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.

Relearning the work

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I keep a postcard at my desk at work that I got at a conference when I was in graduate school. I've had it for years but I haven't had an office in so long, it's most recently been hanging out in our guest room (to inspire my guests, I suppose). It says: "I cannot learn other people's lessons for them. They must do the work themselves, and they will do it when they are ready." I have read it a million times but I don't always retain it. Do you know what I mean? It's similar to that social work joke (yeah, I'm telling it): how many social workers does it take to change a lightbulb? Just one but the lightbulb has to want to change. Groan away but the point stands. And whether it's a bad joke or my little postcard, I know this lesson to be true. I know it from personal and professional experience. So why do I sometimes forget it?

Here's a good example. When I was a medical case manager I had a lot of clients who were constantly in crisis, usually financially. Every month we would talk about where their money went and how to budget and I would help them fill out forms to get services. Every month I would say, "you should have enough money if you do x, y, and z." And they would agree. Then we would do it all again the following month.

The thing is, I was doing it wrong. I didn't allow my clients to come up with their own goals; I told them what the goal should be. I'm reading about motivational interviewing right now, which is a strategy that can be really useful in changing behavior. One of the tenets about MI that really speaks to me was that no one wants to fail. No one wants to set an unachievable goal but often that's what we're asking patients to do: we've decided what their goal should be so we've also come up with the solution to acheiving it. It's a theme I sometimes saw in hospice too: for months or years, patients had been told to "fight" their disease. Then suddenly, we told them to accept their death. We didn't give them a choice to change their goal so much as tell them the goal had changed while they were doing something different.

I think most helping professionals like to consider themselves good listeners; I know I pride myself on it. But I'm not sure we always hear what our clients are saying. We walk in with a goal already in mind and that leads our visit. Motivational interviewing encourages the practitioner to help the client name their own goal. It's difficult to want to achieve something you have no stake in. Helping clients name their own goals and helping them see what changes they can make to accomplish those goals makes them stake-holders, not just people who get lectured and then feel guilty when their problems don't go away. 

Now, in this new role, I keep looking at my postcard. Not only can I not do someone else's work for them, I can't tell them what the work should be. I became a social worker because I wanted to help people. It's been a long journey of reminding myself that I can only help people who want to be helped. And even then, I can only do so much. 

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.

Can crying be part of practice?

I'm reading a lovely book about narrative therapy called "Retelling the Stories of Our Lives," by David Denborough. So much of it is surprisingly moving to me: not just the case studies but also how he describes the practice of retelling our stories in order to regain some control over our lives. One particular passage just struck me as I was reading. Dr. Denborough recounted a situation where the client began to sob during a phone call; this display of emotion brought Dr. Denborough to tears. That's all he says about it: his client was overcome with emotion and he was as well. I was both charmed and startled by this anecdote. Charmed because it is the great joy of our work to be deeply moved by our patients; and startled because this is something I think about a lot. Specifically, I often wonder about how much we should share with our clients and when and how we can do it effectively.

Crying with my patients is particularly interesting to me, not least because I just spent the last five years doing hospice work. A supervisor I had in my graduate school internship once told me that it's ok to cry in front of your patients, as long as you aren't crying more than they are. To that end, I'm usually able to maintain a certain amount of distance in emotionally charged visits while also remaining compassionate and open. But once in awhile, someone's story moves me unexpectedly and I feel those little pinpricks behind my eyes that signal the start of tears. Is it ok then if my eyes well up during a visit? Is there a way to be (slightly) tearful and have it be therapeutic for the client? Is there an appropriate amount of tears? Are any tears acceptable?

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This is a tricky question for me. I think that part of what draws people to social work and other helping professions is a certain amount of sensitivity to others. In fact, we need to be sensitive and vulnerable with our patients in order to allow them to be vulnerable with us. However, we also have to protect our clients and ourselves. We cannot cry at every sad story; if that's happening, it's a bright red flag of compassion fatigue. At the same time, we are only human. There will be moments when we feel overwhelmed with emotions. My question is, what do we do at those times?

As with most things, there are lots of variables. Regarding Dr. Denborough's example, there are two indicators that crying was appropriate in this case. First, this was a client he had a fairly long relationship with; therefore he would have been able to judge how his own feelings would impact his client. In this case, I suspect the client felt validated and touched by his therapist's tears. Second, this took place during a phone call. Not being in the same physical place is a good thing here, so that the therapist could be discreet about his reaction if the client was startled or upset by it.

I'm always interested to hear about how other people handle this. When I worked in hospice, my own rule of thumb was to take a deep breath when I felt those pinpricks and examine my reaction later. I suspect the same rule will apply in my new role. But I reserve no judgment for practitioners that allow a little tear here and there. Tell me, is crying ever a part of your practice?

