Saturday, March 31, 2007

Laughter is a drug

This started out as a comment to respond to some comments in Your Doctor is Making Jokes About You, but it got so long that I thought I'd post it. Midwife's comments (dang, I see she removed them but they deserved to remain) about being able to laugh at tragic circumstances provoked some anonymous comments about insensitivity, which is the other side of the coin to humor (all humor has this Janus quality... it is insensitive to laugh at that poor chicken's difficulty getting to the other side of the street). Mid wife apologized for inciting a riot.

There's no riot. This is a healthy discussion about what it is like to work in a job where one deals with human tragedy on a daily basis.

The problem, I believe, that the anonymous poster has trouble getting his or her arms around, is that physicians (and here I mean all health care "professionals") are not perfect. We do not possess some unique ability that shields us from anger, fear, depression, loneliness, despair. Yet, for some reason, there is an expectation that we are somehow above these human foibles.

We are not.

In the past week, I have dealt with near-lethal suicide attempts, single women who have had their children taken away from them (probably forever) because their brain illnesses currently prevent them from providing adequate parenting, people who have recently lost a loved one, a home, a job, their freedom. I have also dealt with people making more incremental steps of improvement in their life (another week of sobriety, making it to their follow-up appointment, getting a job, making a new friend).

And, I'm afraid, this is a typical week.

Just writing this comment, I feel tears welling up. That's fine. I'm in touch with my pain. I'm down with that. Woo. But I cannot be in touch with it all the time. That may work for some, but for me it would impair my ability to be effective.

So humor is my way of managing these emotions, both in me and in others. And I use it like I use a medication... with a particular dose to achieve a desired outcome (that is, in my work with patients and staff... at home, my humor is much more random... in my posts, it is somewhere inbetween, depending on the topic). (Mind you, I am not talking about "humor" where one laughs at another's misfortune in a way that is intentionally harmful/evil/superior to that person... that is not what I am talking about here.)

My intent is to heal... both myself and others. Just like a drug may have unintended side effects and be harmful, so might humor. I choose medication which I think is uniquely appropriate for a given patient. My patients do not get angry and hurt when a drug makes them have a dystonic reaction. A shot of Cogentin makes it better, and I avoid that type of drug again. They know my intent was to help.

Similarly, I choose the words I use intentionally for a given patient because it is important to use language that they often use. It helps us understand each other. When my humor has an unintended side effect and is experienced as harmful, my patients also do not get angry and hurt. An Apology makes it better, and I avoid that type of humor again. They know my intent was to help.

On the internet, when one stumbles onto a near year-long, extended conversation about psychiatry, mental health, blogging, ducks and fish, it is all too easy to jump right in, read some comments that appear hurtful or mocking, and take offense. This casual blog observer does not know what the intent is, unless they take the time to understand. Similarly, in the hospital, it would be easy to judge me, for example, as insensitive if I am administering one of my therapeutic aphorisms and someone walks past the door, only to hear "You gotta cut this shit out, Joe," or "So your right arm became paralyzed just after your boss told you that you didn't do a good job on the report that you've spent all month working on? I tell ya, it's a good thing it happened when it did, because if that woulda happened to me, I would have wanted to punch him right in the nose."

My approach (in life, but especially on the net) is to assume benign intent. This takes work, because I am, deep down, somewhat suspicious. But at the end of the day, I am convinced that this way of viewing the world makes the world a better place.


Anonymous said...

Hi Roy. Can you meet to do a podcast tomorrow? I may have bronchitis, hoping I can keep from coughing long's always something.

So I'm still of the mind that the humor we use in speaking with our patients is different then the humor that MWWAK is talking about, a more blow-off-steam laugh AT the situation kind of mocking humor, then the stuff we say TO patients, a kind of laugh-or-cry setting.

We're having different discussions here. Thanks, Clink, for opening up this issue. Maybe you could throw in some pedophile jokes?

To MWWAK-- if you're here, No apology was needed, and I will happily repost your comments if you want. I like riots, and you didn't seem to incite one. I understand where you're coming from, but when I got to the line about "std's are actually funny.." I guess I thought that a non-medical person with an STD wouldn't think so.
I have trouble seeing the humor in some of the stuff, but you know, there's an audience out there for dead baby jokes, so hey.

I'm very specific about what I find funny, and since Clink has recently deemed me "Goofy" (now is that dignified for a psychiatrist?), I don't think I'm
terribly serious. There do seem to be entire flavors of humor out there that escape me-- slapstick, and probably most of what Roy amuses himself with.

Midwife with a Knife said...

