreement changes its pitch. The added ingredient in all confrontational disagreements is anger. A confrontational disagreement occurs when the patient is trying to change the belief or opinion of the clinician and the patient is doing so with an angry affect and tone of voice. It is important to note that beneath the anger in the vast majority of confrontational disagreements, the careful listener will hear the echoes of the patient’s pain. Although the anger of a patient may be shrill, and even frightening, on an all-too-human level it is the pain of the patient that one is hearing. In this respect, in addition to anger, the other common denominator of almost all confrontational disagreements is pain.
Thus far, we have been viewing confrontational disagreements (the first of the three types of MADS, the other two types being oppositional behaviors and passive-aggressive attitudes) as pivotal junctures. They represent points in which disengagement is already occurring and which, if unresolved, may result in total destruction of the therapeutic alliance. Consequently they, as well as other MADs and PDQs, were described in the introduction to this chapter as clinical gremlins or therapeutic beasts of a sort, both unpleasant and unfortunate to encounter. As I indicated earlier, I can’t argue that MADs, in general, and confrontational disagreements, specifically, are pleasant, but I can argue that they are frequently fortunate if handled adeptly. Let us look at this process in more detail. How do confrontational disagreements, if resolved, sometimes enhance the engagement process? By way of explanation, let’s look at just one way, albeit a striking one.
For some patients struggling with severe personality dysfunction, the aggressive track that they have taken with the clinician is a common interpersonal defense utilized by the patient in his or her everyday encounters. It is the type of defense (driven by the patient’s own pain and fears) that often causes people (friends, lovers, bosses, and strangers met in everyday circumstances) to reject the patient. Frequently, the patient’s hostile statements trigger equally hostile responses from others. Most people respond to antagonism with escalating antagonism.
Patients that project that others hate them, often unconsciously defend against such rejection by keeping people at a distance with aggressive comments. Ironically, such unconscious defenses often result in the very rejection that the patient fears. People lash back at the patient. To the patient (who is completely unaware that he or she is being aggressive) it appears that people hate them, exactly what they suspected. It is a sad state of affairs – the patient’s behaviors (aggressive comments) create the very actions from others (hateful responses) that the patient feared in the first place (in psychoanalytic literature this process is often called “projective identification”).
The technical name for this type of unconscious, yet tragic, interpersonal trap, is not so important for understanding why angry disagreements can become powerful healing moments. What is important is the simple fact that this type of angry counter-attack from people is what the patient is used to receiving. Consequently, it is also what the patient anticipates he or she will receive from the interviewer. If the interviewer – in contrast to the people with whom the patient interacts on a daily basis – does not respond with antagonism or rejection, the patient is often surprised. In fact, if the clinician is able to respond in a calming, non-defensive fashion, the patient experiences a corrective emotional experience. It can be a profoundly positive one.
To the patient’s surprise, here inside this clinic office or emergency room, they have met a remarkable human being (the interviewer) who did not counter-attack. They have met the person beneath the label of a “therapist” and have found that person to be a safe interpersonal haven. Such a safe haven can be hard to resist to someone who has never found one before. In this fashion, deftly transformed confrontational disagreements sometimes provide the interpersonal magic that was necessary to secure a second appointment. Much of this chapter is about how to create such apparent therapeutic magic from the intensity inherent in all confrontational disagreements. Before we proceed, it is of value to examine the second sibling in the MAD family, it is a sibling whose voice is often raised in an initial interview.
2. Oppositional Behaviors
Just to make sure that we have a picture from actual clinical practice of what is meant by an oppositional encounter, let me share one that I experienced myself. In actuality it was both a classic MAD (moment of angry disengagement) and a PDQ (potentially disengaging question) bundled into a single exchange.
I vividly remember a patient (we shall call her Ms. Travis) who was coping with borderline personality dysfunction. I was meeting her for the first time. She had actually been involved in numerous therapies over the years. I thought our initial engagement was going rather well. Apparently, I thought wrong.
About 15 minutes into the interview, Ms. Travis abruptly cut me off asking, “Can I say something here?” Without any sense of impending ambush I quickly chirped, “Of course.” She curtly nodded her head and said “Thank you.” She leaned forward adding with a deceptive softness to her tone of voice, “You know, I’ve been around the block with many different therapists over the years. And I can safely say that you are the worst one I have ever seen. You are totally incompetent, are you aware of that fact?” She leaned back.
Suffice it to say, I was unaware of that particular fact. I suddenly found myself in Wonderland with Alice, for Ms. Travis had basically stated that I “had no more sense than a baby.” Unfortunately, I was not in the imagined world of Wonderland but in the all-too-real world of an outpatient clinic. Ms. Travis was expecting an answer to her question and a response to what she felt was an astute observation. She was also sporting a bemused look upon her face. Ms. Travis knew a direct hit when she had launched one.
In such situations, we have only seconds to verbally respond. Moreover, unless we are remarkably polished, we will immediately begin responding nonverbally via our facial expressions, not always to our advantage I might add. In this instance, I believe my first nonverbal response was the dropping of my jaw in dumbfounded disbelief. Ms. Travis was not impressed. Moreover, at such undisguised moments, the patient will immediately pass judgments upon our responses (both verbal and nonverbal). She did. And those judgments may determine the very fate of the initial therapeutic alliance. It did.
