Keywords: Mental health, self-care, patient-provider relationship, participatory medicine, shared decision making, collaborative care.
Citation: Johnson-Quijada S. An introduction to self-care. J Participat Med. 2012 Mar 16; 4:e6.
Published: March 16, 2012.
Competing Interests: The author has declared that no competing interests exist.
When my older brother’s baby was born, she was vulnerable and premature, so tiny that she needed help to live. Now when I look at her intelligent smile, thriving body, and the lovely nape of her neck with her baby curl of hair, I have difficulty thinking about those precarious first days of her life at the University of California, San Diego Medical Center (UCSD). As a physician myself (I am a practicing psychiatrist), it is not always easy to be in the role of patient, or to look on from the sidelines while loved ones manage the uncertainty that comes with placing trust in medicine during illness or suffering. A little over one year later, while playing ball with my niece on the floor, I started to reflect upon the ways my brother’s experience — indeed, our shared family experience — at UCSD has shaped my own clinical practice of medicine.
Collaboration Leads to Inspiration
The physicians at UCSD were highly collaborative with my big brother, including him in their daily decision making, informing him of any medical study results, and asking his opinion regarding treatment options. They encouraged him and my sister-in-law to participate and they served as examples of physicians who valued participatory health care.
I’ve sometimes struggled to collaborate with patients at various points during my practice of medicine. Providing patients with clear explanations of their illness and data about their mental health care is not always as straightforward as it seems. Hearing my big brother talk about how he was treated, however, has emboldened me to modify my communication with my patients in ways that enable them to engage more effectively in their care.
Making a choice to emphasize trust and transparency with patients can be a challenge for any physician. I have noticed a paradigm shift taking place in my own clinical work as I move forward to embrace this improved participatory model of medical practice. In my practice with psychiatric patients, I describe this model to them as “becoming a friend to yourself,” or “self-care.” These terms are interchangeable.
What is my working definition of self-care? It is most easily described with the phrase, “Everything starts and ends with Me,” in which I use the biopsychosocial model to direct our attention (the physician’s and the patient’s) to what is fundamentally valuable about self-empowerment and personal accountability. Using this terminology of “Me” is a means to encourage us to see ourselves as vital beings worth the work it takes to achieve health. “Me” is capitalized because it names the bit in each of us that is unchanging, that is more than our memories, more than the constructing forces of time, and it remains even when our bodies are gone. “Me” is the essence in us that is special, not because we suffer but because we are human. Capitalizing and speaking of the “Me” in this way also gives us a tool to view ourselves more objectively. Me. Lovely, isn’t it?
For my patients, I explain that self-care is living consistently with the belief that they are a friend to “Me,” or in other words, to themselves. We share the hope that each patient practices being his or her own advocate, knowing that he or she is valuable and that his or her brain health is worth the fight. Self-care also entails the practical: review of sleep patterns, prescriptions of medicine, and monitoring of diet and exercise. In doing so, they transcend the stigma associated with brain illness and the frequently associated victim-role. They work through relationships that were damaged by symptoms of mental illness. They humbly account for their lives, remembering that each person is free despite past difficulties. At any time, if the path to best treatment becomes unclear, they can simply ask, “Is it friendly to Me?”
The Challenges and Rewards of Self-Care
Last spring, I began work with Patricia. She came into my office on our first meeting with a self-diagnosis. Sure she was struggling with ADHD, she explained that she couldn’t focus, had difficulty connecting with others, and acted impulsively. This limited her intimacy, she felt, with people she wanted in her life. Patricia, after reading about ADHD, came to me hopeful that a prescription for a stimulant would improve her symptoms. She projected confidence self-diagnosing. Her temperament and coping skills predisposed her to this.
Self-diagnosis can feel more congruent with a patient’s inner self, depending on his or her temperament. Self-diagnosis might intuitively feel more congruent than a diagnosis by a physician. However, let’s consider how it might also be influenced by a patient’s fear of, or lack of trust in, his or her medical provider. My challenge with Patricia was to support her good instincts of participation in her own care, while opening her mind to choosing a level and type of care that would suit her biopsychosocial needs. Her self-diagnosis was informative for me as a psychiatrist, and I was able to use her self-reported symptoms to give nuance to my own diagnostic tools. Patricia’s self-diagnosis showed that she was in search of self-knowledge, an attribute that might ultimately enable her quest toward mental health. Curiosity and self-interest can be empowering.
