A few years ago I blogged about my ongoing search for help with my own sleep apnea and after about 15 years of "experimenting" with CPAP and related interventions, I find myself still struggling. And so, I've been asking myself, "Why is it so complicated to get this right?" The problem, I think, is that the solution to any medical problem sometimes "takes a little time" which the medical world is not always so good at tackling. The "quick solution" approach, when it works, is terrific...if only life were always like that.
With CPAP treatment for sleep apnea, as an example, the solution for some is quick and positive: It works and keeps on working. Great! Problem solved: Patient and doctor are all happy. But in most cases, complications arise: The settings on the CPAP machine aren't quite right, the mask leaks, a titrating machine would work better than a staticly set machine, the patient is swallowing air and needs to try lower pressures, a Bi-Pap machine is needed (one that forces air in and out), and so on.
And so, many sleep apnea patients need to have ongoing communications with the prescribing doctor (usually a pulmonologist or ENT doc) to make adjustments and changes on a frequent basis. But, the medical system doesn't always work that way, instead requiring that patients make appointments, often weeks or months out, to discuss issues that should more efficiently be handled by brief telephone contact. Patients then become discouraged due to the "hassle factor" and come to believe that CPAP is unworkable.
Then there is the intersection with medical supply companies which provide the equipment. They are bogged down with insurance company demands, including scheduled times when you are allowed replacement parts ("Sorry, you are not allowed a new mask until the middle of next month"), communication problems with prescribing doctors (resulting in incorrect machine settings, which in turn lead to poor experience with CPAP), outlandish costs (e.g., $38 for a piece of plastic tubing that connects mask and machine).
Interesting also is the views of the doctors and medical supply companies of patients: They see patients as "non-compliant" ("Patients give up so easily after we have given them this expensive equipment" or "Patients become nasty and demanding" when replacement parts fail to show up in the mail after weeks of waiting). But doctors especially, fail to see the systemic problems that lead to giving up: The medical system fails to maintain an easy communication system that facilitates problem solving. I'm sure that thousands of patients, for example, have given up CPAP when they would have otherwise succeeded if they had only learned how to adjust a mask properly, or switch to a different size, and so on. Years ago I nearly gave up when I experienced my tubing "sweating" from condensation during a cold winter in NH...until a colleague at the College recommended that I shove the tubing under my bed covers to eliminated the contrast between cold and warm air producing condensation.
Why am I writing about these systemic problems in medicine? Because I see similar types of systemic problems that reek havoc on other problems as well...including helping children and adults with neurodevelopmental problems (I'll save this for another piece). But leave it be said, that we need to move beyond "Clinical" conceptions of helping, and include "Systemic Analysis," when working with a range of people seeking help.
Just received this announcement from Shelley Viles, the Director of the Autism Certificate Program at Antioch University in Keene, NH:
These presentations are free and open to the public and will be held in the Antioch University New England lobby at 40 Avon Street in Keene. Certificates of attendance will be provided to participants at no charge. More information is available on our website.
I take my digital video camera almost everywhere I go just in case a "teachable moment" pops up...some combination of visual and audio that I may find useful in teaching Abnormal or Clinical Psychology. This past summer I was in NYC and took a jog through Central Park in my weird new "running shoes" called Vibram Five Fingers, basically just a thin cover for my feet (with toe holders) to simulate barefoot running. I was a little embarrassed at first (excessive worry about what other people might think or say) but battled those fearful thoughts with some cogntive countering ("Who cares what others may think?") and some exposure therapy ("just do it"). The result was a positive experience and extinction of social anxiety connected with evaluation concerns by passersby, at least as it relates to wearing funny running shoes in NYC.
People with Autism Spectrum Disorders are frequently misdiagnosed as having social phobia, largely because clinicians, and others, may confuse "what they see" (social avoidance) with "process" (what the person with Autism is thinking). In most cases, people with ASD's do not worry excessively about what other people are thinking...they do not have excessive "evaluation concerns"...quite the opposite...we worry that they do not "worry enough" about these things. Social Avoidance? For sure. Social Anxiety? Not in the same way that it is experienced by more "typical" individuals. Here's my video (in HD thanks to my dept's cool camera) from NYC:
A few recent incidents while driving got me thinking about the issue of differing trajectories and its effects on problems in driving. A few weeks ago I was driving at a leisurely pace (at about or slightly above the posted speed limit) on a local highway. I wasn’t paying much attention to what was going on behind me when I was suddenly passed by a really angry woman with a van full of kids (off to a game?). Even though I was doing nothing wrong, I hadn’t notice a van right on my heels, desperately trying to pass me. What struck me was the angry glare from the driving mom, who clearly was experiencing a dramatic spike in physical and emotional arousal. But why? I was driving safely and she clearly wanted to drive fast. We we are on different (and conflicting) trajectories.
In a separate incident, I was the one experiencing sudden and dramatic physical arousal and anger. I was trying to get out of a parking lot on campus and another driver was moving much slower, in search of a parking spot. I raised my hands to make it clear that she was “screwing up” and should “get out of my way.” This time I was the one being irrational (did I think that the other driver taking seconds to find a parking spot was really creating a significant drag on my schedule? My sense of time was distorted, but my trajectory was clearly being messed with.
I now see the problem of “conflicting trajectories” in many walks of life: College students turning to their cell phones and Facebook in class while a professor plods through content (The “talking head” professor meets the multi-tasking, speed addicted student). The colleague who drops in my office to talk about his kid or his car or his golf game, while I’m preparing for class or reading or ordering a shirt on Lands End online. The conflict in agendas combined with the change in speed is a recipe for a kind of autonomic reaction which translates in to anger or anxiety.
People make several mistakes when in contact with conflicting trajectories. One is cognitive: A tendency to personalize the other person’s behavior and to believe that it is personally directed toward oneself (“the slow driver is trying to ruin my day”). Such conclusions are obviously wrong: The slow driver has every right to drive slowly and may actually be viewed as a model for safe rational driving. As for the bored college student seeking refuge in Facebook or I.M., growing up in a speeded up, visual image based culture obviously leads to a clash with the verbally and content oriented professor. The second error has to do with Attribution: a tendency to attribute to the “other person” a personality type (e.g., “she’s an “old lady” driver” or the college student is a “superficial” member of a junk culture).
And, the connection of trajectories to relationship problems are many and varied. The older adult couple where one is retiring and slowing down, while the other continues professional engagement at a high level; The Middle School girl who becomes focused on academics versus her close friend who is attracted toward non-academic activities. The couple where one becomes intensely focused on family while the other seeks a more independent lifestyle.
While conflicting trajectories can not always be resolved (ie., the college student will want more action in class than most professors are able to provide), it may be helpful to simply be aware of these issues. A quick “treatment algorithm” might look like this:
Step 1: Radical Acceptance of your emotional response (“I’m angry”)
Step 2.: Identify any conflicting trajectories
Step 3: Identify errors in personalizing
Step 4: Catch yourself making personality type attributions
Step 5: Glasnost (openness): Talk about these differences with offending persons whenever possible.