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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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.

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.

Every conversation is clinical

My first experience with providing clinical supervision was about a year and a half ago, supervising an advanced-standing graduate student during her internship. The student's MSW program provided 6 sessions of training for new clinical supervisors (free CEUs!). One theme we kept returning to was the complaint from the student that their placement wasn't "clinical enough." I empathized with this; I recall expressing the exact same complaint as a grad student. I hated my first placement deeply, partly because I felt like it wasn't "clinical." (There were other reasons of course but that's a drama for another day). I was inclined then, at this training, to side with the students on this point. Some placements just don't seem to be given to enhancing clinical skills. But my trainors reminded me of a simple and true fact about being a social worker: every conversation you have with a client is a clinical conversation. Every. Single. One.

That was by no means the first time I ever heard someone make that point. But prior to that training, I didn't really believe it. When I was doing case management, for instance, it was easy to forget the clinical piece because so much of my job was about providing concrete resources to people in crisis. I often got caught up in the (sometimes very complicated) surface issues: pending evictions, drug or alcohol relapses, medication compliance. I sometimes forgot that I could utilize my clinical skills during these conversations because I was focused on what I could do right that minute.

I burned out of that job pretty quickly because I felt like all I did was put Band-Aids on broken legs. Now, several more years into my career, with different experiences and more education, I think about that job differently. Knowing what I know now, I think I could have been better at it. This feels especially true as I learn new skills, like motivational interviewing. When I was case managing, stuck in the weeds of constant crisis, I often forgot to use my clinical skills to tease out the underlying issues. Why, for instance, would someone relapse after a year of successful sobriety? Why did this one client, who seemed to have a reasonable income, constantly end up on the brink of eviction? Maybe I asked the client that, but not in a skillful way that elicited a thoughtful conversation. I focused on the resources I could provide and forgot, sometimes, the clinical skills I learned as a student.

It's easy to do that, when we are pressed for time and have limited tangible help we can offer our clients. But we have tools at our disposal that are unique to this profession: we know how to look deeper at what is said and not said in a client meeting. As soon as we start a conversation with a client, we are doing clinical work: assessing body language, physical presentation, affect, what they're saying and what they may actually mean. Don't be fooled by the weeds you sometimes get into: every conversation is clinical because this work is complicated. And your skills are growing every time you interact with someone. 

Happy Social Work Month! Do good work and be proud of it.

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?

Practicing within my scope

I can tell you a lot about physical illness. I can tell you about how particular cancers metastasize; I can tell you how the body begins to fail at the end of life. In nursing homes and as a medical case manager and in hospice, I became well versed in the way that physical health impacts mental health. I consider myself an expert in that field. Switching to a therapist role has been challenging of course, but I went to grad school; I was sure I would be able to transfer the majority of my skills into this new role.

And I have! Mostly. But last week I was caught off guard during a session with a patient and I can’t stop thinking about it. In the course of what was already a fairly intense conversation, one of my patients disclosed a history of childhood sexual abuse. The breath nearly went out of me. Anxiety rose in my chest. My first thought was: I don’t know how to handle this.

Not exactly helpful for my patient.

My second thought was how I could help her. Perhaps the best thing for her is to see another therapist. One of the ethical obligations we have as social workers is to practice within our scope of knowledge and experience. If this were a question on the LCSW exam, the answer would be to refer out. In fact, I’m quite sure this was a question on my LCSW exam. I’m not a trauma expert; I’m just not equipped to treat her. I’m going to have to refer her to someone else.

But I hesitate to do so at our very next meeting. This patient has been in therapy off and on for many years and I’m the first therapist she’s told. She’s entrusted me with a major confession and I’m not sure it’s appropriate to immediately terminate with her and send her to someone else. This needs to be handled with care. 

So, what are my next steps? First of all, I can honor what she told me. I can thank her for being vulnerable and open and for trusting me to hold her grief and pain and not run from it. I can acknowledge how incredibly difficult it must have been to say the words out loud. (I did that in the moment but I believe it bears repeating). Secondly, despite everything I've been saying about referring her to someone else, I can continue to treat her for a few sessions. She was referred to me for help developing strategies to deal with stress and pain; I can still help her with that. Lastly, I can start to lay the groundwork for referral. I can’t one day say, “Ok, it’s been great, I’m going to send you to someone else now.” Instead, we have to have an ongoing conversation about my role and her needs and where the two may not intersect.

I’m also taking this to supervision. Like, it may be the only thing I talk about for the entire hour.

This is a theme I keep returning to: we cannot work alone. We have to have not just the support of a more seasoned clinician, but also the objectivity of one. All the self-introspection in the world cannot replace the objectivity of someone else. Additionally, I think it’s also necessary to have a confidante in a supervisor. Despite knowing that the best thing is to refer this patient to someone who is qualified to help her, a part of me feels guilty that I can't provide the help she needs. I trust my supervisor to validate that feeling and help me examine it critically. I also trust him to help me find the right words to say to her the next time I see her.

My biggest hope is that I do this right. With supervision support, I think I can.

