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 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. 

Who I am/What I do/Is there a difference?

My dad is a doctor. So is his brother and so were both of their parents. It's probably part of the reason I'm drawn to medical social work. I never wanted to be a doctor; I don't have the interest or the aptitude in science. But I did want to somehow be a part of the medical field. I was always drawn to my family's stories about illness and disease. It's just that I was more focused on the story part: what was the family doing? How were they behaving? Had I known then about genograms, I probably would have convinced him to draw me one for the more interesting cases (sans names and identifying details, of course). The point is, I was fascinated by the people part of his work. That's a big part of how I got into this part of the field.

Photo by  Hush Naidoo  on  Unsplash

Photo by Hush Naidoo on Unsplash

Growing up, my dad's profession was so much a part of our lives: his call schedule, stories about his patients, pens and notepads from the drug reps. He loved being a physician (he's retired now, though he volunteers so he's still doctoring) but I don't think he ever felt that it defined him. If you asked him about himself, I don't think "doctor'' would be the first word that came to his mind. Whereas I feel that so much of my profession is a part of my identity; I can't turn it off.

Still, we're actually not unlike each other in that respect. He may have wanted to turn it off at times but I have a lot of memories of his various in-laws and friends starting a sentence with, "I have this pain" or "can you look at this?" He would always oblige (because he's a kind human) and I don't know if it ever bothered him. For him, I suspect it was just that he had all this knowledge and he was happy to share it if someone asked. 

For me, it's a little more complicated. I find myself unable (unwilling? Something to explore in supervision!) to turn off the social work part of me. It's like having antennae that pop up when someone starts telling me about their complicated family dynamic or their aging parent. I have to stop myself from giving unsolicited advice at times, or even accidentally blurring the line between friend and therapist. My girlfriend calls me a friendapist. It's a very cute nickname but it gives me pause; should I be more careful about turning off the social worker when I'm with the people I love?

Photo by  Will Oey  on  Unsplash

Photo by Will Oey on Unsplash

This is partly in the forefront of my mind because I just finished an ethics CEU. As you can imagine, there was a lot of talk about boundaries. In my practice, they're easy to set: I'll meet with a client for 30 minutes, tops, talk about short term goals to help them, and then send them on their way. There won't be time enough to blur the lines between the professional and the personal. But with my friends and family, do I sometimes blur the lines between personal and professional? And if I do, so what? 

I am a social worker; it's not just something I do for a living. I can leave my actual work at work; it's imperative, in fact, that I do so I don't get burnt out. But I can't detach myself from the part of me that is empathetic and sensitive, that wants to both validate feelings and find solutions to problems. And I think that's all to the good. I'll keep examining my boundaries and my sense of self because that's what my profession asks me to do. But I will also find joy in the fact that who I am and what I do intersect so well. I hope you're that lucky too.

On to the next

Today is my last day as a hospice social worker. I have done this work for more than five years. In those five years I have gotten married, bought a house, struggled with infertility, lost my mom, had a baby, and suffered a miscarriage.  Throughout experiencing all those joys and losses, I have had a team at work that has supported me like a member of their family. They threw me a baby shower; they came to my mom’s funeral; they arrived with food when I had a newborn and barely knew what time it was. They have listened (and listened and listened) as I have talked (and talked and talked) through my joy and my grief, all the while helping me to see how I could continue to do this work.

This heavy and rewarding work. What is there to say about it that will capture the complexity of the last five years? It’s hard, of course, but also more full of joy than I imagined when I started. I have been so blessed by this experience, by the opportunity to meet people facing the unknown and help to bring them a little peace. I have also been frustrated, tearful, anxious, troubled, and stressed out. I have been lucky that those feelings have been balanced by gratitude; by the kindness I have been privileged to witness; by the team I have worked alongside; and by the families I have been privileged to follow. When the balance between gratitude and stress started to tip too far in the wrong direction, I knew it was time to move forward.

I’ll continue writing and reflecting on my experiences in my new role as a behavioral health consultant. I hope you’ll continue reading. This blog has become part of my self-care routine in a way I did not expect and your comments and kindness keep me moving. Thank you, dear reader, for joining me. On to the next!