OK. What would you make of someone who starts a conversation with “OK”? I know that this post is not a conversation — I can write what I want here. I’m in charge. I can start with “OK” if I want, and leave you to figure out what it means…
OK. What it means is, there’s nothing to worry about.
What would there be to worry about at the start of a conversation when nothing has happened yet? Ah…that’s the little question that leads to the big answer.
Imagine a man who has sprained his ankle. You see him walking down the street. You can’t see the sprain. What you can see is the limp. The limp is the behaviour that he adopts to compensate for the sprain, making it less painful for him to walk down the street. When you spot the limp, you can work backwards and understand that he has pain in one leg. If you think about it you can probably work out which leg. An expert (a physiotherapist, a dancer) could probably identify that it’s a sprained ankle, and perhaps be even more specific about the kind of sprain.
So saying “OK” at the start of a conversation is like a limp. It’s a compensating behaviour that makes something less painful. If you think about it you can work out where the pain is. The pain that is comforted by saying to yourself “there’s nothing to worry about” is the pain of anxiety.
And in the middle?
In the middle of a conversation, saying “OK” in response to someone else has two meanings. Its first meaning is as before, “There’s nothing to worry about.” Its second meaning is more subtle.
The person who says “OK” is asserting the right to be the judge of whether there’s anything to worry about. If you tell me something and I say “OK” it means, “There’s nothing to worry about and I am the one who makes that decision.” Saying “OK” to you puts me in control.
If you think about it you can work out what kind of feeling being in control compensates for. It’s a feeling linked with anxiety, a feeling of being helpless.
Chronic states of mind
People who suffer from chronic (long-term) states of mind are not necessarily mentally ill. It’s just that their emotional life is skewed in a certain direction. They adopt compensating behaviours, and they become certain types of people. As long as the compensating behaviours actually work, they are not ill. To some greater or lesser extent this applies to everyone. It’s normal and harmless…except…well, I’ll return to this later.
Chronic anxiety tends to produce two kinds of compensating behaviour. One is simply self-comforting. Saying “OK” inappropriately is an example of this. Some people with mild chronic anxiety eat for comfort. There are lots of other behaviours that people adopt for this purpose.
More severe anxiety makes people feel helpless and out of control, so the compensating behaviours they adopt are aimed at being in control. People like this are often bossy or demanding. Paradoxically, being bossy or demanding can be good for their careers, so that they get promoted to more responsible positions where they feel even less in control and have to become more bossy or demanding.
Being bossy or demanding causes conflict with other people, so some bossy or demanding people adopt secondary compensating behaviours to hide their need to control. They become over-persuasive or devious — anything to exert control without seeming to.
So when you meet someone sweetly over-persuasive or slyly devious, it’s likely to be covering up a need for control. And the need for control is likely to be covering up the pain of chronic anxiety and helplessness. You don’t see the sprain, you only see the limp.
Seeing is believing
Just as before in Really strange, you can see this in a video. Just as before, this is part of a training package for nurses created at Birmingham City University. The video is here:
The person to watch is the woman on the left, Pam. She’s a nurse consultant — at the top of her profession and a smooth operator. Her young patient, Sarah, has an eating disorder.
What matters to Sarah is that she often doesn’t want to eat, and when she does eat she hates herself for it. When she looks in a mirror she can see the fat and she hates it. She sometimes clutches at the hateful fat and hurts herself. She often takes laxatives or makes herself vomit to get rid of food she has eaten. What matters to Sarah, what drives her to do all these things, is how she feels about herself, about her body, and about eating.
What matters to Pam is what Sarah eats, not how Sarah feels. Pam is a nurse consultant and a smooth operator. Pam is going to win.
Pam’s first “OK” is just as the video fades in. It’s easy to miss. Her first nod is three seconds from the start (0:03) between “Thanks for coming to see me today.” and “How was your journey?” Nodding is a body-language form of “OK” — self-comforting and at the same time asserting control. I thought it would be fun to count the number of times Pam starts a statement by saying “OK” and nodding, but it just became tedious. Count them for yourself if you want.