As mentioned earlier, if the patient views the clinician to be overly defensive or, worse still, offensive (the clinician responds antagonistically), the patient will probably never enter the office again. She didn’t. It is a sad but painful truth, that 40 minutes of gifted interviewing can be destroyed in a mere 15 seconds by a clinician’s misstep during an oppositional MAD.
As with confrontational disagreements, oppositional behaviors arise from patient anger. The fashion in which the anger manifests has two characteristics that cleanly distinguish oppositional behaviors from confrontational disagreements.
First, oppositional behaviors may have absolutely nothing at all to do with the patient disagreeing with the interviewer’s viewpoints. In case of point, sometimes the patient displaying oppositional behaviors, at heart, agrees with the interviewer’s beliefs. Patients do not engage in oppositional behaviors in an attempt to change the beliefs of the clinician. Patients do it to irritate the clinician (some patients, such as Ms. Travis, are gifted at the art). Oppositional behaviors can bloom in all age groups, although adolescence seems to be a veritable greenhouse for their flowering.
Second, unlike confrontational disagreements, where the patient’s anger is spontaneous and demonstrates itself without intentionality from the patient (it merely erupts), people displaying oppositional behaviors, such as Ms. Travis above, do so with conscious intent. Moreover, there is often a not-so-subtle bit of glee experienced by the generators of these oppositional darts.
Despite their pronounced differences from confrontational disagreements, oppositional behaviors in an initial interview can frequently be transformed using the same principles that a clinician uses for transforming confrontational disagreements. We shall discover that this effectiveness is rooted in a simple fact. As was the case with confrontational disagreements, beneath the angry glee of an oppositional behavior, pain often resides. In this chapter we will discover how to reach this pain, and, whether we are dealing with a confrontational disagreement or a bevy of oppositional behaviors, address it in a healing fashion. Yet one more sibling in the MAD family exists.
3. Passive-Aggressive Attitudes
This third and final member of the MAD family is a bit different in nature. It has a more enduring and pervasive life than a typical confrontational disagreement or an oppositional comment, for true passive-aggression is more of an attitude than a mere behavior. A passive-aggressive attitude is generally part and parcel of a passive-aggressive personality disorder or may represent partial traits of such a disorder. It can show itself, and often does, with confrontational disagreements and/or oppositional stances, but also is hallmarked by comments and questions that are aimed at subtly undercutting authority figures or people viewed as potential threats, such as an initial interviewer.
One of the most striking manifestations is the remarkable deftness with which a person skilled in passive-aggression has learned the power of the word “but.” Unlike more typical MADs (in which the patient frankly disagrees with the clinician or feels oppositional towards the clinician), the person with passive-aggression does not tend to immediately attack. They are masters of the “I agree, but I don’t really agree” tactic. They are notorious for comments such as, “I think that your suggestion for ongoing psychotherapy is an excellent one, but completely ridiculous at present for I don’t have any money in case you haven’t noticed,” “You sure have some awesome insight on my drug use, but you’ve completely missed the point, I use cocaine because my wife drives me to it,” and “I think you’ve made a few good points, but most of them – not so much.” Yes, indeedy! Fun moments at the office.
All joking aside, passive-aggression can truly rattle a clinician, because there seems to be no end to the “buts.” Every suggestion made by the interviewer is soon followed by a reason that it will not work. Even when collaboratively arriving at a possible solution, many passive-aggressive patients will subsequently undercut their own suggestion by the end of the hour.
Unlike oppositional behavior, passive-aggressive patients are frequently unaware of much of their antagonism, for it is caused by unconscious defense mechanisms. Indeed, they often feel that they are making legitimate points that could be helping the other person in the room (in this case the interviewer) from making legitimate mistakes. They not infrequently demonstrate a surprised indignation when confronted with their passive-aggressive attitude, making comments to the interviewer such as, “Calm down, Dude, I was only trying to point out that that solution was simply not going to work here. Take it easy, Man. Whatever!?” (The patient pauses, then dismissively glances away.) This indignation is not feigned. They really were trying to help.
Of course, anger simmers beneath passive-aggressive attitudes and behaviors, just as it does with the two other types of MADs. The techniques of this chapter can be useful in tentatively transforming this anger and its passive-aggressive manifestations. Indeed, in some instances, our techniques can save a therapeutic alliance that is suffocating beneath a barrage of passive-aggressive comments. Yet, it is important to note that in no way will the techniques described in this chapter permanently transform passive-aggressive attitudes. Such attitudes are much too ingrained. They represent personality patterns that will undoubtedly require ongoing therapy to resolve, a topic far beyond the confines of this book.
Of all of the three MADs, it is when encountering the slap of passive-aggression that it is perhaps most important for the clinician to remember the pain beneath the anger. Recognizing this pain is the secret to not personalizing the patient’s passive-aggression, helping us to gently act in a way to defuse it, while always keeping in mind that our mission consists of helping the patient to be relieved of it. The patient is demonstrating passive-aggression for a reason. It is the reason the patient has entered our office. Our goal is to make sure that he or she chooses to return to it.
In closing, of the three types of MADs, the passive-aggressive type is least responsive to the principles, techniques, and strategies of this chapter. Consequently, we will not focus upon this type of MAD in the following pages, although our techniques can certainly be of some value in their short-term resolution.
