When I Say No, I Feel Guilty (26 page)

One cause for the deterioration of the helping relationship between patients and physicians is the doctor’s inability to cope with patients’ anxiety and demands for specific information he cannot provide. Some physicians have difficulty in coping with demands without ridiculing patients, getting irritated, or telling them to leave and not come back until they get their minds fixed by a psychotherapist. This method of coping with anxious patients, even hysterical ones, leaves something to be desired. It is in sharp contrast to that of a close colleague, Abel, a psychiatrist. Abel has found it much more efficient for himself and for the good of his patients to assertively set limits on what he will do by talking to the patient or relative and explaining that these limits (usually a denial of a patient’s request) are set by Abel and are not a manifestation of some professional code to deal with “hysterical” or “stupid” patients. Without taking anything away from Abel’s skill and competence in choosing to cope with patients in this more realistic way, he is the first to admit that unlike a general practitioner, he cannot pass the buck by manipulatively telling
a patient he is hysterical, unreasonable, and should go see a psychiatrist! Abel’s skill in coping with demands he cannot, in professional conscience, go along with, is an excellent model for assertively working out the practical balance between what the patient wants and what the professional can give. I consulted recently with him on the problems in dealing with the parents of psychiatric inpatients. Abel invited me, with the consent of the father of a sixteen-year-old schizophrenic, to sit in on a meeting between himself and the father.

Setting of the dialogue: The father, Mr. Genic, has seen a remarkable change in the behavior of his son since he was hospitalized five days ago and wants to take him home over the weekend.

MR
.
GENIC
: I’m really glad we brought him to you, Doctor. Larry is almost normal again.

ABEL
:
I can see that Larry’s improvement must make you feel much better, Mr. Genic
, but
he still has a way to go before he can be considered normal
. [FOGGING and BROKEN RECORD]

MR
.
GENIC
: He’s talking to me again and not just hanging his head and keeping quiet I know he’s much better.

ABEL
:
He is better
, but
I don’t want you to get your hopes and expectations up too soon
. [FOGGING and SELF-DISCLOSURE]

MR
.
GENIC
: After we visited him last night, my wife said she would like to have him home this weekend.

ABEL
:
Although Larry has improved, I don’t think it is wise for him to go home on a pass yet
. [FOGGING and SELF-DISCLOSURE]

MR
.
GENIC
: His sister is coming home on vacation from college. My wife would like to have him home to see her. She hasn’t seen him for five months.

ABEL
:
I’m sure your daughter would like to see him
, but
Larry isn’t in shape yet to go home, even on a weekend pass. How about you bringing her here over the weekend to see Larry?
[FOGGING, BROKEN RECORD, and WORKABLE COMPROMISE]

MR
.
GENIC
: I don’t want to upset her by seeing Larry in a mental hospital.

ABEL
:
I’m sure you don’t
, but
she’s a big girl now and I think she has to face the fact that her brother had a psychotic break sometime
. [FOGGING and SELF-DISCLOSURE]

MR
.
GENIC
: I just want Larry to see her at home. Can’t you give him some medication for over the weekend to make him feel okay?

ABEL
:
I can and do give medication when weekend passes are granted to patients
, but
I don’t have any medication that is going to enable him to cope with the stress of being with family at this point in his recovery. I wish I did
. [FOGGING and NEGATIVE ASSERTION]

MR
.
GENIC
: I guess that I’ll take that chance. I want him home on the weekend.

ABEL
:
I’m sure you do, Mr. Genic
, but
I won’t approve a pass for Larry this weekend
. [FOGGING and BROKEN RECORD]

MR
.
GENIC
: You can’t stop me from taking my son home!

ABEL
:
You’re right, I can’t stop you
, and
I wouldn’t want to. But if you refuse to follow my treatment plan, I will discharge your son to your care. You can sign him out A.M.A
. [against medical advice].
It’s your decision
. [FOGGING, SELF-DISCLOSURE, and WORKABLE COMPROMISE]

MR
.
GENIC
: Isn’t that taking this whole thing to extremes? All I want to do is take Larry home for the weekend.

