Boundaries

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

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

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

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

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

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

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

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

Who's doing what?

Yesterday I met with a fairly resistant client. Everything I said—every suggestion, every reflection—was met with, “probably” or “I don’t know.” It was frustrating but I tried to pull out some of my (rusty) motivational interviewing skills and get her to state her own goals. We managed to come up with a couple of strategies to reduce her isolation and improve her mood; I was feeling pretty good about our limited progress. Then she hit me with this response: “So it’s all on me, huh.”

YES. YES, IT IS.

This has been a frequent experience lately in my practice: my patients want answers but they don’t want to change anything. Listen, I hear that. I want to lose weight but I don’t want to stop eating whatever I want. I have no trouble empathizing with that impulse, of wanting to get better without actually doing the work. What I’ve been thinking about during and after these interactions is whether I’m being clear about how therapy works. Namely, which one of us is doing the work here.

As clinicians we often want our patients to do what we think is best: quit smoking; leave an abusive partner; practice some deep breathing. But our patients don’t want to do those things. They want to feel better, sure, but they don’t want to make any changes. We meet at this impasse a lot of the time and try to figure out how to move forward together. We are both resistant. We both want the other to do the lion’s share of the work.

And who’s right? As a clinician, I’d say I am of course! (Ha.) I can’t do the work for people. I can’t put down the cigarette or leave the boyfriend or do the deep breathing (I mean, I can breathe deeply obviously, but not for someone else). But my patient wants to feel better right now. And they think the key to feeling better is making other people do some work.

Of course, I don’t do nothing. Ultimately I try to gently lead someone towards the things that are in their control instead of allowing them to focus on the things that are out of their control. I try to get them to see that they have to do the work, even as they wish that I would do it for them. I wish I could, too. Sometimes they don’t come back, maybe because they’re not ready. Or maybe because I’m not the right fit for them. I have to do my own work there, not to take it personally and use every clinical experience I face as a chance to reflect on my practice. As I told a patient this morning, I’m growing too. That is the gift of the work.

Finding Compassion

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

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

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

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

Then, I think: maybe they can’t.

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

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

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

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

Barriers that can't be helped: What patients see

I’m currently very pregnant. Like, people are surprised I continue showing up to work kind of pregnant. But here I am, seeing my patients, explaining my role, and assuring them that someone will be covering for me when I go out on leave.

Recently, I’ve had a few patients gesture at my belly and say something to the effect of, “you’ve got your whole life ahead of you, you’re doing something exciting/meaningful, and what have I got?”

I used to hear a mildly different version of this when I was a hospice social worker: “you’re young, you can’t understand what this is like,” meaning I couldn’t possibly have experienced loss because of my age. I often struggled with that pronouncement because I have suffered some significant losses and I resented that those experiences were being minimized. Of course, my patients didn’t know that. All they saw when they looked at me was a young woman with her life ahead of her as theirs was ending. The actual words were not so important; it was the feelings underneath that I had to focus on. They wanted to know: how could they be vulnerable with someone who wasn’t in their shoes?

 This is not to say that my feelings in these moments aren’t important. I’ve written before about the need to use our own feelings in a therapeutic role. But the negative feelings that arise during client interactions are better dealt with after a visit. Therapy is for the patient, not the therapist. We have to deal with our shit at a later date.

And deal with it we must! But what do we do in the moment, when our patients challenge us in this way, for things we can’t help, like our youth or ability to bear children or our race or gender? And what do we do with the feelings that arise when we’re called out for the audacity to be different from the person we’re treating?

So much of this work comes back to our early training: good old active listening will help you almost every time. When a patient says that my life is beginning as their life is ending, I take myself out of it as I reflect back to them (after all, I’m not really the issue here): “You feel like you don’t have anything to look forward to.” Or, “it sounds like you feel sort of purposeless, is that right?” I think sometimes patient want to talk about us because it’s less scary than talking about them. That’s a fair impulse. It’s our job to gently redirect and help our patients get back to the heart of the matter. And it’s fair to acknowledge their feelings about talking to someone who isn’t their age/gender/religion/whatever. Naming awkwardness is the best way to get past it. A clinician needs to have some level of vulnerability in order to help her patients be vulnerable too.

But after the visit, how do we sort out our own shit? I may understand rationally why people struggle with my age or my pregnancy or what have you. But when the patient leaves and I’m writing my note, I often feel frustrated by their judgements. I wonder if I was effective in the visit, if I should have drilled down harder on a statement. I second guess myself. I find myself feeling resentful about an off-handed comment. To cope, I do what I tell my patients to do: I examine the thought and try to let it go. If it’s a particularly difficult one, I talk about it until I’m tired of the sound of my own voice. I find that talking about something to death diffuses its meaning. And I remember to view it all with compassion. Our patients come to us with their own shit too; our job is to help them sort theirs out and deal with our own stuff later. Preferably in supervision!

Being the bridge

My role in this job is to see people for short-term issues. Think insomnia, smoking cessation, mild anxiety due to stress, etc. But maybe a third of my referrals are for patients who have a long history of mental illness. These are people who have been disconnected from mental health care for a long time. Part of my job is to be a bridge for them: connecting them to care and hanging with them until they can get into a therapist’s office.