To use our analogy of the fallen tree in the road, when it comes to passive-aggressive attitudes, our techniques can remove the fallen tree blocking the initial meeting, but you can bet your last dollar that by the time our patient returns the next week, we will find another tree strategically placed there. And, despite my use of the word “but,” I’m not trying to be passive-aggressive here, just honest.
Points of Disengagement: Type 2 – Potentially Disengaging Questions (PDQs)
One could argue that anytime a patient asks a question, no matter how benign, depending upon the answer provided by the interviewer, the patient could potentially disengage. On the other hand, there often flows an undercurrent of hostility to PDQs, but unlike MADs, PDQs are not always associated with anger. Indeed, they are not always inappropriate.
Sometimes PDQs are very appropriate, and instead it is the clinician’s unresolved sensitivities that may engender the intimidated feeling in the clinician (as with, “How much experience have you actually had in working with people who have developed schizophrenia like my son has?”). To me, this is a very logical and wise question for any informed patient or family member to ask.
If a trainee has had minimal experience with such types of disorders, he or she, understandably, may feel inadequate. Suddenly, a benign inquiry from a concerned parent may feel like a direct challenge to the trainee. If the trainee (perhaps having only worked with one or two other patients with schizophrenia, having just begun a rotation on a schizophrenia unit) subsequently responds defensively, “Don’t worry, Mrs. Peterson, I know what I’m doing here,” this parent may come away with quite the opposite impression. People sense defensiveness very adroitly. They don’t like it.
We shall soon see why even an inexperienced clinician has no need to feel challenged by such a question. We will investigate a variety of ways to field such questions in a graceful and reassuring fashion.
Of course, PDQs not infrequently possess a hostile undertone to them. In this chapter we will look at strategies for quickly recognizing the tone behind a patient’s inquiry (benign versus hostile) and effective ways for responding to any patient question, whether it is launched from appropriate interest, inappropriate anger, or, perhaps, appropriate anger, for clinicians and mental health systems do indeed make errors. At this juncture let us flesh out our core definitions in order to better see their clinical ramifications and the principles for transforming them.
Part 2: Points of Disengagement – Developing A Contemporary Language for Their Navigation
Clinical Illustration of a Disengagement Point
To help us better understand the above abstractions as they translate into clinical practice, let us look at an actual example of intense anger that unfolded in an emergency room. It arose over a disagreement about the competence of the interviewer. The interaction will give us a chance to see how the interviewer salvaged the moment, re-engaging the patient enough to allow the interview to proceed. It will also demonstrate a classic MAD, in this case an angry disagreement about the competence of the clinician. It even has a subtle PDQ thrown in, highlighting that MADs and PDQs often go hand-in-hand in the real world of clinical practice. There are few places where disengagement points (whether MADs or PDQs) appear more frequently than in emergency departments. It is a good place to begin our explorations.
A woman in her mid-40s had been brought to the emergency department by the police. Apparently her neighbors had become concerned when they heard angry screams pouring out of the screened windows of her living room. When the police arrived, they found the patient, whom we shall call Mrs. Weston, savagely destroying her furniture. She claimed that “the witches have my furniture, it’s no longer mine!” She was brought to the emergency department on an involuntary commitment.
Mrs. Weston was somewhat unkempt and a little rotund. She frequently looked away with an air of disgust. She adamantly claimed that nothing was wrong with her, but that her neighborhood was teeming with witches and warlocks. These people had been invading her house, planting evil things in her furniture. She was also very proud that she had joined a Pentecostal religion, and she did not want any of those “bad drugs” that were given to her in the past during a hospitalization.
She had been treated for schizophrenia for about 10 years but had not taken any medications or been seen for follow-up in the last 2 years. She also admitted to hearing voices and being “hit by demons.” She vehemently denied homicidal or suicidal plans. The clinician was about to explore her psychotic ideation in an effort to determine whether potentially dangerous psychotic processes, such as alien control or command hallucinations, were present.
It was at this juncture that the interviewer made a rather significant error, for which I take full credit, since I happened to be the unfortunate clinician. The error was the relaying of a subtle self-disclosure, which was made with the intention that the patient might take an interest in educating me about her experiences with demons. To my surprise, the plan resoundingly backfired, plopping me smack into Wonderland, as Alice might say. Let us look at both this point of disengagement and the resulting attempts to rekindle the blending process.
Pt.: I don’t know what I’m gonna do about those people; disgusting – that’s what they are. No right being in my living room, no right at all, ruining my furniture, giving it to the Devil, his dues alright!
Clin.: Mrs. Weston, one thing that you could help me to understand a little better is what it’s like to be hit by a demon. I’ve never had that experience and I’m wondering what it feels like to you.
Pt.: You never been hit by a demon? (said with surprised indignation, a curious style of PDQ, representing the first cannon shot of a soon-to-be-launched barrage of disengaging statements)
Clin.: Well … I’ve never had that exact experience. (I felt both caught off-guard, a bit defensive, and was uncertain exactly how I should respond)
Pt.: Then what are you doing talking to me! (She sits bolt upright, shaking her finger brusquely.) You ought to know all about this stuff, and you’re telling me you ain’t been hit by a demon. Who are you anyway? (another subtle PDQ, angrily challenging the clinician’s competence) You’re full of crap. I ain’t talking to you no more. (mumbled angrily beneath her breath, the MAD has fully evolved with several angry statements challenging the clinician’s competence)
Clin.: Mrs. Weston, help me to better understand what is concerning you about my lack of knowledge about being hit by demons. What specifically about that is upsetting you?
