BRINGING EMOTIONAL INTELLIGENCE TO MEDICAL CARE
The day a routine checkup spotted some blood in my urine, my doctor sent me for a diagnostic test in which I was injected with a radioactive dye. I lay on a table while an overhead X-ray machine took successive images of the dye's progression through my kidneys and bladder. I had company for the test: a close friend, a physician himself, happened to be visiting for a few days and offered to come to the hospital with me. He sat in the room while the X-ray machine, on an automated track, rotated for new camera angles, whirred and clicked; rotated, whirred, clicked.
The test took an hour and a half. At the very end a kidney specialist hurried into the room, quickly introduced himself, and disappeared to scan the X-rays. He didn't return to tell me what they showed.
As we were leaving the exam room my friend and I passed the nephrologist. Feeling shaken and somewhat dazed by the test, I did not have the presence of mind to ask the one question that had been on my mind all morning. But my companion, the physician, did: "Doctor," he said, "my friend's father died of bladder cancer. He's anxious to know if you saw any signs of cancer in the X-rays."
"No abnormalities," was the curt reply as the nephrologist hurried on to his next appointment.
My inability to ask the single question I cared about most is repeated a thousand times each day in hospitals and clinics everywhere. A study of patients in physicians' waiting rooms found that each had an average of three or more questions in mind to ask the physician they were about to see. But when the patients left the physician's office, an average of only one and a half of those questions had been answered.47 This finding speaks to one of the many ways patients' emotional needs are unmet by today's medicine. Unanswered questions feed uncertainty, fear, catastrophizing. And they lead patients to balk at going along with treatment regimes they don't fully understand.
There are many ways medicine can expand its view of health to include the emotional realities of illness. For one, patients could routinely be offered fuller information essential to the decisions they must make about their own medical care; some services now offer any caller a state-of-the-art computer search of the medical literature on what ails them, so that patients can be more equal partners with their physicians in making informed decisions.48 Another approach is programs that, in a few minutes' time, teach patients to be effective questioners with their physicians, so that when they have three questions in mind as they wait for the doctor, they will come out of the office with three answers.49
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Moments when patients face surgery or invasive and painful tests are fraught with anxiety—and are a prime opportunity to deal with the emotional dimension. Some hospitals have developed presurgery instruction for patients that help them assuage their fears and handle their discomforts—for example, by teaching patients relaxation techniques, answering their questions well in advance of surgery, and telling them several days ahead of surgery precisely what they are likely to experience during their recovery. The result: patients recover from surgery an average of two to three days sooner.50
Being a hospital patient can be a tremendously lonely, helpless experience. But some hospitals have begun to design rooms so that family members can stay with patients, cooking and caring for them as they would at home—a progressive step that, ironically, is routine throughout the Third World.51
Relaxation training can help patients deal with some of the distress their symptoms bring, as well as with the emotions that may be triggering or exacerbating their symptoms. An exemplary model is Jon Kabat-Zinn's Stress Reduction Clinic at the University of Massachusetts Medical Center, which offers a ten-week course in mindfulness and yoga to patients; the emphasis is on being mindful of emotional episodes as they are happening, and on cultivating a daily practice that offers deep relaxation. Hospitals have made instructional tapes from the course available over patients' television sets—a far better emotional diet for the bedridden than the usual fare, soap operas.52
Relaxation and yoga are also at the core of the innovative program for treating heart disease developed by Dr. Dean Ornish.53 After a year of this program, which included a low-fat diet, patients whose heart disease was severe enough to warrant a coronary bypass actually reversed the buildup of artery-clogging plaque. Ornish tells me that relaxation training is one of the most important parts of the program. Like Kabat-Zinn's, it takes advantage of what Dr. Herbert Benson calls the "relaxation response," the physiological opposite of the stress arousal that contributes to such a wide spectrum of medical problems.
