Who's in charge here?

I never know what I’m walking into when I have a new hospice admission. Likewise, my patients and their families don’t always understand why I’m there. The nurse and the home health aide, even the chaplain, have very clearly defined roles. When I tell people I just want to talk, it can make them nervous.

At that first visit, death doesn’t always come up in the conversation. It’s a delicate balance: building rapport and offering education and being present without pushing too hard on the door to deeper issues. However, sometimes the patient opens the door for me. Take, for instance, the other day: I visited with a new patient who almost immediately wanted to talk about her impending death. She wanted to know how much time she had left (can’t tell you, sorry); how involved she could be in her funeral planning (as involved as you want!); and how it was possible to feel physically ok and somehow still be dying (take that one as a gift, my friend). We had a difficult but very nice conversation and I think I was helpful.

The next day, the nurse called me to tell me that the patient’s sister didn’t want me to talk to the patient about end of life issues. (Imagine me rolling my eyes).

Luckily, the nurse is no shrinking violet; she informed the sister that the patient is alert and oriented times 72 and gets to be a part of her care planning. In fact, the regulations (if you, like me, are a rule-follower) insist upon the patient being involved in her own care.

But families don’t care about the regulations; they care about their loved ones not being sad, or scared, or “losing hope.” I can’t tell you how many times a (well-meaning) family member has said to me, “We don’t want him to know he’s on hospice” or “we didn’t tell her that she’s dying.” (Spoiler alert: people typically know that they’re dying). And truly, I get it: we don’t want the people we love to be afraid or feel sad or suffer. But, as I always remind those family members, we don’t get to make decisions for other people as long as they’re capable of making their own. We can be tactful; we can be kind. But I will not lie to a patient who asks me a direct question. I will not change the subject when a patient wants to talk about her death. It’s easier sometimes, as I tell my patients and their family members, to bear one’s soul to a stranger, if only because they don’t have to be careful. I won’t start crying or tell them it’s going to be ok; they don’t have to protect me the way they want to protect their loved ones.

In my most gracious moments, I can acknowledge that protection is what people like the afore-mentioned sister are after. In my more annoyed moments, I start crabbing about how it’s all about control and who wants it and who has it. Both can be true! What’s important is to focus, once again, on the person we are serving and to (kindly, firmly, lovingly) set boundaries with everyone else. Advocating for patient choice is foundational to this work; what a joy when it is so easily done.

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Living in the village

The other day, I just about ran out of a joint visit. It was a tough one: the patient’s caregiver is struggling, to put it mildly. His anger is palpable. He is hyper-focused on a story he tells every time I see him, of how the hospital and the doctors wronged him and his partner, and how he will get revenge (his words). It is a difficult house to be in, so the nurse and I have made a couple of joint visits.

As a rule, I love joint visits. This work can be isolating and lonely and it’s helpful to have someone else with you sometimes, if only to cut your eyes at when the family leaves the room. I’ve been lucky over my career to work with a lot of wonderful nurses who relied on me for my expertise just as I relied on them for theirs. I think of hospice—of all interdisciplinary work, really—as a village. At its best, the team functions as a mini village where each person has their own role to fulfill: the nurse, medical care; the home health aide, physical care; the social worker, emotional care; the chaplain, spiritual care. Beautiful, right? Everyone has their own set of skills in the village, which complement each other and serve the patient.

There’s a balance to village life: just as I’m able to give to others, I have to do some taking, too. Obviously it’s not always an even split; that’s life. But with this co-worker of mine, the split is so off that something has to change. And I’m struggling with how to set a boundary without derailing a fairly new professional relationship. This visit may be the straw that is breaking my back.

I don’t want to go into too much detail, because the minutiae is not terribly important. The gist is, this co-worker attempted to do some psychosocial interventions in a clumsy, overbearing, awkward way, that only set the caregiver off (I told you he was angry, remember) and took the oxygen out of the room for a few minutes. It’s not her fault that she did the interventions poorly; she didn’t go to social work school. Just as I would never take someone’s blood pressure or tell them how much medication to take, another discipline can’t do social work.

Despite this very large misstep, she had a good rapport with the caregiver so the visit didn’t end in a yelling match. The visit was over shortly thereafter and even though I knew she wanted to debrief, I had to get out of there. I just about ran to my car, angry with her for disrespecting my skillset, frustrated with myself for not cutting the conversation off the moment it began, and overall feeling horrible, about that particular interaction and about how poorly I’d set boundaries with this co-worker.

Luckily, I have good supervision at this job so I called my supervisor for some validation and guidance. She gave me both and helped me find a way to set some solid limits. I want to be helpful; I want to be emotionally present for my colleagues. At the same time, I can’t be all things to all people. I love the village concept but as I said, there is a balance. I hope this co-worker and I have found the right balance so that we can move forward. This job is easier when you’ve got other people on your side.

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The perks of being grounded

Recently I got together with some of the girls I grew up with for lunch. It’s been more than fifteen years since we’ve all been together and I was expecting it to be a short little meetup. After all, what do we have in common after so much time apart? Instead, we chatted for more than two hours, until we all reluctantly had to get back to our families and our Sunday chores. I left feeling happy and surprised but also deeply grounded. These women know the most core parts of me. We’ve lived a lot of life in between our high school graduation and now, but still, they understand me; they brought me back to myself.

Since that lovely lunch, I’ve been thinking about that feeling of being grounded: namely how it makes this work easier. It’s different from self-care, a term which has been co-opted by pop culture so much I think it’s lost a bit of its meaning (a rant for another blog post). Being grounded is not exactly about self-care, though that certainly factors in. What I’m referring to is being strong in my own sense of self. So often in this job I’ve lost myself: because of difficult clients, micro-managers, my own counter-transference. There is often chaos in what we do, swirling around whatever the core of the issue is, preventing us from getting to the point. It’s easy to get drawn into the chaos. I think of family meetings I’ve been in where I was overtaken by stronger personalities or louder voices (hard to imagine, I know). Over the past decade of doing this work, I’ve replayed client interactions where I lost my patience or got over involved in the minutiae, missing the part I could actually help to change. At times I forgot how to listen, how to be still: core skills of our job.

