When the patient becomes the doctor’s caretaker

In a video interview, the anonymous doctor’s frustration comes through loud and clear. She takes care of complex patients with many health needs, often working 11 or 12 hours a day, sacrificing time with her family. Yet the message she constantly gets from administrators is that she’s “dumb and inefficient” if she can’t crank patients through the system every 15 minutes.

In a word, she’s abused.

And patients ought to care enough about their doctors to ask them if they’re being abused, according to Dr. Pamela Wible, who raised the issue recently on her blog. “The life you save may save you,” wrote Dr. Wible, a primary care doctor on the West Coast who established her own version of the ideal medical practice after becoming burned-out by the corporate model of care.

This is one of those issues that’s like lifting a corner of the forbidden curtain. Many patients probably don’t think too much about their doctor’s challenges and frustrations. After all, physicians are paid more than enough to compensate for any workplace frustration, aren’t they? Isn’t this what they signed up for?

The problem with this kind of thinking is that it ignores reality. Medicine, especially primary care, has become a difficult, high-pressure environment to be in. One study, for example, that tracked the daily routine at a private practice found the physicians saw an average of 18 patients a day, made 23.7 phone calls, received 16.8 emails, processed 12.1 prescription refills and reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports.

And when physicians are overloaded, unhappy and feel taken advantage of, it tends to be only a matter of time before it spills over into how they interact with their patients.

The million-dollar question here is whether patients can – or should – do anything about it.

Dr. Wible advocates taking a “just ask” approach. Compassion and advocacy by patients for their doctors can accomplish far more than most people think, she says.

One of her blog readers agreed, saying the pressures “must frustrate them beyond endurance. I’m going to start asking.”

Another commenter sounded a note of caution, though: “I feel there is a risk for a patient to ask such a question to a dr. who might be hiding how very fragile he/she is.”

More doubts were voiced at Kevin MD, where Dr. Wible’s blog entry was cross-posted this week. A sample:

– “Abused is a very emotionally loaded word that brings up powerful emotions and feelings like shame. I think if a doc is asked by a patient whether he/she is abused, they might actually end up feeling accused.”

–  “I’m having a hard time imagining most docs responding well to their patients asking them if they are abused and I doubt that most docs would respond ‘yes, I am being abused’ to patients who do ask that no matter what was going on in their workplace. Nor do I think most patients want to spend a big chunk of their doctor visit talking about the doctor’s problems and issues.”

– “And what could I do if the answer is ‘yes’?”

I’m not sure what to think. At its core, health care is a transaction between human beings that becomes most healing when all the parties are able to recognize each other’s humanity.

Yet reams have been written about doctor-patient boundaries and the hazards of too much self-disclosure by the physician. Can it ultimately damage the relationship if the doctor shows vulnerability or emotional neediness? What are the ethics of a role reversal that puts the patient in the position of being caretaker to the doctor?

What do readers think? I’d like to know.

After the storm

In the months after Hurricane Andrew devastated south Florida in August of 1992, researchers assessing the emotional well-being of survivors made some concerning observations:

When 400 people living in Dade County were interviewed six months after the hurricane, 25 percent reported distress that was severe enough to meet the criteria for post-traumatic stress disorder. The researchers found clinically significant cases of depression and anxiety among some of the survivors. Many others experienced general distress, health problems and chronic struggles in their daily life.

Most significantly, a small percentage of people continued to show signs of distress and impairment nearly three years later.

As news footage has been unfolding this year of earthquake and tsunami devastation in Japan, towns laid waste by tornados in the United States, wildfires burning in the Southwest and floodwaters swelling rivers and creeks, it’s worth remembering some of the lessons learned from previous natural disasters: that they carry an emotional impact often lasting long after the disaster response teams and outreach services have packed up and moved on to the next crisis.

There’s a large body of research on how people fare psychologically and socially after a natural disaster. Often the emotional toll is far greater than the financial impact of losing a home, business or possessions.

PTSD appears to be the most common issue, followed by depression and anxiety. When studies have followed survivors over a long period of time, most of these people eventually recovered or at least had some improvement in their symptoms. But researchers have consistently found a minority of individuals who are not able to get better on their own.

Disaster survivors who experience long-lasting difficulty seem to have some factors in common. They’re more likely to be dealing with other life stresses, such as financial problems. They also tend to have lower self-esteem and weak social ties.

Various studies have found that children, older adults and individuals from diverse cultures can be especially vulnerable to distress and psychological problems after a disaster. This isn’t absolute, however, and often can be mitigated with the right kind of support.

The National Center for PTSD notes that individual beliefs seem to matter when people are dealing with the emotional impact of natural disaster: “Adults at risk for mental health problems think that they (a) are uncared for by others, (b) have little control over what happens to them, or (c) lack the capacity to manage stress.”

In a very real sense, the volunteers who show up to clear away tornado debris or mop up floodwaters are demonstrating social support that can help survivors move forward.

