Erin Donovan - 2014 Samuel L. Becker Memorial Conference

uh yes your eyes i'm sure yes okay thank you

so is uh um oh that's true like this

yes oh oh hey good morning everyone if you could all come please take a seat we're about to get started

okay good morning my name is christina sharp i am a graduate student at the university of iowa and i'm so excited to welcome you to the becker memorial conference this morning

today i have the great pleasure of introducing dr erin donovan who is an assistant professor in communication studies at the university of texas at austin

dr donovan has won numerous top paper awards the iarr steve duck new faculty award and many other accolades for her research having published over 25 peer-reviewed

journal articles on both interpersonal and health communication topics it's no surprise that dr donovan has a lot to offer us regarding the conference theme interesting questions in health

specifically dr donovan specializes in the way individuals disclose avoid and make sense of information while coping with stress illness and uncertainty when she's not conducting research and

teaching dr donovan loves spending time with her sweet and busy two-year-old daughter listening to live music in austin and walking the trails at the lady bird johnson wildflower center

personally i couldn't be more excited to be in the audience today dr donovan is an outstanding role model and a in conducting rigorous and timely research let's give a warm welcome to dr erin

donovan who will now deliver her presentation on coping through communication coping with communication collective uncertainty management in health contexts thank you thank you christina

well thank you so much for having me i have to say what an honor it was to be invited and how pleased i am to be a part of this conference christina did such a nice job introducing me so you have a little bit

of a sense of what i do but i wanted to share with you some of the scholarly interests that i have and some of the theoretical currents that have really guided me um and expressed my

appreciation for the theorists who have been the foundation upon which my work has built those of you who are interested in interpersonal health communication are going to recognize all of these names of course

but i'm interested in disclosure and avoidance especially in interpersonal and health context and to a great extent disclosure and avoidance are all about uncertainty management some people would argue they're all

entirely about uncertainty management and my interests lie primarily in how people are coping with serious illness chronic illness and i've studied a variety of health contexts hiv aids

prenatal health but most of my research looks at cancer survivorship so i'm mostly going to be talking about people who are coping with cancer and one of the reasons why i'm so interested in cancer survivorship is because it is a

type of health context that is very much characterized by a lot of uncertainty um so these are some of the the works that i'll be referring to and of course i have to um give a special

thank you to professor fifi and professor pp for what in my world um my my students just called the purple book so it's like where's the purple book who has my purple book today um so we'll be

um talking about this type of work these are the types of sentiments that i come across that you may have heard that you may have said in your own life it's hard to talk to people about illness

about health issues i wish i knew how to talk about things with my family i'm not sure i want to talk about it i need someone to help me understand this what's going on how to make sense of this information

where can i find out where can i find some good information and these are concerns that people have that really move me for personal reasons and for scholarly reasons so if you don't study uncertainty

which you might want to because it is awesome here is a definition uncertainty and again i'm looking at health context uncertainty in health context is a person's perceived inability to make

sense of health or illness related information and it is feeling unable to predict or explain your circumstances so usually when we're studying uncertainty we're considering the perspective of the person who feels uncertain so it's not

my job to tell you if you're uncertain if you feel uncertain then you are uncertain if you can't really make sense of what's happening and uncertainty arises from a number of sources your symptoms are ambiguous you're not

sure what to make make of them the health care system is incredibly complex and hard to navigate and you don't know how to get through all the paperwork and you don't know who to ask your questions and so there are just a number of things that really

characterize illness as a time that is marked by a great deal of uncertainty for people so a whole host of research has established the premise

that uncertainty is a prevailing experience among people who are coping with illness like cancer as well as others and theorists generally will argue that many people

experience uncertainty as a negative state so uncertainty makes us anxious we don't like it we want to minimize it it's frustrating when you can't make heads or tails of what your doctor has

told you but we also know that sometimes people will embrace uncertainty they will appraise it positively you might not want to know your test results or you don't want to know them right away or you don't want to know if you have a genetic mutation and my

undergraduate students are always very skeptical about this whole appraisal of uncertainty and then i say okay well if you or someone you know has ever had a pregnancy scare and you didn't want to take the test

because you didn't want to know and they're like oh yeah yeah so we also know that uncertainty can be appraised neutrally so it's just there you know that there are things you don't

understand um but it's not the primary um negative or positive thing that you're experiencing so as communication scholars are very interested in uncertainty because uncertainty is managed through communication if you're uncertain what

do you do you ask people questions you go online you find information and you try to seek answers to minimize or reduce some of your uncertainty

but because communication is so complex sometimes communication can actually arouse uncertainty it can contribute to uncertainty you go and get a second opinion and it turns out the second opinion conflicts with the first opinion

that you got about your diagnosis or your treatment options you're not sure what to do or you talk to one person in your family about your medical history and talk to someone else and that information is conflicting so i study uncertainty against this

backdrop of theories like stress and coping and communal coping if you take a look at some of the research on that is guided by lazarus

and folkman stress and coping paradigm which is very much predicated on the idea that when we're exposed to a potentially stressful stimulus we go through the appraisal processes of

primary appraisal how bad is this is this a threat to me what is it stake what do i have to lose and then we go through the secondary appraisal if we have decided that that initial stimulus is a stressor we're going to ask ourselves what am i going

to do what resources do i have to cope with this what is available to me there's some evidence that in times that are characterized by a lot of uncertainty this primary and secondary appraisal process is difficult and that

makes sense right because you don't know what's happening and so it's hard to decide how bad is this what am i going to do what's going to happen to me if i if i choose this coping route do i have the resources to deal with it

among women who are coping with breast cancer there's also evidence that if they report that they have higher uncertainty about their condition and they feel less control over their circumstances and then they are more

likely to engage in certain types of coping behaviors so again if you're not familiar with this type of research we can categorize coping behaviors into things like emotion focus versus problem focused and escape avoidance versus

active coping and if you have more uncertainty and less control you may be more likely to engage in emotion focused coping which is distracting yourself and pretending that this isn't really happening and asking your friends to

keep your mind off of things or engaging in denial or turning to religion or turning to alcohol instead of things like actively attacking the problem and trying to find solutions so the

uncertainty and the coping processes are very much interrelated now we have these theories about uncertainty management and michelle's theory of uncertainty and illness is one of the big ones brochures theory of

communication and uncertainty management as well they tend to focus a lot on individual coping with uncertainty and this is similar to