I don’t recommend this strategy as a way to get grounded. As important as it is for us to examine our work, it’s even more important to walk in to the work confident in our strengths and aware of what we can’t offer. When we are grounded, when we know ourselves and feel strong in that sense of self-knowledge, that’s when our best work comes out. That’s when we are able to get to the eye of the storm and offer real help.

So. As you walk into your week, into the frustrations and successes and surprises of our work, I hope you are acutely aware of what it takes to ground you. For me, it’s being with old friends; watching my daughters play; and being outside. These are the ways I come back to myself. I hope you have a way back, too.

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A (small) ethical question

I’m in the midst of a lot of professional training, both for work and for my side hustle (“clinical supervision” doesn’t roll off the tongue as nicely “side hustle”). I love continuing education: I love being with other social workers; I love reading case studies; I love doing exercises about theoretical framework. (It turns out I kind of miss being in graduate school). Because clinical social workers are required to have ethics training every two years, a lot of my recent continuing ed programming has involved some ethics credits. We start, always, with the most egregious examples of social work ethical dilemmas: stealing from your workplace (BAD); falsifying documentation (PRETTY BAD); having sex with a client (SO VERY BAD). Those ethical questions have straightforward answers: don’t do that shit. It’s the grayer stuff that I like to turn over. And today I’d like to turn a personal one over with you.

Don’t freak out! I am not involved in any egregiously bad activities! It’s definitely one of the gray ones.

I have a patient I really like: she’s bright and funny and interesting. She has a fascinating career. I’m sure that if we met in a different setting, I would strive to be her friend. But we haven’t met in a different setting; I’m offering her counseling, not friendship. And sometimes I find myself forgetting that.

I write often about use of self and counter-transference but I don’t think I’ve yet touched on this: what happens when we really like our clients? Obviously we like most of them; social workers typically like people. I’m talking about the unique problem of liking a client personally, the way you would like a new friend for instance, and how to manage that.

In my current job, I’ve met almost 300 different patients. Of those, there are maybe 3 that I’ve bent the rules for: seen them for a whole hour instead of the usual 30 minutes, provided a few more personal details than I normally do with my patients. See? Nothing egregious. But definitely gray.

I had a colleague once who told me, when I worked in hospice, that if you get attached to one out of every one hundred patients, you’re ok. Any more than that and you should take a good hard look at your practice. I’ve passed that advice along a dozen times, at least; it makes sense to me. I’m not causing any harm here, to my patients or to myself. I won’t overstep any boundaries: we won’t meet for coffee or see each other outside of this professional setting. But I do want to pause and consider what it means that these people get a little more from me than my other patients get. Being mindful of how much of ourselves we give is one of my favorite ethical questions. Do I give less to the patients that make my skin crawl? Do I give more to the ones that are pleasant and friendly? Do I give too much or too little based on my own feelings? And, ethically speaking, is it ok if there are (small) differences in the care I provide?

The cool and also deeply frustrating thing about ethics is that there are often no clear answers; there are multiple scenarios and variables to walk through. In this case, I lean towards the side of giving myself permission to be a human person who sometimes gives a little less or a little more, depending on the circumstance. Of course I’ll always examine my practice and look closely for signs of trouble. But I also want to allow myself that one in a hundred; it’s part of what makes the work worth doing.

Photo by  Dil  on  Unsplash

Photo by Dil on Unsplash

Compassion Satisfaction

I’ve started—and subsequently wandered away from—a handful of blogs about secondary trauma and compassion fatigue. I’ve managed to write about the beginnings of burnout and a lot about self-care and self-reflection. But I was having trouble writing about the intense issues of compassion fatigue and vicarious trauma. Let’s face it, these aren’t the cheeriest of topics. But last week I was fortunate to attend a continuing education program that inspired me to finally finish a post about the emotional risks we face as social workers and how to manage those risks.

The event was offered by my hospital for social work month. We watched a deeply moving video about ow to heal caregivers. First responders, firefighters, police officers, nurses, and, of course, social workers spoke about their experiences with secondary trauma. I cried a couple of times, feeling the pain of strangers who joined a helping profession to help and found themselves mired in suffering. They talked about how their bodies reacted to stress over time or how they found themselves unable to sleep. Each of them showed an enormous amount of vulnerability as they shared some of the low points of their careers.

It was riveting. And it also showed me some beautiful interventions for combatting vicarious trauma. What follows are some takeaways from the video that have really changed my perspective; I hope you have a similar reaction.

  • Do you have a safety plan for burnout? We use safety plans for our patients all the time: for those who live with abusive partners or those suffering from suicidal thoughts. It never occurred to me that as helpers, as witnesses to that kind of intense suffering, we too could benefit from a safety plan. It doesn’t have to be dramatic: my go-tos have always been long lunches and journaling. The occasional root beer float has also greatly helped me on the hardest days.

  • Do you honor your grief? The program’s facilitator pointed out that secondary trauma and compassion fatigue are often grief. We use ourselves in our practice: we open our hearts and humanity to others and share their pain. It only makes sense that over time, the grief begins to pile up. As helpers, we need to honor our losses. I can tell you the names of patients I loved, who touched my heart and changed me; I honor those relationships by holding their memories close, by telling stories about them and smiling.

  • Do you celebrate your successes? My favorite part of the program was hearing the phrase “compassion satisfaction.” Of course there is fatigue in caring for others, but we are also drawn to this work for a reason. As social workers, we are trained to constantly reflect on ourselves and our work but I think we tend to reflect on our challenges and our failures. Instead, the facilitator of this presentation encouraged us to focus on our successes. I challenge you to do the same: what have you done well? What joy did you get to take from your work?

I love being a social worker. It is one of the great pleasures of my life to do this work. As we end social work month, I hope you feel honored by your co-workers and by our profession. Share your joy; we are helpers and healers and we deserve to be recognized for our good and useful work.

