Families, Systems, & Health 2014, Vol. 32, No. 4, 436 – 438

© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000088

FAMILIES, SYSTEMS, AND HEALTH IN OUR LIVES

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Aesthetics of Change Deepu George, MS

Rebekah Hughey, MD

University of Texas–Rio Grand Valley

Duke University

My pager beeped: “Consult. Green.” A behavioral health consult usually involves either a “meet and greet” for a therapy referral, or a situation in which the physician is concerned about a patient’s mental health. Sometimes, I find myself in the room with an uncooperative or angry patient. Even though I have done several behavioral health consults, I still get a little nervous. I greeted Dr. Hughey in the green section. I checked the environment for cues of any potential crisis. Dr. Hughey, nurses, and others around looked calm. Confirming the absence of any anxiety, I shifted my attention to prepare for the encounter. Dr. Hughey described the patient as a 52year-old African American woman on her third office visit to address her elevated blood pressure and obesity. She explained, “Two visits ago, [the patient] agreed to make changes in diet and exercise, to avoid taking medicine. But her blood pressure and weight have steadily increased. Today, I counseled her about starting medication for her blood pressure, but she is adamantly opposed to that.” This was an unusual description for a consult, I thought. Usually, consult themes include depression, tears, family troubles, low support, anxiety . . .. As I listened, I knew I had to open myself up for new possibilities in this interaction. Dr. Hughey continued.

“I am not sure why she is refusing medication. We wanted to see what you can find out about that, help her think about her lifestyle and health behaviors, and so forth, and speak to her about medication as well.” “What else did you notice about her?” I asked. Hughey noted that she is fairly reserved and had a flat affect. So, here we were; trying to understand the reasons behind her rejection of medication and curious about lack of behavior change, despite strong medical advice. “I told her we have a behavioral health consultant who can help her keep her commitment to health behavior changes. She said okay to seeing you.” Certain environments invite intimate conversations whereas other locations make even the most intimate conversations impersonal. The aesthetics of an exam room has the capacity to promote either, depending on judicious use of available props. I sat in a round rolling chair against the wall for back support, placing me in a position to maintain direct eye contact. Dr. Hughey introduced me to Ms. Smith, who sat on the exam table, dressed in blue jeans and a light gray t-shirt. She greeted me with a cold, loose handshake. People often associate behavioral health with the stigma of being crazy, and this can prevent honest, intimate communication. I wondered what she was thinking. “How are you doing, Ms. Smith? My name is Deepu George.” “Fine.” she said, politely. One word answers are a signal for me to start the process of psychological fishing— offering bait to help the patient pull out their story, answers, and experiences. Like fishing trips—no guarantees!

Deepu George, MS, Department of Family and Community Medicine, University of Texas Health Sciences Center at San Antonio (University of Texas–Rio Grand Valley); Rebekah Hughey, MD, SR-AHEC Family Medicine Residency, Duke University. Correspondence concerning this article should be addressed to Deepu George, MS, Family Health Center, 2821 Michealangelo Drive, Suite 400, Edinburg, TX 78539. E-mail: [email protected]

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AESTHETICS OF CHANGE

“I work with the physicians to help patients understand health issues from psychological, behavioral, and social aspects of your life. I would like to spend a few minutes with you to learn about your recent experiences here. Dr. Hughey informed me that you have a goal to change your health behaviors to better manage your weight and blood pressure. How is that going for you?” She looked down, with a sense of culpability. Silence enveloped our shared moment. She spoke slowly, softly. “I tried to exercise, avoid eating meat. I try to eat a lot more vegetables.” “Okay. So you’ve made some changes based on previous recommendation. How are these changes working for you?” “I have not been consistent. I have started and stopped,” she answered swiftly. Her slow, calm speech invited me to ask a closed ended question: “Okay, did you stop both diet and exercise, or just one?” “Both.” I waited. I employed the 20 second rule before breaking the silence. She continued, “It was okay in the beginning, but I just could not stick to it. I mostly walked. I was not sure what to really eat.” “Okay. So you’ve made some strides but have not been consistent. Dr. Hughey also told me that she recommended pills for your blood pressure. What are your thoughts about that?” “My mother is 75 and she is in good health. My grandmother died at the age of 92. Both of them – very healthy. They never took pills. When they finally took my grandmother to the hospital, she was diagnosed with cancer and died 6 months later. My family has not taken pills.” She reiterated with emphasis. In some schools of Family Therapy, resistance is seen as serving a function within the larger family and social organization of people’s lives. Ms. Smith’s “out of the box” response to this question raised my curiosities about the “function” of her pill refusal. I began to perceive the ‘resistance’ as a ritual of honoring her mother and grandmother. In the most innocent way, Ms. Smith just provided us with clues to deeper layers of her organization. “Oh wow! So, you come from a line of healthy women!” She nodded in the affirmative.

