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.

Photo by  Deniz Altindas  on  Unsplash

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

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.

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.

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.

Supervision after the MSW: Now what?

I love meeting other social workers in the wild. There’s a real benefit to belonging to a kind of community. I’m not sure how it is in other professions but when I meet another social worker outside of work there’s an instant camaraderie. We get each other. We may come from different agencies or work with different populations, but we will immediately have a strong bond because we have almost certainly had some shared experiences. I’m lucky to know a lot of other social workers and to count many of them as my real life friends as well.

Photo by  Zoran Nayagam  on  Unsplash

Photo by Zoran Nayagam on Unsplash

Today’s blog post was inspired by one of those social worker/IRL friends. She’s been considering the lack of formal supervision in our profession after the Master’s program is over. As graduate students we are supervised intensely, with individual and group supervision, process recordings, class discussions etc.  We are constantly writing about and reviewing our clinical work as we learn how to do it. Then we go into the professional world and it just… stops. My friend made the excellent point that we’re required to have 30 hours of continuing education to renew our social work licenses but we’re not required to have any supervision hours once we obtain an LCSW. We don’t stop requiring supervision when we become LCSWs; and yet, for many of us, supervision stops being a priority after we reach that professional milestone.

This is not to say that there is no supervision in the real professional world for social workers. For instance, in my last job we had group supervision once every month or two, which was tremendously helpful. But that was pretty much it and it was definitely not enough. In fact, part of the reason I left that job was because there wasn’t a lot of support. I was mostly alone in my car, going from house to house, from sick person to sick person. The only contact from the office came in the form of emails throughout the day asking for consents to be signed or fires to be put out. Certainly my supervisor was available for questions and dire situations. But that didn’t replace an ongoing supervisory relationship. And ultimately I wasn't able to continue at that job.

So why don’t all agencies require clinical supervision? Why doesn’t our licensing body? I’ve been considering these questions and I’d venture a few guesses based on my own experience. One is that it costs both money and time; this is not a field that has a lot of extra of either. On the long list of things we’re required to do, supervision can seem like a lowly priority. Then there's a question of what kind of supervision is available in our agencies. Agency supervisors have their own agenda as representatives of the agency. They can’t be truly impartial because they have a stake in the game. So supervision may exist but it fulfills a different goal: namely that the agency’s standards are being met and not necessarily that the clinician is growing professionally.

I think professional growth is actually another reason we tend to view supervision as less important post-Master’s: as we get more clinical experience, we tend to think we don’t need formal supervision anymore. I spent five years at my last job; I felt like an expert most of the time. Sure, things came up, but not the way they did when I was a new social worker. So although I felt unsupported at times, I didn’t seek out additional supervision because I felt like I had it pretty much under control. By the time I realized that I was burnt out, I was ready to move on. Maybe formal supervision could have helped me recognize the signs of burnout before it became overwhelming.

As social workers, we are advocates. But how often do we advocate for ourselves? Are we getting the supervision we need to keep us working in the field and working effectively? My fellow social worker/mom/friend brought up a good point when she gave me the topic for this post. The question I’m left with is, what should we be doing to change things?

Termination

One of my first social work classes was an undergraduate course. It was a basic overview of the field really, some practice theories, a brief history, etc. I recall that my professor started the course by talking about termination. He told us that termination should start at your very first meeting with a client. It was not the last time I heard this point, of course. Termination is the goal for social workers; the therapeutic relationship has an end date. Sometimes it's because of the barriers of the agency; sometimes it's because the treatment goal has been met; and sometimes, as for me right now, it's because the social worker is changing jobs.

I'm not great at terminating. I also haven't typically had to do it for five years. In hospice, our patients die and bereavement takes over to help the families through their first year after a loss. I make condolence calls but it's understood from my first visit with a patient and family that I won't be there forever.

Now I'm leaving hospice to start a job as a therapist in a doctor's office, where termination will be a much more regular experience. I'm excited to change jobs and nervous and anxious and all the rest. But I'm also really struggling with terminating my current patient relationships.