ABEL
:
I’m sure it must seem a bit extreme to you, Mr. Genic
, but
I feel that Larry is not ready yet to cope with his family
, and
I have no other option consonant with my professional ethics. I wish I did, but
… [FOGGING, BROKEN RECORD, and NEGATIVE ASSERTION]

MR
.
GENIC
: Are you in charge of this hospital? I want to speak to your boss!

ABEL
: You can speak to the administration if you wish, but
frankly I think all you will get from them is
the soft-soap treatment
. They don’t tell me what to do medically and I don’t tell them what to do administratively.
Still, I’ll make an appointment with them for you if that will make you feel any better
. (Reaching for the phone) [SELF-DISCLOSURE and WORKABLE COMPROMISE]

MR
.
GENIC
: No! Don’t bother. I’ll just pick my son up on Friday afternoon.

ABEL
: I’ll have the ward nurse fill out the discharge papers A.M.A. and have them ready.
I’ll also talk to Larry and see if I can help him prepare for the discharge, and prescribe a thirty-day supply of tranquilizers
. Okay? [WORKABLE COMPROMISE]

Larry’s father took him out Friday afternoon and was back in Abel’s office at 9:00
A.M
. Monday with a different opinion on the value of Abel’s advice. Even with continued medication over the weekend, Larry’s behavior and mood in the family situation changed drastically, as Abel predicted it might. Although Abel’s confrontation with the patient’s father might seem, at first, a disaster from the treatment point of view, it was of great benefit subsequently. Upon Abel’s recommendation, both the father and mother were engaged in family therapy with their son while he was still an inpatient, and later on a continuing outpatient basis. Larry showed continued improvement as his parents changed their own behavior, through therapy, toward each other and toward him. One important part of this therapy was that when Abel said something to this family, they knew he meant it—he gave them no confusing double messages and did not put any blame on them for choosing not to follow his professional advice. He simply spelled out what he thought might be poor coping and let them make their own decision on what to do about it. They learned from him that they could do the same thing, and did it!

9
Everyday authority situations—
assertively coping with
supervision or expertise

Learners generally express greater self-doubts in coping with situations that have fewer a priori rules on how things are done—relationships that have less structure than the formal, commerical transactions talked about in the
previous chapter
. In commercial situations, all the rules are spelled out, sometimes in the form of a legal contract or even by procedures of common law, and most learners rely heavily upon this structure for guidance on what they “can” or “cannot” do. They feel more at ease in asserting themselves when there are a lot of accepted ways of doing things that other people respond to also. When there are fewer rules, less already-agreed-upon structure that spells out how things “should” be done, the novice learner has more anxiety about asserting himself. You may have noticed this same emotional and behavioral pattern in yourself. You can “get yourself up” to deal with the sloppy repairs to your car by rehearsing your angry feelings the night before you see the mechanic, but can you do the same thing with your boss who has a different type of relationship with you? There is less defined structure in your relationship with your boss than with your garage mechanic, more potential loose ends. If your mechanic doesn’t like what you say, what can he do? Nothing! But what can your boss do if he doesn’t like what you say? Can he fire you? Can he demote you? Can he give you all the lousy jobs to do? Is this possible result spelled out in the job structure you hired into? One answer to those questions is probably “No,” if you are working under a signed legal contract worked out by
your attorney or that of a union. Another answer, and probably a more realistic one, is that these outcomes are dependent upon what compromises you assertively work out between your boss and yourself. The assertive working out of compromises with persons holding authority (including yourself) is the subject of this chapter.