Not all types of social support are helpful, though. Studies of assault victims and motor vehicle crash survivors have “consistently shown that the presence of negative social support impedes recovery,” the National Center for PTSD explains. “Family members’ critical comments about the length of time taken for recovery seem to stand in the way of trauma victims’ recovery for treatment of PTSD.”

Some of this is obvious. Everyone who experiences or witnesses a natural disaster is affected in some way, and grief, shock and distress are painful but normal reactions. Extra effort may be needed, though, to identify and help survivors who are more likely to have trouble recovering. Nor does the recovery period end when the news cycle moves on to the next big thing. The aftermath can be lengthy and takes time, patience and understanding.

Additional resources:

Minnesota Department of Health

Federal Emergency Management Agency

National Resource Center on Advancing Emergency Preparedness for Culturally Diverse Communities

Photo: After the Joplin, Mo. tornado – Associated Press

Social butterflies and the law of correlation

When it comes to interpreting the findings of health and lifestyle studies, there’s one axiom to keep firmly in mind: Correlation does not equal causation.

Got that? Correlation does not equal causation. In other words, just because two things appear to be associated with each other, it doesn’t necessarily mean one of them caused the other.

This principle leaped rather strongly to mind this week after reading a new study about the impact of social relationships on mortality. The study, which was published in the latest issue of PLoS Medicine, analyzed 148 previous studies that examined the effect of social relationships and whether people who were well integrated socially lived longer than those who were more isolated.

It’s an intriguing question to ask. As the study’s authors point out, there’s been a trend in industrialized nations for people to be less socially connected. It’s logical to wonder whether we’re headed in the wrong direction or whether increasing social isolation might translate into a negative effect on physical and mental health.

After analyzing a large collection of prior studies and calculating the “effect size” of social integration on mortality risk, the researchers concluded that people with what they termed “adequate social relationships” had a “50% greater likelihood of survival compared to those with poor or insufficient social relationships.” What’s more, the effect appeared to be comparable to quitting tobacco and was even stronger than well-established risk factors such as obesity and lack of activity.

The study describes the implications:

Physicians, health professionals, educators, and the public media take risk factors such as smoking, diet and exercise seriously; the data presented here make a compelling case for social relationship factors to be added to that list. With such recognition, medical evaluations and screenings could routinely include variables of social well-being; medical care could recommend if not outright promote enhanced social connections; hospitals and clinics could involve patient support networks in implementing and monitoring treatment regimens and compliance, etc.

The authors conclude: “Social relationship-based interventions represent a major opportunity to enhance not only the quality of life but also survival.”

It’s all certainly very intriguing, but I’m not quite ready yet to run out and make 10 new friends just so I can tack on an extra few years of life. Despite all the data and the number-crunching, this study did not demonstrate conclusively that social integration in and of itself is a protective factor against early mortality. Sure, it showed an association – but this is not the same thing as proof.

In some ways, the study actually raised more questions than it answered. How should “adequate social integration” be defined? Are strong family relationships better for our health than friendships with peers? Are 10 friends better than two or three? Which is more protective – a large circle of casual acquaintances or a small handful of close friendships?

It’s entirely possible that people who are less socially integrated and die sooner are in poorer health to begin with – and that their poorer health status is the reason they aren’t as socially active. (The researchers said they controlled for this but it’s always tricky to draw conclusions from multiple studies, all of which might have been designed in different ways.) Or maybe there’s some other factor that hasn’t been accounted for, such as particular physical, emotional or behavioral characteristics that might influence someone’s likelihood of being both socially engaged and living longer. Perhaps social engagement is a surface expression of something deeper, such as a sense of personal belonging, purpose and meaning.

It’s also interesting to note the study’s implicit bias: the assumption that social integration is almost always beneficial and should be vigorously pursued for better health. American culture is fundamentally open and gregarious – we’re the ones who gave the world Facebook, after all – and extroversion has come to be viewed as the norm. When this is the case, people who are introverted and more comfortable with solitude can be seen as not quite right or somehow in need of fixing. Researchers might conclude we should all be more socially engaged because it’s good for us, but an introvert could well find this stressful and not particularly beneficial to his or her well-being. In fact, more than a few social observers have lamented that Americans, with their dependence on cell phones and 24/7 access to the Internet, are becoming too connected.

It all seems like an area ripe for further research. Just remember, though: If it appears that people who are more socially engaged tend to live longer, it doesn’t automatically follow that their social life is the reason for their longevity. Correlation does not equal causation.

West Central Tribune file photo by Bill Zimmer

Sick in the workplace

In many ways, it has been a welcome trend for employers to be more actively involved in promoting healthiness among their workforce. If employers are serious about lowering the cost of health insurance, it stands to reason they should try to do something about it.

More than a few businesses are getting tough, according to a story in the Wall Street Journal this past weekend:

In an effort to control the escalating cost of care, especially from chronically ill workers, many companies have been increasingly providing financial incentives to encourage workers to lose weight, stop smoking and manage a chronic illness. But a growing number also are starting to penalize workers who don’t – with higher insurance premiums, deductibles and out-of-pocket expenses.