Stuck in the weeds

There is not enough money in the world for me to ever consider doing couples therapy. Honestly, I’ve always felt that way; I know what’s in my comfort zone and what’s not. The reason I bring it up today though, is because I found myself thrust into that role and it. Was. Tough.

I’m not in love with my current job but there are perks. For one, it’s short-term so even if the patient I’m seeing is incredibly difficult, I have a nice out: we only have to see each other a handful of times and then either we’re done or I’m referring out to a community therapist. Another perk is that although the majority of my referrals are people with anxiety and/or depression, I encounter a variety of situations. I’ve seen someone with a bridge phobia; recently met a woman struggling with her fiance’s infidelity; and have provided education about a possible Bipolar II diagnosis (a few times, actually). For all my complaints about this job, it’s been a good opportunity to enhance and vary my skill set. Hospice had its variations, of course, but I was there for five years and I was pretty comfortable with my role. This job has a whole other set of challenges and even a year and a half in, I’m still facing new and tricky situations.

Like yesterday, for instance! A woman called to schedule an appointment for her partner (which always puts me on guard because how motivated are you if you aren’t even making your own appointment?) and then they all showed up together: the patient, the partner, and their small child. Which is fine, in theory; a lot of people prefer their loved ones to be with them at doctor’s appointments. But about fifteen minutes in, it became clear to me that my patient and his partner need some serious marital counseling that I cannot provide. First, because my role doesn’t allow for it. Second, it’s very much out of my scope of practice. And third—probably most importantly—the counter-transference was suffocating.

This is not to say that my marriage is in shambles and I didn’t realize until this session; it wasn’t that Freudian. It was more that in my heart, one person was SO wrong and the other was SO right and it made me feel sort of thought-blocked. Like, I knew I couldn’t say that out loud but I also was really having trouble navigating my own feelings. I spent a lot of time saying, “It sounds like you’re saying X and you’re saying Y, and you’re not really in agreement about the basic facts.” It was not my most insightful work, friends. But afterwards, as I’m processing and debriefing and writing this all out, I’m not sure there was anything more I could or should have done.

This many years into my career, I’m comfortable telling people I don’t know the answer. But every so often, a session gets a little bit away from me and before I know it, I’m trying to navigate a situation I don’t really have a handle on. In those sessions, I have to get back to basics: here’s what I can do, here’s what someone else may be able to do, what do you want to do? I’m left with another good reminder to be mindful of what the goal of the work is: to help, whenever and however we can, and to know when we can’t.

The gift of the work

I started off my day already over it. Yesterday only one of my five scheduled patients bothered to show up. This day was starting with a patient I had seen a year ago who told me the exact same story she was telling the first time we met. This was followed by another no-show and yet another frequent flyer patient who never wants to do anything to change. Overall, I was ready to leave the building.

My last scheduled appointment was a lady who didn’t really want to see me. Her son had cajoled her into coming and she went along with it because she’s a mother and sometimes we do things we don’t want to do. Granted, this woman’s son is in his 60s but still: you never stop being a mom. And your kids never stop wanting you to be well.

Still. This lady wanted no part of it. And I really couldn’t blame her. She’s depressed because she’s basically just waiting to die. She’s had a lot of loss, more than her fair share, as she says. And for awhile we just sat there staring at each other because she didn’t know what I could do for her. “Nothing’s going to change,” she kept saying. “What’s the point of talking about it?”

I was mentally cursing her son for not hearing his mother clearly say she didn’t want to come when suddenly something did change: she started to talk. We talked about what it means to get older, how much loss there is and how lonely it is. She talked about how even in her depression, she’s content with her life. She talked about the child and husband she’s had to bury and how she’s kept those losses tucked away in a little box that she hides from the outside world because she doesn’t want to disturb them. Then she talked about climbing trees when she was a little girl. She smiled. I did too. She said she’d think about coming back.

The rest of the day shifted in my mind. It’s been a long week and I was feeling useless and out of my depth and frustrated. I could hear myself being impatient with my other patients, wanting to rush them out of the office because I didn’t know what they wanted from me. I know what burnout looks like and I could see myself gliding towards the flames. This lovely lady brought me back, just by opening up a little bit and allowing me to listen.

Now I’m not saying that we should rely on our patients to keep us engaged and upbeat about our work. But I also can’t deny that success with one patient at the right time can make a world of difference. It is, I think, what keeps us in the work: watching people be helped, even just for a moment, and knowing that we are the helpers.

I’m also not denying that I’m nearing a burnout point; it’s time for a vacation, clearly. But I am relieved to know that I haven’t completely checked out. This is another gift of this work: the reminders that come from the grace of others, in letting us bear witness to their pain, even though we don’t have any magic answers. How lucky for me that this lady came along today, to remind me.

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The wave of grief

My referrals seem to come in waves: one month it will be folks who need help managing their diabetes; the next will be a wave of young patients with anxiety. This is only anecdotal evidence of course, but it was like this in hospice too: you begin to notice some trends. This particular month, it’s grief.

I’m quick to say I lead a blessed life, but it has not been without great losses. My mom died three and a half years ago when I was pregnant with my older daughter. It was a terrible time, of course, but her death was not unexpected. In some ways it was a relief; she suffered for a long time. And since I was pregnant with a very wanted baby, there was a lot of joy intertwined with my devastating loss. When she first died, I still worked in hospice and I found that I was able to use my grief to help patients. Not every day of course, but sometimes the conversation opened the door to self-disclosure and it felt both clinically appropriate and personally beneficial.

More time has made it both easier and harder. Lately, the patients I’m seeing who are struggling with their grief are focused on how much time has passed. “It’s been two years,” one told me, “I should be better.” Should is a useless word, especially when it comes to how we feel. I describe grief to those patients as ocean waves: you can be standing at the shore for a long time and not notice them. Then suddenly one knocks you over without any warning. I know this as a clinician and I know it as a daughter without a mother, but still. Still. My own grief sometimes sits on my chest like a weight, making my breathing a little shallower. There is a pricking feeling behind my eyes that signals tears. In those moments, I am afraid that I won’t be able to hide it. I haven’t lost it yet but recently I have felt very close.