the the research trends in the coping literature which focuses mostly on individualized coping and then recent theorists have been looking more carefully about how people engage in

coping together so communal coping and collective coping and social support processes brashears at all argued several years ago that despite the pervasiveness of collective uncertainty management

processes so people are doing things for you to help you manage your uncertainty or you are seeking assistance through communicative acts assistance to manage your uncertainty we don't really know much about this

collective uncertainty management so this has been kind of in the back of my mind and i remember asking um dale at one point uh you know well what about if i'm managing my uncertainty

how is that affecting your uncertainty and other people's uncertainty and they'll say well we don't really know and he said he said that would be a good dissertation topic and um i went a different direction for my dissertation which was you know that

worked out fine um but um but i'm still really interested in this so it's just been kind of sticking with me so on that trend on that theme of coping

uncertainty and control i want to share with you some findings from one of the studies that my team and i have done this was a study of people coping with cancer and we did focus group interviews and one-on-one interviews we asked them

about the uncertainties they had about interacting with people and some of the the resources that they use and the questions that they had about talking about their cancer we took a grounded theory approach

and one of the broad conclusions this grounded theory that we developed really had to do with the idea of control so we noticed that people were talking about cancer as this time that was

characterized by a great loss of control you've lost control over your body right your body has turned on you you may have little control over your treatment options either because

your cancer is a specific type that only has one or two potential routes or because your hmo limits you in terms of where you can go for treatment you may have financial concerns you may have lost control over the fact that you have to take six

months off of work we had participants talking about the loss of control they felt in their personal and social lives and one woman said that she and her husband had to cancel their symphony subscription for the season which was really

disappointing to her because she couldn't be in an environment where she was around lots of people who could get her sick when she had a compromised immune system so all of these things make people feel as though they're out of control and this is consistent with other literature

what was interesting to us is we noticed that people talked about managing their communication as a way of gaining or regaining some of the control that they had lost so there's so much i can't

control but you know what i can control who i talk to about my cancer and i can control the way that i tell them and when that happens and i can control whether to do it before or after my brother-in-law's wedding

some examples of this paul he's a an older gentleman who was still very active in his career and he was a businessman and he was wearing a port for his chemotherapy and he knew

that his clients could see it and they were curious about it so we saw some of paul managing other people's uncertainty or perceived uncertainty he says he would say to them i'm doing chemo for my

colon cancer we didn't get it quite as soon as we'd like to but i'm in a good statistical group so kind of reassuring them i'm still going to be here i'm going to be working with you a year from now don't you worry

amos was quite a character um amos was talking about how he tried to regain some control over his social interactions and one of the ways he did this was he said his wife he says when i was up getting my chemo i didn't want my

wife hanging out there she'd come and sit there and knit and i was like get the hell out of here and he he said it in an affectionate way it looks kind of mean but he was affectionate about it and he said i just didn't want that it was kind of like a death watch i don't

know what it was but when i was up getting my chemo that was my world up there and i was working them nurses and i didn't need anybody and so amos wanted to go and flirt with the nurses

they were i guess young and cute and that made him feel more vibrant and that was a way of regaining control over the fact that he um you know had lost

so much of who he thought he was now go back to the model for just a moment because the other issue that comes up is we notice that there are limitations if any of you

is at all a control freak you know that you can try to orchestrate things as much as possible but some things are just beyond your control and we're supposed to be able to accept that right so we see that people are running into

these constraints on how much they can actually control their communication and control the communication about their cancer for one thing you can't really control the responses of others people try to say well i'm going to deliver the

news this way because i want to make sure my kids don't get really upset i don't want to traumatize people but you don't really that's not your call so people are going to say things to you that are going to surprise you the conversation is going to go in a

direction you may not have anticipated and then we saw some boundary turbulence so folks who study privacy management talk about boundary turbulence where if i bring you into my boundary of my

private information about my cancer you may then do something with that information that i don't really like that i don't really appreciate so there could be some leakage there could be some

spreading of that information so we had found this and then just recently i came across this advice column where a woman wrote in and she's describing some of what we had seen in

our research and she says dear carolyn recently i had breast cancer diagnosed at an early stage but will still require surgery and other treatment i've told few people one was a friend of more than 20 years who then told an acquaintance

someone i never would have told there is so little i can control about this process but this is the one thing i should be able to control especially given that i'm a very private person i was very angry that my alleged friend

told someone else i didn't tell her not to share but no one should need to be told that i don't believe that she was being malicious but still she didn't have the right so she goes on she's very frustrated she's they've been friends for 20 years how could she not know that

i wouldn't have told that person um the advice columnist goes on to say you've been friends for 20 years how did you not know your friend wasn't going to be a big blabbermouth about this i'm like why are you surprised

but she does it also then say look when you are dealing with something so big sometimes it's the little things that you feel like you can really manage and deal with and those are the ones you fixate on now i don't know that i would

argue that communication is a little thing but i get what she's saying and i think that speaks to some of the findings that we've had so why do people talk about their illness why do people

talk about their cancer and there are a whole number of reasons why people feel that it's worth talking about this above and beyond some of the findings that we have about control so catharsis you want to get it

off your chest you need to vent a little bit if you want to seek help you need some support from people you need to let them know what's going on at least to a certain extent a lot of people will talk about a duty to inform and this is something that i'm

going to come back to later in my talk so i may feel a duty and obligation to tell you for your own safety so hiv aids something i need to tell you so that you can take care of yourself but cancer in our studies this tends to be more about

it's my duty as your mom it's my duty as your friend to live up to these expectations that we have for trusting each other i might want to educate people or advocate on behalf of my condition i might want to

test people's reactions before i tell them the good bad and the ugly of what i'm dealing with i want to see how they're going to react to maybe some of the softer information and then of course disclosing is one way that people

become more intimate if i see someone that has also experienced my health condition i may feel a sense of similarity and solidarity with them so all of these are reasons

i have been very interested in this notion that people make plans for disclosing so we know that people have reasons to do it reasons not to do it kathy sharmas has researched illness

disclosure and her book was one of the ones that i i showed you on my second slide there good days bad days the self in chronic illness and time and her work is really is just wonderful and she talks about

the distinction between spontaneous disclosure where you just blurted out and protective disclosure and sometimes protective disclosures are very clinical it's called informing where you really just give people the facts and you just

say this is the medical information but sometimes you do what's called strategic announcing which is where you see some of our participants talking about how you package it and you think about what do you really want people to take away from the message you want to