“The passive nature of the work force has been troubling for employers, says Jim Winkler, U.S. leader of the health-management practice at consulting firm Hewitt Associates. “What they’re trying to do is motivate people to change their behavior.”

Leaving aside the question of whether this veers into coercion, I can’t help noticing there’s one thing missing from the list of ills among the work force. That’s right: stress.

Stress can be just as costly - maybe even more so – than chronic conditions, smoking or lack of physical activity, the triad that usually gets singled out in workplace wellness initiatives. Consider some of the statistics contained in a report by the National Institute for Occupational Safety and Health.

– In a survey conducted by Northwestern National Life, 40 percent of respondents said their job was “very or extremely stressful,” and 25 percent viewed their job as the main source of stress in their lives.

– In another study carried out by St. Paul Fire and Marine Insurance Co., problems at work were more strongly associated with health complaints than any other source of stress, including family or money issues.

When the nonprofit Families and Work Institute carried out a national survey in 2008, it found that 41 percent of workers reported experiencing three or more indicators of stress sometimes, often or very often. In the same survey, one-third of the respondents said their job drained their energy, leaving them with little left over for family or personal time.

Layoffs, increased workloads and the need to do more with less have arguably made the workplace even more stressful in the past couple of years.

A certain amount of workplace stress is unavoidable. It can even be beneficial when it revs up people’s energy and creativity. But chronic or unrelenting stress at work can ultimately be very corrosive, not only to the employee’s mental well-being but also to his or her physical health. From the NIOSH report:

Short-lived or infrequent episodes of stress pose little risk. But when stressful situations go unresolved, the body is kept in a constant state of activation, which increases the rate of wear and tear to biological systems. Ultimately, fatigue or damage results, and the ability of the body to repair or defend itself can become seriously compromised. As a result, the risk of injury or disease escalates.

In the past 20 years, many studies have looked at the relationship between job stress and a variety of ailments. Mood and sleep disturbances, upset stomach and headache, and disturbed relationships with family and friends are examples of stress-related problems that are quick to develop and are commonly seen in these studies. These early signs of job stress are usually easy to recognize. But the effects of job stress on chronic diseases are more difficult to see because chronic diseases take a long time to develop and can be influenced by many factors other than stress. Nonetheless, evidence is rapidly accumulating to suggest that stress plays an important role in several types of chronic health problems – especially cardiovascular disease, musculoskeletal disorders, and psychological disorders.

By now, you’re probably connecting the dots. Who has the time or motivation to exercise and prepare healthful, home-cooked meals when they work all day long and come home wiped out? How is someone supposed to successfully quit smoking/lose weight if cigarettes/comfort food have been their emotional crutch during times of stress? How do you manage heart disease or high blood pressure when one of the contributing factors to these conditions is stress?

Workers are being asked to keep themselves healthy (and risk being financially dinged if they don’t measure up), yet when they’re under constant stress at their place of employment, it’s hard to see how the work-related stress won’t often undermine their best efforts. By all means, let’s encourage employers who want to do something about employee health – but if they fail to acknowledge the role of workplace stress or take it into account as they design their wellness programs, they’re missing the boat.

Multitasking Nation

On your way to work this morning, or dropping off the kids at school or going to the store, how many of you were yakking on the phone while you drove? Maybe you were drinking coffee or, heaven help us, applying your makeup or eating breakfast. When you arrived at work you were promptly busy juggling three or four – or more – projects, checking your voice mail, checking your e-mail and surfing your favorite Web sites. As the day progressed, the work piled up, along with countless distractions and interruptions. You drag yourself home at 5 or 6 p.m., make dinner while watching TV, and divide the rest of your evening between paying your bills online, texting and checking your voice mail while doing the laundry, unloading the dishwasher, walking the dog and supervising the kids.

Welcome to Multitasking Nation, where more, more, more equals MORE. Or so we’d like to think.

Somewhere along the way, the number of tasks we can juggle at any given time seems to have become the yardstick for how successful we are at managing our lives. What we’re conveniently forgetting (or ignoring), however, is the fact that biology is stacked against us.

The human brain is a pretty amazing thing. It can process thousands of bytes of sensory input – what we see, hear, smell, taste, feel, remember – at lightning speed. Even when the brain is injured, it can adapt. But what it apparently can’t do is process multiple things simultaneously – or at least not process them with any proficiency.

The brain’s ability to multitask has been getting a lot of attention in recent years, probably because of our increasingly hurry-up lifestyle and the growing number of distractions to occupy our time. The Neurophilosophy science blog explored this issue awhile back with a good explanation for the layperson:

We know well that it is very difficult to concentrate fully on more than one task; researchers are now beginning to gain an understanding of the neural bases of the limits of multitasking (and some hope to overcome them with augmented cognition). Recent neuroimaging studies in which participants switch between one task and another have implicated several regions of the frontal cortex as bottlenecks to the processing of information. It is emerging that multitasking places excessive demands on executive control centres in the frontal lobe. Hence, multitasking is counterproductive – not only does completion of all the tasks take longer than if they were performed one at a time, but performance on all tasks is also impaired.

