Unintended Effects
Medicine can have intended and beneficial impacts which alleviate target symptoms, or unintended and detrimental ones. The latter may be referred to as iatrogenic effects, a type of adverse outcome directly attributable to treatment, more traditionally defined as one brought about by the healer. Medications, even those designed to treat even the most innocuous conditions are not neutral—even placebos exert observable and measurable effects.
In the nursing facility that I work at, some of the symptoms displayed by the residents are labelled “behavioral.” In such cases, the psychiatric consultant might be asked to intervene—either with medication, a behavior plan, or with psychotherapy—to change or to eliminate the problem behavior. But shouldn’t the first question be “What exactly is behavior?” And for what reasons should a specific behavior be changed, and how?
Very often, patterns of current behavior often have roots extending back to the earliest stages of an individual’s life. Behaviors have purpose—one of which is to solve problems.
Behaviors may be directed to obtain or achieve a goal or to aid the person in avoiding or escaping a situation—but irrespective, their aim is purpose-oriented. If the psychiatrist or physician simply tries to change the surface of a behavior with medication, or with psychotherapy without understanding its purpose, we might more likely simply bring about a different type of behavior that serves the same purpose or makes it worse. So to change behavior, I as a clinician need to knowingly address the purpose or aim of that behavior.
Behavior is communicative, as well as purposive. Behavior communicates or reflects social meanings. Behaviors do not occur in a social vacuum—they always have an interactive component to them. I may notice that behavior X is bothersome or disruptive to the milieu but fail to notice that I may have contributed to or participated in the occurrence of that behavior. I have found that it is far more productive to attempt to identify (as best I can) the purpose of a behavior, and to then consider the kinds of circumstances in which that behavior X is more or less likely to occur. I must also consider how my own response to that behavior may actually make it more disruptive to the milieu or disturbing for the patient.
My reaction has equal power to displease, calm, excite, reassure, or aggravate the patient. How quickly, how abruptly or loudly, or how calmly, deliberately, and gently I act or react will have a direct and immediate impact on the wellbeing of both the patient and others nearby. I have noticed that even patients with dementia can still “read” the language of the caregiver's tone of voice and behavioral communication.
I have been most effective in my work with these patients when I intervene through purposefully calm, pleasant, and comforting actions and by avoiding loud, harsh, critical, or demeaning types of actions. Demonstrating those unpleasant types of actions tends to excite and provoke symptoms such as fear, anger, sadness, or mistrust in others. This is behavioral iatrogenesis.
Residents of a nursing facility do not simply demonstrate pleasant behaviors or problem behaviors. Simply labeling patients such as these “behavioral” diminishes them and reduces the complexity of their behavior to what is seen on the surface by those who tend to them. Each individual may exhibit some pleasant behaviors or some disruptive or problem behaviors under different conditions and circumstances. The key point for clinical staff persons is to learn to notice the specific circumstances or conditions under which a particular person will be more or less likely to display positive—or negative—behaviors.
The heart and art of behavioral management is therefore the management of my own behavior. I must constantly consider how my actions serve as good medicine or as bad medicine. In any interaction with a patient, whether it is through casual or informal conversation or within the therapeutic moment, I must consider whether I am contributing to the anxiety or sadness or embarrassment or anger of the person I am ostensibly trying to help.
Max
Max was a 59-year-old, single gentleman with a complex history of medical and psychiatric illnesses. He reported active bereavement over the death of his father. He also reported distressing anxiety over medical ailments—to the point of panic; and he reported auditory hallucinations. Max had a diagnosis of Schizophrenia and cognitive impairment associated with intracerebral aneurysm, meningioma, and encephalopathy; dysphagia with prior placement of G-tube; and decreased renal function. Two types of target behaviors had been identified for Max: repetitive questions and moaning or yelling vocalizations (“Can I have a glass of water? Can I have a glass of water?, OOOH, OOHH, OH OH”). What internal experiences motivated those actions for Max? While it might have been far easier to attribute these behaviors to his cognitive impairment and mental illness, it was more productive (and humane) to ask, “What do these actions help him to avoid or to acquire?”
Max was beset daily by significant feelings of anxiety, and he felt burdened as well by feelings of loss. He experienced acute feelings of vulnerability about his body, his well-being, and his prognosis. Sensations of bodily discomfort such as pain, thirst, or hunger triggered bouts of sharp anxiety for Max. Those target behaviors served as a barometer of the current level of obsessive anxiety he was experiencing. He tried to find relief and solace, and to communicate his distress, through those target behaviors.
During psychotherapy sessions Max had verbalized awareness that when his anxiety built he found it difficult if not impossible to curb his actions, even when he knew that he should, and that others might be annoyed by his actions. Indeed, his awareness of the frustrations of others added to his anxiety and further diminished his ability to stop or control those actions. He could not (unaided) comfortably tolerate the tension of frustration as he waited. If a care provider became annoyed or impatient with his actions, Max would notice it, his anxiety would be fueled, and the target behaviors intensified. Giving corrective attention to the surface of his actions (“Stop it, Max,” “I already gave you a drink”) would only cause then to increase—so we want to instead give supportive attention and praise to his efforts at waiting calmly and quietly (“Good job, Max, thanks for waiting”).
File under: The Art of Psychotherapy, Musings and Reflections
Medicine can have intended and beneficial impacts which alleviate target symptoms, or unintended and detrimental ones. The latter may be referred to as iatrogenic effects, a type of adverse outcome directly attributable to treatment, more traditionally defined as one brought about by the healer. Medications, even those designed to treat even the most innocuous conditions are not neutral—even placebos exert observable and measurable effects.