tell them not just what you have and what the diagnosis and prognosis is but you also want them to know here's how i'm feeling about it here's how i want you to treat me here's how i want you to react or whatever

the other thing that sharma says is that this telling this disclosing does not end so when we're talking about chronic illnesses this is something that goes on

and she says in the case of chronic illness the telling chronically ill people must tell and retell their news to many people and frequently do so at each step along the path that their illness takes and moreover they must live with the telling

so this becomes part of your narrative and you may have new people who come into your life that you have to or you want to disclose about your health status or things have changed so you need to

update people so i think that this idea of the ongoing element of communication and disclosure is important especially because

communication theorists like brashears argue that in chronic illness situations the uncertainty is also chronic the uncertainty is ongoing and it can change

it can heighten it can lessen at various points in the illness trajectory so along these lines of disclosure and uncertainty management and some of the interests that i have in how people

manage others uncertainty i've taken up this interest in confidance we know a lot more about disclosures than we know about confidants and obviously it makes sense that we would

start by looking at disclosures and what disclosures are trying to do and their risks and rewards and reasons for disclosing what i think is interesting is when i disclose to you then i am providing you

with new information which can then arouse a great deal of uncertainty in you so you're learning about the fact that i've been diagnosed with a serious illness and you may have all these questions like when did this happen and how long have you known and

what does this mean and are you going to be okay and what can i do and why are you telling me this way so i have these questions about the medical uncertainty as well as the the personal and the social uncertainty

so we've been working on a series of studies about parental disclosures and these were specifically looking at young adult confidants so

if you try to find information about how parents talk to kids about illness you're mostly going to find information about how parents talk to little kids so you're going to find things that say you

know use body part terms and use words that they can understand and say things like mommy is sick but i'm going to get help from the doctor and obviously that makes sense but we don't really know much about how

parents might be able to talk to older kids which i think is problematic because if you think of kind of the typical age range where somebody would be diagnosed with a serious illness um if they're older you know middle aged to older

adulthood their kids probably aren't very very young and there's evidence that older kids tend to be confident more so than younger kids for reasons that i think makes sense so

we asked young people for undergraduates to report on times when their parents had disclosed important news to them and we asked them to describe in great detail and we have a lot of different

topics but almost 60 of them pertain to health topics so usually it was the parent disclosing that he or she had been diagnosed with an illness or the other parent had and i'll share a couple of examples with

you so about five years ago my mom was diagnosed with breast cancer it was christmas break and my family was driving back from my grandparents house where we had spent christmas on the car ride home she told my brother and i that she was going to have surgery because the doctors thought she might have

cancer she said she was still optimistic and that this was just a test procedure she told my brother and i that we should not worry because she was going to be fine she told us we should be praying about the situation and for healing i remember it being a serious conversation

but i do not remember if she cried or not when she told us at this point though she was not about to have a serious surgery though another example my mom was going to the hospital to get checked up too many times i started to think that something

serious was wrong with her and she didn't want to let me know and then one day i asked her why she was going to the doctor so much she avoided the topic for months until one day out of nowhere she told me she had a tumor in her uterus but it wasn't a threat if it didn't grow

anymore she didn't look at me when she spoke she knew i'm very sentimental and she waited so long to tell me just so i wouldn't worry for her and now all we have to do is wait so i think these are so interesting because there's so much

going on here you're not just saying this is what i have but you're saying it in a certain way and the kids are remembering it a certain way and they have these memories kind of embedded

these flash bulbs of what happened so we thematically analyzed the responses we also asked them things like what do you think was successful about this conversation what was unsuccessful what would you do differently what questions did you have and i'll share

with you just a couple of the themes that are most relevant to my talk today um you saw the one participant describing how my mom waited so long to tell me

for a reason so we noticed that people were talking about the idea of a delay and we took some of these statements we created some scales out of them and

assessed the extent to which these features of the disclosure predicted whether confidants felt the disclosure was handled appropriately so we used a scale of communication competence

the extent the greater that the participants perceived that there had been a delay in telling them the less they thought the disclosure was competent so there seems to be a time a

temporal element that's important to confidant here they also noticed or seemed to have some ideas about whether their parents had put some time and thought into the conversation so

my parent you know obviously had thought that they should do it when we were all together or they wanted to make sure that we weren't going to have any interruptions and i know that she had probably thought about how i was going to react

and so we asked about this idea of planning and the greater the perceived planning on the part of the parents when disclosing the higher the perceived disclosure competence so people seemed

to appreciate that now one of the reasons why i'm interested in this is because parents struggle with how to talk to their kids about such serious and important news and they say that they want to disclose

the right way which i mean that could be so many different things and i thought it was notable that our participants were critical of the disclosures and they pointed out the things they thought their parents had done well and had done relatively poorly

but they were also pretty sympathetic and they thought you know what i know she waited but she was just doing it to help me and i know she seemed kind of overprotective um but what are you gonna do this is just a really stressful thing

to talk about her um i wish my mom hadn't broken down so much in front of me because i was hard to deal with but it is a sad topic and i understand that so the broad takeaway that has been kind

of feeding into some other questions we have about this is that there is this there seems to be this assessment that confidence confidants make about disclosures

in terms of what it does for their own uncertainty how it arouses uncertainty them and how their parents are managing this uncertainty that they have created and then are subsequently trying to to

mitigate perhaps another issue that was very important to our components was the extent to which they could access additional information from their parents so that i feel like my parent had taken

this topic off the table like they gave me the news and then they said i don't want to talk about it anymore it's done or did they say okay if you have any questions please ask either at that time or down the road and we found that

confidants really wanted to be able to ask their parents follow-up questions and access additional information and the disclosures were rated higher in quality to the extent that they could do that

so those of us who are interested in disclosure are often also interested in avoidance and this is a tweet that caught my eye this woman says i hate having to hide the fact that i'm upset because i don't want to discuss it or because i don't

want to hurt anyone and this catches my eye because it has to do with avoidance and coping with something stressful now just as i've been interested in the

confidence perspective i'm also interested in oh is that better oh okay good thank you i'm also interested in the perspectives

of the avoided um so again we know more about people who are avoiding conversations than about people who are avoided and so i we've done a little bit of work looking at people who receive topic

avoidance messages this was a study where we described a scenario to people we said your friend is coping with something really stressful you know about it but you don't know much and you bring it up during a conversation and