NPR put together an interesting series back in 2008 that took a closer look at what happens when the brain tries to multitask, and why so many of us are fooled into thinking we’re good at multitasking:

“People can’t multitask very well, and when people say they can, they’re deluding themselves,” said neuroscientist Earl Miller. And, he said, “The brain is very good at deluding itself.”

Miller, a Picower professor of neuroscience at MIT, says that for the most part, we simply can’t focus on more than one thing at a time.

What we can do, he said, is shift our focus from one thing to the next with astonishing speed.

“Switching from task to task, you think you’re actually paying attention to everything around you at the same time. But you’re actually not,” Miller said.

“You’re not paying attention to one or two things simultaneously, but switching between them very rapidly.”

Some research suggests that with cognitive training, people can become better at juggling multiple brain activities. Even with training and practice, however, it appears that task performance is generally better when the tasks are carried out independently than when they’re done simultaneously.

I’m all too familiar with the feeling you get when your synapses are overloaded. As we approached a major deadline here in the newsroom last week, a couple of colleagues remarked that their brains had turned into oatmeal. (Mine felt more like cold molasses.)

The implications of multitasking on people’s ability to function effectively are obvious – particularly so in highly cognitive fields such as health care, where the demands on one’s focus, concentration, and attention to detail and accuracy are extreme. Distractions and interruptions are significant contributing factors to medical errors. When a Minnesota surgeon accidentally removed the wrong kidney from a patient a couple of years ago, distraction and subsequent failure to note the correct surgical site in the patient’s medical record during a pre-surgery office visit were cited as among the causes.

In one study that looked at the emergency room in a large teaching hospital, registered nurses experienced an average of three interruptions per hour, usually a phone call, a page or face-to-face discussion. Even background noise can be a serious distraction to providing safe patient care, which is one reason why many hospitals are trying to create a quieter environment. When Rice Memorial Hospital built a new patient wing a few years ago, it incorporated medication rooms where a nurse or other clinician can step away from a busy nursing station and prepare a medication dose in somewhat less stressful surroundings.

Like many of the rest of us, health care professionals tend to think multitasking comes with the territory. An interesting article that appeared a few years ago in the journal of the American Association of Perioperative Nurses notes how this has been ingrained into health care culture:

… There is little opportunity to say “no” or “not now” to distractions or interruptions. There may even be an unspoken expectation that part of a health care clinician’s job is to handle all types of interruptions effectively and to do so without appearing stressed or flustered. The reality is that humans have a limited capacity to manage distractions and interruptions in a safe manner.

We’ve all heard the phrase “do more with less.” And up to a point, it’s true. But eventually the returns start to diminish and we find we’re not doing more with less, we’re just doing less. No matter how good we think we are at multitasking, we can’t outwit our own brains.

The shock of the new

Orphaned by civil war in Sudan, John Bul Dau, Daniel Abol Pach and Panther Bior left behind everything that was familiar. The drive to survive led them across the sub-Saharan desert in the company of thousands of other displaced youths collectively known as “the lost boys.” They scrounged for food and fended off lions, hyenas and rebel soldiers. Finally they reached a U.N. refugee camp in Kenya, where John, Daniel and Panther were among 3,800 lost boys selected for resettlement in the United States.

A documentary crew filmed their amazement and apprehension as they boarded a plane for the flight across the Atlantic. Over the next four years, the filmmakers chronicled their new lives in the United States and the process of adjustment. The result is an award-winning documentary, “God Grew Tired of Us,” a story both of immigration and of the human response to being culturally uprooted.

I saw the film last night at a film festival being hosted this month by the Willmar Area Comprehensive Immigration Reform coalition. One scene particularly stands out in my mind: Daniel and Panther’s visit to a shopping mall at Christmastime, where they’re speechless at the sight of Santa Claus and a towering Christmas tree.

Talk about a moment of culture shock.

What exactly is culture shock? Anyone who travels is probably familiar with some of the signs: unfamiliarity, stress, disorientation, homesickness. It’s a common reaction to being placed in strange surroundings, and it’s often experienced by immigrants, expatriates, international students and anyone who lives or works abroad. The Amigos Web site at San Diego State University describes it this way:

The term, culture shock, was introduced for the first time in 1958 to describe the anxiety produced when a person moves to a completely new environment. This term expresses the lack of direction, the feeling of not knowing what to do or how to do things in a new environment, and not knowing what is appropriate or inappropriate.  The feeling of culture shock generally sets in after the first few weeks of coming to a new place.