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In the nursing facility that I work at, some of the symptoms displayed by the residents are labelled “behavioral.” In such cases, the psychiatric consultant might be asked to intervene—either with medication, a behavior plan, or with psychotherapy—to change or to eliminate the problem behavior. But shouldn’t the first question be “What exactly is behavior?” And for what reasons should a specific behavior be changed, and how?
Very often, patterns of current behavior often have roots extending back to the earliest stages of an individual’s life. Behaviors have purpose—one of which is to solve problems.
Behaviors may be directed to obtain or achieve a goal or to aid the person in avoiding or escaping a situation—but irrespective, their aim is purpose-oriented. If the psychiatrist or physician simply tries to change the surface of a behavior with medication, or with psychotherapy without understanding its purpose, we might more likely simply bring about a different type of behavior that serves the same purpose or makes it worse. So to change behavior, I as a clinician need to knowingly address the purpose or aim of that behavior.
Behavior is communicative, as well as purposive. Behavior communicates or reflects social meanings. Behaviors do not occur in a social vacuum—they always have an interactive component to them. I may notice that behavior X is bothersome or disruptive to the milieu but fail to notice that I may have contributed to or participated in the occurrence of that behavior. I have found that it is far more productive to attempt to identify (as best I can) the purpose of a behavior, and to then consider the kinds of circumstances in which that behavior X is more or less likely to occur. I must also consider how my own response to that behavior may actually make it more disruptive to the milieu or disturbing for the patient.
My reaction has equal power to displease, calm, excite, reassure, or aggravate the patient. How quickly, how abruptly or loudly, or how calmly, deliberately, and gently I act or react will have a direct and immediate impact on the wellbeing of both the patient and others nearby. I have noticed that even patients with dementia can still “read” the language of the caregiver's tone of voice and behavioral communication.
I have been most effective in my work with these patients when I intervene through purposefully calm, pleasant, and comforting actions and by avoiding loud, harsh, critical, or demeaning types of actions. Demonstrating those unpleasant types of actions tends to excite and provoke symptoms such as fear, anger, sadness, or mistrust in others. This is behavioral iatrogenesis.
Residents of a nursing facility do not simply demonstrate pleasant behaviors or problem behaviors. Simply labeling patients such as these “behavioral” diminishes them and reduces the complexity of their behavior to what is seen on the surface by those who tend to them. Each individual may exhibit some pleasant behaviors or some disruptive or problem behaviors under different conditions and circumstances. The key point for clinical staff persons is to learn to notice the specific circumstances or conditions under which a particular person will be more or less likely to display positive—or negative—behaviors.
The heart and art of behavioral management is therefore the management of my own behavior. I must constantly consider how my actions serve as good medicine or as bad medicine. In any interaction with a patient, whether it is through casual or informal conversation or within the therapeutic moment, I must consider whether I am contributing to the anxiety or sadness or embarrassment or anger of the person I am ostensibly trying to help.
Max
Max was a 59-year-old, single gentleman with a complex history of medical and psychiatric illnesses. He reported active bereavement over the death of his father. He also reported distressing anxiety over medical ailments—to the point of panic; and he reported auditory hallucinations. Max had a diagnosis of Schizophrenia and cognitive impairment associated with intracerebral aneurysm, meningioma, and encephalopathy; dysphagia with prior placement of G-tube; and decreased renal function. Two types of target behaviors had been identified for Max: repetitive questions and moaning or yelling vocalizations (“Can I have a glass of water? Can I have a glass of water?, OOOH, OOHH, OH OH”). What internal experiences motivated those actions for Max? While it might have been far easier to attribute these behaviors to his cognitive impairment and mental illness, it was more productive (and humane) to ask, “What do these actions help him to avoid or to acquire?”
Max was beset daily by significant feelings of anxiety, and he felt burdened as well by feelings of loss. He experienced acute feelings of vulnerability about his body, his well-being, and his prognosis. Sensations of bodily discomfort such as pain, thirst, or hunger triggered bouts of sharp anxiety for Max. Those target behaviors served as a barometer of the current level of obsessive anxiety he was experiencing. He tried to find relief and solace, and to communicate his distress, through those target behaviors.
During psychotherapy sessions Max had verbalized awareness that when his anxiety built he found it difficult if not impossible to curb his actions, even when he knew that he should, and that others might be annoyed by his actions. Indeed, his awareness of the frustrations of others added to his anxiety and further diminished his ability to stop or control those actions. He could not (unaided) comfortably tolerate the tension of frustration as he waited. If a care provider became annoyed or impatient with his actions, Max would notice it, his anxiety would be fueled, and the target behaviors intensified. Giving corrective attention to the surface of his actions (“Stop it, Max,” “I already gave you a drink”) would only cause then to increase—so we want to instead give supportive attention and praise to his efforts at waiting calmly and quietly (“Good job, Max, thanks for waiting”).
Nurses and nurses aides were responding with understandable yet counterproductive frustration to Max’s questions and moaning. I observed tongue clicking, eye rolling, head-shaking, and sarcastic remarks—“Oh, there he goes again”—even when Max was ten feet away from us.
I met with the unit manager, social worker, and Max’s brother/guardian to discuss the situation, and I then had three in-service training sessions with the three shifts of unit staff. After one session a nurse approached me and said, “I see now, I was getting mad at him and that made it worse.”
***
When I returned the following Wednesday, the nurse said, “Oh, Max, he’s fine; that’s not a problem anymore.” Max was quietly engaged in a craft project in the activity room.
Enhancing understanding of the problem-solving nature of the behaviors and awareness of how our actions might increase or decrease the frequency of a “problem behavior” helped to change the dynamic and direction of interactions between Max and his caregivers.
File under: The Art of Psychotherapy, Musings and Reflections