then your friend says to you i don't want to talk about it and we had different types of messages uh instant different message instantiations to basically communicate this is a topic avoidance move

and then we asked people what do you make of that why do you think your friends said that we asked them a bunch of different questions about how they would respond not surprisingly given the way we framed the task the most frequent

interpretations of that were my friend doesn't want to talk about it because it's just stressful it's hard to talk about they need some time they need some space it's too emotional they've already been kind of mired in these negative emotions

and talking about it would just make it worse so i think they were pretty again sympathetic they weren't taking it terribly personally we also noticed that

there can be some ambiguity in these topic avoidance messages so again this issue of uncertainty if i avoid talking about it with you you might have some uncertainty about why

you know has it gotten worse or did they not trust me with the information this to me is kind of an interesting practical uh takeaway that the more potential explanation somebody

has for your topic avoidance the more likely they are to bring it up again because they think well maybe it's because they're mad at me or maybe it's just bad timing or maybe they're just having a rough day so if you are coping with something

stressful and you really don't want to talk about it then give people a very clear reason why and don't let them have much uncertainty about why you're avoiding the conversation of my that's my rule of thumb that i

have received from this study all right so i'm i'm thinking about these issues of how people are disclosing and receiving disclosures and how people are avoiding and receiving avoidance messages and how they're

coping with illness i just keep thinking man that seems like a lot of work and you already have all of this stress to deal with and then the communication can be hard on top of it and you see all these websites that are like talk to

people about your cancer and i think that makes sense um but then i also think aren't you just giving people one more thing to do that is also stressing them out so as we were doing our interviews with cancer

survivors i was thinking about this idea of work and fortunately there is a theory about work during chronic illness and it is called the theory of illness trajectories

so any of you who do grounded theory research cite strauss and corbin all the time and you cite glazer and strauss because they are the folks who have codified grounded theory principles for us um but of course when coordinates routes were working they were also

interested in conceptual issues not just methodological issues and juliette corbin is a nurse theorist and ansem strauss was a medical sociologist and one of the things that they did was publish a book called

unending work and care the self and chronic illness and time this was a study where they followed couples they interviewed couples and they observed them

and they wanted to see what people were doing to manage chronic illness in their home because as more and more people were diagnosed with chronic illness this book was published in 1988

people weren't just being treated in hospitals or care facilities they were being released and sent home and they had a lot of work they had to do for themselves and strauss actually had some previous

interests in healthcare organizations and occupations and how people manage workflows in health settings so they were developing this idea of work so they noticed that chronic

illness is persistent it's one of the defining features of it it is unpredictable to a certain extent and it requires work their definition of work was basically a collection of tasks that various people

are responsible for during the illness trajectory this is hard work is unpaid work it is divisible labor and they talked about three distinct

lines of work that people engage in when they're coping with chronic illness the first is called illness-related work and illness-related work is all the stuff that you have to do to manage your illness at home so

testing your blood sugar checking your blood pressure taking your medications going to physical therapy going to your follow-up appointments with your doctor they talked about biographical work which is the second line biographical

work is resolving all of the identity issues that crop up when you're coping with something like a serious illness who am i now what does it mean if i have to stop doing the profession that i love and i'm so invested in who am i if i can't be a

marathon runner anymore what if i have to resign and then they talk about the day-to-day living or the everyday life work and this is just the stuff that grown-ups have to do so day-to-day

living work is washing the floors and unloading the dishwasher and going to the grocery store and balancing the checkbook and amid all of the

everyday life work is the work that is specific to the illness so i reread the book and i'm trying to figure out okay well how does communication factor in here and coordinate straws talk about

communication in the theory they actually describe communication as a pivot point around which all of the other lines of work happen because you have to do what they call articulation work meaning you have to

coordinate with people and set goals and say okay well who's going to pick up your prescription and who's going to pick up the kids from school and sometimes you have conflict about who's responsible for what but i just keep thinking but sometimes

the communication is hard too right sometimes the communication is work and they don't really didn't really get into that which is fine because that's not the lens that they had so one day during one of our focus

groups we were moderating this series of comments came up martha says if you're not comfortable telling the people close to you how are you going to be comfortable in a support group or with a mental health counselor and holly says because it's a

secret thing that usually stays in the room and martha says yeah because you may feel like crap and you don't want your family to know you feel horrible but it'd be easier to tell a stranger that you feel horrible and holly says well sometimes you don't want to reveal

your inner feelings to your family for fear of scaring them and martha says sounds like a lot of work if you're sick so then i'm trying to like i'm in the focus group and my research system andy's on the other side of the room and i'm trying to be cool and i'm like

and he's like you know because we've been talking about these work issues and then i'm hearing it coming up and i'm like i'm not crazy this is actually happening um but we kept it cool we just took our notes and then went on from there

so so then we started incorporating some questions about this into our interview guide and then we developed this concept of communication work that we wrote about and we argue that the concept of

communication work problematizes communications it doesn't just take it for granted as this background process that happens but it is a collection of interpersonal and informational tasks for which various parties are

responsible during the illness trajectory we described four pillars of this additional line of work one communication work is effortful now not all communication is work but

some communication is and it's hard and it is sometimes a burden you have to help people understand what you're going through you have to manage awkward attempts at social support you have to coordinate the flow of

information we notice that people describe this idea of duty which as i mentioned comes up in the illness disclosure literature and people talk about feeling responsible for updating people and keeping them

informed and doing it the right way so there's a sense of communication competence which i think is interesting and our participant says if you're going to communicate this you better do it well because you feel this sense of

obligation to manage your friends and family members emotions the third pillar is preparation so people talked about preparing for conversations planning for talk

they were and there's there's some other research on imagine interactions among cancer survivors and thinking through how you're going to talk to people about it it was interesting that people sort of felt like they had to not just anticipate what people were

going to say but anticipate the questions and so they had to kind of do some extra research because one of our participants said it helps to have planned out the same questions that you had about what are you going to do what's it going to do to you how this is how about how long it's

going to take this is what your progress appears to look like so that they know that up front because those are the questions that they're going to ask and if you don't know you can't reassure them so you have to kind of come prepared do

your homework before the conversation so that you can manage their uncertainty about it and then we saw people engaging what we called active message design which other people have written about so these are

discursive strategies so you want to be positive but you also want to be honest you want to give people hope and maintain that for yourself but you don't want to lie to them people talked about drafting messages so they would write an email for their family and friends and they would sit on

