Chest Pain

Chest pain

by Robert Lanz, LCSW

Anthony Bourdain: Parts Unknown on CNN

When asked about making friends in his travels gave this simple (social work like) answer.

“It’s pretty simple. Just show up and be grateful. Be a good guest. And be interested in the simple things. What people cook, what they eat, what makes them happy-it’s a very intimate conversation.”


What do chest pain, gambling, Mexican food, jail and social work have in common? I’m about to explain, so pay attention.

I did family therapy in juvenile hall as my first straight job out of grad school-unless you consider breakfast cook, dishwasher and baker at a ski resort straight jobs. As a family therapist, I was given 10 weeks to try to fix some seriously dysfunctional family dynamics with my what we call in social work the “identified patient”, the delinquent kids in jail. I learned quickly which families were motivated and which weren’t and which kid was fixable and which wasn’t. And I learned my most valuable lesson early on. Everybody didn’t grow up like I did in a basic middle-class, educated household with everyone trying to do the right thing most of the time. If there was a problem at my house we fixed it ourselves or sought out the right resources to help fix it. Of course, I knew everyone didn’t grow up like me and my family, but that didn’t mean that everyone else shouldn’t do the best they could to improve their family dynamics. It was just a matter of using the available resources. That was me. The available resource. I took my job seriously and had a good relationship with my wards: Potheads, burglars, gangsters, and all other types of delinquents assigned to me. I was supposed to make them better.

Right off, I made sure they always knew the rules as well as the consequences for breaking them. For most of them, that kind of consistency was the first they’d experienced in their lives and I pushed hard on that issue with the kids over whom I had almost total control. The problem was, I only had access to their families for an hour a week. Pretty hard to get the control I needed from the family in an hour, especially when they thought their kid was the whole problem. This would limit, and of course, guide my interventions.

There was one young man I really liked, probably because he responded so well to the limits I set on him. In any case, away from the gang he was a good guy, not nearly as tough as he pretended to be and not nearly as mean as he wanted the other kids to think. When we were alone in my office talking about his life I could actually make him cry pretty easily which, of course, I did often. His parents didn’t speak much English and communication was an integral part of the therapeutic process, so my rudimentary Spanish, lacking nuance, was not very useful. After two sessions I recognized that Jorge’s parents were good people from another culture who didn’t get the whole East Los Angeles gang thing. They thought that Jorge should’ve just stayed home and done his homework. Of course they were right. And if he had, he wouldn’t have ended up in juvenile hall.

But when he went to school he would get his butt kicked every day if he showed too much interest in his schoolwork. He had to flow with the culture that was available to him at the time and that culture offered a lot of gang activity. If he was seen as a wimpy kid in a macho culture, it would be pretty tough on him and the consequences could even be fatal. This was hardly a conflict you could expect a 15-year-old to be able to resolve. It was hardly a conflict you’d expect his unsophisticated parents to be able to resolve. The dad’s response was to lecture his son, giving him the right information but in the wrong style. Jorge got defensive when he tried to explain his rock-and-a-hard-place dilemma to his parents. What can you expect a 15-year-old to do when he feels he is under attack?

Stay with me here, the story has a point. I wanted to change the whole family dynamic in a couple of months of one-hour-per-week therapy, and given that restraint, there was no way to use conventional family therapy. I would have to try something different. Something creative. Something simple. Something I had more or less learned in grad school: Start where the client is.

Jorge loved his parents but he wasn’t sure they loved him. I could tell that his parents did love him, an important factor, but not as important as Jorge realizing it himself. Their style of communication would need some serious tweaking and that would come from me, the middle-class white guy/probation officer/surfer.

The parents were rural, marginally educated conservative folks from Mexico and Jorge was sort of caught in middle of that first generation American culture clash. The city guy stuck in a high school gang culture that would crush all but the toughest and most independent kids. So what did we all share in this equation? How could we all start in the same place and be at peace together for an hour a week? What would we all have in common? Love of Mexican food would be a good guess.
At the next family session, I began by asking Jorge if his mother was a good cook. Before he could answer, his father announced proudly that she was an excellent cook. Jorge confirmed it.

