The heaviness of command
Follow my prescription; Take the medicines; You must not go for a ride for a long route; Do these tests; Don’t even dare to think to have children, you have cancer…
These are some doctors’ quotes transcribed by patients. Some are more known and obvious, You must take medicines; some are much more invasive, because the carer not only “orders”, but also heavily insinuates in “other’s lives” – until recommending to not have children.
Let’s analyse language. The tense used is the present, that means that we are in the here and now, but for asking it’s used the subjunctive: and this, hides the imperative. Using the imperative belongs to the culture of power, hierarchy and subjection.
According to transactional analysis [1], this language considers two main Ego states: the one of the carer, usually expressed in the Critical Parent status, in a top powerful position, and the one of the patient that, to coherently reply to the order, situates him-herself in the Adapted Child status (when the patients considers exhortations as good), in the Submissive Child status (when the patient obeys to everything the carer says, even if it’s considered as unjust), or in the Rebel Child status (when the patient, leaving the doctor’s office, thinks This doctor won’t see me anymore).
The harsh language of some healthcare professionals – and in general of people in a powerful position – may have sense if used cum grano salis, that is when it’s really necessary. If it’s true that with some patients the order Stop smoking works, with other patients it doesn’t. The imperative enters weakly in patient’s voluntas, in the mature, voluntary and aware choice: it represents an overwhelming command, difficult to bear.
I can tell you that smoking is bad. If you will continue to do it, your lungs will be full of substances that will destroy their elasticity, and breathing will be more and more difficult for you, until the risk of suffocating… Do you understand me? But if you will choose to stop smoking – I guess your fatigue, but I’ll be by your side – you can do a lot in order to recover your body and wellbeing. This may be a light and effective way to inform the patient on smoking damages, and to activate the Adult status, so that the patient can understand benefits of ending this dependence. The doctor has the role of the Affective Parent reassuring the scared Natural Child, and of the Adult explaining smoking consequences.
When we are in the waiting room, as well as when a nurse commands us to stretch out our arm for a blood sample, it’s hard to be calm and quiet: we are scared by the words we will hear, by the way in which they will be told us, and by the pain we may feel for investigations that remind torture tools. I don’t exaggerate: laces, needles, retractors, pincers are present in torture museums, even if in a small and reduced form.
In addition to the “torture” of the body, there are medical examinations – painful, but sometimes necessary; and more, carers’ scaring words. These words, when used in the imperative, hurt the person’s self-esteem, putting him/her in a “not equal” position, not only physically – as there’s already a hierarchy between healthy and “sick” people (in Latin, sick is male aptus, incompetent, unsuitable) – but also verbally, with the orders Take your clothes off, Get dressed. These are little violations of the identity, and the person find him-herself alone, defrauded of clothes, sometimes ruthlessly undressed.
Patients, often in a passive subjection, in a phase of restitution [2], regress to infantile situations and feel small, like when Alice take a wrong dose of the medicine and almost disappears in the White Rabbit’s Hole. The logistical situation of the clinics, professionals’ jargon, exams are all factors hard testing the sick person, already fragile and vulnerable. This condition is heavy as lead.
The lightness of smile
Can we escape this situation? We cannot avoid some aspects: in order to find a blood vessel we need a needle, a cancer diagnosis cannot be changed, we have to put the catheter if necessary…
Yet we could do a lot with little. Let’s start from pyjamas and nightgown: why they cannot be customized, beautiful and colourful, and wide enough to allow carers to easily find veins for the sample, to lightly touch the body, without making patients feeling ashamed to be branded by a depersonalising uniform such as the one of “the boy with the striped pyjamas”?
And then comes the language: in healthcare professions, the cornerstone on which building the relationship done by gestures, sounds and words, is called empathy.
Empathy is often an overused word, taught through the slogan “to be in one another’s shoes”: a utopian, impossible definition, in my opinion. The healthy person will never be, never want to be, and never can be in a sick person’s shoes. So, what can we do? Let’s dethrone this evangelical concept of empathy. Let’s search with curiosity – as taught by Atul Gawande [3] in his book With care – who is the person with whom we are interacting, listening and observing as widely as possible, so that this person can be understood, affectionately supported in finding him-herself with a new way to live with disease. The excessive use of the imperative might be replaced by the optative, that is the world of desire, potentialities, options. Ancient Greeks used the optative independently, as imperative; we Italians express it through the concepts to want, to desire, can, to decide, to choose. And then there’s the future, opening to hope and optimism. Before saying to the patient You must or You must not, it may be appropriate to understand with whom we are talking, his/her values and believes, fears, resistances, loves, passions. Professionals are there to take care, reinforce the patient’s identity, support him/her in difficult moments in which the patient feels guilty because he/she feels physically useless, a reject, a possible source of sufferance for who loves him/her.