Anthropologist Dr. Kalervo Oberg appears to have been the first person to coin the term “culture shock” and to identify its distinct stages: the honeymoon phase, when newcomers often are eager to absorb their new surroundings, followed by a hostile and unhappy phase which eventually gives way to adjustment and even enjoyment.

Although it’s only been within the last 50 years that culture shock has been officially recognized and given a name, it has surely been a common experience in much of human history. One of the most memorable characters in American immigrant literature can be found in “Giants in the Earth,” a saga of Norwegian homesteaders on the Dakota prairie. (The author, O.E. Rolvaag, was the father of Karl Rolvaag, Minnesota’s 31st governor; the book was first published in 1929.) It’s an unflinching look at the difficulties that come with pulling up stakes and settling in a new home. The intrepid Per Hansa takes to homesteading with gusto but his wife, Beret – lonely, homesick and feeling unmoored from all her familiar values and traditions - cannot adapt. Although I doubt Rolvaag, who was himself an immigrant from Norway, would have used the words “culture shock” to describe Beret’s emotional turmoil, he clearly recognized this is how some people react to a new and unfamiliar environment.

In many ways, it’s hardly surprising that cultural transplantation leads to some level of stress or difficulty with adapting. Unfamiliar customs and language barriers can make even the normal daily routine more challenging. Moving from a tropical to a more temperate climate, or vice versa, also involves physical adjustment. Then there are all the cultural assumptions that we take for granted when we’re at home - for instance, our concepts of privacy and social distance.

For many, the adjustment is not easy, especially if they’re transplanted to a culture significantly different from their own. As the global gap widens between the haves and the have-nots, and as people are increasingly displaced by armed conflicts, I suspect the trauma and the adjustment challenges may rise to a level we haven’t previously seen. Partway through “God Grew Tired of Us,” we learn that one of the lost boys who came to the U.S. with John, Daniel and Panther disappeared for a couple of days, broke down and ended up in a psychiatric hospital.

This doesn’t mean everyone who experiences culture shock has a mental health disorder. Most people, in fact, eventually do adjust, although for some it can take many months. By some estimates, approximately half of Americans living abroad never fully integrate into their new surroundings.

How do you know when you’ve arrived, culturally speaking? An online guide for Americans living and working overseas offers some of the mileposts:

– You begin to feel less isolated.

– You reach the level where you feel you can function effectively in the new environment.

– You don’t feel the same frustration or helplessness anymore.

– You find a middle ground where you can converse comfortably in the language.

– You have made friends and can share common enjoyment in leisure pursuits with your new friends.

– You have accepted the differences between your home society and the new society.

This seems to be true regardless of who you are or where you’ve come from. There were some moments of levity in “God Grew Tired of Us” as the lost boys of the Sudan were introduced to an American escalator and the trappings of a city apartment, none of which they’d ever encountered before. You have to wonder, though, what would happen if the situation were reversed. How many of us would have been able to survive in the desert as these young men did?

By the end of the documentary, John, Daniel and Panther have more or less adjusted and have turned their attention to finding and helping their displaced relatives in Sudan. John plans to return and build a clinic. Panther wants to start a school. None of them are bitter. It’s a pretty amazing lesson in how resilient we can be, even in the face of earth-shaking changes in our lives.

For those who are interested, the Willmar Area Comprehensive Immigration Reform is hosting two more nights of its film festival this month. The next film, “La Misma Luna,” will be shown at 6 p.m. Monday, March 22, in the theater at Vinje Lutheran Church. The final film, to be shown at 6 p.m. March 29, will be chosen by the audience.

Photo: Immigrant children at Ellis Island, New York, 1908. Source: National Archives.

The agony of defeat

The Winter Olympic games are over. The athletes have all gone home. Some have medals (way to go!) but most do not. For every athlete who won gold, there was another who finished dead last.

The thrill of victory is wonderful for those who experience it, but what about the agony of defeat? How do you handle the emotional blow of being a loser without, well, being a loser about it?

It’s one of life’s hard lessons, usually encountered early in childhood, that you can’t always be the winner. Most youth athletes perform on a much smaller stage than the Olympics, but that doesn’t make defeat any easier to swallow, explains Dr. Claudia Reardon of the School of Medicine and Public Health at the University of Wisconsin. Here’s her perspective for parents and other adults who work with young athletes (it’s advice that could equally apply to kids in other competitive activities such as spelling bees and math contests):

"Youth sports can be a really physically and emotionally healthy activity, but the reality is that not every bounce, play or game is going to go your child’s way," says Dr. Reardon. "The way you choose to handle can really help them grow, both as individuals and as athletes."

Step one is to acknowledge your child’s feelings. While they’re likely to take things to a catastrophic extreme when they come up short or their last-second shot bounces off the rim (think phrases like "I’m the worst player EVER" and "My life is ruined!"), you can help them take a more measured approach.

"Saying something as simple as, ‘I understand you’re feeling upset that you didn’t win the race’ can open up a discussion and let them know you’re there to listen," says Dr. Reardon. "And it’s OK if the conversation stops there; some children need to work through the disappointment on their own."