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This is grief, I remind myself. This is a big ocean wave. This is because I had a baby recenty and my 3 year old only knows my mom through pictures and because the holidays just passed and because now that I’m a mother, I understand her so much better but I can’t tell her that and because… Because. This is grief.

The question now is, what will I do with it? I’ve been guarding it like a secret but I know that sunlight is the best disinfectant. So here I am, bringing it into the light: I’m having a hard time. Now I’m going to be mindful and intentional and not let myself be swallowed whole. Self-care is sometimes stepping back and being well. And the occasional afternoon hot chocolate. I learned that one from my mom.

The body knows

I had a tricky interaction with a patient a couple of weeks ago. A patient of mine (who has an extensive trauma history) made some comments about my children not being safe in daycare. She knows I have kids because she asked once and it’s such an innocuous question, I didn’t even think about answering it. In fact, I don’t generally have strong feelings around self-disclosure; sometimes I think it can be helpful to build rapport and trust so I don’t worry about answering mild questions from patients. This is all to say, I had no problem with this particular patient knowing a little personal information about me. That is, until she hit me with this nonsense about my kids being in danger because I’m not at home with them full-time. This is a touchy subject for me, because it’s a deeply personal choice that has several variables and the judgement around it feels absurdly sexist. When she said that I should be careful, that bad things could happen to them because they’re with strangers most of the day, I had to work very hard to be still and not let my face betray my internal, white-hot rage.

In the actual moment, it passed fairly quickly. I squashed it down and told myself that this woman thought she was being helpful; she wasn’t intentionally being cruel. (She even told me that she was being grandmotherly with her concern. Ok, lady). It was later, when I brought it up in supervision, that I realized just how very upset it made me. Telling my co-workers about the experience, my hands started to shake; I felt my breath quicken and my face get hot. And I realized, I was still really worked up about those few minutes!

It got me thinking about how we listen (or don’t) to our bodies when we’re working. I’ve written before about working with frustrating patients and suddenly becoming aware that my shoulders are up by my ears and my fists are clenched. How does it sneak up on me? Because I’m not really paying attention to my own body. There’s a lot we have to do when we’re with clients: listen actively, reflect back, read their body language, etc. But we also have to listen to what our bodies are telling us; often we react physically before we’re able to name what we’re feeling.

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Personally, I especially struggle with being in touch with my physical self when I’m uncomfortable with the energy in the room. Give me someone on a crying jag any day; I can sit with that heaviness and have no problem being in my body: breathing deeply, being still, creating a space for vulnerability. But when a patient touches a nerve (usually unknowingly), my fear or discomfort or anger arrive first in my body, try though I may to ignore those feelings. In those moments, I’m trying so hard to reserve judgement and be still and present that I ignore the warning signals that I’m about to emotionally check out. When I feel my toes curl in my shoes and my hands grip the sides of my chair, it’s usually a sign that I’m not going to be at my best, clinically. In those moments, I have to recenter: I take deep breaths; I practice stillness. Then I take my ass to supervision, because clearly I have some things to work out!

The body knows; we do better when we remember that and listen to what we’re being told: to slow down, to reflect, to breathe. And to utilize supervision!

Expanding with creativity

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I’ve struggled to find my voice as a therapist. I’ve tried on some different hats: motivational interviewing, CBT, narrative therapy. Part of the challenge is that my role in this job has been nebulous to say the least: there’s no standardized practice yet so I’m just kind of… on my own. I also see such a variety of patients, I find myself constantly looking things up and reviewing interventions. It’s interesting in that way, but it also adds to the challenge of figuring out which intervention feels right, both for me as a clinician and for my patients. In order to provide the best care, clinicians need to be comfortable with the model we’re using. For a long time, I’ve shied away from being creative in my work because I felt uncomfortable. But the more I grow into this role, the more I see the benefit of some more creative thinking.

Social work lends itself to invention and innovation. There are all kinds of ways to get people to open up to you and for some patients, the outside-the-box stuff works best. I must admit, I’ve been resistant to using creativity in my practice for years. Colleagues of mine in hospice talked about using empty chairs to signify the presence of a departed loved one, or using art or music to help clients express their feelings. The thought of doing those things made me feel deeply awkward. I felt similarly as a grad student whenever we had to role play to practice our clinical skills; it felt silly and inauthentic. That feeling carried over into my work: it would be too uncomfortable for me to ask someone to talk to a chair and pretend their deceased loved one is in it; it would be too awkward for me to explore a piece of music with someone in therapy and ask what kind of emotions it brought up for them. Actually even writing that sentence feels awkward. But why is that? Why should my fear of feeling silly block out a large chunk of practice?

It’s not an overnight change. Little pieces have been creeping in over the past year as I try to figure out how to work with patients who really want solutions. I’m somewhat limited because my role is short-term but there are options. For instance, I sometimes encourage my patients to create a Tree of Life (a narrative therapy tool) so they have a visual expression of their values and goals. It’s an exercise I’ve done myself and I think that’s key: we have to be comfortable with what we’re asking others to do. Most recently I attended a training about psychodrama and sociometry and used one of the exercises (a locogram/floor check) in my supervision group. We all got a chance to move around a little and talk about what skills we have, which we want to develop, and why we’re drawn to/avoid some populations.

I’m excited to stretch in this way. I’ve written in the past about how frustrated I’ve been in transitioning to this job and this is a great way to get unstuck from that. Using my brain in a different way helps me reorient to what I love about this work: every day is a new and different challenge.

Boundaries

I think (and write) a lot about boundary setting in my work. It was a thornier issue for me when I worked in hospice; being in people’s homes makes the lines all the more blurry and the boundaries rather flexible, in my experience. Now that I’m in a doctor’s office, it’s easier to draw some firmer lines. No one is offering me food, for instance. I’m not sitting on the edge of someone’s bed. I visit with patients in empty exam rooms; there aren’t any pictures of my family or any personal artifacts. Still, the balance of building rapport while keeping firm boundaries remains.