Roy, thank you for explaining what I was so unsuccessful at saying.

I took the comments down for several reasons (not the least of which was the fact that I was starting to get very frustrated and at least a little angry at the anonymous poster), but if you want them back up there and you have the means, you have my permission to put them back up.

I don't want people to think that I'm laughing at the pain of others. I'm not a racist, I don't make racist jokes. I don't think that loosing a baby is funny. I never make jokes about the rape evals.

But if a joke about how tragically high our adolescent pregnancy rate (i.e. we have so many pregnant 14 year olds that it makes a 20 year old look ancient in comparison )is, or a humorous acknowlegement of our inability to stem the spread of chlamydia, gonorrhea and syphilis in our population helps me to maintain enough emotional equilibrium to do my job (and it is inappropriate for me to walk into a patient's room crying, because I'm supposed to be the one available to support the patients, I don't get to need or to expect emotional support from the patients (and crying in front of someone is a way of asking for emotional support, even if you don't want it))not only that, but our division director reprimands people (attendings and residents) for crying in public for unprofessional behavior, not that I'm much of a crier anyway, but it is clearly inappropriate to be emotional in my workplace, then that's what I'm going to do.

Also, for the record, for anonymous, emotions are not fleeting. Emotions are strong, and compelling and I can't just feel 2 seconds of sadness and move on. Maybe in your view that means I don't belong in medicine, and certainly sometimes I wish I had found something else to do with my life, but I am who I am, and I am what I am and I am where I am, and I have to make it work.

I also don't think that that is a cop-out, for the record.

Anonymous said...

Well said, Dr. Roy.

ClinkShrink said...

Dang, I come back to the blog after a day gone to find three new posts and a boatload of comments. You guys have been busy.

MWWAK I agree with Roy and Dinah that your comment was a contribution not a riot-inciter. I understand why you felt like you needed to take it down though.

I liked Dinah's point (which I completely and entirely overlooked in my original post) that some people are just naturally and genuinely given to humor, and that it would be unreasonable to expect them to purposefully create a serious but false professional persona. (That's what I took away from the post, correct me Dinah if I'm confused. Sometimes I am.) Looking back on it I think I didn't take that approach with the post because I expected I'd get a "that's not a good enough reason" response. Odd to be in the position of having to justify one's personality.

And now I'm off again. See you tomorrow for podding. Let me know if you want me to bring anything. I'm good at burned popcorn.

NeoNurseChic said...

It makes me feel sad that some places would write someone up or criticize them for showing emotion in the healthcare workplace. I don't think there is anything more personal to an individual than their health - or in some cases, lack thereof. One of the things I was always taught in nursing school was that it's okay to cry with your patient - you don't have to leave the room - and in fact, crying in front of the patient at a time when they are going through tremendous sorrow is one way to show them that you are also human and that their suffering is not just their suffering - but also affects those of us caring for the person.

Now I'm not saying to break down every day or all the time - or to break down unconsolably...not that at all. But for instance, lately we have had some very very sad situations in the NICU. And sometimes when the family comes in, they are crying - and during a baptism or end of life or other times when the news is extremely sad, it's okay if we shed a tear or two with the patient. We certainly don't have to - and they won't dislike us if we don't show emotion with them - and it should never be "put on" in order to demonstrate sadness or caring - but I don't feel that it should be hidden away.

In these types of situations, I don't think this is asking for emotional support. I think this is simply showing the feeling side of ourselves - allowing the patient to see that we are affected by their tragedy. I know my words here won't do it justice, and perhaps it will be incorrectly interpreted. However, I feel strongly about this. I very rarely cry in front of patients - but if I do feel a bit teary during a tragic moment at work, I dont' walk away....not unless I'm about to lose it. It's one thing to let a tear or two roll down y our cheek - and entirely another to cry hysterically.

I remember the first time I ever cried over a patient as a nursing student. She'd had to have a below the knee amputation, and because of a mistake at another hospital, more of her leg had to be taken than was originally planned. She was such a sweet little old lady. I had cared for her many times prior to the surgery. And the day after (I think?) the surgery, I was on the unit. Her room was darkened, and she was laying in bed - obviously in some pain. When I saw her, I felt the tears start...and I walked into the room, took her hand, and told her how sorry I was that she had to go through this.... I'll never forget her...or the emotion I felt at that moment.

So once again I'm not writing about humor...but rather the fact that I believe allowing yourself to have human emotions in front of patients actually really does help them. As I said in other comments, I don't cry all the time - and sometimes I feel weird for not getting emotional over something clearly very tragic - but when I do feel moved by a patient's story, I think it's okay to share that with the patient - as long as the focus doesn't become about you.

