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A closer look at chronic illnesses
- Chan C. Y. Zenobia (2 October 2002)
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Re: A closer look at chronic illnesses
- Peter Morrell (4 October 2002)
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Chan C. Y. Zenobia, RN, PhD Candidate The Chinese University of Hong Kong
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Chronic illnesses are just like a rusty nail. The sufferings are accumulated day by day. They are also like an ant inside your ear. The endless sufferings, annoyance and the hopeless prognosis will affect the healthy sense of self in terms of individual's self and the social self. In contrast, acute illnesses come suddenly but at least, people know whether they will recover or not. Further, social disturbances such as employment and family relationships are less than in chronic illnesses. The healthy sense of self consists of individual's spontaneous, natural part and the socialized part. Both work together to maintain the equilibrium of self. For people with chronic illnesses, the instant self is affected by body dysfunction. The socialized self is also affected by the social interactions, adaptation, functional and structural changes of individuals. Chronic illnesses will destroy the social integration of sufferers. Chronic illnesses are deviants in societies and the sufferers are provided with secondary terms of medical resources. The medical profession gives the sufferers of chronic illnesses a lower priority for treatment because the conditions lack urgency and not much can be done for them. Many chronically ill persons still seek medical advice regularly though there is no any improvement at all such as in arthritis and headache. They treat the consultation as a kind of conformity by modern discourses of illness behaviors whereas the doctors treat them just because of doctors' roles. The stereotyping of individuals' experiences of illnesses hides the subjective feelings and social influences for them. Anyway, although we can do little for treating chronic illnesses in physiological aspect, a social healthy sense of self is really helpful to the individual's quality of life. |
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Peter Morrell, freelance researcher, history of medicine, UK
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Sir,
As Zenobia Chan’s eloquent letters imply, although most clinicians would freely acknowledge that, "psychological issues," [1] "multiple perspectives," [1] and "the patient's social context,"[1] including "an ecological perspective on health and illness,"[1] all impinge centrally in the "dynamics of doctor-patient communication," [1] including that "the patient and the social environment are interdependent," [1] and generally speaking that, "patients are in the secondary position,"[2] in this dialogue. However, "the role of confession," [2] is not exclusively "a one-way process," [2] in what is not necessarily, "a domination-subordination relationship." [2] Many doctors do reveal much about themselves in their interactions with patients; much is revealed to the discerning eye. This account seems to suggest that the power to help and heal can come perilously close to the power to dominate, smother and control. Inadvertently and accidentally perhaps, but the doctor can be an obstacle to cure by not empathising with the patient deeply enough and not feeling their sickness as if from within and 'getting inside their head.' What goes on in the patient's head regarding their condition is often not seen by the doctor, yet it can be highly relevant to the discourse. This is especially the case for long-term chronic conditions and terminal cases. Therefore, although doctors should be empathic both with their ‘skills’ [drugs, science, medical theories] and with their patients, their laying greater stress on the empathy with patients might allow the 'art' in medicine to compensate for any excessive tendency towards the 'science' in it. It allows them to read the inner feelings of the patient more clearly and see their hidden narrative just as if they were sincerely asking the question - how does this illness make you feel about yourself? Because of the incapacitation and denial of self-motivation and liberty that asthma involves, for example, one feels helpless and dependent and this can create a considerable mountain of pent-up anger and resentment that only the truly empathic physician can attune to, and acknowledge, let alone try to deal with. This anger seems to flow from a thwarted will, a big sense of failure and restricted freedom. This in turn can add up to mountain of anger just below the surface and a ‘failure mentality’, or ‘poverty consciousness’. One feels a brooding sense of failure in all one does; illness can make one feel like a victim. Doing nothing seems preferable to attempting things that will certainly fail. All chronic disease of long-standing is suffused with this inherent sense of failure and often a deep sense of shame, impurity and much anger too. Being hidden below the surface, means that only the truly empathic physician brings these inner aspects of sickness to the fore, much to the benefit of the patient. Just talking about these matters can bring great relief and inner strength as in a true ‘confession.’ Although "doctors are in the dominant position,"[2] yet unless the doctor pulls closer to the actual position of the patient, then they are in danger of becoming just hollow, anonymous and unfeeling medical scientists with precious little humanity. Though deeper involvement with his ‘skills’ does not inspire deeper empathy with the patient, yet it is deeper empathy and identification with the patient, with human beings, that makes the ordinary doctor a more luminous and compassionate source of help to patients that is a benign person who connects with and understands others at the deeply human level. The gulf between patient and doctor is often a gulf between the patient’s inner experience of sickness and dependency, such as feeling helpless, isolated and ashamed of one's ill-health and lack of freedom, and the fact that many doctors may simply fail to attune to all this. Unless they can attune to the inner hurt of the patient and the doctor simply fixing the outer part of sickness, then this falls a long way short of the true process of cure. Deeper attunement comes about only through empathising with the predicament as the patient sees it, not from any overtly medical or scientific construction of the situation. In a profounder sense, to use Zenobia’s words again, it is clear that “chronic illnesses are just like a rusty nail. The sufferings are accumulated day by day. They are also like an ant inside your ear. The endless sufferings, annoyance and the hopeless prognosis will affect the healthy sense of self in terms of individual's self and the social self.” [3] The sense of self and self-worth become progressively eroded, through pain, loss of liberty and increasing dependency on others, such that chronic illnesses “destroy the social integration of sufferers.” [3] Certainly, such a woeful onslaught “can permanently spoil the individual’s identity,” [4; 130] primarily because chronic illness engenders a pervasive “sense of loss and a heightened self-consciousness.” [4; 140] Such sickness is “especially damaging to the self when it is experienced as overwhelming, unpredictable and uncontrollable.” [4; 140] For example, losing one’s “independence is threatening to one’s sense of self…[because] it impairs one’s ability to participate.” [4; 141] Many such individuals live their “lives in a deliberately collapsed world because the larger world is unmanageable and threatening…[their life becomes dominated by] problems of uncertainty and dependency,” [4; 141-2]. It is easy to see how doctors might be oblivious of such factors at work in the psyche of the chronically sick, much to the detriment of their empathic engagement with their patients. It is as if they live in utterly different worlds that might at times fail to engage. All sickness can damage the sense of self, but persistent, serious and incapacitating sickness causes especially deep and lasting damage to one’s natural sense of joy, liberty, self-worth and independent autonomy. Being progressively eroded, these can become sources of the despair and resentment that can in turn spawn lack of cooperation with treatment, defiance of authority and negative attitudinal issues connected to medical dependency and the ‘why me?’ problem. Because one’s innate sense of value, meaning and purpose in life becomes so challenged and damaged by chronic disease, thus, long after a patient feels relief from their treatment, they can still be saddled with unresolved inner hurts, negative self-beliefs, a failure mentality and a profoundly damaged sense of self-worth. Such is the invisible inner legacy of chronic disease. While one fails to see how drugs and a few 8-minute consultations with the average GP can address such issues, let alone resolve them, yet the challenge of greater patient empathy holds out the real prospect of greater hope within the context of human suffering. Doctors choosing such a path should draw themselves closer to the feeling side of human nature than the purely technical skills of medicine. Such a path offers a deeper form of cure than the mere technical fix of crude drugging. For again, in Zenobia’s words: “although we can do little for treating chronic illnesses in physiological aspect, a social healthy sense of self is really helpful to the individual's quality of life.” 3] Sources [1] A good doctor--Think beyond the medical model, 30 September 2002 Chan C. Y. Zenobia, RN, PhD Candidate The Chinese University of Hong Kong http://bmj.com/cgi/eletters/325/7366/711#25905 [2] The confession process, 18 September 2002, Chan C. Y. Zenobia, RN, PhD Candidate The Chinese University of Hong Kong http://bmj.com/cgi/eletters/325/7363/548#25601 [3] A closer look at chronic illnesses, 2 October 2002, Chan C. Y. Zenobia, RN, PhD Candidate The Chinese University of Hong Kong http://bmj.com/cgi/eletters?lookup=by_date&days=1#25964 [4] Peter E S Freund & Meredith McGuire, Health Illness and the Social Body - a Critical Sociology, New Jersey: Prentice Hall, 3rd edition, 1999 |
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