Who's in charge here?

I never know what I’m walking into when I have a new hospice admission. Likewise, my patients and their families don’t always understand why I’m there. The nurse and the home health aide, even the chaplain, have very clearly defined roles. When I tell people I just want to talk, it can make them nervous.

At that first visit, death doesn’t always come up in the conversation. It’s a delicate balance: building rapport and offering education and being present without pushing too hard on the door to deeper issues. However, sometimes the patient opens the door for me. Take, for instance, the other day: I visited with a new patient who almost immediately wanted to talk about her impending death. She wanted to know how much time she had left (can’t tell you, sorry); how involved she could be in her funeral planning (as involved as you want!); and how it was possible to feel physically ok and somehow still be dying (take that one as a gift, my friend). We had a difficult but very nice conversation and I think I was helpful.

The next day, the nurse called me to tell me that the patient’s sister didn’t want me to talk to the patient about end of life issues. (Imagine me rolling my eyes).

Luckily, the nurse is no shrinking violet; she informed the sister that the patient is alert and oriented times 72 and gets to be a part of her care planning. In fact, the regulations (if you, like me, are a rule-follower) insist upon the patient being involved in her own care.

But families don’t care about the regulations; they care about their loved ones not being sad, or scared, or “losing hope.” I can’t tell you how many times a (well-meaning) family member has said to me, “We don’t want him to know he’s on hospice” or “we didn’t tell her that she’s dying.” (Spoiler alert: people typically know that they’re dying). And truly, I get it: we don’t want the people we love to be afraid or feel sad or suffer. But, as I always remind those family members, we don’t get to make decisions for other people as long as they’re capable of making their own. We can be tactful; we can be kind. But I will not lie to a patient who asks me a direct question. I will not change the subject when a patient wants to talk about her death. It’s easier sometimes, as I tell my patients and their family members, to bear one’s soul to a stranger, if only because they don’t have to be careful. I won’t start crying or tell them it’s going to be ok; they don’t have to protect me the way they want to protect their loved ones.

In my most gracious moments, I can acknowledge that protection is what people like the afore-mentioned sister are after. In my more annoyed moments, I start crabbing about how it’s all about control and who wants it and who has it. Both can be true! What’s important is to focus, once again, on the person we are serving and to (kindly, firmly, lovingly) set boundaries with everyone else. Advocating for patient choice is foundational to this work; what a joy when it is so easily done.

Stuck in the weeds

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

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

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

Photo by Hutomo Abrianto on Unsplash

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

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

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.

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.

Photo by Sébastien Marchand on Unsplash