Take, for instance, a regular patient of mine. We’ve seen each other off and on since I started this job a year ago. We’re actually nearing the termination process now, much to his chagrin. He’s a nice guy; I like him a lot. But lately he’s been a little more familiar with me and I’m struggling with whether or not to push back.

Familiar feels like an odd word to use here but it’s sort of the only way to describe it. He’s not outwardly inappropriate; there’s nothing he’s said or done that I could point to and tell him to knock it off. It’s been an insidious little bit of boundary pushing. It started with an increase in cursing during our sessions. (Which honestly, if you’ve spoken to me for more than five minutes, you know that I have a foul mouth. I come by it honestly: my mother swore like a sailor). The words don’t bother me per se; it’s more that he used to watch what he said. My patients often apologize for swearing during a session, to which I answer that I’ve heard all the words before. I even allow myself the occasional “this is shitty” or something to that effect, if the relationship is there. But this patient’s frequent use of heavy curse words feels more boundary pushing than before.

Maybe I wouldn’t even have noticed except that the swearing comes along with a little more… flirting, for lack of a better word. Again, nothing so outrageous that I could give a firm, “not appropriate, knock it off.” More a subtle change in his tone of voice, a casual remark here or there. I have a feeling my female friends know exactly what I’m describing. If I mentioned it to him, he’d surely say he didn’t know what I was talking about. It’s subtle and honestly, I’m not totally sure he realizes he’s doing it. Which is partly why I’m struggling with what to do about it.

I should state here that I don’t feel unsafe; that’s a different topic for a different day. My discomfort is more about how I’m reacting to his boundary pushing. I’ve found myself coming back with a little attitude. For instance, he asked why I won’t be at work on a particular day (we were scheduling an appointment) and I jokingly replied, “None of your business.” We have a good rapport, so he laughed and said he was only kidding. It was a deeply awkward moment though. It’s the kind of response I’d give to a guy in a bar, not to a patient. But because I kind of let the boundaries blur, I let things get away from me.

That being said, this is not unsalvageable. And it’s possible that some of the over familiarity on his part is because we’re terminating our relationship soon and he has some feelings about that. Whether we’re going to address them the next time we meet really depends on how the session goes. I can consider different reactions to different things but I cannot predict the future (sadly) so I’ll just have to wait and see how it all shakes out.

In the meantime, I’m considering how I relate to my patients and if I need to take a more clinical approach. I don’t think there are any hard and fast rules here; it’s a case by case approach. I think what’s really needed is a little more self reflection and maybe a little pulling back. I guess we’ll see how hard he pushes and therefore, how hard I’ll have to pull.

Ah, clinical social work: where every interaction is deeply weighted! I guess it’s part of the charm of the work. Right??

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Who's doing what?

Yesterday I met with a fairly resistant client. Everything I said—every suggestion, every reflection—was met with, “probably” or “I don’t know.” It was frustrating but I tried to pull out some of my (rusty) motivational interviewing skills and get her to state her own goals. We managed to come up with a couple of strategies to reduce her isolation and improve her mood; I was feeling pretty good about our limited progress. Then she hit me with this response: “So it’s all on me, huh.”

YES. YES, IT IS.

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This has been a frequent experience lately in my practice: my patients want answers but they don’t want to change anything. Listen, I hear that. I want to lose weight but I don’t want to stop eating whatever I want. I have no trouble empathizing with that impulse, of wanting to get better without actually doing the work. What I’ve been thinking about during and after these interactions is whether I’m being clear about how therapy works. Namely, which one of us is doing the work here.

As clinicians we often want our patients to do what we think is best: quit smoking; leave an abusive partner; practice some deep breathing. But our patients don’t want to do those things. They want to feel better, sure, but they don’t want to make any changes. We meet at this impasse a lot of the time and try to figure out how to move forward together. We are both resistant. We both want the other to do the lion’s share of the work.

And who’s right? As a clinician, I’d say I am of course! (Ha.) I can’t do the work for people. I can’t put down the cigarette or leave the boyfriend or do the deep breathing (I mean, I can breathe deeply obviously, but not for someone else). But my patient wants to feel better right now. And they think the key to feeling better is making other people do some work.

Of course, I don’t do nothing. Ultimately I try to gently lead someone towards the things that are in their control instead of allowing them to focus on the things that are out of their control. I try to get them to see that they have to do the work, even as they wish that I would do it for them. I wish I could, too. Sometimes they don’t come back, maybe because they’re not ready. Or maybe because I’m not the right fit for them. I have to do my own work there, not to take it personally and use every clinical experience I face as a chance to reflect on my practice. As I told a patient this morning, I’m growing too. That is the gift of the work.

Finding Compassion

So what do you do when you just don’t like the patient sitting across from you?

I love people. It’s part of why I chose this profession. I love to hear people’s stories. I like to sit in the front seat of cabs so I can ask the driver a bunch of questions about his family and his life. Call it nosiness; I prefer to call it a love for the human experience. Life is a rich tapestry, as one of my favorite advice columnists often says, and I like to know all about it.

But sometimes I meet a patient that really gets under my skin. I’m not alone in this, I know. We can all point to patients or clients we’ve had that just get on our damn nerves. Right now I have two patients that are casually misogynistic and homophobic; further, they are never the problem. According to them (they’re strikingly similar, actually), it’s everyone else: their children, their exes, their friends. They aren’t the ones making their own lives miserable so why should they have to change?

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I’m sure you can hear (read?) in my tone that I’m irritated with these guys. I especially resent the casual way they demean women when they’re sitting right across from one. Can you not have a little respect for my gender when you’re looking right at me?

Then, I think: maybe they can’t.

Some folks really are stuck. Their life experience tells them that they are victims and they really aren’t interested in looking any deeper than that. And really, in this role, it’s not my goal to go that deep. My goal is to help them figure out what’s making them feel anxious/depressed/stressed out and help them find their own solutions. I have the luxury of not seeing these people for years on end for true psychoanalysis. Rather, I get to help them name their issues and seek solutions for them.

