Lack of Insight

Sometimes, the brain doesn’t accurately analyze reality.

Take this scenario:

   

When this happens for clinical reasons, it’s called “lack of insight.” Patients whose field of vision has been cut in half don’t realize they’re ignoring their clinician sitting to their left. Patients with newly amputated legs try to get up to go to the restroom—and fall.  Patients whose swallow muscles are impaired insist that they can take five pills at a time—and end up coughing and spluttering as something goes down the wrong pipe to the lungs. Patients who can't balance to walk ten feet beg to go home without any help or medical equipment. They fail to recognize their confusion, dysphagia, aphasia, visual impairments….

In my own life, this is called “lack of insight.” I take on tasks far too difficult too handle. I walk into emotionally triggering situations without preparing myself, and I end up exploding. I strike up sensitive conversations, unaware that I’m saying insensitive things and causing a lot of hurt. I fail to recognize my hubris, my weaknesses, my biases and prejudices, my selfishness.

Can you relate?

How can we overcome our lack of insight?

Honestly, I’m not sure I ever will, not really. I imagine I’ll always have biases and prejudices, hubris and weaknesses, and of course selfishness.

But I’d like to be intentional about gaining insight. I try to read articles and books written by people of different perspectives, especially marginalized perspectives. For folks without books and articles to speak for them (I’m thinking of my patients and their families), I have to listen intentionally to their individual needs in the moment. I try to find out what they need me to say or not say, do or not do. And often I find out what I thought was helpful was actually not really so helpful at all—in fact, I’ve been hurtful.

I’m doing a lot of praying for humility these days.

What should I do when I gain some insight? When I realize I’ve been rude or hurtful, I’d like to own up to it and apologize. When I’ve made someone else’s story of suffering about me and my response to it, I’d like to stop and listen. When I’ve put myself on a pedestal, I’d like to step down.

I’m never going to get this exactly right. And my insight will never be perfect. But I can strive for what the Greek philosophers called arête—always seeking to better myself and knowing that I will never be perfect here on this Earth.

I'm sure I'll always suffer from lack of insight.  But every day I'll pray and try to do a little bit better.  

When Poo takes Precedent

(Letting go of our to-do lists and living in the moment in 2020)

I’m a huge fan of plans and to-do lists.  I love seeing everything I have to do laid out before me with cute little boxes I can check off. 

But here's a common narrative in my life:

I’m great at making plans.  But what about when more urgent things come up?

Maybe it’s time we step back and listen to what is needed in the moment.  When we listen to others and ourselves, we get done what actually needs to get done, even if it wasn’t in our plans.

One memorable session, I had an entire hour of therapy planned.  But the patient announced that they had soiled their briefs and bed linens and needed to change.  About twenty-five minutes later, the patient had cleaned themself* (with some help), the brief was changed, the bed linens removed, clothes changed, and the patient was seated in the wheelchair.  What great sequencing!  I thought to myself.  What a great cognitive workout for them!  And now we can work on my therapy plan.

And then the patient looked at me seriously, nodded, and announced that they needed to use the restroom again.

By the time all was finished, there were fifteen minutes left in the session to cover a few items in my Therapy Plan.

What I thought the patient needed was different than what the patient had actually needed in the moment.  

How often am I biased by what I think needs to happen, when I am actually being asked to do something entirely different?

I remember when I was studying abroad overseas, I encountered a lot of volunteers and NGOs doing charity work.  I was (am) no expert, but I did notice a pattern:  the projects that were the most successful were the ones that involved the locals in the entire process, including deciding what their needs were in the first place.  

I am reminded also of a sermon from years ago.  I don’t even remember who gave the sermon, but it was about a priest who was sometimes late for Mass.  Why?  Because if, on his way to Mass, he encountered someone asking for his help, he dropped everything to help that person.  He figured, this must be God asking him to do something more important.  And who was he to deny the requests of his Creator?

This year has been a wakeup call in so many ways.  We are being asked to put our own priorities aside to protect and support others and ourselves in new and different ways.  We are asked to set aside many of our social habits and planned events, to make economic sacrifices, and to wear uncomfortable masks in public in order to defend and protect those with underlying health conditions and immune compromise--and those who do not have the luxury of working from home.  We are asked to set aside our pride in order to listen to and support our Black brothers and sisters.  (Speaking of which, I’d love some help figuring out which adjective is the most supportive.  African American?  Black?  POC?)  We are finding out that even if we have long to-do lists, our mental/physical health may have to take priority sometimes.

This hasn’t been easy for me.  I’ve gone through this year kind of kicking and screaming.  I’m not a fan of constantly changing plans.

But maybe I’m being asked to set aside my to-do list and focus on more immediate priorities.  Like cleaning up some poo (either literal or metaphorical).  Or allowing myself to rest and heal.  Or allowing someone else to speak while I just listen.

Friends, I hope and pray that we will all have the strength and the courage to set aside our to-do lists in favor of the more immediate needs of ourselves and others.