The importance of language

The college I attended was tiny, smaller than my high school, so I didn't graduate with a BSW; there was a social work concentration but no major. Instead, I majored in sociology, which was a little broader of a topic. Still, even as a sociology major, I gravitated toward the micro: family systems, symbolic interactionism, and subcultures. Symbolic interactionism, especially, felt right to me. For those who didn't major in sociology or who have forgotten their intro to soci college course, a quick definition: the theory refers to how we understand and interact with each other within larger systems. It proposes that human beings have agreed upon meanings to words, gestures, and other symbols over time so that we can communicate with one another. Fairly straight forward: we agree on certain symbols as a culture, as a family, as a romantic couple and this is how we are able to exist together. It can also cause miscommunication at times; we sometimes may disagree with each other about the severity of a swear word, for a simple example. One person's damn is another person's... You get my drift.

This is all to say that I've been considering language more lately as I begin my work as a therapist and add more supervision clients. Namely, I've been considering how important words are in the therapeutic context, whether we're talking directly to clients or talking to colleagues about our cases.

I can admit that I've sometimes used disrespectful language when talking with my peers about patients or families. In private with my colleagues, I've used words to describe patients or their family members like "crazy" or "insane," when really I meant that I felt frustrated; that it was me feeling crazy and out of control because of the interactions I was having with a particular client. Using those kinds of words can feel like a balm sometimes, a way of distancing myself from the issue at hand, which is really that I don't feel confident that I can help the patient or family.

Language is powerful. Even if I would never use those words in front of the person I was thinking of, it's powerful to use them in any context, even just to myself. If I assign the label crazy to someone, I'm dehumanizing them a little. I'm making it easier on myself if I feel like I can't reach them therapeutically; it's not my fault, they are irrevocably broken. I've erased any failure on my part; they're just crazy.

This was actually pointed out to me by a supervisor a few years ago. She noted that when I felt frustrated or defensive about a situation, I immediately started saying things like, "they're just nuts." It was not a pleasant thing to hear about myself, as you can imagine. Since then I've tried to be really conscious of how I think and talk about my patients, as well as what words I use when I'm talking with them. If I find myself going back to those old standbys (crazy, ridiculous, nuts), I start to question myself. What am I struggling with here? The same practice can be used in the supervision relationship. One of the tasks of the supervisor is to listen closely to the phrases that keep coming up and helping the supervisee examine them in context: what does it mean that you describe your patient this way? How do you think of yourself in these interactions?

It bears repeating: words matter. I'm working on choosing mine carefully. 

Photo by  Tim Marshall  on  Unsplash

Photo by Tim Marshall on Unsplash

On to the next

Today is my last day as a hospice social worker. I have done this work for more than five years. In those five years I have gotten married, bought a house, struggled with infertility, lost my mom, had a baby, and suffered a miscarriage.  Throughout experiencing all those joys and losses, I have had a team at work that has supported me like a member of their family. They threw me a baby shower; they came to my mom’s funeral; they arrived with food when I had a newborn and barely knew what time it was. They have listened (and listened and listened) as I have talked (and talked and talked) through my joy and my grief, all the while helping me to see how I could continue to do this work.

This heavy and rewarding work. What is there to say about it that will capture the complexity of the last five years? It’s hard, of course, but also more full of joy than I imagined when I started. I have been so blessed by this experience, by the opportunity to meet people facing the unknown and help to bring them a little peace. I have also been frustrated, tearful, anxious, troubled, and stressed out. I have been lucky that those feelings have been balanced by gratitude; by the kindness I have been privileged to witness; by the team I have worked alongside; and by the families I have been privileged to follow. When the balance between gratitude and stress started to tip too far in the wrong direction, I knew it was time to move forward.

I’ll continue writing and reflecting on my experiences in my new role as a behavioral health consultant. I hope you’ll continue reading. This blog has become part of my self-care routine in a way I did not expect and your comments and kindness keep me moving. Thank you, dear reader, for joining me. On to the next!

Termination

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

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

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

Photo by  Giulia Bertelli  on  Unsplash

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

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

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

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

Meet them where they are?

 

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

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

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

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

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

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

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

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

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

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

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.

 

Use of Self

I am kind of an over sharer. I have a tendency to spill out my life story when someone asks me a fairly benign question. For instance, a question about what brought me back to Philadelphia after going to school out of state sends me into a long, complicated tale with details about a protracted break up and a deep sense of homesickness (in case you were interested). I will tell almost anyone almost anything. My co-workers know far more details about my personal life than I think they want to, but that's just the way I am. 

Photo by  Matteo Vistocco  on  Unsplash

With my patients though, I often wonder how much to divulge. I want to recognize and respect that I'm meeting people in their bedrooms, at their kitchen tables, in their intimate spaces, and asking them deeply personal questions. It's only natural that the boundaries between us are a little blurrier than they would be in an office setting. I don't mind answering a few personal questions: am I married, do I have children? I ask these of my patients; they're fairly benign. What gives me pause is when people hit a nerve they don't realize they're hitting. 