Photo by  Giulia Bertelli  on  Unsplash

There are two issues for me here. One, quite frankly, is that some of my patients are near death. It doesn't seem right to tell them I'm leaving after next week if they probably are too. However, I have no crystal ball (see previous blog posts) and I could be wrong in my assessment. Then I've done them a disservice by suddenly saying, "Ok, this is our last visit, see ya!" Proper termination allows for some time. That's why the golden rule is to talk about it at your first visit, as well as throughout the therapeutic relationship. I'm not sure how to handle this thorny time issue; I'm kind of just going with my gut.

The other issue at hand is my own discomfort at letting people down. I've worked hard to build relationships with these patients and their families. And now I'm going to unceremoniously end these relationships just because I want a new job. I'm struggling with the idea that I'm being selfish, even though I know that's a silly thought. Still, it's a thought I'm having. I'm going to meet myself where I am about it.

So what do I do? I've been telling patients in person, when I can, straight forwardly and with kindness, I think. I've accepted congratulations and shouldered comments like, "I'm heartbroken!" I've assured them that they will have a social worker, it just won't be me. Honestly, most of them aren't that worried about it. As with most things, my anxiety about their reaction far outweighs their actual reaction. Still, I have to keep saying the words over and over again and it's really weighing on me. That's my last point about termination: it's hard on the social worker too. We are, as I am constantly reminding myself, only human. I feel attached to some of my patients. It's hard for me to say goodbye.

But here I am. I hope my next blog post about termination is about how I figured out the secret formula to doing it right. I suspect I have a ways to go before that one. For now, I'm going to do it the best way I can.

Meet them where they are?

 

I don’t remember if it’s the very first thing you hear in an MSW program, but I do remember hearing it frequently: “meet the client where they are.” I think of it as a chant, said in unison, ad nauseum, because it was said so often. But that’s because it is one of the most important foundations of our work. We cannot force our patients or clients to do what we think they should do; rather, we have to join them where they are, in their addiction, their illness, their family struggle, and help them find a way forward.

The thing is, that can be hard to do sometimes.

The other day I went to a house to do hospice consents. This is a big part of my job: I explain what hospice can provide at home and discuss with the patient and family what their goals of care are and if we can help them meet those goals with hospice. Not everyone I talk to is ready for hospice; some people can’t get over the word itself or there’s one more treatment they want to try. On the flip side, every so often, I enter a home where the patient is already beginning to die. Hospice can help, but it’s a little late in the game. It also adds a layer of complexity to the admission conversation; if I don’t already have a relationship with the family, how can I begin to tell them that their loved one is going to die?

This particular consent signing was one of those late admissions. This patient had been receiving palliative home care and the family was reluctant to start hospice. There were a lot of emails from management about treading lightly, especially because the patient wanted to continue some treatments that were not benefitting her anymore. I walked into the house already a little anxious, feeling the pressure from above to get the paperwork signed by a hesitant family. Then I met the patient and could see very quickly she was nearing the end of her life.

“Meet them where they are” is a fine sentiment. I agree with it whole heartedly. But standing in front of that patient and her husband, talking about hospice at home and continuing medications that were probably not going to help her anymore, I was torn. Someone would have to tell them that she was dying. Not to be cruel or pushy, but because part of our job as hospice workers is to help people prepare for death. And this woman did not have a lot of time left.

But could I be the one to tell them? I had never met this woman before; I’m not a nurse or a doctor. I’ve been doing this for five years and I’m quite confident that I know what dying looks like. But those emails stuck in my mind; this family wasn’t there yet.

And so, I tread lightly. I spoke with the husband about keeping her at home, in a hospital bed, rather than calling 911 when her heart stopped. He agreed to that. I called the nurse and asked her to visit as soon as possible. I made delicate statements like, “it seems like things are changing.” He agreed. When the patient’s son asked me how much time I thought was left, I gently told him I didn’t think it would be long. The look on his face devastated me.

She died a couple of days later, peacefully and at home, after the nurse and another social worker visited to offer the family some support and help them prepare. I think the family was ready, or as ready as anyone ever is. But I keep thinking about them. Should I have been more aggressive? Is there a place in between “meet them where they are” and “tell the hard truth?”

I’m confident that I did my job: I started the conversation that my team members eventually finished. That is, after all, why we work together in a team; these are not one and done conversations. I was still and present; I used silence and held the space so that the family could ask difficult questions. Should I have pushed harder? Said more? When we meet the client where they are, does that mean we shouldn’t push to move them forward?

