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!

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!

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.