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

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.

Photo by  Leone Venter  on  Unsplash

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

Photo by  Lucas Sankey  on  Unsplash

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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