 

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*English speakers have used “they/their/themself/themselves” for a long time as a singular gender-neutral pronoun.  Let’s be descriptivists instead of prescriptivists :)

Redefining Independence

I frequently tell this parable to my patients.  And honestly, I think I could stand to listen to it myself:

Bob was driving to work when his car stopped.  Bob valued independence above all else, so he decided to fix the problem himself.  He opened the hood of the car and tried to determine what had gone wrong.  It was hard to see through the thick smoke, but Bob kept rummaging through the parts of his car until he found an open flame.  Bob’s hands were badly burned and he fell backward in surprise, injuring himself further.  Bob had to go to the hospital.

Was Bob really independent in this story?  Of course not.  Injuring himself and putting others at risk was not true independence.

Paradoxically, to be independent in this circumstance, Bob would have called the fire department and eventually a mechanic.  To be truly independent, he would have relied on someone else’s help.

Our society seems to think “independence” means doing things on our own.  Anyone who can’t is seen as weak or inadequate.  This attitude is pervasive and has been around for generations—I can even hear it in my geriatric patients’ turns of phrase.  So often, my patients express to me that they feel they are “a burden” to their families for needing so much help.  And I myself fall prey to this lie as well. 

I’ve read enough mommy bloggers to know that a woman is supposed to be able to flip gluten-free pancakes in an immaculately kept kitchen while changing her baby’s diaper with one hand, keeping her toddler out of trouble with another, and helping her first grader with his math homework.  So when my menstrual symptoms affect my balance and I can’t even walk the dog, or I’m overwhelmed with house chores and work, or I need help processing my emotions, or I just can’t seem to do it all on my own, I feel inadequate.  I feel like I've lost my dignity, however briefly.

Maybe we all need to redefine “independence.”

True independence means taking charge of our own safety and using our resources.  Sometimes that means asking a friend or family member for help when we’re overwhelmed.  Sometimes it means making sure someone is with us when we get out of bed so we don’t fall.  Sometimes it means going to a support group or attending therapy.  Sometimes it just means using a walker or safety device.  True independence is different for everyone and changes over time.

I’d like to hear that again, because I’m prone to comparing myself to others.  In fact, I’m going to let Mneme, the Muse of Memory, repeat it for us so we can commit this to memory:

 

Thank you, Mneme.

Once upon a time, when I lived briefly in a barrio in the Caribbean, I encountered a family who seemed to really get it.  In this family, there were several family members with disabilities—some children, some adults.  All the family members helped each other out—nieces and aunties, mothers and daughters all worked together.  Now, that’s not to say there wasn’t suffering, and it’s not to say it wasn’t frustrating.  But as a team, they overcame many more obstacles than any of them could have overcome alone.

We can all learn from this family. 

Many of my patients’ families are similar to the family I just described.  They rely on each other.  I have so much to learn from their bravery, compassion, and healthy interdependence.  I hope to accept help with humility and to stop judging myself for relying on my support network.

I’ll leave you with a quote from the old Claymation Rudolph the Red Nosed Reindeer:  Let’s be independent together.

*

I’ve put a new handout in the SLP freebies section.  It’s a simple text-only motivational poster that’s good for SLPs, patients, and everyone else.  (It’s a little wordy, so probably best for higher level patients, especially those with lack of insight into deficits or who are feeling really discouraged.)  Click here to download the handout.  Feel free to modify however you want.  Please print and distribute freely.

Let's rely on our strengths and resiliencies

As a speech therapist, I am sometimes tempted to focus only on improving my patients’ deficits.  After all, isn’t that what rehabilitation is about?  Fixing “broken” communication, “broken” cognition, a “broken” swallow?

 

This happens with writing too.  Growing up, I always thought that the best way to help a friend to better their story/poem/essay was to bleed red ink all over the page, pointing out what doesn’t work so they can fix it.

 

And don’t we all do this to ourselves sometimes?  Pull out the red pen, evaluate our shortcomings and limitations, focus on the "bad parts of ourselves" so we can become better, kinder, more efficient?

 

What if it’s just as important—maybe even more important sometimes—to acknowledge and nurture our talents and resiliencies?  Of course we must acknowledge our mistakes, shortcomings, and weaknesses.  But what if shift our language—what if we call them "challenges" instead—calls to action instead of traits we're stuck with?  Maybe we have the ability to overcome these challenges—or find a workaround or at least make some progress—by relying heavily on our STRENGTHS.

When I evaluate a patient’s language, thinking, and swallowing skills, I am sure to discuss their troubles with them.  But now I’m making a conscious effort to also tell them and their families about what they do really well too!  Maybe their memory isn’t working the way they want it to (a challenge), but they’re awesome at paying attention, which is going to help them to use their memory strategies.  Maybe they can’t swallow water well right now (a challenge), but they have a strong cough so we can work with that!  Maybe they have trouble focusing (a challenge), but by golly they are motivated and have a positive attitude.  Maybe they have a LOT of challenges, but their support system is working for their good.

