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.

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!

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.

Boundaries

I think (and write) a lot about boundary setting in my work. It was a thornier issue for me when I worked in hospice; being in people’s homes makes the lines all the more blurry and the boundaries rather flexible, in my experience. Now that I’m in a doctor’s office, it’s easier to draw some firmer lines. No one is offering me food, for instance. I’m not sitting on the edge of someone’s bed. I visit with patients in empty exam rooms; there aren’t any pictures of my family or any personal artifacts. Still, the balance of building rapport while keeping firm boundaries remains.

Take, for instance, a regular patient of mine. We’ve seen each other off and on since I started this job a year ago. We’re actually nearing the termination process now, much to his chagrin. He’s a nice guy; I like him a lot. But lately he’s been a little more familiar with me and I’m struggling with whether or not to push back.

Familiar feels like an odd word to use here but it’s sort of the only way to describe it. He’s not outwardly inappropriate; there’s nothing he’s said or done that I could point to and tell him to knock it off. It’s been an insidious little bit of boundary pushing. It started with an increase in cursing during our sessions. (Which honestly, if you’ve spoken to me for more than five minutes, you know that I have a foul mouth. I come by it honestly: my mother swore like a sailor). The words don’t bother me per se; it’s more that he used to watch what he said. My patients often apologize for swearing during a session, to which I answer that I’ve heard all the words before. I even allow myself the occasional “this is shitty” or something to that effect, if the relationship is there. But this patient’s frequent use of heavy curse words feels more boundary pushing than before.

Maybe I wouldn’t even have noticed except that the swearing comes along with a little more… flirting, for lack of a better word. Again, nothing so outrageous that I could give a firm, “not appropriate, knock it off.” More a subtle change in his tone of voice, a casual remark here or there. I have a feeling my female friends know exactly what I’m describing. If I mentioned it to him, he’d surely say he didn’t know what I was talking about. It’s subtle and honestly, I’m not totally sure he realizes he’s doing it. Which is partly why I’m struggling with what to do about it.

I should state here that I don’t feel unsafe; that’s a different topic for a different day. My discomfort is more about how I’m reacting to his boundary pushing. I’ve found myself coming back with a little attitude. For instance, he asked why I won’t be at work on a particular day (we were scheduling an appointment) and I jokingly replied, “None of your business.” We have a good rapport, so he laughed and said he was only kidding. It was a deeply awkward moment though. It’s the kind of response I’d give to a guy in a bar, not to a patient. But because I kind of let the boundaries blur, I let things get away from me.

That being said, this is not unsalvageable. And it’s possible that some of the over familiarity on his part is because we’re terminating our relationship soon and he has some feelings about that. Whether we’re going to address them the next time we meet really depends on how the session goes. I can consider different reactions to different things but I cannot predict the future (sadly) so I’ll just have to wait and see how it all shakes out.

In the meantime, I’m considering how I relate to my patients and if I need to take a more clinical approach. I don’t think there are any hard and fast rules here; it’s a case by case approach. I think what’s really needed is a little more self reflection and maybe a little pulling back. I guess we’ll see how hard he pushes and therefore, how hard I’ll have to pull.

Ah, clinical social work: where every interaction is deeply weighted! I guess it’s part of the charm of the work. Right??

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.

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.

Finding Compassion

So what do you do when you just don’t like the patient sitting across from you?

I love people. It’s part of why I chose this profession. I love to hear people’s stories. I like to sit in the front seat of cabs so I can ask the driver a bunch of questions about his family and his life. Call it nosiness; I prefer to call it a love for the human experience. Life is a rich tapestry, as one of my favorite advice columnists often says, and I like to know all about it.

But sometimes I meet a patient that really gets under my skin. I’m not alone in this, I know. We can all point to patients or clients we’ve had that just get on our damn nerves. Right now I have two patients that are casually misogynistic and homophobic; further, they are never the problem. According to them (they’re strikingly similar, actually), it’s everyone else: their children, their exes, their friends. They aren’t the ones making their own lives miserable so why should they have to change?

I’m sure you can hear (read?) in my tone that I’m irritated with these guys. I especially resent the casual way they demean women when they’re sitting right across from one. Can you not have a little respect for my gender when you’re looking right at me?

Then, I think: maybe they can’t.

Some folks really are stuck. Their life experience tells them that they are victims and they really aren’t interested in looking any deeper than that. And really, in this role, it’s not my goal to go that deep. My goal is to help them figure out what’s making them feel anxious/depressed/stressed out and help them find their own solutions. I have the luxury of not seeing these people for years on end for true psychoanalysis. Rather, I get to help them name their issues and seek solutions for them.

