Presence and Its Challenges
Notes from a Family Meeting, Vol. 4, No. 9
I sat with my patient - no, my client - and struggled to pay attention. Was I nodding too much? What should I say next? What time was it? Oh dear, this story is horrific - how could someone endure what they have? What was that technique my supervisor talked about?
Such were my struggles learning psychotherapy during my residency. I lamented to one of my supervisors that it felt impossible to both “be the expert” and also be present with my client, to attend both cognitively and emotionally. To stray too far as an expert felt like I was missing the person in front of me; to stray too far into empathy felt like free fall.
I don’t think I ever figured out how to do it as a psychotherapist. As a psychiatrist and palliative care physician, though, I think I just saw enough patients that both aspects were drilled into me like muscle memory, sufficient for the tasks of that roles. It required a lot of stumbling through emotion as an analytical expert and stammering through tough questions as an empathic but (seemingly) useless companion. It still does, some days.
Given my ever-present struggle to attend well, this paper from Alexandra Guité-Verret, Mélanie Vachon, and Dominique Girard caught my eye. In it, they write:
“Presence is a way of being that refers to an awareness of the self, the other, and the relationship between the self and the other. … presence stands in contrast with our tendency to a) spontaneously directs [sic] us towards an eternal and over-stimulating environment, and b) enjoins [sic] us to master and categorize everything (and everyone) rapidly. Presence thus offers ‘a less means-oriented focus, where people and things are not quickly reduced to their use.’”
Now you might say, people aren’t used in healthcare; they’re served. But that’s not the whole picture. They are used - to get the right answer (sometimes to the wrong questions). Patients are integral to the game of medicine. Presence, without its metrics or clear goals, can feel like anything but a game:
“By being present, clinicians return to their position as subjects, which brings them back to their finitude - not knowing, not having the solution, not doing, being vulnerable, etc. They confront their relationship to control and limits. They dare to simply be there without expectation. They risk the absence of reference points. They also take the risk of being emotionally moved by the radical otherness of the patient in front of whom they can only be there, unable to cure illness, eliminate suffering, or postpone death. Therefore, they leave the socially valued and often internalized posture of the omniscient and omnipotent.”
This doesn’t feel like expertise. But let’s peek a bit closer at that idea. Do we expect experts to be something other than human? Do we ourselves, the supposed experts, believe that? Experts walk the boundaries between what is known and unknown; they live at the limits. The sensation of pushing a limit might make us feel like the limit doesn’t really exist. If we just push a bit harder…
No matter how hard we push, though, we’ll eventually face the impenetrable wall of our humanity.1 If we recognize that experts are human, then we must confront those limits that underlie and supersede not only expertise, but the experts themselves. Perhaps this where some of the inchoate hope for artificial intelligence points: we’re uneasy with our experts being so fleshy, weak, and fallible. The more machine-like, standardized, and efficient we can make the expert, the better. I’ve written before on what that might mean for us.
But for now, we’ve got human experts who might consider confronting “their relationship to control and limits.” Why do this?
The authors continue: “The aim of accompaniment is not to overcome limits, as it is taken for granted in Western societies, but to be personally shaped and challenged by the confrontation with limits. An underlying quality of clinician presence is the capacity to name and contain human powerlessness.”
To name and contain human powerlessness.
What could come along with that?
Human relationship. This can only exist between humans. Steeling ourselves to become machine-like impairs the reciprocity necessary for humane contact, even if technically efficient interventions yield an optimized outcome for an organ or disease. It’s when clinician meets patient first as a human meeting a human that we can acknowledge together the ancient enframing of our lives: we are a mist for a little while, then we’re gone. We’re born, we love, we eat too much (or too little), run and play and cry, learn (or not), reproduce (or not), and then die. True, this relationship isn’t equitable. The patient brings needs and vulnerabilities the clinician doesn’t bring (even if the clinician has them also), and the clinician brings duties the patient doesn’t bring (even if the patient owes them to others). Despite that, the experience of suffering, illness, and death is one that requires just as much human companionship as expertise. Humans bring one another to hope. They love. They carry one another into the place where healing might happen even if cure does not. Only humans can do the carrying.
Growth in virtue. A plant “freed” from soil dies. Blood “freed” from the middle cerebral artery maims and kills. The body “freed” of its skin suffers pain, infection, and death. It is within boundaries that we flourish. “Naming human powerlessness” provides the context in which we can cultivate those characteristics necessary to pursue health. If we fail to name our powerlessness, we’ll miss the need for compassion, wisdom, patience, courage, honesty, and so many other things. We assume that all we need is another technical intervention when what’s needed is our own presence.
