The Science of Observation Through The Senses

Do you feel like your therapist listens to you? Is there an appropriate time for a health care professional to touch you?

Listen to me, because I'm right here!

That’s an important question. In Washington State, touch between therapists and clients are limited to appropriate therapeutic touch, such as a handshake. However, I hold a license as a Registered Nurse, and there have numerous times when clients have shown me a wound that wasn’t healing, a mysterious rash on the arm, or presented with a cough that sounded more serious than the client was treating it [don’t worry: I always present my credentials, and ask a client if s/he would like my professional opinion on their medical question]. I might ask permission to touch near a wound to feel the temperature of the skin, or smell it to see if it is infected [or ask them to take a sniff if it’s within reach].  While I would never overstep the scope of my practice, I keep “Nurse Imei” ready for work when I’m in the therapy office, because it allows me to practice the best kind of medicine I know: the science of observation through the senses.

In an article posted on, Abraham Verghese MD, Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine, Stanford University, wrote:

The truth is, I love and embrace technology, and have no desire to return to the pre-CAT scan and pre-MRI days of old. But I see no reason to let new technology make us lose the abilities we have had for over a hundred years to make sophisticated diagnosis at the bedside. Indeed, it should make us so much better.

I feel the same as Dr. Verghese. I too love technology and how it has enhanced medical practice. But it shouldn’t prevent or distract us from observing the client with out own eyes, ears, hands, and olfactory nerves. What does this mean for those of us who conduct therapy sessions over the phone, or handle triage in this manner?

If you are thinking of trying therapy over the phone or Internet, your therapist should be thoroughly trained to conduct sessions in this manner.  My telephonic nurse triage training gave me excellent experience in listening to patients because I could not see them. I can’t see a grimace of pain, but I can ask and help a patient evaluate their pain level using an appropriate pain scale. I can’t see if there is blood in their urine, but I can ask a client to describe a color or a smell. I can hear over the phone is someone’s breath is labored, or if their thinking is foggy.

If you are a client attending F2F psychotherapy sessions, it is important that your therapist look — or attend — to you. Attending is a developed skill, requiring hours of learning to observe a person’s normative behaviors, both physical and emotional, while they are describing issues that arise. Even if your therapist takes copious notes, a good therapist is watching body language, eye movement, changes in the tone or strength of your voice, the shifting of your body when you are uncomfortable with a subject, and even the presence of sweat and color changes to your skin. It’s not uncommon for a trained counselor to mention when s/he believes you’re not being honest about your problems.

As an RN, I feel exceptionally lucky to have additional tools of observation to bring to the table. Many of these help cast light on the overall picture of mental health. For example, knowing the complications of long-term sleep issues on the heart, as well as its connection to the incidence of depression, would lead me to prioritize a client’s complaint of poor sleep because his partner wakes him up when he snores. With more observation and interviewing, I could find out that the client has sleep apnea, a condition that contributes to depression, heart disease, and problems with a relationship.

I received a book as gift at Christmas, “The Naked Lady Who Stood On Her Head” by psychiatrist Gary Small and Gigi Vorgan. The stories highlight the many physical observations an MD notes, and they are often so many, I wonder how those without more medical experience (such as a physician or a nurse) function holistically in the mental health office. I must conclude that the best therapists I know rely heavily on observing through their senses, and documenting everything that seems unusual or unexplained. Anything falling the medical category gets noted and referred to a physician.

The corporate client who walks into an office with the smell of body odor and urine alert any therapist to inquire about the patient’s strong odor as a contrast to his normative grooming habits. But if you were trained to detect the smell of ketones on the breath of a diabetic experiencing the beginning of a sharp rise in high blood sugar, these are skills that can’t be as effectively used over the phone or Internet. And that is an important problem in the world of telemedicine.

When Telemedicine Isn’t Going To Work

A woman who has the smell of alcohol on her breath while going through treatment for alcoholism is not going to be detected if she contracts for telemedicine sessions. It is the practitioner’s responsibility to determine who should receive “old fashioned” health care in-office, and the convenience of telemedicine sessions should not be offered to everyone.

Technology has not caught up with our imagination. Some day we might have “smell-o-vision”, but as of today, we can’t smell through the phone. Someday, we’ll have more home devices that can measure heart rates and give us audio of a minute’s worth of auscultation (currently, there is an app that can do this for the heart, but it has not been approved for professional use). Until then, clients and providers should consider when therapy sessions are appropriate for phone and Internet, and when they should be seeing a helping professional face to face.

What do you think? What happens when clients leave the medical office saying, “My doctor didn’t listen to me, ” or “She barely even took a look at my symptoms”? How can we integrate crucial emerging telemedicine technologies with the need for old-fashioned observation?

Five Tips For A New You in the New Year

It’s a new year. Most of us are open to trying something new, making a change, or jumping on a resolution you know you need. Here are five tips to help you create the new you you’ve been waiting for. Don’t wait another year. Get started, now!

1. Write it down. Clear and reasonable goals are the first step to knowing what it is you want in what amount of time, and how you will achieve that goal. When you write your goal down, you are forced to articulate that goal with specific detail.

I find it very helpful to make mini-goals within goals which are time-limited. This helps you track your progress as well as see how close you are to achieving your ultimate goal, especially if your goal includes a long process or a significant lifestyle change.

2. Share it, and share it often. Remind yourself, your loved ones -even your pets! – that you are going to do what you say you are. By sharing your goals with others, you are more likely to follow through with real actions.

3. Ask for help. You don’t have to do it alone. Whether your goal is to learn how to make a budget and stick to it, to lose some excess weight, or change jobs, you can ask others who have done the same to give you some tips on how to follow in their footsteps. Why reinvent the wheel when you someone else has done the work for you?

4. Do a little research. When you study up on what lies ahead in the journey to achieve your goal, you can better anticipate the rewards and pitfalls along the way, and better manage the the potential for setbacks, discouragement, and self-doubt. Google, WikiAnswers, and community-based crowd sourcing communities can help you look at your goals from various angles before you plan your strategy of attack.

5. Build in a reward. People are similar to the beloved pets in our lives. There are many things we’ll do “just because”, but there are some things we do better with a little motivation. Over the years, I’ve seen people do everything from rewarding themselves with extra time to read a book, go out of town for a weekend, put money in a jar for every time they worked on a project, or even take a “kiss break” with their sweetheart.

After you’ve incorporated all five parts of your action plan, the next step is simply to DO IT. Work backwards from your time limit, and make as much headway as you can. Enjoy the process of the journey, and be sure to talk about it with others. It’s the memories you build along the way that form a mental pathway — literally, creating a new groove in your brain as well as your lifestyle.

Some of you reading this may have already tried these things, while scratching your head that you did not achieve the results you wanted. Coaching can often help you get “unstuck” or learn the skills to help you move ahead. Seattle Direct Counseling and Coaching offers coaching services focusing on motivation and “unstuckness” that may be the perfect thing for you. Call for your free 15 minute coaching sample.