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.

Counter-transference, a very fancy word

The first time I heard about counter-transference was in college, in my social work practice class. I was immediately intrigued and also nervous; could this happen to me? It seemed like a clearly negative experience at the time. However, many years after my first understanding of counter-transference, I’m beginning to see the importance of it as a clinical tool.

First, a quick definition of the two-dollar word I’m using. Essentially, counter-transference refers to how clinicians react to what patients project on to them during the therapeutic process. It refers to how a clinician’s personal goals and desires can shape her feelings towards a patient (and change the course of the therapeutic intervention). It can also be about what populations a clinician is drawn to or conversely wants to avoid. Fairly straight forward, right?

A word I associate with counter-transference is boundaries. It’s become a weirdly trendy buzz word over the past few years but it’s a real thing! In my job, where I’m generally walking into people’s homes, boundaries can be tough to define. Being in the home setting is less sterile than the office setting and definitely less structured. When I’m sitting at someone’s kitchen table or in their bedroom, a certain intimacy grows. It can be harder to maintain firm boundaries in these situations. Patients and families want to offer me coffee or food; they want to know about me since I’m with them at such an intimate time in their lives.

And part of what I want to do in this role is form intimate connections with people at their bedside so that the conversation can open up beyond the superficial and into difficult discussions about goals of care and illness and death. As a result, I sometimes become aware of this experience of counter-transference: strong emotions elicited during a visit that can be a detriment to my practice. However, those feelings can also elicit some good work for me as well as within the bounds of the therapeutic relationship. Further, it’s always wonderful when clinicians are able to acknowledge their limitations as well as their strengths in practice. I think recognizing the counter-transference we experience in our practice, or the blurring of boundaries, or just the discomfort sometimes of being with someone who is dying, can aid us in enhancing our clinical skills.

What I’m getting at here is that we can use counter-transference in our practice. We are, after all, only human. There have been times when I have been in a visit and felt a rush of anger so hot and charged that I’ve had to take a deep breath and clench my toes to keep from screaming. That’s a scary feeling for a social worker. But instead of pushing it down and forgetting it, I try to examine it. If I’m feeling so angry, what is the patient feeling? The family? Likewise, I’ve found myself feeling so friendly with a patient (someone near my age, to be fair) that I kind of forget my clinical role. That needs to be examined closely too. it’s dangerous when the boundaries blur too much.

Photo by  Cristian Newman  on  Unsplash

This is where good supervision is necessary. The supervision relationship helps us to look at our practice with a clinical eye. Sometimes we may not realize how counter-transference is affecting us. It takes a supervisor to reflect back what we’re saying and feeling. To do that effectively though, the supervision relationship needs to have the same kind of vulnerability as the clinical relationship.

I have a lot more to say on this subject but I’ll leave it here for now. Visit me in the next few weeks for some more posts about counter-transference with young patients, enhancing clinical skills, and growing the supervision relationship. As always, thank you for reading. Please leave some feedback! I’d love to write about something of interest or importance to you.

 

Learning from early mistakes

I think it’s time to revisit some of the cases I’ve come across that required me to seek supervision. I’m going to start at the very beginning of my hospice journey.

When I first started in hospice, I had four young women patients in a row. They were all mothers; two of them were younger than me. In my personal life, I was about to get married; I was starting a new chapter in my life as these women were dying. It was devastating. I considered that maybe I had made a mistake in taking this job. I talked about it with a lot of people: my manager, the woman who provided my supervision at the time, my preceptor, my dad. Interestingly, my dad gave me the best advice. He said, “Can you stop them from dying?” No, I said. “What can you do?” Nothing! I said. I can just be there. He answered, “That’s right: you can be there with them. Don’t underestimate that.”

Photo by  Soroush Karimi  on  Unsplash

That became the basic foundation of my practice: just being. When I first started though, I maybe took that a bit too literally. I was hesitant to push difficult conversations for fear of saying the wrong thing or shutting down the conversation. In the case that follows, I made a significant error because I was afraid to delve too deep.

Here is the case study (with the patient’s name changed to protect her privacy):

Lily is a 27-year-old hospice patient who has metastatic liver cancer. She has recently transitioned to hospice to broaden care provider assistance at home. She lives with her parents, her brother, her spouse, and her young children. She and her family are Vietnamese and her parents do not speak very good English. She relies on her mother for childcare, as she experiences a lot of pain and fatigue that has impacted her functioning ability. Lily’s spouse struggles to adapt to Lily’s terminal condition and appears angry at Lily’s illness; he complains often about Lily’s lack of ability to maintain the activities she once completed with ease. Lily’s main concern is who will care for her children after her death. Lily states that she knows her prognosis is poor, but she wants to try any new treatment that may become available. She signs an out-of-hospital DNR order but does not tell her family. The social worker works closely with the other members of the team to provide support to Lily but is concerned about counter transference issues due to their similar ages. The agency’s children’s bereavement counselor helps Lily create a video legacy recording for her young children. The social worker encourages Lily to talk to her family about her advanced directive preferences. However, Lily does not tell her family about her DNR. When she becomes unresponsive, the family calls 911. Lily is intubated and after a week, the family decides to withdraw life support.