I use the word “authority” to describe this partially structured way of interacting with someone in its broadest meaning. One common meaning of authority is that a person has the power to tell you what to do, or vice-versa; parent-child and supervisor-employee relationships are examples. Another meaning of authority is that of
expertise
, as in teacher-student or speaker-audience interactions. In these cases, the a priori structure set up beforehand is that the student learns from the teacher, and the teacher grades the student’s progress in learning. The younger the student, the more the teacher assumes the authority of a supervisor, or as we say in the trade,
in loco parentis
—in place of the parent. You may be curious as to why I have emphasized the commercial aspects of the physician-patient relationship more than its other qualities. After all, the original meaning of the title Doctor is
teacher
. Why not simply classify physician-patient relationships as one type of authority interaction because of the doctor’s expertise in medicine? Initially, I assume that any physician I go to will teach me as much about my health as my garage mechanic will teach me about my car. Unless a physician is recommended by another physician whose judgment I trust, I start out with the assumption that I am in a commercial relationship and assertively ask for everything to be spelled out about medication, treatment follow-up, complications, fees,
etc.
Think of it this way: would you trust a strange mechanic to overhaul the Mercedes-Benz you drive in the Monte Carlo Grand Prix?

Thankfully, most authority interactions that involve expertise do not have the potentially serious consequences of our well-being that is inherent in medical treatment. One expert-authority interaction that can even be fun is the relationship between a speaker and his audience. This situation is also partially structured
beforehand. The speaker agrees to speak and the audience agrees to listen; definite initial roles are agreed upon. The expert presents new information to his audience—other professionals, students, the general public, fellow staff, other club members, etc—and the audience responds with requests for more information or clarification and applause (hopefully!). The rest of the interaction between the parties is up for negotiation. How the speaker conducts his talk, the conditions under which he will speak, the material he will or will not cover, for instance, depend mainly upon how he asserts himself to his audience. Coping assertively as the leader or speaker to large groups of people, as in some of the following dialogues, can help you in this very difficult area where knowing what you want to say is not enough to demonstrate your expertise; knowing how to say what you know and how to assertively present your point of view in the face of criticism or even hecklers is equally as important to give your listeners some confidence in what you are saying.

Being assertive is particularly appropriate in some authority relationships where the a priori structure is quite scanty, such as in job interviews where the job applicant ofttimes is asked a number of idiotic questions and can rely only on himself to present a marketable picture of his skills and abilities to the interviewer.

In the following dialogues, the emphasis of being assertive is on working out mutual compromises that build upon the already existing structure in the relationship and at the same time to reduce any manipulative structure that may have been imposed unilaterally by one person in the conflict. This attempt at coping better within authority interactions is valid from both the viewpoint of the subordinate and from the viewpoint of the person in authority. The employee, for example, can assert himself to cope with manipulation from his boss, and the boss can assert himself to the employee both within the already established and agreed-upon rules of the job and in the gray area of behavior between them where no established procedures already exist.

With this brief introduction, let us look at the first dialogue in a series dealing with conflict in authority interactions: a dialogue where an employee assertively copes with excessive demands made upon his personal time by his employer.

Dialogue #16
Mike stops being the elastic
in a poor system of
overtime coverage
at work.

Mike is eighteen, recently out of high school, and working on his first job as a counterman in a franchised food sales operation. The shop where he works employs ten people on an irregular schedule to cover fourteen hours, seven days a week. With this kind of operation, absenteeism is a problem, and employee attrition is high. Mike worked in this job part-time when he was a senior in school and became a full-time employee when he was graduated. He is a conscientious worker and, in addition to maintaining his own schedule of work, has filled in for other employees when they were “sick,” at the request of the manager. Mike’s feelings about his job are mixed. He enjoys working in the food business and serving all types of people, yet the irregular schedule interferes with his social life and this aspect of the job bothers him. Even more bothersome is the manager’s habit of calling on him to fill in for others. Although he resents being called for overtime, he does not know how to cope with the requests of Mr. Teague, the manager. He’s afraid he’ll alienate Mr. Teague and be fired if he asserts himself and says “No” to any of the overtime requests. After coaching in his assertive group, Mike reported the following dialogue between himself and the manager.