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“Well, it seems like you really value how they were able to live healthy lives without medication.” She nodded again, as if my responses were somehow opening up her world in an unexpected way. “It looks like you’re really honoring your grandmother and mother by deciding not to take medication.” “Yes.” Though this was just one word, her nonverbal response indicated a deeper understanding. “That is a wonderful way to honor them. Now that I have a better understanding of your values, I would like to explore with you additional ways you can honor them with healthy choices. We know that back in those days, grandma and mom had much more active lifestyles then we have today. I think it would be meaningful for you to honor them by also being active. “What do you think about that?” Ms. Smith, at that moment, seemed to make some connections in her head. We had a great conversation. She revealed that she did not know about good vegetarian options, never planned her meals, and had no exercise plan. In the 20 or so minutes that followed, she agreed to walk for 45 minutes, three days a week, especially to the grocery store. She agreed that she can be better about adding fruits to her diet. I provided three websites for vegetarian recipes and tips. She was also given a meal planner. Every clinician wonders about the effectiveness of an intervention. About three weeks later, I saw Ms. Smith at the grocery store. We greeted each other and went our separate ways. As I moved swiftly through the aisles, I caught glimpses of Ms. Smith near the fruits and vegetables section, carefully picking her produce. I smiled as I walked out of the store, wondering whether our work had helped her to turn this into an established daily behavior. Several weeks later, I asked Dr. Hughey about Ms. Smith. “I have been meaning to tell you about her,” she said excitedly. “She came by the other day. She was a totally different Ms. Smith. She was smiling, she was talkative. She dressed in bright colors! Never seen that before. She also would not stop talking! She wanted to chat about her family, her church, and changes she’s made in improving her health.”

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GEORGE AND HUGHEY

“Wow” I remarked. “How is she doing with her blood pressure and weight management?” “Well, she managed to reduce it to normal! She has also lost five pounds since then.” With her most recent encounter, Dr. Hughey recalled that she experienced a different side of Ms. Smith. She also recalled the uncanny nature of Ms. Smith’s organization of her behavior. Dr. Hughey informed me that her initial impressions were that Ms. Smith was noncompliant and resistant. As health care professionals, we often define change as linear and a logical process. We determine the best course of action for our patients, we advise them accordingly, and we expect them to comply. After all, “we are acting in their best interest.” However, for many, what we see as lack of adherence to treatment plans is not resistance. It is, in fact, the patient’s way of telling us that they have different principles by which they organize their lives and experiences. In the case of Ms. Smith,

we learned this through the process of allowing her to tell her story. Her openness afforded new possibilities for her own care and strengthened our collaboration within our primary care. Although changes in her behavior could be explained otherwise, we began to wonder how our reframing of her behavior as a ritual honoring tradition helped her to actively engage in her own health care. Every behavior is organized by a social sequence. Behind every sequence is a deeper story, a higher order of meaning. Our perceptions and assumptions about patient response are merely linear, logical, hypotheses. Being a fisherman in the aesthetics of an awkward exam room is sometimes the best way to help patients discover perspectives on why they do what they do. Received December 11, 2013 Revision received August 1, 2014 Accepted September 8, 2014 䡲

Call for Nominations: Health Psychology Division 38 (Health Psychology) is currently accepting nominations for the editorship of Health Psychology for the (masthead) years 2017–2022. Anne E. Kazak, Ph.D., ABPP is the incumbent Editor. Health Psychology is the official scientific publication of the Division of Health Psychology of the American Psychological Association (Division 38), devoted to understanding the scientific relations among psychological factors, behavior, and physical health or illness. Its current Citation Impact Factor is 3.954. Candidates must be members of Division 38 and of APA, and should be available to start receiving manuscripts in 2016 to prepare issues to be published in 2017. Division 38 encourages participation by members of underrepresented groups and would welcome such nominees. Self-nominations are also encouraged. Beverly E. Thorn, Ph.D., ABPP has been appointed as Chair for this search. To nominate candidates, prepare a statement of two pages or less in support of each candidate, and provide a current CV. Submit all materials electronically to: [email protected]. The deadline for receipt of nominations is January 15, 2015.

Aesthetics of change.

The authors discuss a 52-year-old woman, Ms. Smith, on her third office visit to address her elevated blood pressure and obesity. With her most recent...
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