The thing is, that means I have to let go a little of my own stuff. If the patient tells me that his gay son is ruining his marriage, I’m not going to get into a deep discussion of his homophobia, or his own insecurity about his masculinity, or what it means to him that his son is gay. Rather, I have to drill down on what he sees as the issue: it’s him against his wife and son. I have to help him figure out how he wants to handle that.

Inside, I’m cringing. This conversation is so gross to me. The moral part of me is screaming internally. But I’m not in private practice; I can’t refuse to see a patient that’s referred to me by one of my providers because I have feelings about his values. So I see these guys and I remind myself why I’m there: to provide short-term intervention. If it’s appropriate, I can gently push back on some of their prejudices and assumptions… but most of the time, that’s not what I’m here for. Instead, I have to let their comments roll off my back. I have to remind myself that one of my core values as a person and a social worker is that everyone is doing the best they can with what they’ve got. And I don’t get to enforce my morality onto someone else when I’m providing therapy.

So I make space for the sometimes awful things I hear and focus instead on the important underlying truths: there’s a lack of family support. Or there’s an ongoing struggle with conflict. I direct the conversation to what can be changed rather than all the wrongs they see placed upon them. And I direct myself to grace and compassion: it doesn’t matter if I like them or not, my job is to help. I’m not better than the person sitting across from me. These tough patients are a good reminder to be kind and humble, even if they are, in the moment, a real pain in the ass.

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?

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.

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.

The gift of counter-transference

There's a short story collection I adore called The Girl's Guide to Hunting and Fishing. (I highly recommend it, the narrative voice is delightful). There's a line in one of the stories that I repeat to myself frequently, especially when I’m being too hard on myself: "too late, you realize your body is perfect; every healthy body is."

I am especially reminded of this today, as I sit across from a young woman (just a little younger than I, actually) who was diagnosed with a chronic auto-immune disease a little less than a year ago. We are not terribly different: she has two small kids, a husband, a house she wants to keep in better shape, and her mom is not with her anymore. But there the similarities stop. Because she is sick and I am not and that is just our luck: her bad and my good. Sitting before her, sitting with the discomfort of her crying and my inability to do anything that will really help her, I am struck by how lucky I am to have this healthy body. It is a thought that stays with me for the full 20 minute session, rolling around in the back of my mind, begging to be explored further. These are the kinds of feelings that make supervision at all stages of our career a necessity.

What I’m feeling is counter-transference. I’ve written about this phenomenon before and why I think it can sometimes be a good clinical tool. Counter-transference can simply be a deep sense of empathy with a client. Empathy is the core of social work. It is the foundation upon which everything else is built: advocacy, behavior change, clinical therapy. Our ability to see ourselves in other people, to witness suffering and truly understand it, is what makes us good humans and good social workers. Counter-transference can be used to build rapport, even in a short session like the one I had with this woman. But it can also linger in our minds and pick away at us, leading us to burn out.

It's true that I felt helpless sitting across from this woman but the truth is, there are ways for me to help her. There are CBT strategies for people with chronic illness that I can help her explore. I can refer her to a support group. I can witness and validate her pain and frustration. The parts I’m struggling with, the counter-transference that is lingering in my mind, are the other truths: I cannot cure her disease. I cannot fundamentally alter her new path, which is one of doctors and medication and setbacks as she experiences flare ups. These are uncomfortable truths for me, especially as I sit in front of her with my perfectly healthy body and my growing, healthy pregnancy.

Counter-transference is complicated, like most feelings. It is both a help to our practice and a hindrance. Today, for me, it was both: it helped me establish rapport quickly with a new patient but it also hurt me to bear her pain. Ultimately, those twenty minutes are a part of my own personal growth. I was reminded, humbly and beautifully, that this body I complain about (because I’m pregnant, because I’m 5 pounds heavier than I want to be, because because because) is perfect, because it is healthy. And this work, which troubles me and excites me and frustrates me, is a gift. 

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?”

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.

Racism, anxiety, and discomfort

This was a difficult subject to tackle; I’ve started and restarted it a few times. It certainly isn’t a deep dive into race relations or cultural competence in therapy. It’s just one experience that I keep turning over in my mind. What follows is the best I can do and I’m afraid it’s still not a perfect evaluation. Still, it is with me and I just have to keep talking about it.

The other day, a doctor gave me a referral for a patient suffering from anxiety and depression. She has a long psych history and mostly needed to be reconnected to care. Simple enough. But when we met and started talking about her increasingly anxious feelings, a lot more came pouring out than I was prepared for.

I want to be respectful of my client’s right to privacy so I’m not going to write the details of what she told me about. The basics are these: she is a young black woman with sons and she struggles with anxiety about how they will be treated in the world. She faces racism daily, in big ways and small. She knows that her sons will face it too, especially as black men. She is afraid to send them on the bus; she is afraid to call the police if she’s been the victim of a crime; she is afraid.