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Finally, there is the added medical value of an empathic physician or nurse, attuned to patients, able to listen and be heard. This means fostering "relationship-centered care," recognizing that the relationship between physician and patient is itself a factor of significance. Such relationships would be fostered more readily if medical education included some basic tools of emotional intelligence, especially self-awareness and the arts of empathy and listening.54
TOWARD A MEDICINE THAT CARES
Such steps are a beginning. But for medicine to enlarge its vision to embrace the impact of emotions, two large implications of the scientific findings must be taken to heart:
1. Helping people better manage their upsetting feelings —anger, anxiety, depression, pessimism, and loneliness —is a form of disease prevention. Since the data show that the toxicity of these emotions, when chronic, is on a par with smoking cigarettes, helping people handle them better could potentially have a medical payoff as great as getting heavy smokers to quit. One way to do this that could have broad public-health effects would be to impart most basic emotional intelligence skills to children, so that they become lifelong habits. Another high-payoff preventive strategy would be to teach emotion management to people reaching retirement age, since emotional well-being is one factor that determines whether an older person declines rapidly or thrives. A third target group might be so-called at-risk populations—the very poor, single working mothers, residents of high-crime neighborhoods, and the like—who live under extraordinary pressure day in and day out, and so might do better medically with help in handling the emotional toll of these stresses.
2. Many patients can benefit measurably when their psychological needs are attended to along with their purely medical ones. While it is a step toward more humane care when a physician or nurse offers a distressed patient comfort and consolation, more can be done. But emotional care is an opportunity too often lost in the way medicine is practiced today; it is a blind spot for medicine. Despite mounting data on the medical usefulness of attending to emotional needs, as well as supporting evidence for connections between the brain's emotional center and the immune system, many physicians remain skeptical that their patients' emotions matter clinically, dismissing the evidence for this as trivial and anecdotal, as "fringe," or, worse, as the exaggerations of a self-promoting few.
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Though more and more patients seek a more humane medicine, it is becoming endangered. Of course, there remain dedicated nurses and physicians who give their patients tender, sensitive care. But the changing culture of medicine itself, as it becomes more responsive to the imperatives of business, is making such care increasingly difficult to find.
On the other hand, there may be a business advantage to humane medicine: treating emotional distress in patients, early evidence suggests, can save money—especially to the extent that it prevents or delays the onset of sickness, or helps patients heal more quickly. In a study of elderly patients with hip fracture at Mt. Sinai School of Medicine in New York City and at Northwestern University, patients who received therapy for depression in addition to normal orthopedic care left the hospital an average of two days earlier; total savings for the hundred or so patients was $97,361 in medical costs.55
Such care also makes patients more satisfied with their physicians and medical treatment. In the emerging medical marketplace, where patients often have the option to choose between competing health plans, satisfaction levels will no doubt enter the equation of these very personal decisions—souring experiences can lead patients to go elsewhere for care, while pleasing ones translate into loyalty.
Finally, medical ethics may demand such an approach. An editorial in the Journal of the American Medical Association, commenting on a report that depression increases five fold the likelihood of dying after being treated for a heart attack, notes: "[T]he clear demonstration that psychological factors like depression and social isolation distinguish the coronary heart disease patients at highest risk means it would be unethical not to start trying to treat these factors."56
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If the findings on emotions and health mean anything, it is that medical care that neglects how people feel as they battle a chronic or severe disease is no longer adequate. It is time for medicine to take more methodical advantage of the link between emotion and health. What is now the exception could—and should—be part of the mainstream, so that a more caring medicine is available to us all. At the least it would make medicine more humane. And, for some, it could speed the course of recovery. "Compassion," as one patient put it in an open letter to his surgeon, "is not mere hand holding. It is good medicine."57
PART FOUR
WINDOWS OF OPPORTUNITY
12
The Family Crucible
It's a low-key family tragedy. Carl and Ann are showing their daughter Leslie, just five, how to play a brand-new video game. But as Leslie starts to play, her parents' overly eager attempts to "help" her just seem to get in the way. Contradictory orders fly in every direction.
