photo: jetheriot
You can tell a lot about how a person’s brain works by watching him make a pot of tea. And since figuring out how a person’s brain works is what I do for a living, every now and then I like to sit down with a patient and enjoy a pot of tea together.
When a brain is injured, some parts of the brain malfunction while others continue to run just as smoothly as before the injury, and while there are certain commonly seen patterns of deficits, each brain is unique, and the constellations of injuries are as plentiful as they are idiosyncratic, often so subtle or so camouflaged that it takes days, even weeks of careful observation to notice.
Sometimes the deficits are so obvious that everyone can see them, but this isn’t always the case. A person’s brain may appear to be running smoothly when in fact there are glitches. Higher-level cognitive skills such as planning, organization, judgment and reasoning are common symptoms of brain injury and are notoriously difficult to measure. Tests such as the Mini-Mental Status Examination have proven to be very good at sampling and assessing an array of cognitive functions, but clinicians wanting a more nuanced characterization of higher-level functions must look elsewhere. Why not a cup of tea?
Brewing a pot of tea requires skill and coordination of the body and the mind, making brewing a pot of tea a useful thing to observe. Before we begin, I ask the patient to name some things brewing a pot of tea might require. To accomplish this, he must imagine making tea in his head and come up with a list of required items. For many people with brain injuries, this is not an easy thing to do. The part of the brain necessary for foresight and abstract thought as well as organizing and sequencing – the frontal lobes – are inevitably injured after a significant blow to the head, and a person may struggle to come up with a list. If he can’t think of anything besides “tea” and “teacup”, I ask him “How are we going to boil the water?”, “What if we spill?”, “How are we going to carry our supplies from the kitchen to the table?” and I note how he responds. Planning ahead, that’s what I’m assessing.
When the items have been assembled, I guide his execution of the task. Can he understand me when I give him instructions? Is he slow to comprehend? Can he hear me? Is he so distractible that he hears me but doesn’t hear me? Can he use the numbered lines running down the side of the kettle to measure water? Is he right- or left-handed? Is a kettle full of water too heavy for him to carry? Can he count out teaspoonsful of tea? Can he use a clock as a timer? After two or three minutes, does he forget that he is supposed to be keeping an eye on the clock? Can he use his phone or his watch as a timer? When he pours the boiling water into the teapot does he do it with the attentiveness handling boiling water demands? When he pours tea into the cup does he do it with delicacy? If the tea at first pours out too quickly, is he able to adjust the flow? Does multi-tasking make his brain go haywire? How are his fine motor skills? Is he frustrated when he spills? Does he rattle the teacup anxiously? Once the tea has been poured, can he smell it? Can he describe its flavor? Does he feel numbness in his fingertips when he holds it? When he swallows it, how does that make him feel? How does he feel today? Does he take turns in the conversation or speak without interruption? What memories does the tea conjure? Can he remember that the name of the tea is Phoenix Pearls?
Not only does making tea serve as a practical diagnostic screen for a variety of brain functions, it serves to build rapport. Something about tea bridges the distance between doctor and patient. Maybe it’s the way we sit around a table together, suffusing an otherwise dry encounter with the warmth of a soothing beverage, our roles still clearly defined, but united by a sense of common purpose. Maybe it’s because it reminds us of a shared meal. In this genuine atmosphere, not only will a patient be more likely to speak freely, but he will also be more likely to listen carefully to what a doctor has to say, so I use the opportunity to hammer home some useful information.
We talk about how when it comes to things like stress and anxiety, medications can be useful but they’re not cure-alls. We talk about how even though we feel overwhelmed by our emotions and powerless to do anything about them, we’re not powerless. We talk about the tools each of us has been given to shape the movements of our minds and the importance of practicing these tools. I ask him to notice how inhaling and exhaling makes him feel, how the tea makes him feel, calling attention to the fact that he’s more relaxed now than he was when we started. I ask him to imagine feeling that way every day, even if only for a few minutes. “If all it takes is a cup of tea once a day and a minute or two of deep breathing,” I tell him, “wouldn’t that be useful?”
I am not naïve enough to believe that mood disorders, especially severely disabling ones, can be cured with tea and breathing alone, but I do believe that every person with anxiety or depression should at least one time in their often chaotic journey through the maze of our medical system be presented with the idea that medication alone isn’t the answer either, that a person has to work at it in other ways, that with practice and discipline, we are more powerful than we've been led to believe. If I’m not the one to tell him, he might never hear it from anyone else.
When the teapot is empty, I tell him that the most important part of making tea is cleaning up afterwards, since this sets the stage for the next pot of tea. Then we wash the dishes together. We’ve both gained something in the process. I’ve come to a greater understanding of my patient. He’s learned some peaceful habits. And we’ve both had a nice cup of tea.