Pam establishes control by starting the conversation off-topic. She sets the agenda, and moves the conversation on at her pace. Then (0:30) she removes any hope of confidentiality. Worded as a question, but framed between OKs and delivered with constant nodding:
Pam: OK, so how about we have a chat to start with, and then if you feel comfortable we can invite your mum in for the last ten minutes or so…just to have a three way discussion about what we’ve talked about, yeah? … OK
Even when Pam doesn’t start a statement with “OK”, she constantly asserts her own opinion of how Sarah should feel. In this example (0:44), Sarah gets 7 seconds to explain how she really feels before Pam interrupts her with another “OK”:
Pam: So, I guess it’s been quite hard coming today. How are you feeling?
Sarah: Nervous…and a bit frightened…like I was going to be shouted at…
Pam: [interrupting] OK, so you’re worried…
Sarah: …made to eat.
Pam: Made to eat…yeah…
Notice how Pam’s interruption is inaccurate. Sarah says she feels nervous and frightened. Pam says Sarah feels worried, denying Sarah’s nervousness and fear. Specifically, Sarah fears that she might be shouted at and made to eat. Pam specifically avoids reassuring her, leaving the impression that, yes, she might be shouted at and made to eat.
Now Pam takes control again. It’s back to Pam’s agenda, and Sarah just complies:
Pam: …Yeah… So you’re worried that you might be shouted at.
Sarah: Yeah.
Pam: …Yeah… So are you having trouble eating at the moment?
Sarah: Yeah.
Pam: …Yeah… And has that created any difficulties at home?
Sarah: Yeah.
Pam: With people maybe shouting at you.
Sarah: Yeah, my mum sometimes. She just gets a little bit frightened, I think.
But Pam doesn’t want to talk about frightened. (You understand why, don’t you?) So Pam ignores what Sarah has just said and repeats her own previous statements. Remember that being worried, having difficulties at home, and having difficulties with eating are not things Sarah has ever said about herself:
Pam: So you’re worried about being shouted at. I’m just wondering if things at home are quite difficult around any difficulties with eating.
The struggle
The rest of the video just continues this unequal struggle. Sarah is mostly compliant, but she occasionally tries to express how she really feels. Each time she does this, it threatens Pam’s control. Look closely at Pam’s body language (3:07) when Sarah recalls being upset. You can see Pam’s tension as her control slips for a moment. She allows Sarah to talk for several seconds, but then her next statement excludes any recognition of Sarah’s feelings (3:30):
Sarah: …but it doesn’t make me happy.
Pam: Yeah. I guess it’s hard trying to do things to please other people… especially if these things are creating difficulties for yourself.
Sarah says her problem is that she is upset and unhappy. Pam says Sarah’s problem is that trying to do things for other people is hard. And moments later Pam changes the subject completely.
Ha-ha!
Another control slip (12:09) is evident when the subject of exercise comes up. (What do you think two OKs in a row might indicate about the subject of exercise?)
Pam: OK…OK…And how long have you been doing that amount of exercising?
Sarah: For about six months.
Pam: OK… Sounds very tiring to me… Ha-ha! Yeah…
Sarah: I am tired.
Pam: You are tired…
Sarah brings Pam back on track by responding to the factual content, not the laugh. Pam’s nervous laugh was a statement about how Pam feels about herself — about her own body in relation to exercise.
No let-up
Throughout the session, there’s no let-up in Pam’s assertive domination of Sarah. It’s a mesmerising performance from a skilled professional who is determined not to allow Sarah to express who she really is and how she really feels. Sarah’s few attempts to assert herself are easily swatted away by the much more experienced Pam.
I’ll give just one more example (18:26).
Pam: OK, and in that moment in time, when you’re eating, what’s going through your head? What sort of thoughts are you having?
Sarah: Sometimes I’m enjoying it, and I’ll eat it. And that’s mainly when I’ll go back upstairs and then hate myself for it. And sometimes I can’t even swallow it. It just goes round and round and round, until like… I’m the last one at the dinner table, and everyone’s like, “Come on Sarah, you can finish that.” And I just can’t finish it, which would normally be when I’m already struggling all day, so probably would just be in my pyjamas.
Pam: OK, so you’re saying that [at] the time that you’re eating you’re able to get some enjoyment from that, but it’s afterwards, yeah? And what is it that you’re worried about afterwards?
Sarah: No. I’m not worried. I can actually see it.