 

Joseph Fink and Jeffrey Cranor, authors of the Welcome to Night Vale podcast and various spinoff novels and podcasts, emphasized once that in writing, a more motivating and helpful way to critique someone’s work is to point out what is working really well so they can bring out more of those aspects in their work.

 

Maybe this could work on a societal level.  When we encounter a negative societal behavior, like racism or sexism or selfishness or unwilling-to-listen-ness, first we must of course acknowledge the problem.  This takes work.  And obviously, merely acknowledging the problem is not enough—we must face it and work to overcome it.  So what's the next step?  

To face these problems, we can draw on our collective compassion and kindness as a society to work to overcome those obstacles.  By exploring and utilizing our positivities, we can fight our societal problems.  Will we ever truly overcome a societal weakness?  Probably not entirely, but a positive human trait I believe in strongly is perseverance.

This is something that I find so encouraging about the Black Lives Matter movement—I'm hearing a lot of rhetoric that readily acknowledges that we are going to make mistakes.  Everyone does.  It's uncomfortable to learn that we've made mistakes, but the emphasis is on apologizing and learning how to use our humility and kindness to do better.  Learning about our mistakes and weaknesses is not about shaming us—and it never was.  It's about creating positive change.  For a really genuine and heartfelt conversation about this, I recommend listening to Brené Brown's conversation with Austin Channing Brown on the podcast Unlocking Us.

 

I’d like to apply this principle to my own life, and I invite you all to as well.  I make TONS of mistakes—maybe even in this post you have found some mistakes.  It's easy for me to dwell on them without moving forward.

So here is my resolution:  when I recognize or am told that I’m behaving impatient or interrupty or selfish or racist or small minded or making silly mistakes or being ignorant, I’d like to label my predisposition toward a “less than ideal” or even just plain "bad" behavior as a CHALLENGE rather than a failure of character.  This way, I can be motivated to change my behaviors in the future.  If I don’t identify with my undesirable behaviors but instead see them as obstacles to overcome, I give them less power.  I’ll probably never be perfect at facing any obstacle.  But I can keep trying.

And how do I face these challenges?  By using my virtues and resiliencies to face the obstacle.  I strongly believe that all of these strengths come from God.  And He is bigger and stronger than any obstacle or challenge I could ever encounter.

 

 

Listening, Learning, and Answering the Call to Change (with links to empowering organizations)

I am sickened by the recent deaths of Breonna Taylor, Ahmaud Arbery, George Floyd, and now Rayshard Brooks—and all similar unnecessary deaths.  I am angry on behalf of my friends, family members, and patients who have been subjected to judgement, put at a disadvantage, or even put in danger because of their race.  I am afraid for patients of color (especially African American) with communication disorders, who are at higher risk of incarceration and being misinterpreted as hostile.

For the last few weeks, I have been extra intentional about listening and learning.  So far, these are the calls to change that I am hearing:  examine our own biases, follow the leadership of communities we wish to help, and support organizations that empower minorities, even when it’s not “trending”. 

Today, I'm posting a list of some empowering organizations led by (or working hard to empower) people of color--most especially African Americans and immigrants/refugees.  This list focuses on education and religious organizations.  

Remember, it’s no single person's job to support every organization; we are not “saviors”!  We are just humans accompanying other humans on a difficult journey.  With that in mind, please consider supporting some of these organizations with me.

Thanking the Whole Person (and a medical SLP freebie)

Whenever I wipe poop off a bottom (or a toilet, or a wall), I make a mental note to say something extra positive to our nurses and sanitation staff.  Sometimes it takes a big mess to draw my attention to the ones who do the most thankless tasks.

Well, we’re in a big mess right now, and our attention is drawn.  

Helping myself (and my patients) to grow: Treatment vs. Evaluation

I often set expectations for myself and fail to meet them:

~I want to wake up earlier.  But I continue to go to bed late.  

~I want to pray more.  But I fill my life with more and more distractions.

Of course I am not making changes if all I ever do is “check in” with myself, evaluating and re-evaluating without providing solutions.  

This reflection is *not* about self-optimization.  It’s about growth and self-acceptance.  It's difficult to grow as a person without lots of reminders, or a structured organized foundation for change.  If I “fail” to change, there is no need to shame myself—that’s just a sign that something isn’t working yet. 

As usual, I need to learn from my patients.

Being Intentional (with an SLP freebie)

Many patients are surprised that my cognitive therapy sessions don’t involve logic puzzles or crosswords.  With me, cognitive therapy looks a lot more like intentional planning for daily life.  Most of the time, the “strategies” I suggest to my patients are practical habits such as repeating new information to themselves, using reminders in their environment, or making sure to double- and triple-check their work.  “But I already do those things,” they protest.

“Of course,” I reply, “these are normal ways of learning and remembering.  But as your body and your brain are healing, you may find you have to be more intentional about doing things that once came naturally or automatically to you.”

Maybe the same is true for soul-healing.