Care goes in. Crap goes out. 

Susan Silk is a clinical psychologist who is also a breast cancer survivor. In a story for the Los Angeles Times, her friend Barry Goldman recounts the day a friend wanted (needed) to visit her immediately following surgery:

Susan didn’t feel like having visitors, and she said so. Her colleague’s response? “This isn’t just about you.”
“It’s not?” Susan wondered. “My breast cancer is not about me? It’s about you?”

Following her experiences at this time, Susan developed a technique to help people stop communicating un-skilfully, unhelpfully or even harmfully to the wrong people during times of crisis. She calls it,  The Ring Theory.
As communication is such a important ingredient in our own care delivery, I have modified Susan’s rings slightly to fit over our own environment. Here it is:

The Rings:


  1. Draw a small circle in the middle of a piece of paper. This is the centre ring. This is your patient.
  2. Now draw a larger circle around the first one. In that space goes the people closest to your patient. Their immediate family, their closest friends.
  3. Then draw another ring. In this space place other friends and more distant relatives.
  4. In the next ring out, place yourself and (perhaps) the doctor who is the primary care giver for this patient.
  5. Next ring out. Other nurses directly caring for this patient.
  6. Next. Other doctors and healthcare professionals in your unit.
  7. Next. Other nurses, doctors and staff in your hospital.
  8. Managers. Executive.
  9. Etc. Etc. You get the idea.

The Rules:

The person in the centre of the ring can offload or vent, whinge or complain to anyone in any of the circles.

This is one of the very few perks of being in the centre ring.

They can complain and feel sorry for themselves. They dont have to. But they can.

They can get angry, and frustrated, and say bad words. They can whinge and whine, and complain some more. All the way out.
We do not have to like listening to it. But we are in an outer circle, so here it comes.

If you dont like it, you can whinge about it. But only outwards.
Everyone in the outer circles can do likewise. But only to people in larger rings.

When you are talking to someone in a ring that is smaller to yours, the goal is to provide support, compassion, care and your skilful attention.

Likewise, you should receive the care and support of EVERYONE in larger rings than yourself.

Go back up to the rings and see who that is.

Care goes IN. Crap goes OUT.

You should not dump your personal communication crap into a ring smaller than yours.

I don’t mean people shouldn’t be accountable for what they say.
And I don’t mean it is OK to be verbally abusive or aggressive or hurtful to those in outer rings. These things are NOT OK.
No, we are not talking about violent communication here, what Susan is referring to in her ring theory is Kveching.

Kveching is a Yiddish word meaning chronic complaining, nagging, grumbling.
If you want to scream or cry or complain, if you want to tell someone how shocked you are or how icky you feel, or whine about how it reminds you of all the terrible things that have happened to you lately, that’s fine. It’s a perfectly normal response.
Just do it to someone in a bigger ring.

Also, you are in different rings in different situations. Perhaps you even get to be in the centre ring sometimes.
Its all common sense really. But I’m sure you can remember times you have witnessed the crap going IN (or perhaps been guilty of dumping inwards yourself ).

So I think it makes a useful visual map to remind us……and importantly, perhaps it could be a useful guide you could use to help your patients relatives and friends visualise their own communication dynamics during times of stress or crisis.


Original article (worth reading) in the Los Angeles Times: How not to say the wrong thing.

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