Should you forgive or stay angry?

When I first started as a hospice social worker, I had this vision in my head of the deathbed. In this fantasy of mine, the soon-to-be bereaved are with the dying and everyone is saying whatever needs to be said. It was a very pretty picture. But it didn’t take too long in real life practice to see that vision vanish.

Don’t get me wrong, it does happen sometimes, that everyone says the Four Things: I love you, I’m sorry, I forgive you, thank you. I’ve facilitated those conversations, I’ve witnessed them, and they are truly beautiful. But more often than that, a lot goes unsaid and unresolved. Maybe it’s because everyone thinks there will be more time; or there’s a fear of upsetting each other; or it’s just too hard to start the conversation. Then the person dies and the bereaved are left with whatever went unsaid or unresolved or unforgiven.

Also, not everyone who dies is saintly, or unconditionally lovable. Difficult people die too. They have loved ones who are left with complicated feelings. They have loved ones who are angry or hurt and now there can’t be a resolution. Maybe there couldn’t be a resolution when the person was alive either but once they’re dead, there’s really no way. In that case, what do we do? Should we forgive or stay angry?

I’ll answer this question with one of my own (just call me Socrates): who is forgiveness for? Is it for the person who’s wronged you? They don’t always want your forgiveness, and when they’re dead they certainly don’t care anymore (I imagine; I guess I’ll find out for sure one day). If it’s not for them, can it be for you?

You’re allowed to hold on to your anger for as long as you want. Even if the person you’re angry at can’t fight with you about it anymore, you are allowed to keep being mad. But everything has its tipping point. One day your anger won’t serve you anymore. Then you can consider forgiveness, if not for someone else, then for yourself.

Finding hope

There is a lot of hope in my work.

I know that sounds strange because I work with people who are dying and grieving, but my experience mirrors that old adage that hope is like oxygen: we need it to survive. The concept of hope changes for my patients over time; they go from hoping to get better to hoping to die, comfortably and with dignity. But still, the overwhelming feeling I meet is hope. And while I am inspired and awed by it, witnessing hope in these circumstances can be tricky.

A few years ago I went to see a young patient who was actively dying. I can’t remember her name but if I close my eyes, I can see her face: I am in her apartment, with her husband and her sister; I can see their faces as well. I can see the patient beginning to leave her body; that is, she was physically still with us but her soul (or whatever you want to call it) was not totally there. And I will never forget, while she was breathing in that shallow, erratic way that means death is close, her sister said to me, “Other people get miracles; maybe she’ll get one. Do you think that could happen?”

I’ve met this experience so many times during the six years I’ve worked in hospice: hope crashing into reality. And what is my role then? How do you validate someone’s hope and fears and raw grief while also educating them about what is actually happening? How do you say nope, no miracles today, she’s already leaving us? It would be cruel, in that moment, to say those things but it would also be cruel to lie and say, yes, it’s possible she will sit up and the cancer will be gone and she will be your sister again.

Despite the scene being so vivid in my mind, I can’t remember exactly what I managed to reply. My hope is that it was something like: “I hope that’s what happens; but what we’re seeing makes me think we’re at the end. And I’m so sorry.”

My words are lost to me now, because they aren’t that important. Instead, the lesson of being very still is what has stayed with me. In those moments, when the family is in a kind of chaos, I am always tempted to rush: to meet the family’s anxiety with my own out of some weird empathetic sensibility. Instead, I have trained myself to become as still and quiet as possible, to try to spread calmness through the room, even as I feel afraid to say out loud that there will probably not be a miracle.

I’m writing this today because I have been thinking a lot about hope in the past several months. I often feel a dearth of it when I read too much Twitter or see someone in the Wawa not wearing their mask correctly. I wonder when this will end, when we will get to the other side, when I will be able to hug my friends again. At moments (just moments) I feel hopeless. But my work brings me back, somehow. There is hope to be found even in dying. If that can be true—and I promise, it is, I have seen it—then there must be hope to be found anywhere.

Image by John Towner

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?

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?

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.

Photo by Nevin Ruttanaboonta on Unsplash

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.

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.

Narrative therapy or, what do you DO exactly?

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

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

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

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

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