Pediatric Bioethics: Interpreting Anger – Reframing and De-Escalating in the Exam Room

Entering the space of the exam room can be fraught with tensions both known and unknown, agendas spoken and unspoken, fears named and unnamed. At a time when basic facts are questioned, and opinions exist not on different sides of an aisle but on opposite sides of a canyon, we know that emotions run high. The average provider increasingly finds themselves tasked with fulfilling the role of clinician, as well as health care communicator, diplomat, and sometimes hostage negotiator. Fulfilling these roles in a job complicated by the political climate, administrative demands, and complex patient needs means that the average clinician is pulled in multiple directions during routine encounters.

Thus, when disagreements arise, when parents and clinicians are at odds, or when exams are entered into with the intention of dissent, clinicians who are already stretched thin can find themselves in the painful space of facing not only the escalated parent or patient, but verbal and sometimes physical violence.

It is this bioethicist’s opinion that there is hope to be found in reframing and re-identifying the clinician’s role in this situation not as diplomat or negotiator, but as translator and interpreter. For just as the good clinician is able to interpret descriptions of symptoms into meaningful clinical indicators which drive a diagnosis, the good clinician must be able to translate and interpret the behavior of the escalated parent or patient into an understanding of what lies behind that distortion and then use that understanding, not to drive a diagnosis, but to bring about de-escalation or peace.

This article is intended not as a panacea, acknowledging that the conflict faced in these situations often extends outside the clinic and runs deeply into the community life, but rather as a recognition of the challenges therein. And, hopefully, it may serve as a tool that can expand and deepen the ability and knowledge of the pediatric physician to enter into the acute conflict of the escalated parent and patient in the exam room and de-escalate the violence.

As a chaplain and theologian, I interpret escalation and anger more as language barrier, rather than conscious choice or act of ill intent on the part of the escalated party. Often, it is the only language that a person possesses for communicating their fears, hurts and desires. It is not that they intend to hurt their medical team or other people around them, but rather that they are desperately trying to communicate something complex that they lack words for, or fear will not be heard. It is an expression of need that is presented in a language that we are unable to hear, or that our systems are unable to understand.

Among primary educators there is a popular adage: “All behavior is a form of communication.” It is intended to help parents and teachers of young children to reframe classroom outbursts and uncomfortable moments into moments of learning. Yet in the context of the escalated parent or adult, it rings just as true. Human behavior — positive, negative, and downright bizarre — is a form of communication. Our challenge as clinicians and mediators is to function as peacemakers, and more integratively as interpreters. Often in this act of interpretation we can de-escalate the situation and simultaneously establish trust and discern the root cause of the escalation.

As clinicians, we know that anger limits insight,[1] impairing our understanding of the source of that anger, but also the behavior that it drives. Thus, the work of translation falls to us, rather than the person expressing the anger. Morally, this work is ours not merely because we have taken on the burden of diagnostician, or because we recognize the privilege of clarity. Rather, in order to fulfill the obligation of providing holistic care, we must do the work of interpreting the hurt that is emotional, spiritual, and psychological, alongside the physical.

We must remember that anger is often the face of fear, or even past wrongs buried deep. When we meet with anger as the primary emotion in the exam room, often the first step to de-escalation is not the platitudes that we are taught, or the body language that we are trained to present with, but an empathy that seeks to do more than validate the presenting emotion. It seeks to sit with discomfort, pain, and fear, accompanied by a curiosity that seeks to understand their source. For just as we name a symptom or validate physical pain, we name and thus validate the escalation, anger, fear, or distortion. And as we seek the root cause or pathology of a disease process, we do the same with the anger or escalation, so that these emotions might be heard and understood.

This is de-escalation that does more than placate or mediate. It seeks to repair something that has been broken. By seeking a causal root, it translates anger. It hears not only the expressed anger but a vocabulary unique to that person, one who is trying to communicate in the present that which they have previously experienced, their fears, and their wounds.

May we all seek not only to listen, but to understand.

Reference:

1. Richard Y, Tazi N, Frydecka D, Hamid MS, Moustafa AA. A systematic review of neural, cognitive, and clinical studies of anger and aggression. Curr Psychol. 2023; 42:17174-17186. doi:10.1007/s12144-022-03143-6