"To the right, to the right—stop. Stop. Stop!" Ann, the mother, urges, her voice growing more intent and anxious as Leslie, sucking on her lip and staring wide-eyed at the video screen, struggles to follow these directives.
"See, you're not lined up . . . put it to the left! To the left!" Carl, the girl's father, brusquely orders.
Meanwhile Ann, her eyes rolling upward in frustration, yells over his advice, "Stop! Stop!"
Leslie, unable to please either her father or her mother, contorts her jaw in tension and blinks as her eyes fill with tears.
Her parents start bickering, ignoring Leslie's tears. "She's not moving the stick that much!" Ann tells Carl, exasperated.
As the tears start rolling down Leslie's cheeks, neither parent makes any move that indicates they notice or care. As Leslie raises her hand to wipe her eyes, her father snaps, "Okay, put your hand back on the stick . . . you wanna get ready to shoot. Okay, put it over!" And her mother barks, "Okay, move it just a teeny bit!"
But by now Leslie is sobbing softly, alone with her anguish.
At such moments children learn deep lessons. For Leslie one conclusion from this painful exchange might well be that neither her parents, nor anyone else, for that matter, cares about her feelings.1 When similar moments are repeated countless times over the course of childhood they impart some of the most fundamental emotional messages of a lifetime—lessons that can determine a life course. Family life is our first school for emotional learning; in this intimate cauldron we learn how to feel about ourselves and how others will react to our feelings; how to think about these feelings and what choices we have in reacting; how to read and express hopes and fears. This emotional schooling operates not just through the things that parents say and do directly to children, but also in the models they offer for handling their own feelings and those that pass between husband and wife. Some parents are gifted emotional teachers, others atrocious.
There are hundreds of studies showing that how parents treat their children—whether with harsh discipline or empathic understanding, with indifference or warmth, and so on—has deep and lasting consequences for the child's emotional life. Only recently, though, have there been hard data showing that having emotionally intelligent parents is itself of enormous benefit to a child. The ways a couple handles the feelings between them—in addition to their direct dealings with a child—impart powerful lessons to their children, who are astute learners, attuned to the subtlest emotional exchanges in the family. When research teams led by Carole Hooven and John Gottman at the University of Washington did a microanalysis of interactions in couples on how the partners handled their children, they found that those couples who were more emotionally competent in the marriage were also the most effective in helping their children with their emotional ups and downs.2
The families were first seen when one of their children was just five years old, and again when the child had reached nine. In addition to observing the parents talk with each other, the research team also watched families (including Leslie's) as the father or mother tried to show their young child how to operate a new video game—a seemingly innocuous interaction, but quite telling about the emotional currents that run between parent and child.
Some mothers and fathers were like Ann and Carl: overbearing, losing patience with their child's ineptness, raising their voices in disgust or exasperation, some even putting their child down as "stupid"—in short, falling prey to the same tendencies toward contempt and disgust that eat away at a marriage. Others, however, were patient with their child's errors, helping the child figure the game out in his or her own way rather than imposing the parents' will. The video game session was a surprisingly powerful barometer of the parents' emotional style.
The three most common emotionally inept parenting styles proved to be:
• Ignoring feelings altogether. Such parents treat a child's emotional upset as trivial or a bother, something they should wait to blow over. They fail to use emotional moments as a chance to get closer to the child or to help the child learn lessons in emotional competence.
• Being too laissez-faire. These parents notice how a child feels, but hold that however a child handles the emotional storm is fine—even, say, hitting. Like those who ignore a child's feelings, these parents rarely step in to try to show their child an alternative emotional response. They try to soothe all upsets, and will, for instance, use bargaining and bribes to get their child to stop being sad or angry.
• Being contemptuous, showing no respect for how the child feels. Such parents are typically disapproving, harsh in both their criticisms and their punishments. They might, for instance, forbid any display of the child's anger at all, and become punitive at the least sign of irritability. These are the parents who angrily yell at a child who is trying to tell his side of the story, "Don't you talk back to me!"