Patricia was fairly sure that receiving an ADHD diagnosis would explain to the people she had hurt why she hurt them. It would give her a name for the chaos. Having a diagnosis that comes from a figure of perceived authority, say a Doctor of Medicine like myself, offers a patient a reason for his or her suffering. It is like a judge who pronounces one person innocent and another guilty. This is not a bad or good motive, yet the naming of such an illness, if different from her own, might regrettably corrode the patient’s trust in her physician. In my relationship with Patricia, I perceived her defensiveness and insecurity when I began to question her diagnosis.
As a practicing clinician, it is not simple to resist the lure of treatment when it would be easy to make our patients happy. After all, if we agree with the patient, the visit is a quick one. If we do not agree with a patient’s self-diagnosis, there is much more work to be done. It takes more time to build trust and to educate him or her to be informed and involved participants in his or her own care. It takes time to sell the benefits of becoming a “friend to yourself,” or, in other words, putting in the time and energy to treat oneself the way in which one would treat a valued friend. Even though it is easier not to, however, when we take the time initially to collaborate with the patient, we spend less time later patching a poorly constructed relationship and treatment plan.
Being a patient takes courage. Happily, courage is more easily found with insight or at least the ability to see into oneself: the ability to accept vulnerability, humility, and self-respect. Yet I have noticed that those traits are likewise required of a successful practitioner.
When Patricia came into my office wanting my signature on her diagnosis, I noticed myself beginning to wonder how her opinion of me as a medical professional might change for the worse if I challenged her to question her information. I did not like the view from the gutter as much as I did up on the pedestal. I had to find the humility that comes with being a teacher: in the progressive paradigm of participatory medicine, the doctor-patient relationship is evolving to one of reciprocal teaching and learning.
This relationship becomes, in the ideal, an alliance and a connection. When my patients enter my office feeling defensive, agitated, or angry, I know their feelings aren’t personal to me. What is personal to me is to remain present and to find the teaching opportunities that participatory medicine, or in my own words “self-care,” both celebrates and facilitates.
Understanding Patricia’s agenda in making her appointment with me was a boon in our efforts to build trust with each other. Although Patricia did not have a clean diagnosis of ADHD, I developed a differential diagnosis that began our work to heal her biological, psychological, and social “Me.” She presented symptoms of frontal lobe disinhibition, inattention, and anxiety spectrum disorder. We started working on Patricia’s coping skills, developing patterns that were friendlier to herself. She found effective help through a good DBT (dialectical behavioral therapist) outside of my clinic. She cleaned up her sleep hygiene and prioritized exercise time, working to let go of her guilt at taking time apart from her children in order to do so. Patricia also began to take medicine. In the course of treatment, Patricia and I learned quite a bit from each other.
Just as I champion self-care for my patients, I try to practice being friendly to myself, too. My personal journey with self-care enabled me to view Patricia’s quest for brain health with more compassion. Patricia, in turn, has added to my learning to see all people from the self-care angle. I look for those sticky bits where we can connect and collaborate, even when I am out of my office, even if I am stuck in a long line at the grocery store. I ally myself with a person’s self-respect, with what I believe to be their intuitive desire to be friends with themselves. My quality of practice has definitely improved. I believe we all are men and women of great value.
Physician, patient, friend, or family member of a suffering loved one — who isn’t blessed when he or she sees the courage to face stigma, shame, and bewildering illness? Who isn’t more informed every time someone chooses the freedom to do self-care, chooses to live, fights hard as my niece did, or as Patricia did, and shows what that fight is worth? We all learn from the work of that fight. When someone loses bits of her identity to the defacing ravages of disease but still knows she is worth the labor, like Patricia, working beside her as her clinician is one of the best places in the world to be.
Copyright: © 2012 Sana Johnson-Quijada. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.