Thursday, July 20, 2017

Self-Disclosure in the Clinic and the Classroom

As I mentioned in a recent post, I'm in Vermont while my wife teaches at the Middlebury College Bread Loaf School of English, a program in which the students are primarily high school and middle school English teachers.

Tomorrow I'll be leading a second workshop on "Making Ethics Part of High School and Middle School English Class."At the workshop on June 30th the teacher/students identified a topic they wanted to come back to: should they bring their own moral and political selves into the classroom, and if the answer is "yes," how should they do it?

I've never taught in high school or middle school and can't claim any direct expertise on how to deal with the question the teachers raised. But I've given a lot of thought to what is typically called "self-disclosure" in medical care and have written about it (see here). In contrasting the issue as it comes up in the clinic and the classroom, I see self-disclosure as a vastly tougher question for high school and middle school teachers than it is for physicians and other clinicians.

In the clinic, self-disclosure occurs largely in a 1:1 setting - the patient and the doctor. The major question for the physician is whether self disclosure will further the clinical objectives. Research suggests that the impulse behind self-disclosure is often fulfillment for the doctor more than benefit for the patient. The commonest risk is that the patient will feel less listened to and less rapport. The most serious risk is that physician self-disclosure will lead to a slippery slope of increasingly intimate interactions. Many situations that end with doctor-patient sex began with physician self-disclosure.

When we physicians contemplate self-disclosure we should ask ourselves three relatively straightforward questions. First, a bit of introspection: do we tend to talk about ourselves too much? If so, we should be especially on guard. Second, is there anything special about our relationship with this patient - such as a wish to impress the patient or to be his friend  - that draws us towards self-disclosure? Finally, what is the rationale for anticipating that self-disclosure will help the patient?

In high school and middle school, the teacher is an adult dealing with a classroom with 15 - 30 youngsters. Student reactions, of course, are likely to vary, so there's no way to guage the potential impact on every student in advance.  But the most challenging aspect is the school setting itself. Even if the patient-physician dyad occurs in an organizational setting like a clinic or group practice, it's primarily a two person relationship. By contrast, English class is just one piece of the student's relationship with the school. And in the background, the students' families properly regard themselves as having a central role in their child's education.

To prepare for the workshop I tried to imagine myself as a new high school or middle school teacher thinking about self-disclosure in the classroom. I pictured a series of steps to help me develop an approach:
  1. Talk with my experienced colleagues. How have they handled self-disclosure in their classes? What guidance can they give me?
  2. Talk with my department chair and perhaps the principal. They are responsible for and most knowledgeable about the school's relationship with its community. Are there issues of particular sensitivity to be aware of?
  3. Consider the environment the students come from. What is the cultural starting point for the class likely to be? How will this influence how the students hear me?
  4. Examine my own skills. Am I someone who students can feel comfortable questioning or challenging? Can I model a stance of curiosity and mutual respect?
I'm looking forward to learning from the teachers who will participate in the workshop. What a privilege it is to be able to explore ethics in the classroom with a group of experienced and devoted teachers!

Saturday, July 8, 2017

Psychiatrist-Patient Sex - plus a detective

When I was looking for audio books for my drive to Vermont, how could I resist Shrink  Rap, especially since the author was the wonderful Robert B. Parker of "Spenser" fame. Here's the blurb from the jacket:
Boston P.I. [private investigator] Sunny Randall is working as a bodyguard for popular romance writer Melanie Hall, who is being stalked by her psychiatrist ex-husband. Melanie was a patient before becoming his wife, but now she is absolutely terrified by him. To find out why, Sunny puts on a disguise and goes to the shrink for therapy.
The most-read posts on this blog are those under the tab of "doctor-patient sex," and I was eager to see Parker's take on the topic.

Melanie Joan Hall is a wildly successful chick lit writer and, like her heroines, a romantic soul. She falls in love with her psychiatrist (Dr. Melvin) whose practice is entirely composed of needy female souls like herself. Dr. Melvin allows an erotic transference to form, but then instead of using it as an opportunity to minister to Melanie Joan, he exploits it for sex and control. 