Finally, there are parents who seize the opportunity of a child's upset to act as what amounts to an emotional coach or mentor. They take their child's feelings seriously enough to try to understand exactly what is upsetting them ("Are you angry because Tommy hurt your feelings?") and to help the child find positive ways to soothe their feelings ("Instead of hitting him, why don't you find a toy to play with on your own until you feel like playing with him again?").
In order for parents to be effective coaches in this way, they must have a fairly good grasp of the rudiments of emotional intelligence themselves. One of the basic emotional lessons for a child, for example, is how to distinguish among feelings; a father who is too tuned out of, say, his own sadness cannot help his son understand the difference between grieving over a loss, feeling sad in a sad movie, and the sadness that arises when something bad happens to someone the child cares about. Beyond this distinction, there are more sophisticated insights, such as that anger is so often prompted by first feeling hurt.
As children grow the specific emotional lessons they are ready for—and in need of—shift. As we saw in Chapter 7 the lessons in empathy begin in infancy, with parents who attune to their baby's feelings. Though some emotional skills are honed with friends through the years, emotionally adept parents can do much to help their children with each of the basics of emotional intelligence: learning how to recognize, manage, and harness their feelings; empathizing; and handling the feelings that arise in their relationships.
The impact on children of such parenting is extraordinarily sweeping.3 The University of Washington team found that when parents are emotionally adept, compared to those who handle feelings poorly, their children—understandably—get along better with, show more affection toward, and have less tension around their parents. But beyond that, these children also are better at handling their own emotions, are more effective at soothing themselves when upset, and get upset less often. The children are also more relaxed biologically, with lower levels of stress hormones and other physiological indicators of emotional arousal (a pattern that, if sustained through life, might well augur better physical health, as we saw in Chapter 11). Other advantages are social: these children are more popular with and are better-liked by their peers, and are seen by their teachers as more socially skilled. Their parents and teachers alike rate these children as having fewer behavioral problems such as rudeness or aggressiveness. Finally, the benefits are cognitive; these children can pay attention better, and so are more effective learners. Holding IQ constant, the five-year-olds whose parents were good coaches had higher achievement scores in math and reading when they reached third grade (a powerful argument for teaching emotional skills to help prepare children for learning as well as life). Thus the payoff for children whose parents are emotionally adept is a surprising—almost astounding—range of advantages across, and beyond, the spectrum of emotional intelligence.
HEART START
The impact of parenting on emotional competence starts in the cradle. Dr. T. Berry Brazelton, the eminent Harvard pediatrician, has a simple diagnostic test of a baby's basic outlook toward life. He offers two blocks to an eight-month-old, and then shows the baby how he wants her to put the two blocks together. A baby who is hopeful about life, who has confidence in her own abilities, says Brazelton,
will pick up one block, mouth it, rub it in her hair, drop it over the side of the table, watching to see whether you will retrieve it for her. When you do, she finally completes the requested task—place the two blocks together. Then she looks up at you with a bright-eyed look of expectancy that says, "Tell me how great I am!"4
Babies like these have gotten a goodly dose of approval and encouragement from the adults in their lives; they expect to succeed in life's little challenges. By contrast, babies who come from homes too bleak, chaotic, or neglectful go about the same small task in a way that signals they already expect to fail. It is not that these babies fail to bring the blocks together; they understand the instruction and have the coordination to comply. But even when they do, reports Brazelton, their demeanor is "hangdog," a look that says, "I'm no good. See, I've failed." Such children are likely to go through life with a defeatist outlook, expecting no encouragement or interest from teachers, finding school joyless, perhaps eventually dropping out.