Pt.: It would mean you ain’t no doctor, that’s what it would mean. (said angrily)
Clin.: And how would it mean that I wasn’t a doctor? (asked in a gentle tone of voice)
Pt.: Because to be a doctor you got to deal with demons all the time, any idiot knows that … I just don’t know what is going on here, I just want help with these demons and they send me to a moron.
Clin.: (continuing in a gentle tone of voice) I’m going to be honest with you because I think that is very important. I must admit I may not know everything about things that are important to you, but I am genuinely trying to understand better what has been happening to you, and you can help me to do that. And I didn’t mean to upset you. If other things I say upset you, please let me know. I’m wondering if the demons have tried to hurt or enter your daughter?
Pt.: Yes they have, and I ain’t gonna let it happen.
Clin.: What have you done to protect her?
Pt.: I put extra locks on her doors.
Clin.: And where does she live?
Pt.: She lives down on the East Side.
Clin.: Roughly how far away from you?
Pt.: Too far for her own good.
Pt.: She doesn’t have a good head on her shoulders, she thinks she knows everything, but she’ll learn, she’ll learn the hard way. She’s just growing up and don’t know no better.
Clin.: What are some of the things you’ve been trying to teach her?
Pt.: To learn to be more careful with men. She don’t know what is going on. They’re with the Devil I tell her. She’s been hit by demons before, that I know.
Clin.: How does she act when she’s been hit?
Pt.: She gets that dazed look in her eyes, talks real funny. A mother can tell she can, and I know she’s got demons in her.
Clin.: Have you thought of any ways to get them out?
Pt.: Praying with the Lord, that’s all I know.
Clin.: Do the demons in her ever ask you to hurt her or try to trick you into killing her?
Pt.: They ask me to do things like that. They told me to cut off her eyelids, but I know that’s the Devil talking. And I seen him in her eyes. Somehow I’ve got to get him out.
At this point it looks as if the interview is back on track. The blending, although still tenuous, is certainly a good deal better than it was when Mrs. Weston had mumbled, “I ain’t talking to you no more.” Besides the improvement in the blending, Mrs. Weston is providing the exact type of lethality material that is of interest.
In this interaction, I made the mistake of sharing personal material with a patient experiencing intense paranoia. When I related that I had never been possessed, I had no anticipation that Mrs. Weston would find this fact unsettling or odd. But it goes to show that paranoid patients can frequently twist personal pieces of information if provided by the interviewer. Consequently, it is generally best not to self-disclose to such patients.
The subsequent situation was a little bit like Alice referring to Humpty Dumpty as an egg. Alice had no idea she was putting her foot in her mouth, but somehow it found its way there. MADs and PDQs may arise from such awkward clinician maneuvers, or they may arise spontaneously without any error on the part of the clinician. Let us now develop a language for more effectively dissecting this illustration of a disengagement point, so that we can begin to more effectively transform moments when they occur.
Recognizing the Surface Structure of MADs and PDQs
In order to analyze the appearance and handling of both types of disengagement points, the clinician must first determine the behavioral fashion in which the disengagement point shows itself (Figure 19.1). This observable aspect of the MAD or PDQ is simply called the surface structure of the disengagement point. This surface structure may appear with a verbal, nonverbal, or mixed presentation. The latter form (mixed) appears most frequently. In the above example, the surface structure of both the MADs and the PDQs were mixed. Mrs. Weston’s challenge to my identity as a doctor first manifested verbally with a series of accusations and even a challenging PDQ (“Who are you anyway?”), culminating in an angry statement of her intention to no longer talk. I had, in a sense, been dismissed. Simultaneously, Mrs. Weston expressed her anger nonverbally as well. For instance, her tone of voice became undeniably irritated, and she brusquely wagged her finger with the unmistakable gusto of an Inquisitor General. In this case, the nonverbal indicators were quite obvious, complementing her blatant verbal accusations.
Earlier I had indicated that one of the principles for more effectively transforming MADs and PDQs is being better prepared to field them. The old saying, “Forewarned is forearmed” is actually true here. Being more prepared for an upcoming MAD or PDQ can allow a clinician to proactively prepare non-defensive replies in his or her head. What are some of the warning signs of impending disengagement points?
One such warning sign is the presence of anger from the patient being directed towards people other than the interviewer. Anger can quickly shift from one target to another and the interviewer should anticipate that he or she may quickly become the next target. Such was the case with Mrs. Weston, who demonstrated significant anger towards others long before she turned it on to me with the PDQ, “You never been hit by a demon?” In addition to anger towards other people, certain overt types of psychopathology should alert the clinician that an imminent disengagement point might be just around the corner. At the top of my list are paranoid states (as with Mrs. Weston), manic states, and intoxicated states with alcohol or drugs.