it and they would edit it so that they could say things the right way so i'm talking to my colleague um brad love who's a faculty member in the moody college of communication with me and he

also studies cancer survivorship and i'm thinking i'm like is this work thing is this does this make sense what do you think and i'm running it by him and so he and i have started working on some additional studies to test out this concept and

what we've been arguing is basically that the theory of illness trajectories makes so much sense and i just think it's really useful but it it was written at a time where perhaps there wasn't as much

communication work because this was the 80s people weren't going online to find information about their health conditions there wasn't as much patient empowerment and patient self-management as there is

today with chronic illness there may have been less of or there may have been more of a paternalistic approach to medicine at that time and so this idea of having the

job of being a communication a communicator and a cancer survivor i think has more heuristic value perhaps today so we're trying to think about communication work in the theory of

illness trajectories in the 21st century and brad's area of expertise is new media and how cancer survivors use that so we've been collaborating on some projects looking at issues of communication work in a web 2.0 this is

what we called it in the journal of cancer education these studies have been specific to the aya cancer context and aya stands for adolescent and young adult cancer survivors these are folks who've been

diagnosed between the ages of 15 and 39 and this is a really tough age because you're too old to be a pediatric cancer patient and you don't want to be in the pediatric ward of course but you're too young to really relate to a lot of the

average or typical cancer survivor concerns because you're you know perhaps still a college student you're dating you're at a very different life course and these folks have really bad health

outcomes so cancer survivorship has improved for kids and for older people and for ayas it has not gotten any better over the last couple of decades

so we did an analysis and we had access to an online support group that is supported through the livestrong foundation and we were analyzing some of the posts that people were providing talking to each other and

looking for instances of the work that they were doing we saw that people were seeking information to prepare for offline conversations they would log on and say how do i talk to my boyfriend about this or

i'm not sure i feel like i disagree with my oncologist but i don't know how to tell them that what do you all think they were also then referring each other they were saying well here's what i did but then take a look at this as well

so here's an example this person says i think everyone on here can really relate to the woefully inadequate information out there on this incredibly important subject and they're talking about fertility problems which

is a big issue if you've had cancer treatments at a young age and she says if this is really important to you consider delaying treatment and moving quickly to preserve your embryos obviously you your doctor and your family need to make the decision that's

right for you but my experience was that it was well worth it check the fertile hope website which which gets referred to a lot people really rely on fertile hope also look online for whoever is the most

recommended reproductive endocrinologist and re in your area any support group for people having fertility issues ask friends and neighbors who their friends saw about their ivf

cold call local gynecologists office ask for recommendations for an re so this gets my attention because i see the the work of researching what to do i

see the work of communicating in this forum somebody took the time to write this post and offer this what we would describe as informational support you're managing the original poster's

uncertainty by providing this answer to the question there's also this collective uncertainty management because lots of people are logging in and seeing this response and then adding to the thread and most of these threads average about eight posts and some go as

many as you know two or three dozen and then you're also kind of doing some of the ground work for this person but then giving them new you know to use the metaphor um assignments right so do this

then do this then do this and here's more informational work for you to do and and i don't i'm not judgmental about that i just notice this sort of pattern

so building on kind of the the web the 2.0 the new media um platforms for communication work right now a couple of my research teams and i are working on a cancer blog

content analysis um and this as far as we know this will be the largest content analysis of cancer blogs especially from a communication perspective and we went 50 pages deep into a google search for cancer blogs and then we found every cancer blog that

was linked to every other cancer blog that came up in that search and we ended up with about 500 blogs and we've since called that down because some of the links don't work anymore and some of them aren't really about cancer so we're

deleting some from our data set but we're analyzing these records and these entries these blog posts basically is quasi diary data to see how

people are engaging in uncertainty management over time as they're coping and to see how people are engaging in communication work over time and how those are overlapping

so this is an example of one of our blogs my lymphoma journey this is andrew's blog and this is his about me page and i have a couple of bracketed sections here that i'll read to you i know that's a little

bit small he's saying after i was diagnosed i was depressed over the next few weeks uncertainty shifted from what do i have to what does it mean learning about the mcl on the web made

things worse my prospects appeared bleak confronted me with my mortality i had to deepen the level of discussions with family and friends while broadening the circle to include staff and colleagues to let them know my situation sharing the news did

not become easier with repeated telling which is consistent with charmaz's perspective one of the things that i grappled with throughout the diagnostic process was beyond immediate family and friends who needed to know when and how much to

share in the very practical question of being absent from work for six months at least as well as deeper discussions with family and friends i began to realize that while the lymphoma was about me the impact was upon others others that i

related with so then he goes on to talk about how he created this system of weekly updates and he had this process of keeping everybody posted everybody updated he

used his blog as this forum this is jessica she is living with stage four lung cancer which is remarkable she's been she was diagnosed about two and a half years ago

and she says i started this blog because i was tiring of telling my story over and over again so i see that i'm like yes this is hard doing the face-to-face disclosure can

become tiresome and tedious and so the blog may be a way of performing the work provides this communication tool as i wrote the first post though i felt some of the burden lifting from my shoulder some days there

is a fine line between sharing my honest feelings and depressing the hell out of my friends and family but most of the time though i just tell my story and i hope to make my readers laugh more than crime some of the themes that we're noticing

um in the work so what corbyn and strauss did was they argue that there are lines of work the illness related the biographical the everyday life and i would argue the communication and then within each line there are tasks so

these are more discrete and concrete processes we see people seeking information preparing for talk exchanging information and sometimes that is laborious shaping the conversation orchestrating

things to get it to go a certain way keeping people updated managing their own and others emotions we see some i don't know some meta-communicative work we see people doing the work of the blog keeping the blog but then negotiating

with their audience their blog people and saying um it's too much for me to respond to all of your comments but i'm going to answer some questions in this post so i keep thinking about this and i i hope that one of the

the premises that i'm making clear to you is that i think communication work is one way of thinking about uncertainty management and collective uncertainty management and how it is effortful uh and how

it might be worth it even though it is so effortful so in honor of um the conference theme i'm trying to i'm hopeful that the questions that i've already been working on answering seem

interesting to you i know they're interesting to me and i'll share with you some of the next steps that i think will be interesting questions as well the theory of illness trajectories is called the theory of illness trajectories because it's actually about

this idea of illnesses following a path and having a trajectory and what corbin and strauss were articulating is that there are these ups and downs and there's an eventual decline and at different points in the