The difference between the two outlooks—children who are confident and optimistic versus those who expect to fail—starts to take shape in the first few years of life. Parents, says Brazelton, "need to understand how their actions can help generate the confidence, the curiosity, the pleasure in learning and the understanding of limits" that help children succeed in life. His advice is informed by a growing body of evidence showing that success in school depends to a surprising extent on emotional characteristics formed in the years before a child enters school. As we saw in Chapter 6, for example, the ability of four-year-olds to control the impulse to grab for a marshmallow predicted a 210-point advantage in their SAT scores fourteen years later.
The first opportunity for shaping the ingredients of emotional intelligence is in the earliest years, though these capacities continue to form throughout the school years. The emotional abilities children acquire in later life build on those of the earliest years. And these abilities, as we saw in Chapter 6, are the essential foundation for all learning. A report from the National Center for Clinical Infant Programs makes the point that school success is not predicted by a child's fund of facts or a precocious ability to read so much as by emotional and social measures: being self-assured and interested; knowing what kind of behavior is expected and how to rein in the impulse to misbehave; being able to wait, to follow directions, and to turn to teachers for help; and expressing needs while getting along with other children.5
Almost all students who do poorly in school, says the report, lack one or more of these elements of emotional intelligence (regardless of whether they also have cognitive difficulties such as learning disabilities). The magnitude of the problem is not minor; in some states close to one in five children have to repeat first grade, and then as the years go on fall further behind their peers, becoming increasingly discouraged, resentful, and disruptive.
A child's readiness for school depends on the most basic of all knowledge, how to learn. The report lists the seven key ingredients of this crucial capacity—all related to emotional intelligence:6
1. Confidence. A sense of control and mastery of one's body, behavior, and world; the child's sense that he is more likely than not to succeed at what he undertakes, and that adults will be helpful.
2. Curiosity. The sense that finding out about things is positive and leads to pleasure.
3. Intentionality. The wish and capacity to have an impact, and to act upon that with persistence. This is related to a sense of competence, of being effective.
4. Self-control. The ability to modulate and control one's own actions in age-appropriate ways; a sense of inner control.
5. Relatedness. The ability to engage with others based on the sense of being understood by and understanding others.
6. Capacity to communicate. The wish and ability to verbally exchange ideas, feelings, and concepts with others. This is related to a sense of trust in others and of pleasure in engaging with others, including adults.
7. Cooperativeness. The ability to balance one's own needs with those of others in group activity.
Whether or not a child arrives at school on the first day of kindergarten with these capabilities depends greatly on how much her parents—and preschool teachers—have given her the kind of care that amounts to a "Heart Start," the emotional equivalent of the Head Start programs.
GETTING THE EMOTIONAL BASICS
Say a two-month-old baby wakes up at 3 A.M. and starts crying. Her mother comes in and, for the next half hour, the baby contentedly nurses in her mother's arms while her mother gazes at her affectionately, telling her that she's happy to see her, even in the middle of the night. The baby, content in her mother's love, drifts back to sleep.
Now say another two-month-old baby, who also awoke crying in the wee hours, is met instead by a mother who is tense and irritable, having fallen asleep just an hour before after a fight with her husband. The baby starts to tense up the moment his mother abruptly picks him up, telling him, "Just be quiet—I can't stand one more thing! Come on, let's get it over with." As the baby nurses his mother stares stonily ahead, not looking at him, reviewing her fight with his father, getting more agitated herself as she mulls it over. The baby, sensing her tension, squirms, stiffens, and stops nursing. "That's all you want?" his mother says. "Then don't eat." With the same abruptness she puts him back in his crib and stalks out, letting him cry until he falls back to sleep, exhausted.
The two scenarios are presented by the report from the National Center for Clinical Infant Programs as examples of the kinds of interaction that, if repeated over and over, instill very different feelings in a toddler about himself and his closest relationships.7 The first baby is learning that people can be trusted to notice her needs and counted on to help, and that she can be effective in getting help; the second is finding that no one really cares, that people can't be counted on, and that his efforts to get solace will meet with failure. Of course, most babies get at least a taste of both kinds of interaction. But to the degree that one or the other is typical of how parents treat a child over the years, basic emotional lessons will be imparted about how secure a child is in the world, how effective he feels, and how dependable others are. Erik Erikson put it in terms of whether a child comes to feel a "basic trust" or a basic mistrust.
