Stuck in the weeds

There is not enough money in the world for me to ever consider doing couples therapy. Honestly, I’ve always felt that way; I know what’s in my comfort zone and what’s not. The reason I bring it up today though, is because I found myself thrust into that role and it. Was. Tough.

I’m not in love with my current job but there are perks. For one, it’s short-term so even if the patient I’m seeing is incredibly difficult, I have a nice out: we only have to see each other a handful of times and then either we’re done or I’m referring out to a community therapist. Another perk is that although the majority of my referrals are people with anxiety and/or depression, I encounter a variety of situations. I’ve seen someone with a bridge phobia; recently met a woman struggling with her fiance’s infidelity; and have provided education about a possible Bipolar II diagnosis (a few times, actually). For all my complaints about this job, it’s been a good opportunity to enhance and vary my skill set. Hospice had its variations, of course, but I was there for five years and I was pretty comfortable with my role. This job has a whole other set of challenges and even a year and a half in, I’m still facing new and tricky situations.

Like yesterday, for instance! A woman called to schedule an appointment for her partner (which always puts me on guard because how motivated are you if you aren’t even making your own appointment?) and then they all showed up together: the patient, the partner, and their small child. Which is fine, in theory; a lot of people prefer their loved ones to be with them at doctor’s appointments. But about fifteen minutes in, it became clear to me that my patient and his partner need some serious marital counseling that I cannot provide. First, because my role doesn’t allow for it. Second, it’s very much out of my scope of practice. And third—probably most importantly—the counter-transference was suffocating.

This is not to say that my marriage is in shambles and I didn’t realize until this session; it wasn’t that Freudian. It was more that in my heart, one person was SO wrong and the other was SO right and it made me feel sort of thought-blocked. Like, I knew I couldn’t say that out loud but I also was really having trouble navigating my own feelings. I spent a lot of time saying, “It sounds like you’re saying X and you’re saying Y, and you’re not really in agreement about the basic facts.” It was not my most insightful work, friends. But afterwards, as I’m processing and debriefing and writing this all out, I’m not sure there was anything more I could or should have done.

This many years into my career, I’m comfortable telling people I don’t know the answer. But every so often, a session gets a little bit away from me and before I know it, I’m trying to navigate a situation I don’t really have a handle on. In those sessions, I have to get back to basics: here’s what I can do, here’s what someone else may be able to do, what do you want to do? I’m left with another good reminder to be mindful of what the goal of the work is: to help, whenever and however we can, and to know when we can’t.

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.

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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Replacing "I'm sorry" with "Thank you"

Photo by  Nicole Honeywill  on  Unsplash

I went to a Motivational Interviewing training the other day (highly recommend; it was super helpful and engaging). Lots of pieces of the training struck me but the one I keep thinking about is the power of saying “thank you” instead of “I’m sorry.” Let me explain: a big tenet of motivational interviewing is reflecting what a patient has said to you, the practitioner. Sometimes we misunderstand our clients, since we’re only human, and our reflection is off base. When this happens to me, I typically apologize. This trainer explained that when she misunderstands a client and they correct her, she likes to say “thank you” instead. That really stayed with me.

It reminded me of something I read on Facebook a while ago. (I usually ignore those positive meme/message things but this one caught my eye). It said, to paraphrase, “Instead of saying I’m sorry to friends, I’ve started saying thank you. If I’m late for instance, I’ll say, thank you for waiting for me.” I find that idea so powerful. It takes away the blame factor and invites the person on the other side to feel appreciated for being gracious rather than annoyed. And that’s important both in our professional and our personal lives. So much of this work is about relationship building. Won’t it build a stronger relationship if we foster graciousness rather than blame and apology?

There is a time, I believe, to apologize in therapy. Sometimes we unintentionally offend our clients. I, for one, am sometimes guilty of making a joke that doesn’t land very well that I have to walk back. In those moments, apologizing seems like the right thing to do. But if we reflect something back to a client and we just misunderstood, saying “thank you for clarifying that” seems like a more helpful response. We’re inviting our clients to continue to be honest with us. We’re encouraging them by thanking them for their vulnerability. Saying sorry can make things awkward; saying thank you is like opening the door a little wider.

Ultimately that’s what we want to do, whether we meet with a client one time only or once a week for a year: open the door. Invite honesty. And being grateful rather than apologetic may be one good way of doing that.