Now I have to give you a little more information--I'll try not to overdo it but it's important to this particular post. My mom died on hospice two years ago. She was comfortable and we had an enormous amount of support from the staff and from our friends and family. All that being said, I am still grieving and maybe will be for the rest of my life. 

I'm sure it's clear to you how this effects my clinical work, in this particular field. I frequently meet families that struggle with making end of life decisions. They hesitate to give medication or sign a do-not-resuscitate order or choose hospice at all. I have been asked sometimes, "What would you do, if it was your mom?" That's the nerve they (unknowingly) hit.

This is where I struggle with use of self. I have to ask myself, in the brief moment I can pause before it becomes too pregnant a pause, what am I willing to divulge? What will be therapeutic? What does this family need to hear? Sometimes I simply say, "If it was my mom, I would want her to be comfortable." Only recently have I been able to say, "I have been through this and I know it is incredibly difficult." And you know what? I don't know if that's the right thing to say. That's the thing about use of self, or about any part of therapy: one size does not fit all. There are so many variables.

This work has a science to it, of course. We use evidence-based theories to help people. But there is also a true use of instinct and intuition. We would not have become social workers if we weren't sensitive to other people's moods and body language. And so, when faced with this question that tugs at my heart in a very profound way, I must rely not only on my training about use of self and the therapeutic benefit, but also what my gut tells me. Sometimes it's wrong. Sometimes people's compassion for me derails the conversation and it's hard to get it back on track. But sometimes they are able to see the bridge I've laid out in front of them and thank me; they can trust what I'm telling them.

As always, I end this with no real answers. (Notice a theme here?) But I do believe it's an interesting question: how much do we divulge? How sharp should our boundaries be? What is self-serving and what is client-centered? Food for thought. Or, better yet, tell me your answers! I love to hear your feedback and look forward to it. Until next time, let's keep talking. 

How much time is left?/Questions I don't want to answer

Photo by  Uroš Jovičić  on  Unsplash

Several times a week, a patient or family member asks me this question that immediately stresses me out: “How much time do you think is left?”

The short answer is, I don’t know. The longer answer is still I don’t know but I can add some variables. There are signs that tell us the body is shutting down: changes in breathing, mottling of the hands and feet, a fever, etc. But there’s no exact science to determine how long the dying process can go on. I tell people that I’m wrong as often as I’m right. Still, people want to know.

Usually I answer that question with a question of my own: what would you do differently if you knew how much time was left? Generally, the answer is nothing. Occasionally there are some practical concerns (taking time off work, for instance). But on the whole, this is a question borne of anxiety: what should I say? What should I be doing? There are no magic answers to these questions.

That being said, I did read once that there are only four things you need to say when someone is dying: I’m sorry, I forgive you, I love you, and thank you. Sometimes I tell my families this. I remind them that even if their loved one isn’t answering, they can hear; hearing is the last sense to leave us. But mostly, when faced with this question, I reinforce that everyone is doing everything right, and how much time doesn’t really matter.

This makes me think about all the questions we get asked as social workers that we really don’t want to answer or that we simply can’t answer. Early on in my practice, I was not great at fielding these questions. I so wanted to have an answer to everything that I sometimes forgot to pause and consider my words before I spoke. Sometimes I would answer before I really knew what I was saying because I was so anxious to fill the silence, to reassure the patient or the family, to be the most knowledgeable person in the room. I quickly learned the power and importance of taking a breath before speaking. Sometimes this makes family members nervous and they say, “You can say it, it’s ok, what are you thinking?” Then I have to explain that I’m not trying to hide anything, I just want to give them a thoughtful answer.

I hate not being an expert at something. It’s a flaw of mine. But one thing this job has taught me is that you don’t need an answer to every question. I often consider why I chose this work. Ultimately, I became a social worker to fix problems. But that’s not my role. My role is to guide people on the path and point out the landmarks along the way. I don’t have to have all the answers. Which is a relief, because some questions, like how much time is left, aren’t answerable. Once I got comfortable with that, I stopped trying to be the most knowledgeable person in the room and worked on being the calmest. What our patients and clients really need is someone to be still and hear them. Which honestly, may be what we all need: not an answer, but someone to sit with us and witness and tell us that we are doing the right thing.

Politics

Photo by  Emily Morter  on  Unsplash

Photo by Emily Morter on Unsplash

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

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

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

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

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

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

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.

In Defense of Good Enough

I know how the title of this one sounds but I stand by it. Good enough is good enough.