Let’s work scientifically with words. Let’s try to increase in patients the production of endorphins, the “sweet narcotics” that we synthetize in our body and give us wellbeing. The smile, the laughter increases the synthesis of endorphins [4], but only in the 15% of cases this increase is due to jokes. In the remaining 85% the triggering factor is the quality of the relationship, the sense of the connection that allows the smile, the laughter, and not the laughter on command as in sit com where we laugh and applaud for duty.
The relationship producing smile involves not only two Ego states as two Adults – the carer and the patient at the same level – but also their two Natural Children, that play for example with the prescription, Follow my prescription and I’ll take your recipe for… We all have a secret recipe that gives pleasure: one for go climbing, one for cooking, one for reading a good novel.
Positive acknowledgments produce smiles, and so endorphins: You look good, That blue dress fits you, Your nephews are really nice. Or the simple – but not gloomy – recognition of what the patient thinks about politics, how things are going on in the world, which places he/she would like to visit. Until asking What would you like to do today?: maybe the whish is impossible, but expressing it to the carer allows more intimacy in the relationship.
These are just proposals to authentically develop that feasible empathy that creates a relationship, and that allows the production of endorphins both in patient and in carer: the professional will feel at ease, less rigid in his/her role, in a hard and full of responsibilities profession. In the Eighties, in some hospitals there was – is still there? – the room of laughter: a place where patients could relax, play, talk between them or with their carer. A necessary moment of Carnival, before coming back to medicine’s orders. Pediatric wards are full of Patch Adams, but there is nothing for adult and older people: too often we think that they will face disease, exams and prescriptions with the right willingness thanks to the sense of duty.
Together with the word, it comes the music: to each his/her own music, which produces endorphins [5], because the ear is used to love more certain pieces and to reject others. In waiting rooms and during the hospitalization, there’s no time to listen to their music, which is even able to raise pain threshold. And then the music itself as a drug, as in the words of Oliver Sacks: often the music, the sound, is the most powerful medicine, because it rests on an archetypal language that comes before the capability to speak, and then enters into the essence of the person [6]. And it’s also the tone of language a factor that can produce endorphins, if it’s sweet it can soften the harshness of the words, accompanying the verbal component to the realm of para-verbal, the worlds of the voice.
There’s another extraordinary finding regarding endorphins and language [7]: the language take care of itself in order to allow its own evolution. A Spanish and German research team found that learning a new language or inventing new words produces endorphins. Maybe this happens to facilitate both learning in childhood and the infinite evolution of language. We construct it and have many possibilities to invent new games and to escape the verb must, that activates a regressive sense of guilt and inadequacy, looking at other horizons of Poetry. The verb “must” isn’t present in semantic primes forming the natural semantic metalanguage, that universal language spoken by the entire world [8]. There are the verbs to think, to want, to feel, to see, to do. So, the word “duty” is consequent to a social construction and not to the natural language.
I conclude coming back to Poetry and Smile, with Italo Calvino and his Six memos for a new millennium: lightness, rapidity, exactness, visibility, multitude, and coherence [9]. Among this values, I like lightness: that thoughtful lightness that can make appear frivolousness as heavy and opaque. Expected jokes and cynical irony: they are lead trivialities. Calvino writes Whenever humanity seems condemned to heaviness, I think I should fly like Perseus into a different space. Perseus, the hero that wins Medusa looking at her reflected and with detachment, and with the winged sandals donated to him by Hermes, the god of language, he’s capable to lightly fly over the horror of human affairs.
[1] Eric Berne, What do you sy after you say hallo?, New York Time book, 1972
[2] Arthur Frank, The wounded story teller, The University of Chicago Press Book, 1995
[3] Atul Gawande, Con Cura, Einaudi 2008
[4] Allan Pease, Barbara Pease, The definitive book of body language, 2016
[5] Dunbar RI, Kaskatis K, MacDonald I, Barra V. Performance of music elevates pain threshold and positive affect: implications for the evolutionary function of music. Evol Psychol. 2012 Oct 22;10(4):688-702.
[6] David Hendy, Noise, 2013, Companion to BBC Radio Series, Wellcome Edition
[7] Pablo Ripolles et al. The Role of Reward in Word Learning and Its Implications for Language Acquisition. Current Biology Journal, 2014.
[8] Wierzbicka, Anna.. Understanding Cultures Through Their Key Words. Oxford: Oxford University Press, 1997
[9] Italo Calvino, Le lezioni Americane, Garzanti, 1988
