Barrett L. Dorko, P.T.

"You know, someone said that the world's a stage,
in it you must play a part."

                                                  Elvis Presley, "Are You Lonesome Tonight"

          Michael Meade* suggests that there are three levels of human interaction. The first level contains the simple greetings, common decency and working agreements of polite society. It is dedicated to simple harmony and maintaining the status quo. It's bumper sticker is "Have a nice day."

           The third level is the area of deeply shared humanity, fundamental oneness, justice and transcendent functioning. A third level bumper sticker says "Visualize World Peace."

           You may have guessed that the second level of human interaction is not as nice as those on either side. It is the territory of anger, conflict, vulgarity, sadness and disappointment. I think you can come up with it's bumper sticker on your own.

           The reason I mention all of this is because I have for a long time wondered about the question, "How are you?" Despite my best efforts to the contrary, I am forced to ask this question several times a day and too often the answer makes me cringe.

           Sometimes I get the first level answer, "Fine", when I am looking for something beyond that. Sometimes "Fine" is really all I wanted and I am hit with a list of symptoms and expressions of frustration that I am not prepared to receive.

           Asking people how they are is a risky business. In the classic novel The Trial by Franz Kafka, the protagonist Joseph K. is in the midst of a terribly confusing and upsetting set of circumstances and accusations that have totally disrupted his normally mundane routine. A stranger on the street innocently inquires of him, "How are you?" and he is thrown into a prolonged fit of recrimination, renewed fear and consternation. It is the result of a clash between the first and second levels of interaction, and I know I've done the same thing to patients in my office.

           It is possible, at least to some degree, to maintain interaction on the first level by in some way making it clear that you don't want to hear any bad news. Do you know any therapists or physicians who manage this? I have long felt that without knowing it, therapists create a "play" in the clinical setting and choose their part and the parts their staff will play long before the patient arrives. The part remaining for the patient becomes clear sometime during the course of their first few interactions and for the most part they settle into their role. None of this is obvious and that is why it is so powerful. It explains why some therapists get three phone calls each day from patients wanting advice and I get as many in a year. I never ask them to play this part.

           I think I tend to be a second level kind of communicator. Pleasantries are absolutely necessary to order society, but I want to move on. I know that unless discomfort is spoken of authentically, it will simply hide in the shadows until the worst possible moment. Perhaps the patient will wait and tell the doctor how awful they really feel and how little help therapy has been. Who needs that?

           The second level may not be an easy path, but it can't be denied that it leads to the third level where acceptance, transcendence, understanding and human empathy may be found. There is no other path.

           Elvis had a point. What's the play like in your clinic?

* Meade M. The Rag and Bone Shop of the Heart. New York, NY: Harper Collins; 1992