Take care,

Gerbil said...

We've come a long way from the notion that therapists have to be a blank slate, ready to receive any and all projections.

I have to agree with Dinah that there are two different kinds of humor, one for when the client is in the room and one for when the client is not in the room. There's just so much bizarreness inherent in this line of work that I think anyone who doesn't find at least one thing to laugh about should be evaluated for coma.

I think laughter in session is a good thing. I mean, no one ever decides to seek therapy because their life is fantastic.

DrivingMissMolly said...

Roy, (hugs to you),

This post reminded me that a couple of months ago, as I left Therapist's office, I thought to myself that regardless of how bad I have felt, he generally makes me laugh at least once during session.

It doesn't matter how down I am, or even if I am suicidal, I usually laugh. I just fall into it so easily with him!

I just had the thought that what is considered funny can be group specific. This assumes an amount of inclusion and exclusion; the patient hears docs laugh and feels excluded, as an example.

At my last visit to Dr. McShrinky, as I waited in the tiny waiting area, I heard his boisterous laugh. He was with a group of students. How I envied them! His secretary asked me; "Did he see you" and I assumed not. I didn't want her to catch him and tell him I was there because I wanted to hear this moment and pretend that I belonged.

Cops, docs, paramedics, nurses, they ALL have their own group humour. I assume it keeps them sane when they are dealing with the gore and chaos of what they witness.

You can't judge these people and I don't. I can't because I haven't been where they have.

I even make jokes about suicidality, mine or of others. The most deeply pathetic is often humorous.

I must admit that I expect a certain amount of seriousness in a psychiatrist. I need to be able to have them on a pedestal. I need them to be perfect.

I have only been seeing new shrink since September so I do not think we are at the joking point, but I do find that I make a HUGE effort to be charming, funny and entertaining FOR him because I want him to like me.

I search his face for any hint of disapproval or irritation. I need to see him smiling and engaged. I need that.

I don't feel like I could ever be enough of an insider to share a laugh with my psychiatrist.


PS Hey ANON, I'm calling you out! Anyone can hide behin the "Anon" label. Why don't you step out from behind the tree you're hiding behind! It's easy to throw stones when you're wearing a mask!

Anonymous said...

Lily, I'll defend this anon poster for a moment. I have a sneaking suspicion that with a title like "Your Doctor is Making Jokes about You" the author knew she would receive some not so happy responses - Now, I'm going out on a limb here but I suspect that's true.

We all have different tolerances for what we find funny. I remember several years ago when we had this crusty old gentleman running for governor. He made a joke about rape. Now, I don't think he probably does find the issue of rape funny. At least I would hope not. But, the point is it caused a firestorm. There were those that said, Oh, come on he's just a good old boy. Don't be so sensitive. And then there were those who just weren't amused. We all see things a little differently I guess.

I, myself, have a pretty gallows sense of humor. I poke fun at myself and am not above poking fun at people in positions of power.

Jessica (okay, not really Jessica but Jessica for the moment)

Anonymous said...

I had one last thought on this topic. Several years ago I was in a psychiatric hospital for a couple of days. The staff decide we're all going to play Pictionary. Now, I have to admit it was quite comical. The drawings resembled nothing. The things people called out were so off the wall it was hilarious. So, when it was my turn I looked at the drawing which looked like a box with a circle attached to it. I joined in and called out something random. I said, "Chocolate chip cookie." The staff member gasped, "That WAS the answer. How in the world did you know?" Of course, I didn't know. I was just calling out random things but I told her (big mistake on my part) that I was telepathic. Not wise to make jokes like that in a psych hospital as they tend to think you're serious. She told my doctor I thought I had special powers. I have never laughed so hard in my life.

Not really Jessica

Anonymous said...

I don't have any trouble with anonymous posters except that if you have more than one it gets really confusing. I suppose we could ask people to voluntarily be anon #1, anon #2 etc if they comment more than once on the same post.

I'm only Jessica when I burn popcorn.

Anonymous said...

Obviously, you do have telepathic powers.

Just burn the popcorn in your own house.


Dr. A said...

Ah HA! A podcast is coming! I can't wait for this one...

And, I just want to clarify that I am NOT the anonymous poster. I have my own unique name *smirk*, and I've already kind of revealed myself (he, he - see podcast 9)

Anonymous said...

Dinah, telepathic powers. I just happened to notice another patient eating a chocolate chip cookie during the festivities so that's what I called out. (Dear god I hope she didn't write that in my medical records. Oh, well.)