Such emotional learning begins in life's earliest moments, and continues throughout childhood. All the small exchanges between parent and child have an emotional subtext, and in the repetition of these messages over the years children form the core of their emotional outlook and capabilities. A little girl who finds a puzzle frustrating and asks her busy mother to help gets one message if the reply is the mother's clear pleasure at the request, and quite another if it's a curt "Don't bother me—I've got important work to do." When such encounters become typical of child and parent, they mold the child's emotional expectations about relationships, outlooks that will flavor her functioning in all realms of life, for better or worse.
The risks are greatest for those children whose parents are grossly inept—immature, abusing drugs, depressed or chronically angry, or simply aimless and living chaotic lives. Such parents are far less likely to give adequate care, let alone attune to their toddler's emotional needs. Simple neglect, studies find, can be more damaging than outright abuse.8 A survey of maltreated children found the neglected youngsters doing the worst of all: they were the most anxious, inattentive, and apathetic, alternately aggressive and withdrawn. The rate for having to repeat first grade among them was 65 percent.
The first three or four years of life are a period when the toddler's brain grows to about two thirds its full size, and evolves in complexity at a greater rate than it ever will again. During this period key kinds of learning take place more readily than later in life—emotional learning foremost among them. During this time severe stress can impair the brain's learning centers (and so be damaging to the intellect). Though as we shall see, this can be remedied to some extent by experiences later in life, the impact of this early learning is profound. As one report sums up the key emotional lesson of life's first four years, the lasting consequences are great:
A child who cannot focus his attention, who is suspicious rather than trusting, sad or angry rather than optimistic, destructive rather than respectful and one who is overcome with anxiety, preoccupied with frightening fantasy and feels generally unhappy about himself—such a child has little opportunity at all, let alone equal opportunity, to claim the possibilities of the world as his own.9
HOW TO RAISE A BULLY
Much can be learned about the lifelong effects of emotionally inept parenting—particularly its role in making children aggressive—from longitudinal studies such as one of 870 children from upstate New York who were followed from the time they were eight until they were thirty.10 The most belligerent among the children—those quickest to start fights and who habitually used force to get their way—were the most likely to have dropped out of school and, by age thirty, to have a record for crimes of violence. They also seemed to be handing down their propensity to violence: their children were, in grade school, just like the troublemakers their delinquent parent had been.
There is a lesson in how aggressiveness is passed from generation to generation. Any inherited propensities aside, the troublemakers as grown-ups acted in a way that made family life a school for aggression. As children, the troublemakers had parents who disciplined them with arbitrary, relentless severity; as parents they repeated the pattern. This was true whether it had been the father or the mother who had been identified in childhood as highly aggressive. Aggressive little girls grew up to be just as arbitrary and harshly punitive when they became mothers as the aggressive boys were as fathers. And while they punished their children with special severity, they otherwise took little interest in their children's lives, in effect ignoring them much of the time. At the same time the parents offered these children a vivid—and violent—example of aggressiveness, a model the children took with them to school and to the playground, and followed throughout life. The parents were not necessarily mean-spirited, nor did they fail to wish the best for their children; rather, they seemed to be simply repeating the style of parenting that had been modeled for them by their own parents.
In this model for violence, these children were disciplined capriciously: if their parents were in a bad mood, they would be severely punished; if their parents were in a good mood, they could get away with mayhem at home. Thus punishment came not so much because of what the child had done, but by virtue of how the parent felt. This is a recipe for feelings of worthlessness and helplessness, and for the sense that threats are everywhere and may strike at any time. Seen in light of the home life that spawns it, such children's combative and defiant posture toward the world at large makes a certain sense, unfortunate though it remains. What is disheartening is how early these dispiriting lessons can be learned, and how grim the costs for a child's emotional life can be.
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