Plenty of adults seem to struggle with this themselves. Bad sportsmanship is getting a lot of attention these days. You have to wonder what it says about someone’s emotional disposition when his response to winning a silver medal in men’s Winter Olympics figure skating is to snark about the gold-medal winner’s failure to include a quadruple jump in his routine. Or what it says about the adults who think it’s acceptable to swear at coaches and referees and, in some extreme cases, get physically assaultive. Self-control, anyone?

I’m not sure it helps when certain athletes are uber-hyped by the media. It puts them under heavy pressure to succeed, with the implication that anything less than a gold medal constitutes failure. Not only do their fans expect them to win but there might be, as in the case of South Korean figure skater Kim Yu Na, millions of dollars’ worth of endorsements at stake. And what about their teammates, who are often equally hard-working but don’t get the same amount of attention?

In spite of the pressure-cooker of the world’s most elite sports event, though, there were many moments of Olympic grace, among the winners as well as the losers. These athletes displayed what I like to think of as emotional resilience, the ability to hold up under stress and not resort to negative, potentially destructive thought patterns and behaviors. It’s what makes a skater go out on the ice, land a great performance and win a bronze medal less than a week after unexpectedly losing her mother. It’s what makes a skier come back and compete the day after painfully wiping out in the slalom.

There’s been considerable study in recent years of emotional resilience. It has been linked to better health outcomes, increased resistance to stress and an increased capacity to recover from stress. Researchers are looking at how resilience can be fostered, especially in high-stress situations such as combat, trauma, loss or catastrophic illness.

Why are some people more resilient than others? Is it because of nature or because of nurture? We haven’t quite unlocked all the secrets of resilience but most of us know this quality when we see it.

In the end, these are the best lessons I’d like to take home from the Winter Olympics – not who won or lost but how well and how resiliently they played the game.

Photo: Associated Press

Close encounters of the awkward kind

You’re out running errands, shopping for groceries or walking the dog when you run into, of all people, your therapist. What should you do? Hide? Ignore each other? Politely say hello? Launch into a lengthy conversation?

It’s one of those etiquette questions that bedevil the doctor-patient relationship – not only for therapists but for physicians as well.

Dr. Elvira G. Aletta recently explored this issue at PsychCentral, asking the question: “What if I run into my therapist in public?” Then it was taken up at the New York Times Well blog with some interesting discussion and personal stories.

Dr. Aletta writes:

In my dad’s day, there would have been no question. Psychoanalytic thinking was very clear back then. Both patient and therapist should pretend they don’t see one another, even if it is obvious to both that they have.

There are reasons many therapists still feel that way. One is that it could be seen as inappropriate, even harmful, to acknowledge the working relationship outside of the “therapeutic frame,” meaning the clear boundaries of the time and day of the session and the four walls of the office.

Plus there are issues of confidentiality. Saying hi to my patient in public might put them in the uncomfortable position of explaining who I am and why they know me.

Depending on where the encounter takes place, the patient’s level of discomfort might be even higher. One reader at the Well blog shared this experience: “About a year after I completed outpatient therapy for alcoholism (and still sober, then as now) I ran into one of the counselors at the supermarket while shopping for a dinner party – on my way to the wine aisle.” Someone with bulimia recounted hiding after she spotted her psychiatrist while loading up a shopping basket with junk food.

OK, so it’s awkward. But although social encounters outside the professional therapist-client or doctor-patient relationship should be handled with some sensitivity, “I don’t believe we need to be all rigid about it,” Dr. Aletta declares.

Among the guidelines she offers: The first move belongs to the patient. If you do greet each other, it’s up to the therapist to put the patient at ease. The conversation should be kept short and pleasant. References to the therapeutic relationship are off limits.

I’m not sure it should matter who makes the first move, especially if the therapist and client or physician and patient already have a solid relationship. The point, after all, is to be respectful, not to snub each other.

The main question seems to be one of boundaries, which aren’t always easy to negotiate – and let’s not forget the boundaries go both ways. Therapists and physicians need some personal space too. When Dr. Theresa Chan, a hospitalist in rural California, penned an open letter to the patient who accosted her at the supermarket, it struck a nerve with many of her readers. She wrote:

Dear Neighbor/Patient,

It was very kind of you to inquire after the state of my garden when we bumped into each other at Safeway this morning. We haven’t seen much of each other lately and I was pleased to hear your early peas are flowering. We waved good-bye to each other and went about our business. Or so I thought.

Moments later, you cornered me as my food items were being scanned and asked me, “What do you think about all this stuff they’re saying about Fosamax? Should I stop taking it?” I was unprepared for such a question, because my navel oranges were bumping into the large globe artichokes and threatened to clog the upstream progress of the red seedless grapes onto the rubber rolling mat that conveys the groceries inexorably towards the bagging platform.

In short, she writes, “I do not like to be asked medical questions when I am conducting my everyday errands.”