Seeing the real limits. There’s something in knowing where the boundaries really are. Much is cloaked at the onset of an illness. As a patient and clinician trace the borders of the strange land in which the patient has now found herself, thought, the true limits become clearer as do the possibilities. Yes, there’s powerlessness, but there’s an opportunity for action too. Maybe the possibilities aren’t what you thought they were. Maybe what you once took for granted is now an aspirational goal. Yet the real limit is all the way over there; here you are.
The Tutelage of Limits
But how do you get there? I’ve got stuff to do; it’s not all about limits. Which is true. We need to act. But we act with care; we should be care-full. When someone acts on the world through impatience, it‘s coercive. Patient action, on the other hand, often involves waiting. After the waiting could come a slow attunement to the rhythm of a person, place, or time, as Oliver Burkeman writes:
“…meaningful productivity often comes not from hurrying things up but from letting them take the time they take, surrendering to what in German has been called Eigenzeit, or the time inherent to a process itself. … the unfashionable but powerful notion of letting time use you, approaching life not as an opportunity to implement your predetermined plans for success but as a matter of responding to the needs of your place and your moment in history.”
This responsiveness requires presence. Guité-Verret and colleagues agree when they cite Tanguy Châtel: “‘To accompany is first to respect the rhythm of the other without imposing one’s own. It is then to tune these two rhythms to enter, even fleetingly, into a common breath, into the singular rhythm of an always singular relationship.’”
All of this seems too abstract to be useful. “My moment in history?” I’m just trying to get through the work day. And aren’t we just powerless mists on the wind, here today and gone tomorrow? But that’s just it. This is paradoxical power. It’s power that comes by laying aside power. It’s action stronger than technique.
Let’s see if we can make it a bit more concrete. When we talk about health, we’re almost always talking about the health of the patient. Of course. That’s the whole aim of the healthcare system. But if clinicians are human, then maybe there are lessons for how we might be present for our patients when we consider our own health. Les Todres and Kathleen Galvin reflect on the tension that exists between health as rootedness (“dwelling”) and health as action (“mobility”) across different domains of life:
“When dwelling is experienced in a spatial way, one has a sense of being at home; when mobility is experienced in a spatial way, one has a sense of adventure. When dwelling is experienced in a temporal way, there is a sense of being grounded in the present moment; when mobility is experienced in a temporal way, there is a sense of temporal “flow” and forward movement. When dwelling is experienced in an intersubjective way, there is a sense of kinship and belonging; when mobility is experienced in an intersubjective way, there is a sense of mysterious interpersonal attraction. When dwelling is experienced as mood, there is a sense of peace; when mobility is experienced as mood, there is a sense of excitement or desire. When dwelling is experienced as a form of personal identity, there is a sense of ‘being at one with’ the world; when mobility is experienced as a form of personal identity, there is sense [sic] of ‘I can’. When dwelling is experienced in an embodied way, there is a sense of comfort; when mobility is experienced in an embodied way, there is a sense of vitality.”
To expand this reflection to include clinicians, consider dwelling:
Clinicians who feel at home - in their place, in their time - are free to be hospitable, to welcome strangers sojourning in a strange land. One finds a home in a particular place with particular people; not merely a hospital building so easily substituted for anywhere else you could work. To the extent they don’t or can’t feel at home (because of pressures of place or time), they themselves will feel harried and uprooted and fail to help others feel welcome.
Clinicians who feel grounded in the present moment will neither ruminate on what has happened before nor worry about will happen, but will behold what is before them now. To the extent they don’t or can’t find the present moment, they themselves will lead others to ruminate and worry.
Clinicians who feel kinship and belonging are enlarged to face and carry the suffering of others. This means we allow others to have real claims on us (we belong to them, and they to us). To the extent clinicians don’t or can’t feel such kinship, they themselves will struggle to cultivate even the little community needed with their patient. There will be no kinship, only transaction.
Clinicians who feel peace can discern where the warp and woof of their patients’ lives are tangled and pursue its restored wholeness. This allows a state of seeking what’s best now for the whole person. To the extent clinicians don’t or can’t feel such peace, their technique will carry them into meticulous management of detail even to the detriment of the person in front of them.
Clinicians who feel “at one with” the world appreciate the interdependence of their work with all other work - agriculture, law, education. This doesn’t mean medicine becomes totalizing, but that medicine (really, the clinician) gets to participate in a diverse community striving toward flourishing. To the extent clinicians don’t or can’t feel “at one with” the world, they’ll either be driven toward pharmacologically or surgically reductionistic interventions, or else toward a totalizing influence of healthcare over all other domains of life.