trajectory the work changes and so you may have to do more biographical work at this point in time or you may have to your illness work may become more burdensome if you have an acute

event that occurs here you have stable parts of your trajectory where the work becomes kind of routinized and then you have some that are very disruptive and unstable and so when we're analyzing our blog

data we are looking to see what else is happening in the cancer trajectory that is related to the communication work that's going on so has something changed that then

makes the updates very important or more challenging is there something that is good news that then makes the communication work easier i don't know so that's that's what we're

going to be looking at and then as i mentioned you know what are people getting out of this corbin and strauss said that if people are to continue to put forth effort to do this requisite or desired work there

must be some perceived payoff to motivate them to do it and so we are interested in the both the subjective and objective outcomes of communication work what is the payoff for doing this

i think those of us who study interpersonal relationships can come up with some plausible ones from a coping perspective i'm curious as to whether communication work actually feels adaptive and you feel like you're doing

something you're engaging and so that can give you more control make you feel like you're able to control something again it could also be

adaptive escape avoidance coping because well i don't there's nothing i can do to make my chemotherapy more tolerable but there are things i can do to make sure that my friends aren't really

stressed out about this or there are things i can do to help explain this to my work colleagues in a more successful way i wonder about the extent to which the communication work can really take a

toll on people so a longer term goal would be to look at some actual physiological side effects i guess you could call it that and to the extent to which communication work is a double-edged sword so there are some good things you

get out of it but there are some dilemmas in that it is taxing and then finally i've just been thinking about some of the ethical questions that come up because i'm interested in how

we can help people manage their uncertainty but i'm also very cautious about being too paternalistic about that as i said sometimes i get a little bit

frustrated when i see mainstream recommendations for cancer survivors or other people who have illnesses that say well just talk to your family and friends and again those of us who do this no it's not that easy

that's not it that sounds really simple and i wonder can we minimize the burden can we engage cancer social workers can we engage patient advocates some as i said that aya group that we

worked with they're very active and just really wonderful and energetic can we find ways to equip them to minimize the burden of the communication work but then should we right because then that whole issue

of is it doing something good for them are they feeling more robust because there's something they can control and something they could do so should we actually minimize the work for them i don't know whose job is it this is a big issue that comes up this is where the

conflict of managing the illness in the illness trajectories theory comes up is whose job is what how do we divide that and what i found really

interesting about our initial development of the communication work pillars is that people describe this as divisible labor so we had people say they appointed a family spokesperson

because i said it's too much for me so they'd say guess what everyone i appreciate the calls i appreciate the messages but i am tired and i am busy and i can't answer all these questions so leslie's going to

start an email distribution list if you want to know the updates send her your address and she will put you on that or my husband's going to take all the phone calls so i'm curious about whose job it should

be which is more of an ethical question than an empirical question and then i also wonder about the ethical issue of managing other people's uncertainties

and trying to help them i really think this is very well intended and very pro-social but then i feel like it starts to bleed a little bit into

codependency and well i'm going to manage your emotions for you and i'm going to tell you how to feel about this and what to take away with it and you know whether you have

an empirical beef with the codependency measures of the literature i do think that that is something sort of interesting to grapple with so i love uncertainty i hope you're

interested in it i hope you learned a few things from our talk and i'm very grateful for your presence here and happy to answer questions of course thanks

thank you um i just wanted to say those of you following online if you want to ask dr donovan questions you can do so through twitter at

beckercon14 um also we're gonna start our answer q a right now we're gonna end promptly at 10 15 just to give um dr phaedra pizzullo

some time to set up i hope you stick around for her talk is there any questions i was struck by how self-aware many of the

the um individuals you quoted appeared to be and i wonder if you could talk and and as a person who comes from a

psychological perspective i was kind of curious about if you could address individual differences cultural differences um it seems to me those those people seemed more

intelligent more self-aware more self-reflective than is typical perhaps so maybe you can talk about that yeah um well

our focus group and interview um sample was small it's only 40 people which it was enough for the analysis that we were doing we tried to diversify in terms of cancer

site type of diagnosis we didn't necessarily purposefully sample for diversity in terms of educational background most of our participants had either some

college or a college degree so there's that the extent to which trying to think how we would pick up on that they were there was differences in how self-aware they were i think you're

right and of course i'm sharing with you the quotes that really illustrate the points that we were making in the focus group interviews we could probably tap into that more

because there were participants who were saying things and it was clear they were having a hard time making sense of how they really felt about it and they hadn't put as much time and thought into

what their family and friends may be thinking may want to do and then we had other participants who would then chime in and say well it's probably this or um you know in my family they were really concerned about this maybe that makes sense for you which is one of the

great things about focus group interviews right is the participants can feed off of the energy of each other so yes there was a little bit of variation i think if i had to stake a claim i would

probably say that our sample was slightly you know more um self-aware and better educated i mean only a quarter of people in texas have um college degrees so that in and of itself tells you that it's

slightly different um yeah does that answer your question yeah that's a good good point ashley can i add on to your question um

so thank you for your talk it was really interesting and i have a hundred questions and i'll just i'll save i'll save the other 99 for further conversation um and i'm going to start with a question and then i'm going to contextualize it

and my question for you is how do we connect the kinds of communication questions that you're asking to broader scope questions and i hope that in looking at what becker inspired that we

cannot know the answer fully to the kinds of places of those connections so my question for you is what would you really love to know if

you could know anything about how your questions are connected in a broad scope and i'm going to give i'm going to tie back to your piece on here's how i contextualize this so you give some examples from blogs and you

give some examples from places where they say things like sometimes you just don't want to reveal your inner feelings for fear of scaring your family and then when you see these blogs you see them go

to places of like here's what you do first and then second and then third and then fourth and i wonder if this place of like a real fear of who i really am

as a person doesn't get translated into a simple reporting of like here's step one two three four and five and that's one of the things for example that i wonder like how much is fear of

the real if i really know the answer to that question i can't fully be yeah so i come back to that piece of like are there things that you would

hope you can know over the long haul yes i mean gosh there's so many things i wish i knew um so a couple of things one so you're absolutely right but people are kind of saying

well it's not that easy but then here are some diagnostic principles so yes you said here's what to do in some of the online support group data people are

pretty consistently and i would say this i think that's such a good observation about the self-awareness they're pretty self-aware and saying this is just my experience this is just my perspective and they kind of preface

most of their advice with that which again suggests that they're kind of aware of some of the social dynamics or that's just a norm for that that group that organization they say here's my experience but here's what i would