All kidding aside I don't get bent out of shape when health care professionals make jokes. But, I do understand how it might feel hurtful to other people. We're all different. I've always been one to laugh at myself. When my former psychiatrist once asked how I was doing I responded with, "Well, I haven't purchased the Final Exit off my Amazon wish list yet." I never did have that on my wish list, but saracastic humor is how I cope. It's such a part of who I am. I think people do have to realize that doctors aren't perfect people. I work around a lot of them, so it's I guess easier for me to see that now.

Not Really Jessica

jcat said...

Mmm...the two types of humour. And I think they are both important.

The humour I share with p-doc and t-doc is sometimes about the only thing that I can take away with me as an indicator that I'm not yet an absolute total failure. Not if we can still laugh together.

And as Lily says....cops, docs etc all have a 'group' sense of humour. I know from the vet/ emergency vet/ rehab side, it can be very very black humour.

I can only imagine that for people-carers it is even darker and more needed, and for p-docs especially. When you spend your day dealing with the pain that people inflict on themselves and each other, I honestly believe that you have to find something in it to laugh at. Or you'll go home and swallow the gun-barrel yourself.

And it's in those terms that I say I would be really pleased if p-doc found something funny enough about me to go away and joke about it.

Anonymous said...

Well, I've looked at both posts and interesting. I kind of missed out on MWWAK's stuff but okay...maybe I can fill in the blanks. Or not.

I have a very erm...broad, warped, twisted, black...need I go on(?) sense of humour. That is not to say that certain things don't cross lines and that I wouldn't make jokes about but I guess I can find humour in a lot of things.

But for now, we'll limit it to the psych stuff.

I do sometimes josh with my therapist. I'm still without a psychiatrist so we'll have to see if I get anyone funny there. Who knows? I've actually never met a funny psychiatrist. Or at least not in a clinical setting. Maybe they've been a real card in real life.

The relationship might be go that way if it grows into an *intimate* kind as I find there needs to be some kind of development of..."something" between the clinician/patient to be able to make jokes.

Sometimes (like now--definitely now due to life circumstances) I can be come rather emotionally dysregulated and have extreme opposing reactions to events. I mean, a chair caught fire outside our house last night and could have caused serious damage and I was laughing my head off. I mean, potential fire damage is not funny.

But I have no problems with laughing with clinicians/professionals. And sure, if they want to laugh at me, that's fine as well. I can be pretty "goofy" sometimes.

Maybe even like Dinah.

Midwife with a Knife said...

PatAnon: Actually, I think a burning chair might be really funny, especially if nobody's hurt. I accidentally blew up some clothes a few days ago, and I thought that was pretty funny (I choose not to think about the fact that I could have been hurt).

Anonymous said...

I'll bite: How do you blow up your clothes?

NeoNurseChic said...

Hmmm...I don't joke with my psychiatrist. Every once in awhile he says something that makes me laugh - but only on a couple of occasions did I think he intended to say something that would make me laugh. Not sure about that... Sometimes he points out things that are pretty obvious in my life, but I don't see them - and when he puts it in those terms, it sometimes strikes me as funny...but I take a lot of things very sarcastically.

My friends can never tell when I'm joking. My one best friend, Tom, is always joking about everything - he's never serious. But if I make a sarcastic comment back at him when he's picking on me, he gets all apologetic and tells me not to take it so seriously - he has no idea that I'm joking back with him. Maybe it's because people see me as a serious, passionate person and they don't expect my sarcastic remarks to actually be me joking around - but rather as me being literal.

I love humor, though. I try to find humor in just about everything.....but I've gotta say, at least in my psychiatry appts, it's not really a piece of it. Maybe we're not there yet? I feel like when I get into sharing stories about stuff that either happened in the very recent past or even the long ago past, many times he's helping me correct a distorted perception of myself. That is extremely helpful, but humor really is not a part of it....except on those very rare occasions when he says something so obvious and possibly sarcastic that I just have to laugh. We talk about things that make me cry on a regular basis.....and it's funny (no pun intended) how often I don't expect that I'm going to be upset about something, and then I end up bursting into tears over it. I'm always saying things in my appts like, "Well...I think it's funny that.....insert some random observation about my life here...."

I'm one of those people who, once I get started laughing, just can't stop. Well I'd have to say that in school I was more like that than I am now - I guess maybe I'm just not around as many funny people as I used to be. I remember countless times when I'd be in a clarinet lesson or quintet, and my teacher would say something funny, and I just wouldn't be able to play because every time I'd get past the moment and start to play again, I'd bust out laughing and squeak the clarinet. My family doc used to say funny things to me right before he listened to my lungs, and then I couldn't stop laughing. And the worst is that this often happens at completely inappropriate times - like in church or somewhere where I should either be serious or be quiet....if it's a time when I should be quiet, then it might just end in me snorting by trying so hard not to laugh.