I suspect the answers to these questions depend on the situation. Still, this is a case that will be on my mind for a while yet. Examining our practice is an important part of our work. I’ll keep turning it over in my mind from time to time, adding it to the other cases I wonder about. What are some of yours?

Politics

Photo by  Emily Morter  on  Unsplash

Photo by Emily Morter on Unsplash

Don’t freak out; I’m going to talk in the abstract. Although I am a social worker after all, so I imagine you have an idea which way I lean politically. My personal politics are not the point of this post, though. The point is about how politics intersect with our work and how to manage that.

An ad keeps coming up in my Facebook feed. It’s for a seminar or something about how to navigate political conversations with our clients as social workers. I haven’t clicked on it because it gives me major anxiety. Talking about politics with anyone gives me major anxiety. I don’t think I can do it without getting emotional, so I mostly avoid it. I know this isn’t exactly helpful. I hear the dialogue about how we need to talk to each other, to find common ground. I can find common ground with almost anyone; but I don’t want to do it through a political lens.

I especially struggle with this when I’m with my patients. The area I cover for work varies socio-economically but the vast majority of my patients are firmly in the lower middle class. They own their own homes, they collect Social Security, they have Medicare. Some of them have very strong opinions about politics that I, quite honestly, disagree with vehemently. But I don’t engage in those discussions; I change the subject as soon as possible.

Is that the right thing? I justify it to myself this way: I’m not there for that. I’m not a political leader or a social justice warrior. Of course social justice and change are in the nature of our work but I’m a clinical social worker. I sort of hide behind the need to build a strong relationship; and how can I build a strong relationship if I probe into someone’s politics? Personal values are one thing. But a patient’s views on voter fraud and emails and whatever other awful buzzword that’s on Fox News right this minute? I can’t go there.

See, even in my “abstract” writing, I let my leanings show. I can’t keep it together.

I don’t think I’m alone in this. I think most of my co-workers feel similarly. Especially in this political climate, conversations about current events are difficult to navigate. So what’s the solution? Honestly, I don’t know. How do you navigate when someone brings up politics? Give me your favorite responses.

Mentorship (and advice from Glamour magazine)

I subscribe to Glamour magazine. I have forever; it’s crazy cheap and there are frequently good recipes in the back of it. There are also a lot of articles about careers: what to wear to an interview; how to negotiate a salary or ask for a raise; how to deal with making a mistake at work. They have experts from all manner of high-powered jobs, with long titles following their names. A lot of it is general advice. Know your worth, for instance, when you’re discussing compensation. Dress for the job you want, not the job you have. But some of it just doesn’t apply to me because my work is not on Wall Street or in IT.

I always thought that finding a mentor sort of fit into the “doesn’t apply” category so I never really looked for one. I had a preceptor when I started working in hospice and I asked her for advice frequently as I found my footing in a new job. I have supervision, I have peer support; I thought mentors were for people who were looking to get promoted. I have no interest in getting promoted. I like being in the field, doing the clinical work I trained for. I want to succeed in my work, certainly, but success doesn’t look to me like climbing a ladder of some kind.

When I started looking at my career, though, and thinking about what else I want to accomplish, I began to see the benefits of having a mentor. While I don’t have any aspirations for management, I do want to explore other options. Happily, I ended up connecting professionally to a social worker I saw speak several years ago at a continuing education event. Her talk unknowingly helped me find one of my passions (working with young adults in hospice). I reached out to her via email and we are developing a professional relationship that seems a whole lot like a mentorship.

It got me thinking about how to be successful in this field of work. We all want to be successful in our personal and professional lives; it’s part of Erikson’s stages of development, right? No person is an island, especially in this field. At its core, social work is about building relationships. Success is found in these relationships, when we allow others to help us shape our goals and move forward in a meaningful way.  Peer support is necessary and wonderful but it’s not enough. It’s a great benefit to have someone who has walked the road ahead of you point out the landmarks. For me, the combination of peer support, supervision, and mentorship is the perfect cocktail for professional and personal success.

What about you? Tell me about your mentor. Or, if you don’t have one, tell me what your ideal mentor would be like. As always, thanks for reading and for sharing!

Photo by  Matthew Henry  on  Unsplash

Photo by Matthew Henry on Unsplash