share with you from that in terms of broader principles i want it's not like you can have

the most comprehensive theory ever i'm very interested in how what we are already observing in our data dovetails with what other people have

observed in other contexts right so it is now i might be like here are my hopes and my fears it is my concern always i don't want to be

rehashing something that people have already talked about right i don't want to just be giving in a new name and i think there are some distinct elements here because of the complexities of an illness context but

i'm curious about for example um there's the concept of emotion labor right that already exists where people in their workplaces um they part of what they are paid a wage to do is manage their own

emotions so that they can manage other people's emotions i think there's a connection to be made here there's people work so in the occupational literature people who are in like customer service professions like this they do this all the time they

have to engage in the labor of dealing with people and that's what it is for me this isn't just about um we know that conversations can be difficult we know that um

communication can be challenging but i'm so focused on the effort and so i think that's if i had to give you a one word answer to your question it would be the effort and where is the effort located

in other theories and other contexts thanks i see kelly and yes and um i think what i was thinking thank you what i was thinking in terms of um it's kind of a scope question too

um because cancer is so pervasive now but it's not always terminal thankfully right so there's a lot of people um that find out that the outcome is going to be okay in terms of um they'll be able to

continue living a normal life or to some degree um and so you talked about this concept of communication work which is really really cool and it some of the goals are to help the confidant you know in it so you're trying to help them do

work how does that shift um in terms of when the outcome i think a lot of that is is uncertainty about are you going to make it or not is mom or dad going to make it and when they get that answer how does

some of the work shift in terms of the patient or the person with cancer and how might it be different for the types of illnesses where that is not an outcome where it's very much the impact

isn't on the the close others but it's on the person's life do you know what i mean so yeah both in terms of the support they get when they find that answer and in terms of how the the work the communication work shifts when

that's resolved at least right because then i think the the focus of your goals for i don't want to say controlling but managing other people's reactions shifts

because then what you might want them to really take away from the conversation is it's not that bad you hear the c word and i know the c word is scary but i want you to know it's not that bad um

and i'm curious about whether people like our data would suggest that people try to have uncertainty managing data to do that

now we know for example like from the psychological literature that people prefer to receive numerical information about probabilities but they refer to they prefer to communicate um

kind of general so people want to hear well there's a 60 chance of this but they want to say there's a good chance of this so i think you might see some distinctions there i'm also curious

again because i this work just feels like such a useful metaphor to me and you're talking about or what what i take away as an example from your exam from your example is

so you've had this diagnosis let's say when you're in your 40s and your 50s and it's okay and it's taken care of right and you're in remission you're doing great um you know the the biggest

predictor of a serious illness is age so as you get older then you're diagnosed with something new or something different or some or the same condition i wonder about

the practice of having done the work previously like you've done this before this isn't your first rodeo right you've had these difficult conversations you've had some on-the-job training right like i just i could beat that i

can beat this metaphor like a dead horse um but i think that that looking at kind of a long term and how we situate this in illnesses that are survivable

i think that practice might be really useful to people that answer your question yeah thanks aaron's one of the sort of most thought provoking talks

about uncertainty and illness and health that i've heard ever really so my mind's going a million directions but um as you know as i'm thinking about some of these things and hearing these questions

that have also been really helpful and with you starting with the idea of control and tim and i have been thinking about some control the issue of control and some of the things we're doing with uncertainty

and um this i love this idea of communication work etc i'm wondering if the the bigger sort of the the broader thing that ties us together is a an immense lack loss of

control and it's not only loss of control over your health and your survivability we feel like we can control if we do certain things we can live longer and that's gone

in some way some some of these folks it's loss of control over communication work um we there are expectations that people give us up to you know that you give me

updates yes there are expectations that every time that you get a new scan that we learn about this um there are sort of layers of loss of control here that

um that also linked to emotional labor stuff i mean i think this idea of control and how it affects our stress there's a lot of richness a lot of richness here and so i'd like to kind of

get your thoughts i also um appreciated isaac tweeted this this connection between your talk and john sloop's talk yesterday about uh disclosure and

control over that spread of information um so just i'd like to get your your thoughts on that i guess well and one of the things that you mentioned it makes me think about

this notion of responsibility and obligation and a duty to do the communication work and and to take up that role and i think it's it's useful to consider i wouldn't have thought about

it in terms of control but i think you're right um who makes those assignments right most of our participants were this was self-assigned work they were saying i i

want to do this for my family i want to help them because this is going to affect them you know one of our confidants said his dad said you know all of our lives are about to change it

just feels um so uh dramatic um but that's one of the reasons why we wanted to do the blog project because we're curious about the expectations that people have for

you to keep going you know like you have created this site and this platform and you are not just chronicling what's happening to you but you are helping other people and what if what if you want to resign like what if what if

you're done what if you don't want to feel like this is an obligation that endures indefinitely um so yes so i appreciate that thank you we actually have a question from someone

who tweeted who saw you online they wanted to know um do you find that involving patient advocates affect the uncertainty management

involving patient advocates look at how in patient care or in my research that's just what i i guess i could take either out with that yeah so patient care is probably what

they're asking about because i haven't worked specifically with patient advocates um yes if they if they have useful information i mean that's such a a broad and not helpful

answer you know it's like we say to our in my interpersonal healthcom class i say to my students like you're not going to leave this class with the 10 perfect things to say when someone is coping with an illness like that they don't exist

what we can do as all of us in our interpersonal classes do is try to provide them with general principles you know so think about the extent to which this might threaten someone's identity think about

the extent to which this could seem like very well intended sensitive support and yet it backfires so if we could

equip advocates with some of the the tools to help people think about that then yes the other thing is could we just have the advocates do some of the work just take it off of the patient's hands

facilitate conversations uh some of my other research is on informed consent and um trying to think about how to take the burden off of the patient but again it gets

back to the ethical question of we want patients to be engaged so we don't want to just disassociate them from everything so yes my answer is yes but if we can give them good useful information so there are a couple of

questions that i saw here um loved your talk thank you so much and i love the fact that it's qualitative too because i in my own work too i there's just a lot of depth that comes

out in that but then there's also the quantitative half of my brain and i'm wondering um can you quantify the emotional labor

or the emotion work because i also made that connection to the emotional labor as you were talking and i was thinking you know how much does it add on top of the person's actual illness so

people who are better able to manage their emotional labor or what role does your partner take in in being able to take some of that away from you as a couple