But I miss being like that. Now that I'm on this topic, I can't remember the last time I laughed like that. A lot of times, I just don't find things as comical as I used to. I wonder if it's sort of the depression that chronic pain has partnered with. I love to laugh - it makes me feel so much better...and I kinda miss having those hysterical, laughing so hard I'm crying moments. They used to be a near daily occurrance when I was younger. I have some favorite funny movies, and if I'm here in my apt watching them alone, I don't even laugh....I just stare at the tv - even though in the past I found those parts hilarious - it's like if I'm without someone watching it with me, I don't laugh as much maybe!

Today, I took a nursing student and a new nurse (who is actually a very experienced nurse, but just started working in our NICU recently) over to "the dungeon" where we keep a lot of big equipment. On the way back, we heard someone that sounded like they were either laughing or crying hysterically. The one nurse said, "Well...she's either laughing or crying!" and I said, "I think she's laughing, but isn't it amazing how close those emotions really are to one another?" She then replied, "Yeah that is so true...."

I think one can even trigger the other sometimes. I wonder what connects them - now I want to know what's going in the brain, if similar areas are working when laughing or the extremes since those seem to be the most similar.....and other interesting tidbits.

Sorry to ramble!

Take care,
Carrie :)

Midwife with a Knife said...

dinah: I had been filling my car with gas, and there was some sort of gas pump malfunction so that when it was supposed to automatically shut off it didn't. I got covered in gasoline.

I remembered how when I was a kid (DO NOT TRY THIS AT HOME!), we would amuse ourselves by putting lighter fluid on our jeans and lighting it. It burns at a cool enough temperature that it doesn't really burn you.

So, I thought... gasoline is a lot like lighter fluid, and I wasn't sure how to get the gasoline out of my clothes. So, I took them off, put them in my driveway, and thought that maybe I'd burn the gas off.

Well.... they went up in a frightening but amusing ball of flame. Needless to say, don't try that at home either.

Anonymous said...

EEK, I think that humor is the ultimate way to deal with pressure of other people's situations. I have the utmost respect for physicians nurses and other health care workers and I can see how patients could be may see doctors' jokes as insensitive but I feel this is a neccessary part of the job. When I was a paramedic humor was the key to keeping your sanity in what often was an insane situation. Although I worked with a super serious partner (who was also mentally unstable) who told me if I ever laughed on scene again he would have me fired. My boss thought this was very humorous.
I think most people would be appalled to find out what we laughed at and as was said sensitivity can be very critical in these situations. However due to the difficutly in most of these jobs to fault these people for having humor would be like telling them to burn out and go away.

EEEEEK hanid is this what you wanted me to see???? My infectious laughter is nothing compared with my sister's. I love you abf

Anonymous said...

MWWAK: Okay, that is funny. and no, people...I'm not a pyromaniac.

Anonymous said...

I love to laugh. At least 3-4 nights a week, my cheeks hurt from laughing so hard at something funny. I also work at least 3 hours every day of the week on my Forum of over 1200 leukemia patients. I don't laugh much there but I do cry when someone dies. I need my laughter--it is a reminder that life is good. One of my favorite laughs is on a tombstone. It says, "I told you I was sick!" I plan to use that one.

Midwife with a Knife said...

PtAnon: Neither am I (a pyromaniac, that is). I just had a lapse in judgement. Life is funny.

Fat Doctor said...

Very thought provoking. I make fun of patients on my blog and, at times, verbally with my partners. It feels awful when I do it, but I, too, have to vent through humor, no matter how pathetic that is.

Sarebear said...

It's not pathetic, it's human, and a way of coping with tragedy and difficulties.

Sometimes I laugh when I get injured, although that's a different psychological mechanism I think; I somehow can't help it. Even a severe ankle injury (folded my foot under and in half and was stuck on it that way, w/some force, never went to a doctor (officially) for it) I was laughing my head off, although there were tears. Maybe a shock reaction, I dunno.

serious person said...

You're not the only one who treats laughter like a drug. I'm not much a laugher because I like being serious a lot.

It ticks me off that there are people who laugh during inappropriate times and have improper humor.

It also pains me that there are people who judgmental of serious people. They can shove their anti-serious bias up their butt holes. Besides, no one can force anybody to laugh.

I'll always prefer serious people and things because that's how I am.