Recently I experienced again what it is like being on the receiving end of healthcare in the midst of crisis. My husband sustained a ligament tear in his knee joint after a freak gardening accident (very Spinal Tap, I know). It was too painful to hop, and even with creative efforts with wheeled office chairs, blanket slings and gritted teeth I could not get him near the car. So after waiting for a non-urgent ambulance we found ourselves spending a few hours in a busy A&E department, as he turned gradually paler and shakier with pain. A lengthy wait, eventual administration of some inadequate analgesia, and he was eventually seen at around 2 am. In the examination room, the doctor entered the room, didn’t introduce himself, took a cursory look at his leg and said “you’ll need an X-ray”. When I informed him that he had already been X-rayed, over an hour earlier, he muttered something inaudible and left the room for a further 20 minutes. When he returned, he informed us that “nothing’s broken”. Assuming a nonchalant pose with one hand on his hip, he leant over and with his other hand, squeezed and flexed the now-purple leg in various directions.
Every movement caused my husband to wince and cry out, something I had never seen him do – I found myself wincing in response to every yelp, and eventually crying – my mirror neurones were firing like mad. A young healthcare support worker, standing nearby to measure him up for a splint, noticed me quietly sniffing, turned to me and said “you mustn’t cry“.
After a moment or two blinking in the fluorescent lights, I realised two things:
1 – My urge to cry had retreated – the sense of shared pain had been subsumed by something more akin to anger or frustration
2 – She did not consider that she had said anything wrong, or unkind – the words were spoken gently
I managed to restrain myself from reacting and to take a step backwards, literally and metaphorically, clench my jaw and refocus. I tried to rationalise her reasons for saying this – perhaps she considered that his pain might be worse if he noticed that I was also upset, or perhaps she herself felt uncomfortable with tears? Did the tears of a relative inconvenience her on a busy night at work?
Crying is a uniquely human event, a strategy that we are born with which enables the expression of distress, as well as the ability to signal to another person that we are in need. In adults, it is usually a response to strong emotions, although these are not just those associated with negative affect such as sadness, loss, grief and separation. Crying can also result from extreme joy at events like births and marriages, witnessing beauty or feeling awe. Vingerhoets suggests that tears are a powerful symbol of a person’s felt helplessness and that their expression is something that can only happen when a person feels safe; indeed to indicate ones vulnerability in an unsafe space can be risky on many levels. Crying can also indicate a response to extreme positive emotions, such as when one weeps at a birth or a wedding Emotional crying usually results from either a current or remembered source of sadness, but may also occur when confronted with feelings of powerlessness. It is a communicative act: it tells the observer that the person is distressed, is suffering, and is in need of support.
Research suggests that crying offers a self-soothing effect and can restore emotional homeostasis. We have all felt the relief and release of a good cry – and although we do not yet understand how this can occur, it is clear that some biological function is served by adult crying. For the families of people who are dying, crying can offer a means of expressing suffering as well as being an energising experience through which people find additional sources of strength.
I reflected upon how in some clinical areas, such as specialist palliative care and psychology, tears are sometimes seen as a measure of success. A psychotherapist friend describes that tears often heralding a psychological breakthrough in patient therapy, signaling the uncovering of ever-deeper layers of angst. People will try to suppress tears if they do not feel safe or if they are concerned that their tears will bring disapproval or judgement therefore to some extent crying in the presence of a healthcare professional may indicate that the person feels safe enough to do so.
It was once thought that to suppress crying was detrimental to ones health, and that the catharsis that accompanies a good weep has actual measurable benefits – 20 years ago, Frey suggested that the fact that tears contain lysozymes is evidence that they wash away impurities and toxins created when a person is distressed, somehow acting as the emotional equivalent of kidneys. This is now generally considered to be untrue, as the quantities of tears are insufficient to allow any meaningful physical cleansing, but the metaphorical cleansing that crying offers is harder to quantify or define. It appears that crying is helpful – but nobody really understands why.
Freud developed the “catharsis theory” which remains popular in modern psychoanalysis, in which crying is seen as a kind of pressure valve. The release of tears signifies that a person had reached a threshold point of emotional suppression, and that the subsequent catharsis if therapeutic in and of itself. Catharsis has long been a topic of interest for physicians and philosophers alike (for a fascinating historical review of catharsis, see Powell). A study which looked at patients with cancer found that crying was often felt to be a positive thing, a regaining of balance and a purging of emotion. However it is not always true that crying leads to someone feeling better.
A study of over a thousand crying episodes showed that whether or not crying makes one feel better is highly dependent on the context – people who had close friends nearby and who were in a safe environment were more likely to feel better after a good cry, and crying that led someone to new understanding about something was also associated with an improvement in mood. However crying that was associated with being in an unsupportive environment or that involved witnessing suffering frequently led to people feeling worse afterwards. For people with existing psychiatric conditions such as alexithymia, in which people are confused by the source of their own emotions, crying can lead to further confusion and make them feel worse afterwards. In the study of cancer patients, some patients reported that they felt ashamed to cry and for this reason sometimes suppressed their tears.
Who cries and who stiffens their upper lip?