The thing is, that means I have to let go a little of my own stuff. If the patient tells me that his gay son is ruining his marriage, I’m not going to get into a deep discussion of his homophobia, or his own insecurity about his masculinity, or what it means to him that his son is gay. Rather, I have to drill down on what he sees as the issue: it’s him against his wife and son. I have to help him figure out how he wants to handle that.

Inside, I’m cringing. This conversation is so gross to me. The moral part of me is screaming internally. But I’m not in private practice; I can’t refuse to see a patient that’s referred to me by one of my providers because I have feelings about his values. So I see these guys and I remind myself why I’m there: to provide short-term intervention. If it’s appropriate, I can gently push back on some of their prejudices and assumptions… but most of the time, that’s not what I’m here for. Instead, I have to let their comments roll off my back. I have to remind myself that one of my core values as a person and a social worker is that everyone is doing the best they can with what they’ve got. And I don’t get to enforce my morality onto someone else when I’m providing therapy.

So I make space for the sometimes awful things I hear and focus instead on the important underlying truths: there’s a lack of family support. Or there’s an ongoing struggle with conflict. I direct the conversation to what can be changed rather than all the wrongs they see placed upon them. And I direct myself to grace and compassion: it doesn’t matter if I like them or not, my job is to help. I’m not better than the person sitting across from me. These tough patients are a good reminder to be kind and humble, even if they are, in the moment, a real pain in the ass.

Barriers that can't be helped: What patients see

I’m currently very pregnant. Like, people are surprised I continue showing up to work kind of pregnant. But here I am, seeing my patients, explaining my role, and assuring them that someone will be covering for me when I go out on leave.

Recently, I’ve had a few patients gesture at my belly and say something to the effect of, “you’ve got your whole life ahead of you, you’re doing something exciting/meaningful, and what have I got?”

I used to hear a mildly different version of this when I was a hospice social worker: “you’re young, you can’t understand what this is like,” meaning I couldn’t possibly have experienced loss because of my age. I often struggled with that pronouncement because I have suffered some significant losses and I resented that those experiences were being minimized. Of course, my patients didn’t know that. All they saw when they looked at me was a young woman with her life ahead of her as theirs was ending. The actual words were not so important; it was the feelings underneath that I had to focus on. They wanted to know: how could they be vulnerable with someone who wasn’t in their shoes?

 This is not to say that my feelings in these moments aren’t important. I’ve written before about the need to use our own feelings in a therapeutic role. But the negative feelings that arise during client interactions are better dealt with after a visit. Therapy is for the patient, not the therapist. We have to deal with our shit at a later date.

And deal with it we must! But what do we do in the moment, when our patients challenge us in this way, for things we can’t help, like our youth or ability to bear children or our race or gender? And what do we do with the feelings that arise when we’re called out for the audacity to be different from the person we’re treating?

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So much of this work comes back to our early training: good old active listening will help you almost every time. When a patient says that my life is beginning as their life is ending, I take myself out of it as I reflect back to them (after all, I’m not really the issue here): “You feel like you don’t have anything to look forward to.” Or, “it sounds like you feel sort of purposeless, is that right?” I think sometimes patient want to talk about us because it’s less scary than talking about them. That’s a fair impulse. It’s our job to gently redirect and help our patients get back to the heart of the matter. And it’s fair to acknowledge their feelings about talking to someone who isn’t their age/gender/religion/whatever. Naming awkwardness is the best way to get past it. A clinician needs to have some level of vulnerability in order to help her patients be vulnerable too.

But after the visit, how do we sort out our own shit? I may understand rationally why people struggle with my age or my pregnancy or what have you. But when the patient leaves and I’m writing my note, I often feel frustrated by their judgements. I wonder if I was effective in the visit, if I should have drilled down harder on a statement. I second guess myself. I find myself feeling resentful about an off-handed comment. To cope, I do what I tell my patients to do: I examine the thought and try to let it go. If it’s a particularly difficult one, I talk about it until I’m tired of the sound of my own voice. I find that talking about something to death diffuses its meaning. And I remember to view it all with compassion. Our patients come to us with their own shit too; our job is to help them sort theirs out and deal with our own stuff later. Preferably in supervision!

Being the bridge

My role in this job is to see people for short-term issues. Think insomnia, smoking cessation, mild anxiety due to stress, etc. But maybe a third of my referrals are for patients who have a long history of mental illness. These are people who have been disconnected from mental health care for a long time. Part of my job is to be a bridge for them: connecting them to care and hanging with them until they can get into a therapist’s office.

So I have this patient who has seen about a dozen different psychiatrists over the years; in and out of psych in-patient, in and out therapist’s offices, in and out of intensive out-patient programs. To protect her privacy, I won’t go through the laundry list of diagnoses that follows her. But I will say that she has a handful of very complicated diagnoses coupled with a trauma history and a history of substance use. Very much out of my scope, both in this role and in general. But we started meeting anyway, every couple of weeks, to tackle her anxiety and (on my part) try to reconnect her to more intense help.

I like this patient; she has a good sense of humor and we just hit it off. But some of what she told me was just so far out of my experience, I didn’t know what to do. So I went to supervision.

It’s not that I didn’t know what I should do. I knew that she needed a higher level of therapy than I’m qualified to provide. But I didn’t know how to convince her of that. This is a woman who has been in and out of therapy for 30 years; she is deeply distrustful of psychiatrists and very reluctant to meet yet another therapist. But meeting in supervision helped me craft the right words: that while I like her very much and enjoy working with her, I’m not the right therapist for her.

Much to her credit, she was gracious and understanding. She appreciated my honesty and agreed to try it with someone else. So I referred her out to a therapist with a trauma background who was also trained in EMDR. I talked to the therapist myself; she had experience and she was taking new patients. What could go wrong?