Melvin has sex with many patients, but he singles Melanie Joan out for marriage. Although he's a thoroughly evil character, Melanie Joan only catches on when he invites two of his friends to participate in what the narrative calls a "gang bang." Until the "gang bang" moment Melanie Joan has been entranced by what she calls the "master/slave" relationship. But when the potential "gang bang" shocks her into recognizing Dr. Melvin's evilness, she flees. Melvin goes off the deep end and stalks her. Enter private eye Sunny Randall.

Sunny seeks out Dr. Max Copeland, a skillful and ethical psychiatrist, to help her strategize about Melvin. Sunny tells herself she's seeing Copeland for advice, not therapy, but Copeland engages her in self-reflection as well. He's a superb therapist - respectful, insightful, and entirely focused on helping his detective-patient. He obviously likes and admires Sunny, who is brave, honest, funny, and emotionally open, but unlike Melvin he is scrupulous in using his interaction with her to develop a therapeutic alliance.

Parker has excellent insight into the ways patients may idealize a therapist who listens to them attentively. Sunny herself feels the pull when she becomes a "patient" in Melvin's practice. I won't give away how she cracks the case - it's scary and humorous. But when she expresses her puzzlement at how in the early phase of their "therapy" Melvin was actually helpful to her, Copeland responds as I have to comments on earlier posts - physicians who exploit patients A, B and C may also have skills that allow them to practice very competently with patients D, E, and F.

Shrink Rap brought to mind Dressed to Kill. a Brian DePalma film I saw in 1980. I'd not heard of the film until a young woman patient brought it up in a therapy session. She said it reminded her of her treatment. When she went on to mention that the psychiatrist in the film murdered his patient, I remember feeling horrified. Alas, I can't remember what I said to my patient, but I resolved to see the film. I won't give away DePalma's Hitchcockian plot in case you decide to see it, but my patient got the film story right. The psychiatrists really does murder his patient.

Parker and DePalma render the dark side of our fantasies about psychiatrists. The cultural figures who - in our upbeat moods - we see as wise and powerful healers, turn into monsters when they choose to use their power for evil aims. It's the same dynamic as the wolf in Little Red Riding Hood - a loving grandmother on the outside but ravenous wolf within.

Sadly, the stories Parker and DePalma tell so well aren't restricted to myth. The reason my posts on doctor-patient sex have garnered so much readership is that the myth plays itself out in life. The problem isn't new. 2500 years ago Hippocrates asked physicians to pledge fidelity to their patients' well-being, and to eschew sexual exploitation. Hippocrates understood that just as the wolf gives in to temptation when he sees Little Red Riding Hood and her basket of food as tempting morsels, physicians of his day, and ours, are exposed to temptation as they practice their art.

The reason the Hippocratic oath has survived for 2500 years is that Hippocrates saw medicine as a sacred calling that requires an impeccable standard of ethics. Parker and DePalma's engaging stories show what can happen when the oath is ignored.

Sunday, July 2, 2017

Teaching Ethics in High School and Middle School

I'm again in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of 4-5 summers. My wife has been teaching here every summer since 1992 and I enjoy the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

For the past five summers I've been doing a workshop on "Making Ethics Part of High School and Middle School English Class." The idea for the workshop came from recognizing that my underlying goals for teaching medical ethics were similar to the teachers' goals for their students in English class. Working with the teacher-students at Bread Loaf is a pleasure and a privilege. Their commitment to fostering development in their students is similar to the commitment to fostering health and well-being I see in the medical students and residents I work with.

This year the topic we chose to focus on was an experience several of the teachers had (a) teaching courses that explicitly included "justice" or "ethics" in the course objectives and finding (b) that the courses didn't work well. We asked: what was the problem and what could be done about it?

