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

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?

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?