Clinicians who feel comfortable speak with authenticity and warmth. They know their limits and also the possibilities within those limits. To the extent clinicians don’t or can’t feel comfortable, either because they don’t know their limits or are crushed against them by the expectations of others or themselves, they will fail to comfort others.
Consider also mobility:
Clinicians who have a sense of adventure are willing to embrace the creativity needed to meet the needs of the person before them. Yes, the trials say this medication should work, but for this person, right here and now, we need to make an adjustment to the plan. To the extent that don’t or can’t have a sense of adventure, they’ve been hemmed in by an uncertain world that threatens to litigate against them, and will fail to call their patients to a greater sense of possibility in their own lives.
Clinicians who have a sense of “flow” and forward movement can perceive even the smallest glimmers of light and growth. Even for this patient who returns again for alcohol withdrawal, at least they’re here. They’re not dead. To the extent they don’t or can’t have that sense of flow, they’ll stagnate and stumble through their day, and their patients will spin in the eddies they create.
Clinicians who experience “mysterious interpersonal attraction” will see in those around them, patients and colleagues alike, people of invaluable dignity. People have their idiosyncrasies, even their flaws and sins, but nothing destroys their dignity. To the extent they don’t or can’t have that sense of mystery before others, they’ll devalue and dehumanize those around them.
Clinicians who experience excitement and desire will want to seek the best for those around them. To the extent they don’t or can’t have that sense of excitement and desire, they will slide (or hammer) others into categories they’ve made and act accordingly.
Clinicians who experience a sense of “I can” will appreciate, even within their limits, the possibility of helping another person. To the extent they don’t or can’t have that sense of capacity and competence, they’ll obscure hope.
Clinicians who experience vitality pursue their patients’ good, invigorated by perseverance and loyalty. To the extent they don’t or can’t have that sense of vitality, they struggle to show up - at an actual place and time, or else emotionally.
Some might read this and feel a strong sense of indictment. I know I fall short across the spectrum here. But maybe that’s the thing with human presence: it’s fallible and so contingent upon the uniqueness of the one who is called to be present. It is never perfect or standardized, either between people or even within the same person from day to day. Cracks in one’s capacity to be present may show up in one’s work (just as they may show up with one’s partner, children, friends, and so on). These offer opportunities for us to recognize the responsibilities we have to our own humanity. It means our health matters to the health of our patients. But this is also no indictment of clinicians who themselves have substantial illness or disability. This existential framing of health means we can pursue it together regardless of what other burdens we may be carrying.
Technological Trickery
Writing that list was pretty easy. Cultivating those areas of my life is not. I, as a human and a clinician, wrestle with my own existence, and that might show up in my work.
Consider what it might mean to be “shaped … by the confrontation with limits.” In a clinical context, it might mean appreciating what health actually is and how to pursue it. Daniel Callahan, reflecting on this, wrote:
“There are two satisfactions in good health steadily sustained. One of them is obvious: our bodies do not stand in the way of our shaping a life. In good health the body is, so to speak, transparent. It is there, our unobtrusive servant, quietly and faithfully doing our bidding.
The other satisfaction is even more reassuring. Good health gives us a sense of invincibility, a settled conviction that the chaos of illness, the fragility of a body captured by disease, has been held at a distance. Sickness is someone else's problem, not mine. Other bodies go wrong, not mine.
Yet illness as such is not necessarily the greatest threat. Its deepest threat lies in its meaning: it is the undeniable token of our precious hold on life. It reminds us that we are human, not gods, that from dust we came and to dust we will return. The proximate terror of illness is that pain and suffering will ruin us. Its ultimate terror is that it reveals our final fate, which is to lose control of our lives, to see the self that is our deepest possession, the center of our being, as perishable.”
Yes, we should seek to preserve and health. Yes, we should use medication, surgery, radiation, rehabilitative therapies, and all manner of other technologies to do it. And yes, we should respect the limits of our interventions and our bodies in doing so. Health is both the aspiration and the limit of our work.
The irony of so much modern medicine is that it makes good on these promises of our frailty: it disarms our agency, forcing us to submit to the machine. When that happens, we try to use more technology to break the bonds in which its ensnared us, even if it means using technology to end our lives in a final attempt to wrest back control. We’re tricked; in Callahan’s words, we’re “fully persuaded that, given a proper chance, [we] can get just the right amount of technology at the right time in the right way and at the right cost, never doubting that, since technology is the self's creation, its vassal child, it can always say no, can always stop, can always turn off the switch.”