“Look,” I said, “I have to change my schedule around for a couple of months and I wondered if you could come in at six instead of seven. From now on you can bring dinner for Jorge.”

His mom said she would bring dinner for all of us if that was permitted. Great idea. Why didn’t I think of that? So for the next two months we didn’t do any family therapy; we just sat and talked and enjoyed great Mexican food together, eating, laughing and telling stories like, well, a real family.

At the end of our last session I wanted to wrap things up. Jorge had done well in our individual sessions and had become the model prisoner, more or less. His teachers reported he had taken more interest in school and in group therapy he had become one of the leaders, showing real insight. After our weekly dinner, I asked Jorge’s dad if he thought Jorge knew he loved him.

“Of course he knows I love him. He is my son. I’m just afraid for him.”

“So you’re not angry when you raise your voice, you’re afraid?”

“He’s my son I don’t want anything bad to happen to him”.

“Jorge,” I asked, “Did you know your father was afraid?”

“No. My dad is tough. He’s not afraid of anything.”

“He’s afraid to tell you that he loves you.”

That brought the room to a standstill for a moment. Had I pushed the wrong button this time?

Then Jorge’s dad got tearful. He rose up out of his chair, looked over at Jorge’s mother, touched her lightly on the shoulder then embraced Jorge, tears running down his weathered cheeks.

“Jorge, you’re my son,” he said. “I will always love you”.

Jorge told his dad, “I thought you thought I was stupid and you were mad at me.”

“I was never angry, Jorge, I was afraid.”

Jorge embraced his father vigorously and said, “I’m sorry Dad. I didn’t mean to scare you.”

End of story. Confusing the way love and fear and anger are expressed is a common problem addressed in therapy. You just saw one solution.

Fast forward 20 years and there’s a woman down in the cardiac room, fifty-six years old with chest pains. Her EKG is okay but her pulse oximeter is just barely okay and we wanted it to be great. She’s a smoker, so a marginal pulse-ox is to be expected. To add to that, it turns out she’s been in a smoke-filled room for 24 hours straight. That would be the smoke-filled room down at the local card gambling palace in Gardena where she often spent her evenings. Luckily for me I read the newspaper every morning and that very day there had been a major article about the growing poker club business in Los Angeles. Because I read the whole thing, I knew more than the average person about playing poker in card clubs.

While we were waiting for the woman’s  test results I went to the waiting area to talk to her husband and adult children. They were really worried about the patient’s health and as they told the story about her endless nights in the poker parlors, I could see tonight their fears had been compounded by her ER visit. When I asked what they had done about it, they told me that they were all so angry all they could do was make demands and threats. They didn’t get any traction out of that approach, although they kept trying.

Now Mom was in the cardiac room hooked up to a couple of monitoring devices, short of breath and with significant chest pain requiring a full cardiac workup. No surprises here. So far the machines hadn’t recorded any bothersome findings except for the pulse oximeter showing that her ability to uptake oxygen was compromised, same as with any heavy smoker.

When the family and I went back to the room to talk to the patient, all those angry emotions were churning in the air to the point where I could see the changes on her cardiac monitor as soon as we arrived. The social worker who doesn’t glance up at the monitor from time to time and pay attention is missing out on a valuable biofeedback device.

“You know,” I said, “I read this great article about poker clubs today.”

It probably seemed to them that I was just socializing, but I was the guy who had ten minutes or so, not ten weeks, to get everyone to a neutral space and try to gain a little traction myself. My approach was kind of like a Mexican family dinner. A good place to start. The monitor started showing more normal readings and soon we were all laughing and telling poker stories. The adult son even told me a couple of ways to cheat at poker that I hadn’t seen in the newspaper story. It was kind of fun. I liked them and I could see they all loved each other. By then all the tests were back and the docs were done. But I wasn’t. You can probably guess what I said and how it worked. The basic stuff, confusing love and fear and anger is a pretty common problem and we had arrived at a simple solution. Dividing line


About robertjlanz

Author and health care professional.
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