Pam: OK, so you feel that the effects of the food immediately transform on to your body…
Sarah says she is not worried but sometimes feels so bad all day that she doesn’t even get dressed, she hates herself and she can actually see the way eating affects her body. Pam ignores most of this, saying that Sarah is worried and the effect on her body is something she only feels, not sees. Listen to the emphasis on “feel” there as Pam asserts her control. Remember, too, that worry is something that Pam introduced into the conversation in the first minute. Sarah has never said that she worries. (Guess who it is who worries.)
Sarah
What does the video reveal about Sarah?
She sits hunched up, with her heels not touching the floor and her head lowered. Even though she’s probably taller than Pam, and could certainly look her straight in the eye, she sits in such a way that she is looking up in order to make eye contact. What does it mean to sit in a way that makes yourself small, with your heels not touching the ground, looking up at the person who is talking with you? Sarah is reconstructing how it feels to be a little girl.
The really notable thing is how Sarah reacts to Pam’s relentless domination. With only a few exceptions, Sarah just goes along with it. It never makes her upset, angry or frustrated. She never repeats herself when Pam ignores something important she has said. She remains pleasantly compliant throughout, distracting herself by fidgeting. What could possibly make her react like that? Could it be that she’s used to it? Is this how life is for Sarah? Is she expected to be a compliant little girl all the time?
If so, then who is it who expects Sarah to be a compliant little girl? Is it Mum? Is the woman in the waiting room another Pam?
Except…
Above, I wrote that chronic states of mind corrected by compensating behaviours are normal and harmless…except… The exception is when the compensating behaviours extend into close relationships.
It’s fine if you have a sprained ankle and you limp when you’re walking down the street. But when you get home the people close to you need to know about the sprain. That’s what ‘close’ means — you can’t just give them limp and leave them guessing.
It’s the same with mental states. The people close to you need to know the real you. That’s what ‘close’ means. You can’t just give them your compensating behaviours and leave them guessing.
In particular, if you work in mental health and you want to be close enough to your patients to engage with and help with their problems, then you can’t hide behind your own compensating behaviours. You have to engage in a genuine way, otherwise you make your meetings a battleground.
And in particular, if you hide from your own children, then you risk not only that your children will never know you — you risk that they will never know themselves because they will end up compensating for your mental states.
Is that what’s happened to Sarah? It’s only conjecture. What’s certain is that the Sarah we see in this video is perhaps only a couple of years away from death, and the Pam we see there is not equipped to play therapist with Sarah’s life.
Let no one who sees this video on some training course ever imagine for one moment that it’s the way things should be.
I’ve spoken online to the authors of the book and videos. One thing they’ve pointed out is that the videos do contain “deliberate mistakes” which are there for the students to pick out and critique, so they’re not necessarily intended to be ideals of how a session should be.
Even so, I don’t think the video is anywhere near as awful as you seem to think it is.
First off, bear in mind this is a nursing assessment, not a therapy session. Obviously those two kinds of encounters do have some aims and objectives in common, but there may also be some differences as well.
I think possibly you’re over-interpreting the use of “ok”. My impression is that they might as well have been “yes” or “uh-huh”. Just an acknowledgement that she’s listening rather than any kind of control statement.
Is Pam being an authority figure? Well, to a degree she is, though in a relatively benign and non-threatening way. After all, the objective is to bring about a change in Sarah’s behaviour – for very good reasons, so that Sarah’s life can be saved. That said, she may have the status of a consultant nurse, but I’ve seen far, far worse displays of authoritarianism and insensitivity from consultant psychiatrists. (How much worse? This much worse.)
And to be honest, with adolescents with eating disorders, a bit of “tough love” may be a necessary part of keeping them alive. Things like setting boundaries around mealtimes, putting limits on exercise, right the way up to the extreme end of enforced detention and treatment. I work in an eating disorders unit, and I can think of two patients where a purely empowering model of working would kill them in months.
That’s scary – just reading that introduction, I can see that very behaviour in my every day life!
Getting into the meat of the article, it’s made me think of therapists (and other healthcare workers) I’ve seen in action. It’s true, that one word “OK” and how it’s used makes a huge difference in the way the patient reacts. It seems like the secret is to be sure you use the word in the way you want for that particular situation, whether you want to be in control and lead the conversation in a way that gets the answers you need (eg an emergency) or to take a back seat and actually understand the patient.
[...] this latest post, “OK“, got me thinking along some completely different lines. Just the introduction: Saying [...]