As it relates to caring for dying people, for example, we receive two strong beliefs from this age:
“One of them is the naive belief that the watchful self, aided by the right laws and medical practices, can master the body by means of carefully controlled medical technology. That self can, it is believed, understand technology well enough to know when and how in the course of dying to find medically the just-right moment to halt it, to say, ‘No more, stop.’ The other illusion complements the first: that we can know ourselves and our own wishes well enough to manage ourselves with the same precision with which we would control the technology, that we will understand ourselves well enough to know when to give up the struggle to stay alive.”
So, when I consider what it means to be shaped by limits, it doesn’t first mean figuring out how to act when one has reached a limit. That will come. It first means living under the tutelage of the question, “In light of this human frame [all the things I listed earlier and more], who then should I be and how then should I live?” One’s way of life comes before any particular action (“Should I prescribe A, B, or nothing at all?” “Should I take medication A, B, or nothing at all?”). This is the question for both the clinician and the patient, first as humans, and then in their respective roles.
Iris Murdoch, considering this nature of choice-making, wrote:
“I can only choose within the world I can see … If we ignore the prior work of attention and notice only the emptiness of the moment of choice we are likely to identify freedom with the outward movement since there is nothing else to identify it with. But if we consider what the work of attention is like, how continuously it goes on, and how imperceptibly it builds up structures of value round about us, we shall not be surprised that at crucial moments of choice most of the business of choosing is already over. This does not imply that we are not free, certainly not. But it implies that the exercise of our freedom is a small piecemeal business which goes on all the time and not a grandiose leaping about unimpeded at important moments. The moral life, on this view, is something that goes on continually, not something that is switched off in between the occurrence of explicit moral choices. What happens in between such choices is indeed what is crucial.”
Over time, then, and in between the high stakes moments of clinical decision-making, regular contact with and reflection upon human finitude can shape me to become a better clinician. That is, a clinician who more clearly perceives health and how to pursue it. But I can’t do that without acknowledging limits: the limits of medicine, of my patient, and of myself.
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“Hospital culture and intensity of end-of-life care at 3 academic medical centers”
The investigators for this study interviewed inpatient clinicians and administrators about the intensity of care patients received in their hospitals. They described a default toward high-intensity, life-prolonging treatment, and that it requires a lot of work to change focus to a different goal. That effort is easily undermined, even by an individual clinician. We uphold “respect for autonomy” as paramount in medical practice, yet this is another study that demonstrates bigger forces hold sway over clinical decision than mere deference to a patient’s wishes.
“Value placed on comfort vs life prolongation among patients treated with maintenance dialysis”
This a survey with longitudinal follow-up of study participants. There’s a sad figure in the study showing that even when patients made their goals known beforehand (“I want comfort focused care even if it means I might not live as long”), it didn’t change anything about the care they received at the end of life: they discontinued dialysis, enrolled in hospice, suffered in-hospital death, were hospitalized in the last month of life, underwent intensive procedures during the last month of life, underwent CPR in the last month of life, and underwent mechanical ventilation in the last month of life just as frequently as those who had longevity-focused care. I suspect many (most?) patients on dialysis view it palliatively - it assuages symptoms of ESRD. Furthermore, so many of these things go along with the “package” of dialysis, like recurrent hospitalizations. But the sad truth is that it’s really hard to operationalize a comfort-focused plan of care in our healthcare system, particularly if you don’t yet want to enroll in hospice (which, in this case, would mean giving up dialysis). We’re a long way from being able to appreciate the degree of nuance that would provide truly careful care.
“Asking better questions about involuntary psychiatric care”
raises some important questions. The whole system betrays an ethic of control, not care. The law is a blunt instrument, and when it perceives threats to life, it empowers agents (in this case, law enforcement officers and clinicians) to act to preserve life as a top priority. Other things, like the therapeutic milieu, are of secondary concern (or tertiary, or…). What might help is a broader, deeper understanding of health (including mental health) that encompasses notions of liberty and agency beyond mere decision-making capacity.Kristin Collier writes with great hope for the field of medicine as she reflects on how encounters with the humanities might change the dehumanizing trajectory on which it finds itself. I’m less optimistic, as it seems that medicine is co-opting the humanities for its technical and totalizing purposes (more on that here).
Closing Thoughts
“Why is it that we assume that certain ways of being in the world are a waste of time?”
John Swinton, Becoming Friends of Time
I’ll address enhancement and transhumanism another day. However, even in the wildest transhumanist dreams, we must still contend with contingency.