Unfortunately, spotting the surface structure of a disengagement point is not always this easy. A problem may arise if the patient initially telegraphs his or her anger through subtle nonverbal cues. Clinicians can easily miss these unintentional messages. To avoid missing such cues, it pays the clinician to develop the habit of periodically reviewing the blending of the interview. A sudden or unexpected drop in the blending process, even a slight one, is often a harbinger of an upcoming MAD or a PDQ.
Here we have stumbled on one of the major principles for effectively transforming points of disengagement: Spot them early, address them early, and try to transform them early when they are still of minimal intensity. If anger, concern, or suspiciousness is building (whether they be legitimate concerns of the patient or as aspects of psychopathology), it is generally best to deal with such emotions promptly. If they are not dealt with during the interview to the satisfaction of the patient, it is unlikely there will be a second interview.
It is also worth keeping in mind that in the same sense that a patient may demonstrate points of disengagement both verbally and nonverbally, the clinician has the option to respond to MADs and PDQs through either verbal or nonverbal channels. For example, in the above interview, as Mrs. Weston became more hostile, I unobtrusively pushed my chair further away, so as to provide Mrs. Weston with an increased interpersonal space. Small changes, like this one, can sometimes have surprisingly powerful effects on an interview. Similarly, I never type or write notes if a patient appears guarded or paranoid, for such patients can easily, almost routinely, interpret note taking as having a malicious quality to it (distorting their words, taking notes to involuntarily commit them, or communicating magically with some outside malignant source).
Recognizing the Underground Structure of MADS and PDQs: Finding the Person Beneath the Anger
After noting the observable surface structure of a disengagement point (whether it be a MAD or a PDQ), from our perspective of person-centered interviewing it becomes very important and useful to consider the presence of what lies beneath the surface – the seed from which the patient’s disengagement germinates. Most, if not all, observable points of disengagement and anger arise as a defense against some form of patient discomfort, a discomfort that drives the surface appearance of the MAD or PDQ, but may, in actuality have little to do with the content of the MAD or the PDQ. These seeds are none other than the core pains that we explored in Chapter 7 (see Figure 19.1).
For the purpose of review, these core pains include phenomena such as the intense pain of isolation, the pain of feeling wronged or betrayed, self-loathing, fear of the unknown, fear of an impending loss of internal control, fear of an impending loss of external control, the loss of meaning, or the actual fear of physical pain. An ability to understand and eventually sense the presence of these pains lies at the very root of effectively transforming MADs and PDQs, because if the interviewer ignores these underlying seeds, new disengagement points may emerge.
Imagine for a moment a patient who is experiencing his very first admission on a locked unit (a frightening situation for anyone, in my opinion). Now further imagine that this patient, we shall call him Mack, repeatedly complains (in a testy tone of voice) about a series of issues such as wanting different food, needing a place to smoke, not wanting to go to a therapy group, and refusing to participate in the mandatory community meeting. The staff must attempt to resolve each and every one of Mack’s demands as they arise, but upon resolution there is always another complaint from Mack waiting just around the corner.
The truth is that these MADS are merely surface manifestations of Mack’s fears of being hospitalized and his feeling that he has lost control of his life. His complaints are not passive-aggression; they are attempts to regain a sense of active progression. His legitimate goal is to regain a sense of control in such a way that his life will progress according to his own intentions.
Until the staff addresses these legitimate and understandable core pains, Mack’s ostensibly “unreasonable” demands will most likely continue. Soon enough, the staff will quickly begin to tire of Mack’s apparent “attitude problem.” Some staff may unconsciously express irritation towards Mack, perhaps unconsciously instigating even harsher restrictions on Mack’s decision making. In response, Mack will probably escalate both his demands and the anger with which he makes them. A nasty spiral will emerge that could end in confrontation or even violence. Clearly it is better for everyone involved to address the log that has inadvertently fallen across the road of communication between Mack and the well-intentioned, yet weary, staff. And the log is Mack’s fear that he has lost control.
This tendency for the displacement of core pains to mutate into new MADS and PDQs is not inevitable, but it is a common phenomenon. It serves to remind us that as clinicians we have the choice of addressing the observable disengagement point (the surface structure), the seed of the disengagement point (the underground structure), or both. As a basic principle, if the clinician finds that points of disengagement keep reappearing – after he or she has addressed the apparent contentious surface issues raised in a MAD or a PDQ – then the interviewer may need to focus upon the resolution of the underlying core pains of the patient. It is the patient’s core pains that are seeding the patient’s angry behaviors.
Indeed, one of the most common mistakes I see in the handling of MADs and PDQs in initial interviews is the interviewer’s lack of attention to the true drivers of the disengagement point – the patient’s core pains. In the same fashion that we have consistently emphasized throughout the pages of this book the need to understand the person beneath a diagnosis as an integral task of person-centered interviewing, we must spend equal time understanding the person beneath an angry outburst. Whether we are addressing a MAD or a PDQ, we now have a language to help us to more effectively do so (the surface structure of a disagreement point versus the core pain or underground seed driving the disagreement point).
