What happens when disaster strikes? No one goes on the Internet and orders up a stroke or brain injury. It's not something that you plan for or are prepared to cope with. As health care professionals, we deal daily with families who are angry because they didn't ask for this tragedy and are having a very difficult time dealing with it. We too are under unusual stresses with our autonomy taken away and the confines of payers (insurance companies) restricting us in ways we may feel unreasonable. Just like the families in distress, health care professionals feel a loss of control. The people who successfully navigate these events can turn a negative experience into something positive.
We know Sarah Brady had to be very angry when her husband, Jim, was shot during the assassination attempt on President Reagan. However, from this she and her husband became the leading advocates for gun control and eventually saw the Brady Bill passed. The anger was turned around into something constructive.
Frequently, we just see and hear the anger, but don't really hear the story or the feelings behind the rage. Ellen had a brain injury eight years ago and she recalls: "The clock just stopped ticking the day I was injured. I no longer felt connected to my family, my friends or my job. I looked around at my family and they were all angry, but I couldn't remember the accident, so I didn't know what to be angry about. I feel an enormous loss of who I was, what I had and what I might have become. But, my family has other feelings. They are angry at the person who caused the injury. They seem angry that I don't try hard enough to get better. They get angry and embarrassed by my behavior. And, they get angry at the lack of financial resources and the poor service of the health care delivery system. My doctor thinks my parents are unrealistic and that we need to be more accepting of what my futures looks like. Everybody just seems upset and distressed."
Her doctor is upset. He's busy, having to see more patients in the same day for less money. He can't just order the tests that he wants because he has to ask permission. Ellen's family is constantly calling with the same questions and they just "don't seem to get it." "Why don't they just accept the way things are and make my life easier?" On a particularly bad day, Ellen's father suggested that her doctor didn't care enough and that he was having a lawyer look into the case. The usually patient doctor lost it, yelling at Ellen's father and telling him to get a new doctor if he didn't appreciate what he was doing and particularly since he had mentioned the "L-word," a lawyer.
Ellen's family and the doctor's reaction are not unusual. They are both dealing with real losses. Mothers tell me constantly how they look at their injured child and know it is someone that they love deeply, but that the person they are taking home from the hospital after a brain injury is someone else. They have lost part of the person who used to be. Both the family and the doctor have lost control of the situation and both are angry.
Why Are They Angry?
- Both have a perception of having lost control of the problems that are causing them distress. Families may feel swept up in a system that doesn't care or can't make their child better. Doctors share the same concerns and frustrations, having to adapt to a new way of delivering care that seems to move them out of a position of control.
- Parents may feel responsible that a child had an accident. A wife may be angry with the patient for getting sick. A husband is mad because his wife is not supposed to get sick. The doctor is upset because she has done everything she knows to do and the patient isn't improving. She's not used to being a target for people's anger and wants to be the recipient of their praise for a job well done.
- Society gets angry for having to deal with difficult people who can't just fit into the system. Look at the anger of employers towards the American's with Disabilities Act. Why should I have to make concessions? Is it my fault that Ellen is different?
- Families and patients are angry with a public that tends to patronize the disabled and look at them as "less than whole." I have parents who want to put a sign on their disabled child that says, "He is not retarded!" This, in and of itself, reveals their own prejudice toward our citizens with mental handicaps. It is not easy.
- Everybody is troubled by the "miracle stories" that show up on the front page of the newspaper tabloids and on the latest television gossip shows. Health care professionals resent the "false" expectations that are being set. Families are particularly upset because the miracle didn't arrive at their home.
Coping With Anger
Iris Dement, one of our most soulful singers, wrote a song that could be the anthem for patients and doctors: "Easy's gettin harder every day." Ms. Dement can be hard to reach, so I sat down with Hal Hoine Ph.D., Director of Rehabilitation Psychology at the Rehabilitation Institute of San Antonio (RIOSA). Although Ms. Dement clearly identifies the problem, Dr. Hoine gives us ways to cope and deal with our anger. In particular, health care professionals need to realize that these strategies also apply to them, not just to patients and families.
People have the perception of having no control and being attacked. You need to identify those things that you can control, make a list of those things that fit into two columns -- those things you have control over and those you don't. Identify strategies to get input into the system. Education and information are power. Families and professionals are helpless when they don't understand what is going on and don't know how to access the necessary tools to manage a difficult situation.
Under the enormous stress of terrible tragedies, we don't always think logically. We feel responsible for events when we are not. The parent didn't cause the accident and the doctor is not responsible for an insurance plan that doesn't provide adequate coverage. Talk about the anger. Identify the sources of distress. Help all involved to think logically about an illogical circumstance. Frequently no one is to blame. Rabbi Kushner wrote the wonderful little book, "When Bad Things Happen to Good People." It is natural to shift blame to a God who doesn't care, a doctor who is inaccessible, or an insurance plan that is heartless. It is natural to shift blame, but not constructive. We need to acknowledge self-responsibility and the difficulties it proposes.
The White Coat
As health care professionals we frequently hide behind the white coat and feel that it allows us to be immune from the wrath of angry families and patients. It should add responsibilities. Health care professionals need to listen and let their patients and families ventilate. Never argue! We want to talk angry families out of their position and convince them that we are right. The younger the doctor or therapist the more difficulty they have in this role. This is not a contest. The white coat comes with an obligation to absorb the abuse and anger. When the angry family refuses psychological help or counseling, we accomplish nothing by abandoning them or getting angry ourselves. Continue to listen, encourage the patient and family to gain control and continue to constantly educate them. Understand your own feelings when a patient or family ventilates and gets angry; remember that you are the outlet for their anger. If the doctor or therapist is having difficulty controlling their anger, they should seek help. There are seminars and courses for professionals. We frequently ask the family to seek help, but how often do we seek it for ourselves?
It's like walking a tight rope or precipice at times, maintaining hope while trying to give patients and families a realistic view of the future. It's hard work for everyone, holding on to hope can be essential, but difficult. It's our job to intervene at the person's current level of distress and disturbance, understanding not only their feelings, but our own. Control the anger.