Readers quickly chimed in with stories of their own. “I’m a family doc in the small town I grew up in and there is no quick trip to the store,” one person wrote. Another commenter confessed to switching barbers six times in 10 years. “That’s the worst predicament; trapped in the chair providing free medical consultation while someone with sharp objects buzzes around your head,” he wrote.

When it comes right down to it, much of this is just Civility 101: being courteous and acknowledging the other person while refraining from being overly familiar or demanding. “The common social contract that most people subscribe to is that you say ‘hello’ to people that you know,” one of the commenters wrote in response to Dr. Aletta’s essay.

There are even times when out-of-the-office social encounters, when they’re handled well, might help reinforce the relationship between professional and client/patient or be therapeutic in and of themselves. “I find that it comforts a lot of clients to know their therapist is ‘human’ and does the same things or goes to the same places,” one person commented. A therapist who attended a wake for the deceased son of a client and visited another client’s daughter in the hospital wrote that this “seemed like the human thing to do. In both cases, my patients expressed their appreciation and I believe that the therapeutic process was enhanced, rather than threatened.”

Really, can’t we all just get along?

Hoarders: Behind closed doors

Gail’s house has no heat. The support beams, damaged in a fire several years earlier, are threatening to give way. But until Gail cleans up the mountains of clutter she has collected over the years, repair crews can’t get into the house.

Warren accumulates stuff too – tools, refrigeration units, even the old van in which his father died. His wife, Leanne, is worried about how Warren’s hoarding is affecting their 3-year-old son. She has given him an ultimatum: Clean up or get out. Unfortunately the problem isn’t that easy to solve, because it turns out Leanne is a hoarder too.

Watching an episode of “Hoarders” on A&E is a little like watching a train wreck: It’s appalling but you can’t stop looking. And ultimately you have to wonder if it isn’t exploitive to bring TV cameras into these people’s homes and display their dysfunction for everyone to see, even if the purpose of the show is supposed to be educational.

Hoarding is thought to affect somewhere between 2 million and 3 million Americans. While this sounds like – and is – an enormous number of people, it’s still only about 1 percent of the population. Since many hoarders operate under the radar, so to speak, it’s hard to get a handle on the true extent of this behavior.

It’s not even clear whether hoarding should be classified as a mental disorder. It is being considered for inclusion in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, but a task force hasn’t decided yet whether to list it in the manual itself or in the appendix. The DSM-V’s working definition of hoarding disorder:

A. Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.

B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace or other personal surroundings (e.g. office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g. family members, authorities) to keep these areas free of possessions.

C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (including maintaining a safe environment for self and others).

If you’ve never seen the effects of hoarding, an episode of “Hoarders” is jolting. Some of the things that can be learned from this series:

– The clutter and the accumulation of items can be extreme. At some level, many of us probably fear our own personal clutter – the stack of unread magazines, the children’s toys and clothing we no longer use or need – will eventually take over the house. Genuine hoarding, however, goes far beyond the typical clutter of the average household. Hoarders often stop using a kitchen or dining room or bedroom because it’s simply too full of stuff. When we meet Gail, for instance, she’s living out of a bedroom and heating all her meals in a microwave oven in an upstairs hall.

Health and safety can be at risk, and it’s not unusual for living conditions to become downright squalid. A hoarder’s cupboards might be filled with moldy food. In some episodes of “Hoarders,” mice have been found under the silted layers of accumulation. Necessary repairs often don’t get done because the house is inaccessible to repair crews. A surprising number of the individuals featured on the show were living without heat or running water, in some cases for months. In the worst-case scenario, a house can sustain structural damage that’s too extensive to fix.

– Hoarding can escalate into a crisis when people are threatened with eviction or the loss of their children to child protective services, or if the hoarder becomes sick or injured and needs to be rescued from among their mountains of clutter.

– Hoarding affects entire families. Spouses of hoarders feel frustrated and powerless. Children of hoarders can’t invite their friends over. Efforts to help are often met with resistance or resentment, which can further break down family relationships.

– Although hoarding tends to be associated with older people, perhaps because they’ve had a longer lifetime to collect things, it also affects younger people. The syndrome is thought to have a genetic component. (Actress Lindsay Lohan revealed a couple of weeks ago that she “has a lot of stuff” and needs to clean out her home, although it’s not clear if this means she truly is a hoarder or if she’s just disorganized.)

– The emotional attachment that hoarders have to their possessions is very real and not necessarily rational. Gail got increasingly testy when her family and a professional cleanup crew tried to pry away some of her accumulated belongings. Warren was unable to part with his father’s old van, and at the end of the episode, the van was still sitting in the back yard.

There’s a lot, however, that this show simply doesn’t tell you. Are the individual stories typical of hoarders, or do they represent the extreme end of the spectrum? How these people got this way is never really explored, although there are hints that among many of them, the hoarding escalated after a loss or death in the family.