Now there’s no guarantee the family would not have called 911. Remember, this is a 27-year-old mother of three. Further, there was a significant language barrier and cultural implications. It’s entirely possible that even if I had taken the correct steps of holding a family meeting (with a translator), Lily still would have died in the hospital.

All that being said, I should have done more than just “be.” But I was afraid. Also, I was deeply sad. As I said, I was a newlywed when Lily took a turn for the worse. It terrified me to see someone my age fading away from cancer. I felt guilty and anxious and I let those feelings prevent me from really doing the work. I went to supervision, sure, but I wasn’t totally honest with my supervisor. I was embarrassed, I think, that I hadn’t had a discussion with Lily about the DNR and about whether or not she had told her family about it. I wasn’t using supervision to its full extent and I think my patient and her family suffered because of it.

I presented this case at a social work hospice conference three years ago, in part to make sense of it and in part to honor Lily’s memory. I can’t forget her; she changed my practice. I am both grateful and humbled.

Doorknob Communications

In our last supervision, my student told me one of her patients surprised her with a “doorknob communication.” It was their last visit and the patient chose that moment to confess some secrets she had been holding in from everyone. My student was startled but also proud, I think, to bear witness to the darkness this woman had been keeping inside. We talked about termination and what it can mean for a client. Another social worker is going to replace my student in this case so we talked about how to communicate everything to the new social worker while also respecting how difficult it was for the patient to divulge.

Photo by  Nick Tiemeyer  on  Unsplash

Photo by Nick Tiemeyer on Unsplash

The phrase doorknob communication was new to me; I understood what she meant from context but I had never heard the phrase before. Because I kept thinking about it long after our supervision was over, I went immediately to Google for answers. (How anyone did social work before the internet is an ongoing mystery to me. I’m told there were rolodexes and calls from pay phones). According to the good old search engine, it’s just what it sounds like: a client sometimes reveals a huge piece of information to the clinician while they are leaving a final session, with their hand on the proverbial or literal doorknob.

So why do clients do this? There is a safety, I think, in knowing that you won’t be seeing your therapist again. There’s little risk involved in laying out your deepest secrets while you’re walking out the door. The therapeutic relationship can build a deep trust but still, we all keep some parts of ourselves hidden. I think sometimes it’s simply too hard to divulge everything, even in a long-standing relationship. Dropping bombshells while walking out the door must feel liberating in a way: here, hold this; we don’t have to talk about it again.

I wonder more about what we as clinicians do when we are faced with the doorknob communication or, perhaps more aptly, confession. Termination is supposed to feel like a nice, neat bow on the end of a therapeutic relationship: we’ve reached our goal together and the client should feel better somehow. Does it feel like a failure if someone has a sort of breakthrough on the way out? Should we look back on our practice and try to figure out if we could have elicited it sooner? Should we not terminate after all?

I don’t necessarily have the answers to these questions. For what it’s worth (and if she’s reading) I don’t think my student failed this patient at all. I think she opened the door for this woman to release some deep sadness that she was carrying with her. And the patient couldn’t do that until their very last minute together. Those last minutes are a theme in my work in hospice. They carry a lot of meaning for the survivors and for the dying as well. That patient gave my student something precious to hold; in that way, this doorknob communication, confession, whatever you call it, was a gift.

What are your thoughts? Better yet, what doorknob confessions are you holding on to?

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

Narrative therapy or, what do you DO exactly?

The most common question my patients ask me when I first meet them is, "so what does a hospice social worker do?" A lot of people get nervous if I describe myself as a counselor or a therapist so I'm careful in how I describe my work to my patients. I tell people I'm a part of the hospice team, another set of eyes, support for them and for their families. The actual clinical work I do is more in depth than what I describe; it involves some education about disease process, a knowledge of family systems, narrative therapy, and even some mindfulness. Sounds pretty thorough, right? But I have a confession to make: until recently, I wasn't sure how to name the theoretical approach I use in my work.

It was when I started supervising my MSW student that I started considering naming the approach I've been using in my clinical work. My student was deep in her practice class and we often reviewed what theory she was studying and how it would be useful or not in her hospice practice. She mentioned narrative therapy and I thought, that sounds familiar... (Graduate school was a long time ago, after all). 

So I did some research (my go-to when I'm feeling insecure about my skills). Narrative therapy fits me as a clinician. It's about telling the story of your life. The therapist's role is to partner with the client, objectifying the problems they're experiencing and reframing them in a larger context. It's about autonomy and personal drive. It meets the client where they are, as we're told to do in school, while also helping to move them forward. 

It works beautifully with hospice patients, who are often examining the meaning in their lives, and I believe it also works beautifully in supervision. So much of this work is about self-reflection and self-awareness. Narrative therapy within the context of supervision encourages the social worker to tell the story of his or her work and identify the strengths and areas of improvement that shape that work. 

So tell me: do you have a theoretical approach to your work?