To better understand the concept of addressing the seed pains beneath disengagement points, an illustration may be useful. In the following example the patient (whom we shall refer to as Judith) is a young woman in her early 20s. She presents with a sense of agitation, her fingers picking nervously at each other. She is neatly dressed in a business-like blouse and skirt. Early in the interview she seems quite distracted, and at one point she asks for an ashtray to be brought to her. Her tone is somewhat demanding. A few minutes later she stands, moving toward the window. Throughout the exchange she has seemed hesitant, resulting in the development of a shut-down interview. After she stands up, the interviewer gently says, “You might find that in the long run you’ll feel a little more comfortable sitting.” She tersely responds, “I prefer standing.”
She continues to appear unsettled and anxious. After a few more terse responses, the interaction continues as follows:
Clin.: What are some of the things that have been concerning you recently?
Pt.: You know, I really need to take a break. I’m going to sit out in the lobby. If you want to continue the interview there that’s fine with me. (a terse MAD has shown itself cleanly and clearly, it is a classic moment of potential disengagement)
Clin.: Before you step out, can I offer just one thought and then you can step out if you need to?
Pt.: Yeah, what? (said with a tone of exasperation)
Clin.: I guess we’re both sort of stuck here in an awkward situation. Both you and I, we both realize that the first session of therapy is anxiety-provoking and especially so if you feel sort of pressured to be here, which I understand is the case. Who wants to share intimate stuff with a professional who is also a stranger? I get that. I’m just wondering what you thought was going to happen today, so that I’m not doing something wrong here.
Pt.: I don’t know, I guess you’re going to “shrink my head,” isn’t that what shrinks do? (still said tersely but with a little less anger)
Clin.: Well, I guess that depends upon what you mean. In all seriousness, what were you actually expecting today?
Pt.: (said with some exasperation but with less tension) I don’t know. I just don’t know. I thought I would be laid out on some couch and analyzed. I also thought that some students would probably be brought in to “see the nut.”
Clin.: Well, I’m not surprised that you were feeling a little anxious. I can fill you in a little better on what’s going to actually happen. Would you like that? (a question addressing Judith’s core pain – loss of external control – by giving her some control over the interview process)
Clin.: There is no promise that you’ll feel better, but it might help.
Clin.: First of all, there won’t be any such couch or any students. As I said earlier, we will talk for about 40 more minutes. We will talk only about what you feel is important. If something is too difficult to talk about, I want you to tell me. You don’t have to talk about something that is too painful at present or that, frankly, you just don’t think it is my business to know right now. I leave that totally up to you. We need to move at your pace. Does that sound okay to you? (interviewer continues to yield control)
Clin.: By the way, one thing you said concerned me. You said that you felt students would be brought in to see “the nut.” Are you worried that I’m going to see you as unstable or “nuts,” as you said?
Pt.: I must say the thought crossed my mind.
Clin.: What exactly are you worried about?
Pt.: My boyfriend thinks I’m crazy. He’s convinced of it, and I’m beginning to wonder myself.
From this point onwards, the interview could proceed more smoothly and with a significantly stronger blending.
The observable MADs had consisted of repeated expressions of irritation from Judith, eventually culminating in the request to leave the room (more accurately, it was a statement that she was going to leave the room), a not-so-veiled attempt to end the interview. The interviewer could have addressed these observable signs of growing anger directly or even bluntly told her that she needed to sit down, but instead the seed pains of the patient were sensitively explored.
Judith appeared to be struggling with both a fear of the unknown and a fear of an impending loss of external control. To counterbalance these fears, like Mack on the locked inpatient unit, she began to “take control” of the interview by making demands on the interviewer. Her requests were merely manifestations of her seed pains and fears. If the interviewer had ignored these seeds, perhaps by following the patient out the door, then new observable MADs or PDQs would most likely have emerged.
At the moment that Judith “requested” to walk out, the interviewer wisely chose not to address the observable surface issue of whether she should leave or not. Instead, an inquiry was made as to what the patient was feeling about the entire situation. In this fashion, the interviewer was able to explore some of Judith’s seed concerns. Not only did the clinician explore these seed concerns, the clinician attempted to relieve them.
For instance, regarding Judith’s fear of the unknown, the clinician described what would be happening in the session itself. With regard to her feelings that she had no control in the interview, the clinician literally gave her control with phrases such as, “If something is too difficult to talk about, I want you to tell me. You don’t have to talk about something that is too painful at present or that, frankly, you just don’t think it is my business to know right now. I leave that totally up to you. We need to move at your pace. Does that sound okay to you?”
An interview that could have become an exercise in antagonism resolved itself. This example illustrates the value of addressing seed pains. The interviewer can choose to address either the observable MADS or PDQs or the seed pains lying beneath the surface. Different situations require different techniques. Generally speaking, as mentioned earlier, if the clinician finds that disengagement points keep popping up or returning, it is often a good idea to consider the possibility that a seed pain is not being adequately addressed. For example, Judith may also have been coping with a fear of an impending loss of internal control, as suggested by her statements about going “nuts.” The interviewer was wisely beginning to explore this issue, because if it is left unattended, new disagreement points may arise.
Learning to Move With MADs and PDQs: The “Agreement Continuum”
Our example with Judith introduces another basic piece of language concerning the successful navigation of disengagement points. In the handling of any MAD or PDQ, one can delineate whether the clinician went “with” the patient’s concerns or “against” them. Of course, in many instances, the clinician moves somewhere between these two poles. The task consists of determining where on this continuum the clinician acted. In the above example, the clinician would have been fully going with the Judith’s wish if she had said, “Sure, why don’t we both step outside to finish the interview.”