It should not shock you, dear reader, that it did not work out. My patient called me after she had her session with this therapist to tell me that the therapist “couldn’t help her.” At first I thought maybe my patient was misrepresenting what happened (read: I thought she was lying to me). Again, I went to my supervisor. He pointed out that there are bad therapists; what she said could be true. I had to ask more questions.

More conversation with my patient made it clear to me that she didn’t misunderstand or misrepresent the session. She met with the therapist for an hour and it ended with the therapist saying, sorry, can’t help you.

Some self-disclosure here: I’ve seen bad therapists. I’ll spare you the details, but I have certainly left a therapist’s office wondering why they had chosen this profession; their rapport building was so subpar, their attitude so shitty, I felt worse than when I went in. So maybe the therapist I sent my patient to was one of those. Or maybe she wasn’t having a good day. It happens; we are, as I keep writing on this blog and saying out loud to the women I supervise, only human. Still, I was disappointed. I had convinced this patient to see someone else, only to have her be shown the door.

Luckily for me, my patient trusted me and she agreed to try again. This time I was a lot more diligent. I made about ten phone calls. I gave an in-depth report about my patient’s history (with her permission) to the people I spoke to. Just before I was about to give it up for a while, I connected with someone who agreed to see my patient.

This patient stopped in the other day, after she saw her doctor. She’s been going to therapy weekly, which was thrilling for me. She thanked me for my support and my help. She looked good. We got to share a moment of mutual admiration and respect that carried me through the rest of my day.

I know it won’t always end this way. I know I’ll make referrals that patients won’t follow through with or that won’t work out for some other reason. But man, I am holding on to this small victory for now. The combination of supervision and doing some extra leg work paid off and I’m so happy for my patient; she’s getting the help she needs. Often the best thing we can be for the people we meet with is a bridge to something better. And how fortunate we are to be that bridge.

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Meeting Resistance

I met with a lot of resistance when I worked in hospice. I had plenty of patients who didn’t want to sign a Do Not Resuscitate form, for instance, or who didn’t want to take the medication that would keep them comfortable. Sometimes it was frustrating but for the most part, I accepted that resistance as part of the job. After all, people were literally dying. Who was I to tell them how to live out the rest of their lives? I remember once, at a consent signing, the son of a patient told me that his father “wasn’t handling his death well” and I thought… Well, he doesn’t need to; it’s HIS death. I wasn’t particularly troubled by those moments in that job because the big picture was so very big. Death has a way of throwing things into a very clear perspective.

But now I’m not a hospice social worker anymore. Now my job (a lot of the time) is to help people make changes to their behavior so that they have less stress, less depression, less anxiety, and better health. I feel pressure from the doctor who makes the referral and pressure from the patient who says, this is bad, fix it. And in these sessions, when I meet resistance, I struggle.

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I’ve been trying to use motivational interviewing because a lot of what I’m meant to do is help people focus on behavior change. When using motivational interviewing with a patient, the clinician is supposed to keep in mind the stages of change. The first stage is pre-contemplation. Basically, these patients aren’t ready to make any changes. Even if they know they should quit smoking/lose weight/take their medication/you name it: they aren’t there. Sometimes the goal with these patients is just to help them identify what the consequences will be if they don’t take any action. Sometimes they don’t come back. It’s one of the basics of social work, right? MEET THE CLIENT WHERE THEY ARE.

But sometimes I really resist that!

This has been bugging me because I recently met with a patient who shot down everything I said. Every. Single. Thing.  I tried to join him with empathy. I reflected back to him what he was saying to me: job too stressful, health too difficult to manage, lack of social support. I tried to listen for change talk; when he said that he knew he couldn’t continue the way he was going, I seized on that like a drowning man grabs a life preserver. But he wasn’t having it. The session can be boiled down to me saying, “So what about…” and him saying, “nope, won’t work.”

In the end, we were both frustrated. He had started the session telling me that he didn’t think I could help him and honestly, my delicate ego had been marching around my mind the entire time, telling me I COULD help him and I WOULD! But at the end of it, we hadn’t moved much. He was resistant to me and I was resistant to him and we were both stuck.

This is one of those things that keeps coming up for me, however many years into my social work career: dealing with the impulse that screams PLEASE LET ME HELP YOU. It’s disappointing to me when the patient doesn’t want to do anything to change their circumstances. But why is that? Why do I want it more than the patient? Why do I measure my competence as a clinician through how a patient responds in one half hour session? If I’m being generous to myself, I can say it’s because I became a social worker to help people; I want people to leave the session with a plan to feel better. Less generously (but no less true), I let my delicate ego make me think I can save everyone, even people who didn’t ask for it. I’m resistant to their resistance and that’s just not going to work.

So I’m taking a deep breath and stepping back for a second. Pre-contemplation just is; same with resistance. I don’t have to move anyone forward. I don’t have to have any goal except for the goal the patient has given me. I can let my expectations go and get back to hearing what the patient in front of me is saying. And sometimes it may be, “I’m not ready.” And my response has to be, Ok. Tell me more about that.

CBT Yourself

I frequently use my dad as my ad hoc clinical supervisor. He’s a doctor (retired, he’d be quick to tell you) so it’s not quite the same as talking to another social worker. But he’s one of the smartest people I know and he’s also very Zen Master, which is sometimes just the combination I need. Recently I was complaining about someone I work with (I’ll spare you the boring details) and I ended with, “She just gets on my nerves.” To which my dad replied, “You could just… not let her get on your nerves.”

Oh.

I keep turning that over in my mind. This is what we ask our clients to do, right? This is some kind of cognitive behavioral therapy mantra: don’t let it get to you. That’s the strategy I go to with people who are experiencing stress that’s out of their control. I help them find a way to let it go a little, to react in a different way, to retrain their brains. But what if I can’t CBT myself? What do you do when you’re the one who’s stuck?