I think I speak for the majority of us when I say that we put an enormous amount of pressure on ourselves in this field. We became social workers to help people, to fix their problems, to change the world. We can chant “meet the client where they are” a hundred times a day but deep inside there remains a voice that says, “you can fix this!” There is for me, at least. I’m seven years post-Master’s and there are still times that I forget that my goal is not to fix other people’s problems. My goal is to light the way on someone’s path, not lead it. Still, I have patients ask me all the time, “what should I do? What do you suggest?” Those questions put me on edge because I often don’t know the answer. That doesn’t make me a failure, though. It makes me human.

Part of being human means I have my own stuff to work through. There are days when I find my mind wandering in a patient’s house: did I call the air conditioning guy? When will I go to the grocery store? How am I going to get to my next visit on time? In those moments, I have to pull myself back and refocus on the person in front of me. Sometimes that’s hard to do.

Photo by  thr3 eyes  on  Unsplash

Photo by thr3 eyes on Unsplash

When I was on maternity leave and preparing to come back to work, I spoke with a therapist about how I could continue my work. I felt I had a newfound sense of empathy after having a baby but also a newfound sense that nothing else mattered. I feared that a part of my mind would always be preoccupied with thoughts of my daughter: was she eating, sleeping, crying, did she need me? How could I ever be fully emotionally present at work again? The therapist told me, “You will be better at your job and you will also struggle. And that’s ok. You have to accept not being at your best for a while but being good enough.”

I think about that all the time. There are any number of reasons we aren’t on our A game at all times: big milestones, like having a baby or getting married, but also small ones, like an upcoming vacation or an argument with a friend. It is impossible to be the best every single day. I imagine people in other careers have off days; why is it so bad for us to have them too?

I know the answer even before you shout it at me: we’re dealing with real people and their emotions. Our patients don’t care if we fought with our partner this morning or if our oil change is overdue. Their immediate world is fraught with illness and family dynamics and anticipatory grief. They do not have the space to take in our shit, quite frankly. We have to leave it at the door and do the best we can.

And on the days that we know our minds wandered, that we were not the most compassionate, the most healing, the most, we have to forgive that in ourselves. An expectation to be perfect is a good way to feel like a failure. So why set ourselves up that way? Good enough really is good enough.

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

Best and Worst

We had a small celebration for our interns, who are leaving us after several months, and a co-worker who is just beginning her retirement after many years. We asked them each to tell about their best and worst moments. It was easier for the students, who have not been with us an entire calendar year, than my just-retired co-worker, who has been in this particular job for a decade. Over a long career, there are going to be many best and worst moments. Still, some stick in your mind.

Of course it made me think about my own best and worst. Once, when I was working in a nursing home, I developed a good relationship with a patient’s daughter-in-law. The patient was dying and the daughter-in-law was (appropriately) tearful so I put my arms around her to give her a hug. She sat like a statue and I immediately knew I had made a mistake. That was 8 or 9 years ago but I remember it vividly. It stays with me all the time. And it’s not even the worst moment in my career!

It was a good learning experience though. I was so sure this woman needed a hug that I forgot to read her body language and her cues. She didn’t give me any reason to think she wanted to be touched; it was something I would have wanted in the same situation so I went for it. I felt horrible about it afterwards. And I was too inexperienced to acknowledge my faux pas. Instead I think I held on for a beat too long and then excused myself right out of the room.

To be balanced, I should tell you about one of my best moments. But you may think it’s strange if I tell you how it sometimes feels like a victory when someone starts crying or when a patient holds my hand. So I’ll save some of my best moments for when we know each other a little better.

What I will tell you is that I hope you are able to turn your worst moments into learning experiences as well as revisit your best moments when you feel unsure of yourself. I hope the good outweigh the bad of course, but I also hope the bad lead you to reflect; then move forward. I can read a cue now in a way I couldn’t before and I can’t remember the last time I accidentally hugged someone. This work is a long journey full of moments that help us to grow. I think that may be the best part about it.

Accepting feedback

My MSW student is nearing the end of her internship, which is bittersweet for both of us. She is ready to start her professional life and I'm excited for her, but it's been a great experience and I'm sorry to see it end.

In one of our last meetings, I asked her to give me some constructive feedback about our time together this past year. I encouraged her to email me if it was too awkward to do in person. I know that I have a hard time giving feedback, especially to supervisors! She was very gracious about it and agreed to think about it so she could offer me something useful.

It made me think about accepting feedback, which is a tenet of this profession. Use of self is a technique in clinical work; we are tasked with knowing ourselves well. We also need to let others tell us what we cannot see. I know this rationally, but I always struggle with accepting criticism. I have met a few people who are able to do it gracefully and I envy them. I wonder how they can hold open a space within themselves to hear "you can do better" and grow from it, rather than feel defensive or embarrassed. It's a personal goal of mine, to be more gracious in accepting feedback.

Feel free to leave some for me here! Or share with me: how do you accept feedback from your supervisor? From your peers? Do you give it frequently or sparingly? I'd love to hear from you.