The clinician could have directly opposed Judith’s wish by saying, “I’m afraid that it is impossible to go outside, I never interview in public like that. We’ll just have to stay here.” Both of these responses would also represent attempts to address the observable MAD itself without addressing its seed.
However, the clinician avoided committing herself in either direction, because she chose to address the seeds driving the MADs as opposed to the observable manifestations of the MADs. To some degree, her willingness to address Judith’s underlying concerns also relayed an important metacommunication – that she was not opposed to hearing Judith’s views and was certainly willing to listen with an open ear. In this sense, she moved subtly with Judith’s concerns.
But the picture is more complicated and the interviewer’s maneuvers more sophisticated. Let us address what we shall call the “Agreement Continuum” in more detail, to see how (Figure 19.2). The real issue is not solely whether we agree or disagree with the patient. More important is the patient’s perception of whether we agree or disagree and how strongly we agree or disagree.
On the far right of the continuum, we see an area where the patient perceives that the interviewer strongly agrees with the patient’s request or belief. In the middle we see a neutral point at which the interviewer is perceived by the patient as neither agreeing nor disagreeing. On the far left is the region that represents the patient’s perception that the interviewer strongly disagrees with his or her opinion.
One might ask, what is the best track to take, moving with or against the patient’s beliefs or requests? However, this is the wrong question, because no single answer exists. Once again, flexibility remains critical for success as reflected in Figure 19.3. In some instances, the clinician must eventually oppose certain requests. Certainly, in ongoing therapy, people with specific personality disorders, such as the borderline personality disorder, benefit from the consistent application of appropriate limits. And in the initial interview, limit setting is sometimes needed. In general, however, the more the clinician conveys a willingness to move with the patient, the more likely it is that a disengagement point will resolve. The more intensely the clinician attacks the requests of the patient, the more likely it is that the patient will “dig in.”
Herein lies the utility and the nuanced use of the Agreement Continuum. If one has to disagree with the patient’s request or belief, the art is setting the limit but setting that limit in such a fashion that the patient feels as little disagreement as possible.
Regarding Figure 19.3, if the clinician must take a position to the left of the middle neutral point (e.g., the clinician disagrees with the patient’s beliefs or cannot agree to the patient’s request), then it is advantageous to move as little to the left as is necessary to maintain one’s stance. In short, there are many different ways to say, “No,” some of which invite anger from the patient and some of which attenuate such anger. Our basic principle is simple:
If one must disagree, do so with as much gentleness as is possible (e.g., move, both with the content of your words and the nonverbal tone with which you express them, as far towards agreement on the Agreement Continuum as is possible while maintaining your own stance).
Nonverbal communications are often the key to effectively implementing this principle.
Let us return for a moment to the interviewer who was working with Judith. The interviewer utilized the above principles in a deft fashion. Recognizing that Judith, who had been pressured by her boyfriend “to seek help for her craziness,” was feeling threatened by the intimacy of therapy, the clinician decided to directly address Judith’s underlying fears. She strategically decided to employ words that communicated that she very much agreed with Judith’s concerns. She proceeded, “… we will talk about what you feel is important. If something is too difficult to talk about, I want you to tell me. You don’t have to talk about something that is too painful at present …” But she did not stop there. She went a step further.
The clinician had intuited earlier in the interview that Judith felt that “her personal business” was being invaded. Consequently, the interviewer made a wise decision to adopt Judith’s viewpoint, using the very words that she intuited Judith had been thinking to herself as with, “or that, frankly, you just don’t think it is my business to know right now. I leave that totally up to you. We need to move at your pace. Does that sound okay to you?”
It was a rather brilliant bit of interviewing. The interviewer applied our core principle to move as much as possible with Judith on the Agreement Continuum. In this instance, it would have been quite hard for Judith to disagree with this interviewer, for the interviewer has moved completely with her, adopting her stance entirely (even the words describing her stance). The interviewer’s intentional movement along the Agreement Continuum had an almost paradoxical “freeing effect” with Judith, who subsequently shared quite intimate details later in the interview.
At other times, the ability to intentionally move with the patient’s sense of disagreement can be even more dramatically important: it can even help to avoid unnecessary violence. Let us see this principle at work.
Imagine a patient who has just been hospitalized involuntarily, secondary to an assault upon a neighbor triggered by the patient’s psychotic process. Further imagine that the patient is mildly agitated and turns to a staff member saying, “Look, I can’t take this anymore. You need to unlock this door right now and I mean right now. I want to go home. I’m not gonna hurt anybody!” Clearly, on the Agreement Continuum, the clinician must take a stance of disagreement. (The clinician cannot just say, “Sounds like a great idea, I’ll just go get the key.” Such a comment might calm the patient. It would also end the career of the clinician.) But how the clinician handles conveying his or her disagreement is pivotal. We cannot always agree with a patient’s request, but we can always modify how we choose to communicate our disagreement (both verbally and nonverbally).