This is not a new feeling by any means. I’ve had bad jobs. I’ve had bad supervisors. I’ve been to bad therapists (or at least they were having bad days; I like to give my colleagues the benefit of the doubt). I was able to walk away from those situations and from those people. That’s not an option in this instance. I work with this woman and that’s just that. So what do I do with my feelings (which are not facts, as I remind my patients daily!)? How do I take my dad’s very fair point and not LET her get on my nerves?

I’ve written before about how important self-reflection is in this work. Faced with a patient that makes us cringe or a job duty we really don’t want to perform, we are tasked to look beneath it. Why am I feeling this way? Where is this coming from? What can I do about it? But all the self-reflection in the world only gets you so far. I KNOW why I don’t like this woman; it’s partly because she doesn’t like me! (A topic for a whole other post about my own insecurities and ego. I will spare you that particular trip into my psyche). I know why I’m struggling with this working relationship; it’s because I’m struggling with this whole job and this is just another symptom of my frustration. I know all this because I’ve talked with myself about it. The question is now, what to DO about it?

I suppose I know the answer already. It’s what this whole blog is ostensibly about: I have to go back to supervision. In the meantime, I can vent to friends; try to shake it off when I feel it; and, of course, not let her get to me. I’m the one in charge of my own feelings (as I tell my patients. Daily. I’m starting to see why they get frustrated with my helpful suggestions). I’m trying to remind myself, this is just a moment. And if I forget, my dad can put on his clinical supervisor hat to remind me. I’m lucky that way.

The gift of counter-transference

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There's a short story collection I adore called The Girl's Guide to Hunting and Fishing. (I highly recommend it, the narrative voice is delightful). There's a line in one of the stories that I repeat to myself frequently, especially when I’m being too hard on myself: "too late, you realize your body is perfect; every healthy body is."

I am especially reminded of this today, as I sit across from a young woman (just a little younger than I, actually) who was diagnosed with a chronic auto-immune disease a little less than a year ago. We are not terribly different: she has two small kids, a husband, a house she wants to keep in better shape, and her mom is not with her anymore. But there the similarities stop. Because she is sick and I am not and that is just our luck: her bad and my good. Sitting before her, sitting with the discomfort of her crying and my inability to do anything that will really help her, I am struck by how lucky I am to have this healthy body. It is a thought that stays with me for the full 20 minute session, rolling around in the back of my mind, begging to be explored further. These are the kinds of feelings that make supervision at all stages of our career a necessity.

What I’m feeling is counter-transference. I’ve written about this phenomenon before and why I think it can sometimes be a good clinical tool. Counter-transference can simply be a deep sense of empathy with a client. Empathy is the core of social work. It is the foundation upon which everything else is built: advocacy, behavior change, clinical therapy. Our ability to see ourselves in other people, to witness suffering and truly understand it, is what makes us good humans and good social workers. Counter-transference can be used to build rapport, even in a short session like the one I had with this woman. But it can also linger in our minds and pick away at us, leading us to burn out.

It's true that I felt helpless sitting across from this woman but the truth is, there are ways for me to help her. There are CBT strategies for people with chronic illness that I can help her explore. I can refer her to a support group. I can witness and validate her pain and frustration. The parts I’m struggling with, the counter-transference that is lingering in my mind, are the other truths: I cannot cure her disease. I cannot fundamentally alter her new path, which is one of doctors and medication and setbacks as she experiences flare ups. These are uncomfortable truths for me, especially as I sit in front of her with my perfectly healthy body and my growing, healthy pregnancy.

Counter-transference is complicated, like most feelings. It is both a help to our practice and a hindrance. Today, for me, it was both: it helped me establish rapport quickly with a new patient but it also hurt me to bear her pain. Ultimately, those twenty minutes are a part of my own personal growth. I was reminded, humbly and beautifully, that this body I complain about (because I’m pregnant, because I’m 5 pounds heavier than I want to be, because because because) is perfect, because it is healthy. And this work, which troubles me and excites me and frustrates me, is a gift. 

Recognizing our own shit

I was not at my best the other day. I met with a patient I’ve seen a handful of times who is struggling with managing her depression. I won’t lie, I was feeling frustrated. This was our fourth meeting and it was almost verbatim the same conversation we had had in our three previous sessions: her son is annoying, she hates getting older, she wants to meet a man, the people in her building are awful… Every single thing in her life is terrible as far as she’s concerned. It’s an exhausting conversation. Today I just couldn’t take it anymore. So I said (gently), “We’ve been having the same conversation every time you come in.” To which she answered, “Should I not come back?”

Photo credit: Daniel Garcia, Unsplash

I can be honest here, in my safe space, the blog that a half dozen of my lovely friends read: I was briefly tempted to say, yep, don’t come back. But I’m a professional and I can’t give in to my baser instincts. Instead, I silently checked the feeling and took a breath. “That’s not what I meant,” I clarified. “I just meant: I can’t change the way you feel. What I can do is help you figure out how to make changes to try to feel better. And if you don’t want to do that—which is your right!—that’s fine. But if that’s the case, then I don’t know how I’m going to be any help to you.”

Her reply was, “It’s hard.”

Just like that, my compassion came rolling back to me. My shoulders dropped a little (I hadn’t even realized how tense I had been, how physically rigid in reaction to my frustration). She was right: it is so hard. It is hard to feel stuck and depressed and lethargic and not be able to see your way towards the light. It feels permanent, even though it’s not. It feels like shit.

In that small sentence she reminded me of two things: one, it is hard and I should not forget that; and two, it’s not my problem to fix.

I don’t mean to sound cold. But here we are again at another truth of The Work: you cannot do it for someone else. I can’t wave a wand and have this woman feel better. I can only lead her to her own conclusions. And the right thing to do when faced with the frustration I felt is not to say, yeah don’t come back; instead, it’s to push through the ambivalence and the frustration that she is surely feeling and help her decide to make a change.

I don’t know if she will come back; I may have messed up enough that she seeks help elsewhere. I hope that’s not the case. Either way, another learning point for me: check that counter-transference before it interrupts the relationship! This is part of the reason we continue to have supervision throughout our careers: to manage the feelings that bubble up and interrupt. After all, we’re only human.