Nor is there much exploration of hoarding itself. Even the experts can’t completely agree on how to classify the psychopathology. Is it a variant of obsessive-compulsive disorder, or is compulsive hoarding syndome an entirely separate entity? Research suggests there is indeed a difference between compulsive hoarding and hoarding associated with OCD, with implications for how each should be treated. Elements of social phobia, anxiety disorder and ADHD might be intertwined as well. And exactly where animal hoarding fits into the overall spectrum is not clear.

Where “Hoarders” perhaps commits the greatest disservice, however, is in its portrayal of intervention. A convoy of trucks rolls up to the hoarder’s doorstep and the race is on to clear out the home in two days, three days or whatever deadline has been set by the family’s circumstances. As the cleanup progresses, viewers get to see the couch chewed up by mice, the discarded food packages, the dirty and soggy detritus being carted out to the trucks. We get to witness the tears and anxiety as the hoarder attempts to part with his or her possessions, with a few family squabbles thrown in for good measure. By the end of the episode, the house is restored to reasonable order and the family is receiving aftercare and/or ongoing therapy.

To be fair, the show’s producers bring in therapists and professional organizers to help work with their subjects. They’re up front about the fact that not every intervention is successful. But viewers would do well to ask themselves: Is it really fair to deliberately put hoarders into a situation guaranteed to be stressful, anxiety-producing and probably embarrassing, all for the sake of a TV show?

More to the point, is a one-time, aggressive intervention truly effective? It might help temporarily, but most experts agree hoarding is usually a chronic condition. Once the hoarder’s home has been cleaned, he or she often will start accumulating things again. A combination of cognitive therapy and drug therapy shows some promise, but the psychiatric community still has a long way to go in finding effective ways to treat compulsive hoarding and helping prevent relapses. Among animal hoarders, the relapse rate is thought to be nearly 100 percent without intervention, nor is there any standard treatment yet for animal hoarding.

To the extent that “Hoarders” brings the issue of hoarding out into the open, the show is providing a benefit. It’s beneficial too for people who’ve struggled with this disorder, or watched someone in their family struggle with it, to know that some help is available. We can’t forget, however, that the stories on “Hoarders” are about real people with a real disorder. Long after the TV cameras have disappeared, these people will more than likely continue to struggle with their hoarding and some of them will probably relapse. Although the drama of intervention might make for a compelling TV show, in reality there are few easy or long-lasting solutions to the issue of hoarding.

Photo courtesy of Wikimedia Commons

Cabin fever

Tired of shoveling snow? Feeling cooped up by the winter weather? More than a few of us are probably beginning to develop cabin fever, that feeling of crankiness, restlessness and boredom that often sets in among people who are confined indoors too long.

The term “cabin fever” originated in the American West in the early 1900s and was first used to describe the negative effects of being pent up in an isolated cabin. Being shut in, especially in winter, can have a definite impact on mental health, the Midwest Center for Stress and Anxiety explains:

While not an actual disease foreshadowing insanity, cabin fever can be a very real claustrophobic reaction which occurs when a person is isolated for long periods of time. A lack of environmental stimulation, lack of physical exercise and the shortened daylight hours of winter can have a detrimental effect on the healthiest of psyches.

Symptoms often include lethargy, grouchiness, a lack of motivation, cravings for high-carb foods and weight gain. Most of the time, cabin fever isn’t serious. Among some people, though, it can be a sign of seasonal affective disorder or depression and may require some kind of intervention.

How can you tell when cabin fever has crossed the line into something more pervasive? If winter blues are affecting your work, your relationships and your quality of life, you probably have something more than cabin fever, mental health experts advise. Light therapy, psychotherapy or antidepressant medication might be indicated. For some reason, younger people and women seem to be more vulnerable to the winter blahs; SAD also is more prevalent in northern latitudes where winter daylight hours are significantly shorter.

But if what you have is garden-variety cabin fever, a simple change of pace and an effort to be more social and active is usually enough to restore your normal frame of mind. From the U.S. Air Force base in Minot, N.D., (where they really know something about cabin fever) comes this good advice:

One key to a speedy recovery is being able to recognize the symptoms of cabin fever which include but are not limited to: crankiness, loss of sleep, overeating and feeling down due to the inactivity. The idea is not to subject yourself to depression and added stress because of the cold weather. A change in scenery is simple but a tremendous help in overcoming winter blues.

When the Post-Gazette of Pittsburgh, Pa., queried people about how they coped with cabin fever, they got a variety of responses. A long-distance truck driver said he listened to loud country music on the radio. One woman walks her dog outdoors four to five times a day. Others said they volunteer or, when the weather is bad, they stay indoors, read, do crossword puzzles and clean the house.

My personal remedy usually involves an expedition to the Willmar Public Library for a few good books, or a leisurely weekend fortified with homemade soup and quality time with my kitty and canary. It works like a charm, every single time. And when all else fails, well, the first day of spring is only five and a half weeks away.

West Central Tribune file photo by Carolyn Lange