Lots of my clients suffer from anxiety. They tell me about fears they have that keep them up at night, about the pervasive nervousness that is with them all the time. Generally, we focus on utilizing some CBT and a little bit of mindfulness practice. I teach them strategies to examine their thoughts and worries and use their more rational brain. I teach them deep breathing and some basics of mindfulness, telling them that stress can be controlled. But in this case…what can I do when my client’s fears are not irrational? And also, am I the right person to help her?

I’m white. I was raised in an upper-middle class household and I live firmly in the middle class now, with a lot of privilege. There is no way I could totally understand my client’s experiences as a black woman and as a black mother. I validated her feelings, of course; I explored with her how watching the news increases her anxiety, how some people are unaware of or do not believe in the micro aggressions she and her sons experience on a daily basis. But I cannot truly understand those experiences, not at the cellular level that she does. And honestly, I can’t help her examine her fears for irrationality because racism exists.

I referred her to another therapist, because her mental health history demanded a more intensive therapy than I can provide in my current role. But I keep thinking about her. I keep thinking about what it must be like to fear for your children, in a very different way than I fear for mine, because the dangers they face are different than the ones my kids will face. I keep wondering if I could be an effective therapist for her, were my role to provide that kind of long-term therapy. It’s a question I vaguely remember from graduate school about cultural competence and how we work with clients who have cultural differences that we may or may not understand. This woman and I live in the same town; we are both mothers; we are around the same age. And yet, her lived experience is radically different than my own. In short, I can help her but I wonder if the help would lack something essential.

As usual, I end with few answers and more questions. The good news is, I’ll get to see her the next time she visits her primary doctor, so at least I’ll know how she’s doing. I hope she finds the right therapist. And I hope (corny though it may sound) that things keep getting better so her fears become unfounded ones.

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.

The case for cutting someone off

It will possibly surprise people who know me in real life, but when I'm working with a client, I am very good at being silent. It's not that I'm not an innately good listener; it's a skill I've honed over time as a clinician. I've written before about using silence in my work. Sometimes it's the only way to get the client to open up. Most people don't like to sit awkwardly not speaking for a long period of time so they'll start talking just to fill the void. It's a very useful clinical tool. But this blog post is about the opposite and sometimes necessary approach of making people STOP talking.

I generally work with older patients. Forgive me for generalizing, but sometimes they kind of... ramble. They're often socially isolated and their trip to the doctor is part of their socialization. I'm happy to fill that role a little bit; isolation leads to depression and anxiety, which I'm often helping the patient learn to manage. But sometimes (twice this past Thursday, actually), allowing the patient to just go on and on (and ON) about random topics is a detriment to the therapeutic process. 

There's such a focus on active listening in this profession that I think we sometimes forget that we don't have to let patients go on about nothing for an hour. We don't have to listen politely to some long story about the broken washing machine someone's mother refused to replace five years ago (not kidding, this particular anecdote was like ten minutes long). Especially in my role, where the focus is meant to be 20-30 minute sessions that address strategies for how to cope with a specific issue, it's not a good use of the patient's time. 

But asking clients to stop talking is a tricky proposition. This past Thursday, faced with two different patients who couldn't seem to get to the point, I must admit that I hesitated to cut them off. I often write about the importance of building rapport. How can I build rapport if I cut someone off and say, "Ok but why are you here?" And yet, I need to know! What is the problem? Not the long list of grievances you have against every single member of your family (that took up nearly an entire hour) but the problem you are facing right this minute. Is it insomnia? Depression? Anxiety? We have limited time; let's use it to DO something. 

I think a lot of social work roles are like this. Our time is limited; case loads are high. We are tasked with building trust immediately so we can dive into the main issue and look for solutions. Unless you're doing long-term psychotherapy, there usually isn't time to begin from the beginning.

But how do we do it without putting the patient on the defensive? I vote for being compassionate but also goal-focused. "Wow, it seems like you have a lot going on. What specifically brought you in today?" This typically works. Of course, there are always patients who just aren't redirectable: their anxiety is overwhelming or they're just bad communicators. On Thursday, with one patient who really wandered from topic to topic with barely a breath in between, I finally interrupted her and said, "You seem really scattered today. Let's try focusing on what you want to work on right this minute." She wasn't particularly pleased with my assessment but she did focus: she had a goal in mind and she wanted to start figuring out how to accomplish it. Yes! That's why we're here! 

We should err on the side of active listening and compassionate presence. But we should also not let patients steamroll us with rambling thoughts that lead nowhere. Part of our role is to clarify what people are saying and help them start the steps that lead to meaningful change. Sometimes that means a gentle interruption: let's talk about what we can do today.

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.