There are interesting gender and cultural differences in the acceptability of crying in different situations. Men cry less than women; this is thought to relate to the function of testosterone in suppressing tears, whilst prolactin appears to promote it. In evolutionary and tribal terms this could be seen as a mechanism that ensures that alpha-males are able to suppress expressions of vulnerability – one would not want the leader of one’s tribe to weep in the midst of a battle for territory. British people have been shown to cry more readily than Israelis, and in Turkey, medical and nursing students have been found to struggle between feeling as though crying is an acceptable means of emotional expression, and a culture which particularly for men has negative views about individuals who weep. A study sponsored by Kleenex for Men found that a breakdown in a relationship is more likely to lead to tears in London than in Scotland, although a wedding showed the opposite trend – Scots were far more likely to weep when watching a friend tie the knot. Although this study identified that attitudes towards men crying have shifted significantly, men are still likely to keep their tears to themselves or brush over it by resorting to humour. (Interestingly this study also identified that men were far more likely to use their hand or sleeve to wipe away the resulting tears than a tissue…)
It is known that people who are depressed tend to feel flat and numb rather than tearful, and the misconception that sadness always causes tears can lead to people who are severely depressed not being recognised as such. In a clinical area where up to 25% of patients are thought to experience clinical depression at some point in their illness, this is a dangerous misconception. Traumatic experiences early in life can also influence the ease with which a person is able to cry; I can’t recall ever seeing my paternal grandmother cry, even at the funeral of her husband, or her own diagnosis with metastatic bowel cancer – she had survived the Holocaust at the age of 15. Her depression and post-traumatic state was of the quiet, withdrawn, flat and almost-invisible kind. I have no doubt that had she spent her last days of life in a hospital ward, she would have been considered the model patient as she lay there in silence, not crying, despite her impending death. It is easy to imagine that in the absence of overt physical signs of suffering, that a person is coping well with their situation – is “bearing” their suffering.
Wagner et al (1997) found that nurses were more likely to hold a crying patient’s hand than one who was not crying, even if they appeared distressed in other ways. One study showed that people’s willingness to help others was increased if that person was crying, whilst another showed that people with lower natural levels of empathy were slower to respond when shown a picture of a crying woman than people who were more empathic, although the two groups of people responded as equal speed to photographs of people who were sad or angry. It would appear that crying is a unique signal that can evoke increased empathy or increased defensiveness in the observer, depending on the context in which it is expressed.
When health professionals cry
In talking about palliative care with student nurses, a topic often raised is whether it is appropriate to cry in the presence of a patient or family. The idea that crying is unprofessional is pervasive in both nursing and medical students. Students often perceive that it is necessary to remain professionally aloof. I often suggest that there is a line to be drawn – when a relative begins to comfort you or offer you tissues and tea, perhaps that line has been crossed. A study of first year nursing students found that many of them coped with seeing suffering by emotionally switching off, by disguising their emotions, and by helping families to focus on happier things. When I use this paper as a prompt for tutorial discussions, the first year nurses almost always say that they would feel less well supported by someone if they felt that person was hiding their feelings and being inauthentic – and yet this fear of expressing emotions persists.
My perspective on this is that expressing emotions with patients, even tears, is usually okay. When the District Nurses attending to my grandmother wept, it told me that they recognised her as a person and acknowledged her suffering, that her story touched them and that they had been moved. This is generally supported within the literature – a phenomenological study undertaken almost 20 years ago interviewed female patients about their perspectives of nurses who cried with them and found that patients universally felt that it conveyed a sense of connection with the nurse. More recent anecdotes appear to support that in general patients and family members appreciate the expression of authentic emotion from their healthcare team. Certainly, crying alongside someone is thought to strengthen social bonds. But when the emotions evoked by another’s suffering become too intense, they can lead to suffering for the healthcare professional (for a review of transference and counter-transference processes in health professionals, see Katz & Johnson 2006). People sometimes fear opening up too much, being too empathic, and risking burnout and compassion fatigue – but there is no evidence that suppressing or hiding emotions is helpful in this respect. Indeed, burnout appears to result from long-term effects of suppressed emotions.
So why did my husband’s healthcare assistant ask me not to cry? The event occurred in Accident & Emergency, where the ideology of rescue is highly valued; my husband was administered pain relief, wrapped in a splint, and given a follow up appointment – fairly efficiently, effectively and with the minimum of attention to his suffering other than his physical pain. On the way out in a wheelchair, he asked a nurse how he was going to get upstairs to bed; she gazed blankly for a moment, then suggested that he could sleep on the sofa until it felt better. I whisked him out of there, fuming. A&E is a place where things get done, there are protocols and pathways to follow for every injury and condition. 4-hour targets are highly influential – I noticed more than one professional glancing at the clock. One study showed that when someone is crying, people feel an obligation to stop what they are doing – tears demand attention and take priority over other things. Perhaps she simply felt under pressure to complete her tasks and facilitate a rapid discharge, in which case my tears must have been inconvenient distractions. But why did I cry? And what did I need? I cried because I felt powerless in the face of his pain, worried about how we would manage at home, sleep-deprived and wrung out. These needs were not complex – in retrospect, this experience may have felt very different if his pain, and my tears, had been recognised and acknowledged. At the very least, I do not want to be told not to cry.