or as a family and actually quantify it so can you then map that onto a person's illness trajectory and say these people who do this actually

have a better illness trajectory or a worse illness trajectory like where you can say and then give them practical advice so we know that if you do this your your odds of

you know what i mean uh a cure or recovery or a longer life are going to be you know that much better yeah i agree so that's why when we're

looking at the blogs and trying to map those instances of work and uncertainty management onto the trajectory we'll want to see if we can we can quantify that right at least

using nominal categories right and then my question about the outcomes is exactly what you're thinking so can we develop a scale to measure how much work people are doing what's

different types of tasks they're engaging in and then a is that associated with their coping and their functioning at that time um

from kind of an objective perspective how are they doing and then b from a subject to perspective do they feel like they're getting something rewarding out of that because that's why that's why i think it's an ethical issue until we

have the data until we can model it because say well let's minimize the burden but then what if people feel like that's part of their war story it's like i was doing all this and look how well i did it

over time as they modify their emotional labor and the amount of work they do so what if they get exhausted then they put it on a block yeah does that actually help their illness trajectory yeah

or does it just change the work yeah great thank you we had a question over here that um has been up for a while so i just don't want to ignore it that's okay christina someone over here

okay thanks for your chat i really am for your talk i really enjoyed it i'm curious to what patients or disclosers might attribute their cancer their cancer diagnoses um

because i'm thinking here in the case of jessica who said she's never smoked and yet she has lung cancer do patients talk about perhaps genetic links do they have no idea um about

where this cancer might be coming from do they talk about the environment at all in environmental toxins yes they talk about all of those things and they talk about the implications that that has for the people in their

family that comes up in the trying to move toward acceptance of what has happened and then there are

people who just have to as we would say cope with the uncertainty of not knowing what the ideology of the cancer is because so often that is the case and they just they know what they know sometimes they

can't even identify the primary site and so they're going to do the best they can but yes that comes up as a source of frustration that i think bleeds into their other coping strategies as well as their talk with others

yeah good thank you andy you so i i really like this idea of communication work and especially like the idea that the internet can make the

work easier to do but i want to sort of get at the work idea and from the social support literature we know an awful lot about you know what makes someone good at

providing a certain type of message we know a decent amount about what messages are good from a receiver standpoint but we don't know very much about what makes someone a good support seeker or what makes someone willing to do this

worse i just wonder if you have any thoughts about about if it's a a situation of personal factors that you know what gives some more or less ability to to work to get their

the the information the support they want oh so yeah i was i was originally thinking about your question in terms of motivation but you're thinking ability as well well i mean motivation can be in there as well too for sure and i think you know well if we

go back to the the support provision you know ability and motivation support reception literature ability and motivation are both important so it's likely that ability and motivation are important seeking too

right right because the motivation is well i am stressed out about this because i don't know what am i going to do i need to turn to help turn to some help the ability i

think part and this relates to the patient advocate question uh to a certain extent it's making people aware of some of these forums online um you know they're not the silver bullet

and they're not helpful to everyone but at least the conversations we've observed people love having this outlet especially our aya survivors because they just don't know where else to go and so they can find

um similar others who can really relate to them are some people better able to seek higher quality help i think is kind of what you're getting at too

and again relates to the question of self-awareness and health literacy and education um because when brad and i look at the online support group data

these are really engaged smart people you know they are they are thoughtful they are they're taking kind of the planful problem-solving approach um

some of them talk about being you know researchers kind of like how how i would be right how many of us would be like we would instantly we would seek information we would know how to find good information so

so yes i think there there's variation there and i as i mentioned some of our other work has looked at um consent and uncertainty management and health literacy is a big factor not just

education but how much people actually have how well they can make sense of health information and access it and use it and i think seeking that seeking it gets less attention but i think it's part of that

okay i think we have time for one more question hi thank you um my question is um it seemed to me that

in most of with most of the folks that you've been looking at um there's an assumption that their family members and friends are mostly supportive of them

and so i wonder um like in the lung cancer example what if somebody has cancer at least it's perceived because of particular lifestyle kinds of

choices like they are a smoker and they've gotten cancer or it's because of you know their diet or alcohol or whatever yeah um what happens to the way that they

perceive the need to kind of manage their communication if they're potentially expecting maybe some kinds of hostile reactions or if their families are frustrated with them you

know or if they're continuing the behaviors that were unhealthy to begin with right i don't know if that's something that you can even account for but i'm just

curious about if there's potentially conflict involved in those i think there's a complexity involved i don't have uh the specific data to

answer that question entirely but um yes so certain types of cancer are more stigmatized than others and lung cancer is the best example and then one of the first things people ask you is how did you get it were you a smoker

um and so my hunch is given what we've what we've read um that people will part of the the obligation and the duty is going to be

less about getting people not to be so worried and fearful and there will be more of an aspect of getting people not to judge you so much and finding ways

to communicate that and also to come to terms with it and maybe just accept that people are going to have questions like that can you find sort of a packaged answer to frame it for people is that a conversation again kind of go

back to the avoidance issue do you just do not really want to get into that with people do you feel like that's not really any of their business um so yes and there's also variation just in terms of

like the family structure and as you said how supportive families are some of our bloggers don't get good support from their families and some of our bloggers have these amazing partners and

support systems and some don't and so the blog is their outlet and then they connect with people online and one of the reasons why they do it is because they can make these friends

because they're not getting it offline all right well thanks a lot aaron um uh i asked um christina thanks christina as christina to give me the mic for the final uh couple

minutes only because periodically what we're going to be uh sort of announcing letting people know is that we're hoping to continue this conversation after the conference and the research office has funded this conference and

also suggested that there may be some funding for pilot projects that emerge from this project from this conference that our interdisciplinary nature and inner method mixed method in nature et cetera so

at any time during the conference if you decide that you'd like to take part in these conversations what we'll basically be doing is once we have a list we'll be contacting folks in the list and meeting and hopefully

developing four or so research groups that develop white papers the key is that they're interdisciplinary and so if you're interested in that just email at any point you can email

becker-conference at uiowa.edu mention that you'd like to be on the email list and we'll make sure to include you once this is all done so i just wanted to thank aaron again for the fantastic talk

and looking forward to fader's talk next so thanks erin oh like very very clear um is

i could put that um here and then speak there do you think the chords will go or does that make it if it makes life crazy then i won't i'm just asking if it's possible yes

at least