A clinician could walk up to the recently admitted patient, stopping a short distance from him, with arms akimbo. This clinician might proceed to comment with a terse voice, “Look, Buddy. I don’t think you quite get the situation around here. You are on an involuntary commitment. I got the keys, and I decide when you leave, not you. And you ain’t leaving any time soon. And the sooner you get this fact into your head, the easier on all of us. Got it?” One could be hard pressed to picture a stupider clinician. One would also hope the clinician in question has his track shoes on, for the likelihood that he is about to be assaulted is high indeed.
In contrast, a clinician could consciously attempt to mute the intensity of a necessary limit, so as to help a patient feel as calm and non-threatened as possible, despite the refusal of the patient’s request. To effectively do so, the clinician must try to move as close to the neutral point on the Agreement Continuum while still setting the necessary limit that the patient cannot leave the unit (see Figure 19.3).
Let us picture a second clinician in the exact same moment, a moment of high potential for disengagement. This clinician, in contrast to our first one, approaches the patient in a slow fashion. He stops at an unusually large distance from the patient thus providing a sense of safe interpersonal space. The interviewer approaches with palms upwards when gesturing (a nonverbal communication of supplication; see Chapter 8). His tone of voice is gentle and non-authoritative. He verbally sets the limit as follows, “Mr. Jenkins, I wish I could just open the door. The situation is a tough one. We are truly worried about what happened with your neighbor in the incident that brought you in here, and I know you have told us you feel badly about it. We are also worried about the amount of pain you’ve been feeling. Let’s sit for a moment and I’ll fill you in on what you can do about possibly leaving the unit. You have a right to know those things and they can be a bit complicated. And I’m also hoping that we can be of help to you while you are here. Let’s just walk down the hall and sit and talk about your options, so that you really understand what is going on, okay?”
There is no guarantee that this approach will work, but I’m willing to bet big money it is more likely to work than the aggressive limit setting of the first clinician. Note that both interviewers set the same limit – the committed patient could not leave the unit – but the patient’s perception of the clinician’s tone of disagreement will be remarkably different, the second clinician’s behavior being much less likely to provoke a violent incident.
Needlessly opposing a MAD or a PDQ with an antagonistic tone, as the first clinician demonstrated, is asking for a fight with the patient. And the clinician will usually get it. If a clinician discovers a need to consistently and rapidly oppose patient requests by laying down the law, then the clinician should explore his or her own psychological dynamics. Seed pains are not found only in patients.
I am using a striking example above, but the importance of moving with MADS and PDQs is of great importance in almost every attempt to transform disengagement points. It requires a sophisticated ability to engage in participant observation for an interviewer to be consciously aware of his or her own nonverbal and verbal leakage of irritation, anger, and/or countertransference while simultaneously interacting with an angry patient. Sometimes we can’t, and the interaction goes poorly.
As stated in the introduction to this chapter, the language we are creating to describe the nuances of disengagement points and their transformation can still be of great use even when interactions have gone poorly. Retrospectively a clinician can dissect any problematic interaction with a patient by asking himself or herself, “Did it appear to this patient (accurately or inaccurately) that I was moving with or against his or her views?” In short, “Where was I on the Agreement Continuum, and could I have handled the situation in a different fashion?” The answers are sometimes both unexpected and invaluable. I am surprised how often I have needlessly taken a stance that appeared to the patient to be more antagonistic than I had intended.
Sometimes it is useful for an entire team to ask itself these questions. For instance, if, unfortunately, there has been a major disruption on a unit, perhaps even a physical confrontation, it can be useful for a team to sit down and non-judgmentally explore where all the participants fell on the continuum. Such brainstorming sessions can help teams decide upon new approaches with a potentially difficult or volatile patient that can more effectively help both the patient to heal and the staff to feel safer.
As we wrap up our discussion of methods for moving with patients on the Agreement Continuum, I would like to make a point about PDQs specifically. As compared to MADs, PDQs pose one new nuance to the patient. With MADs, from the patient’s perspective, the question is basically a simple one: “How much does this interviewer agree or disagree with me?” Not so with PDQs, for there now arises a second question, in addition to whether or not the clinician will agree to do what the patient is requesting or not. There is now the issue as to whether the clinician will choose to even provide an answer to the patient’s question.
Thus, with PDQs, the patient will also be evaluating to what degree the clinician is moving with his or her request to answer the question itself. For instance, if a patient asks for inappropriate and/or intimate details about the interviewer as with, “What is your own personal sexual orientation?”, two discreet issues arise on the Agreement Continuum. First the patient could be looking to see if the interviewer’s sexual orientation is consistent with his or her own and, second, the patient will make a judgment upon whether or not the interviewer chooses to provide an answer to the question. This curious state of affairs offers both new challenges and new solutions. In Part 3 of this chapter we will see the ramifications and principles for handling particularly awkward PDQs, noting useful techniques for when to answer directly and when it is best not to do so.
Let us review for a moment (see Figures 19.1 to 19.3). Thus far we have determined that in any given MAD or PDQ, one can examine the following points: What was the observable surface structure of the disengagement point (was it primarily verbal, nonverbal, or mixed)? What were the seeds of the underlying structure of the disengagement point (i.e., what were the core pains driving the disengagement point)? And, from the patient’s perspective, did the clinician appear to move with or against the patient’s beliefs and/or requests on the Agreement Continuum? This basic language allows one to discuss and learn from any example of patient disengagement. At this point, a few more terms will complete the tools necessary for understanding how to more effectively transform such moments.
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