The group identified three main reasons the "justice"/"ethics" courses fell flat:
  1. Adolescent cognitive development. Kids of every age show great variation, but teen age thinking tends to be black/white, with the result that for many the idea that thoughtful people may reasonably differ is a foreign notion. Discussions of ethical and political dilemmas may seem to them like a "politically correct waste of time." I'm still embarrassed at a piece of my own black/white thinking from when I was 17. My parents, born in 1905 & 1907, were from a martini-drinking generation, and the practice they and their friends had of drinking several martinis after work and forgetting that there was a child in the home (me), led me to a very moralistic view of alcohol. So when my friends proposed going out for beer when I was a first year college student, I replied "If we're going out for alcohol, why stop there? Why don't we go directly to heroin?"
  2. The school environment. Kids recurrently encounter high stakes tests. Many feel that their future depends on getting good grades, which means "getting the right answer." Their anticipation of being judged inhibits curiosity and limits the pleasure they might take in deliberating about moral dilemmas. Some years ago when medical ethics was an elective at Harvard Medical School (now it's part of the required curriculum) I had designed a session on "personal mission in medicine." I thought it was a great plan, so when the class completely bombed I was puzzled and asked the students to help me figure out what the problem was. The students told me what I'd missed: "This is our first semester in medical school. Our mission is not to flunk out. We have no interest in speculating about what our mission  should be 5-10 years from now!"
  3. Culture of narcissism. Several teachers commented on a culture of narcissism symbolized by the popularity of "selfies." This isn't a new idea. Christopher Lasch popularized it in his prescient 1979 book subtitled "American Life in an Age of Diminishing Expectations." The teachers felt that social media reinforced the longstanding cultural pattern. I was especially struck by the observations of two teachers who also coached high school sports teams. Both commented on the decline of "teamness" and the tendency for young athletes to be preoccupied with their own goals and achievements.
The participants exchanged tips on what teachers can do to bring moral reflection to life for their high school and middle school students:
  1. Careful planning. It's important to find works of literature that entice teenagers into moral reflection. Two teachers mentioned The Ones Who Walk Away from Omelas, a short story by Ursula Le Guin I'd never heard of, no less read. It's a moral fable that can be seen as challenging capitalism and the division between the rich and the poor. (The story is just 4 pages - I encourage you to follow the link.) Other teachers emphasized the value of "warm-up exercises" like improv to get the students loosened up and readier to experience curiosity about themselves and others.
  2. Role modeling. It's important for teachers to demonstrate open mindedness, readiness to be questioned & challenged, and interest in the views of others in their interactions with the class.
  3. Drawing on established frameworks. One of the teachers leads a course called "Theory of Knowledge," which is part of the International Baccalaureate curriculum. The course focuses on what it means to claim to "know" something and what forms of evidence apply in different realms of activity. It encourages students to examine their own presuppositions and to recognize their biases. Another teacher uses the Harkness approach - a discussion method developed at Phillips Exeter Academy. Since a central goal in ethics teaching is to cultivate the habit of thoughtful inquiry into the basis of views held by self and others, it makes sense for teachers to do this themselves by learning from each other about how best to pursue this important goal.
  4. Trust the students. Open, thoughtful deliberation requires activity on the part of the high school/middle school students. Telling them what's required doesn't do this, just as telling an athlete how to carry out a skill doesn't take the place of practice. The term "safe space" was used to describe the aim of fostering an environment that supports curiosity and inquiry. Of course, teenagers, like all human beings, are not always trustworthy. This part  of the discussion reminded me of one of my clinical rules of thumb - start with the most optimistic hypothesis that is safe and prudent and retreat from it as necessary. Thus if a patient with depression was not suicidal or at risk in other ways, we could start with the hypothesis that the condition would be readily reversible. If that proved true - great! If it didn't we'd move on to a more demanding approach.
Over the years of my work with high school and middle school teachers, I've come more and more to 
see their work as similar to health care in the shared aim of enhancing human capacity. If health care is a sacred calling, which I believe it very much is, so is the work the teachers are doing!