So I have this patient who has seen about a dozen different psychiatrists over the years; in and out of psych in-patient, in and out therapist’s offices, in and out of intensive out-patient programs. To protect her privacy, I won’t go through the laundry list of diagnoses that follows her. But I will say that she has a handful of very complicated diagnoses coupled with a trauma history and a history of substance use. Very much out of my scope, both in this role and in general. But we started meeting anyway, every couple of weeks, to tackle her anxiety and (on my part) try to reconnect her to more intense help.

I like this patient; she has a good sense of humor and we just hit it off. But some of what she told me was just so far out of my experience, I didn’t know what to do. So I went to supervision.

It’s not that I didn’t know what I should do. I knew that she needed a higher level of therapy than I’m qualified to provide. But I didn’t know how to convince her of that. This is a woman who has been in and out of therapy for 30 years; she is deeply distrustful of psychiatrists and very reluctant to meet yet another therapist. But meeting in supervision helped me craft the right words: that while I like her very much and enjoy working with her, I’m not the right therapist for her.

Much to her credit, she was gracious and understanding. She appreciated my honesty and agreed to try it with someone else. So I referred her out to a therapist with a trauma background who was also trained in EMDR. I talked to the therapist myself; she had experience and she was taking new patients. What could go wrong?

It should not shock you, dear reader, that it did not work out. My patient called me after she had her session with this therapist to tell me that the therapist “couldn’t help her.” At first I thought maybe my patient was misrepresenting what happened (read: I thought she was lying to me). Again, I went to my supervisor. He pointed out that there are bad therapists; what she said could be true. I had to ask more questions.

More conversation with my patient made it clear to me that she didn’t misunderstand or misrepresent the session. She met with the therapist for an hour and it ended with the therapist saying, sorry, can’t help you.

Some self-disclosure here: I’ve seen bad therapists. I’ll spare you the details, but I have certainly left a therapist’s office wondering why they had chosen this profession; their rapport building was so subpar, their attitude so shitty, I felt worse than when I went in. So maybe the therapist I sent my patient to was one of those. Or maybe she wasn’t having a good day. It happens; we are, as I keep writing on this blog and saying out loud to the women I supervise, only human. Still, I was disappointed. I had convinced this patient to see someone else, only to have her be shown the door.

Luckily for me, my patient trusted me and she agreed to try again. This time I was a lot more diligent. I made about ten phone calls. I gave an in-depth report about my patient’s history (with her permission) to the people I spoke to. Just before I was about to give it up for a while, I connected with someone who agreed to see my patient.

This patient stopped in the other day, after she saw her doctor. She’s been going to therapy weekly, which was thrilling for me. She thanked me for my support and my help. She looked good. We got to share a moment of mutual admiration and respect that carried me through the rest of my day.

I know it won’t always end this way. I know I’ll make referrals that patients won’t follow through with or that won’t work out for some other reason. But man, I am holding on to this small victory for now. The combination of supervision and doing some extra leg work paid off and I’m so happy for my patient; she’s getting the help she needs. Often the best thing we can be for the people we meet with is a bridge to something better. And how fortunate we are to be that bridge.

Meeting Resistance

I met with a lot of resistance when I worked in hospice. I had plenty of patients who didn’t want to sign a Do Not Resuscitate form, for instance, or who didn’t want to take the medication that would keep them comfortable. Sometimes it was frustrating but for the most part, I accepted that resistance as part of the job. After all, people were literally dying. Who was I to tell them how to live out the rest of their lives? I remember once, at a consent signing, the son of a patient told me that his father “wasn’t handling his death well” and I thought… Well, he doesn’t need to; it’s HIS death. I wasn’t particularly troubled by those moments in that job because the big picture was so very big. Death has a way of throwing things into a very clear perspective.

But now I’m not a hospice social worker anymore. Now my job (a lot of the time) is to help people make changes to their behavior so that they have less stress, less depression, less anxiety, and better health. I feel pressure from the doctor who makes the referral and pressure from the patient who says, this is bad, fix it. And in these sessions, when I meet resistance, I struggle.

I’ve been trying to use motivational interviewing because a lot of what I’m meant to do is help people focus on behavior change. When using motivational interviewing with a patient, the clinician is supposed to keep in mind the stages of change. The first stage is pre-contemplation. Basically, these patients aren’t ready to make any changes. Even if they know they should quit smoking/lose weight/take their medication/you name it: they aren’t there. Sometimes the goal with these patients is just to help them identify what the consequences will be if they don’t take any action. Sometimes they don’t come back. It’s one of the basics of social work, right? MEET THE CLIENT WHERE THEY ARE.

But sometimes I really resist that!

This has been bugging me because I recently met with a patient who shot down everything I said. Every. Single. Thing.  I tried to join him with empathy. I reflected back to him what he was saying to me: job too stressful, health too difficult to manage, lack of social support. I tried to listen for change talk; when he said that he knew he couldn’t continue the way he was going, I seized on that like a drowning man grabs a life preserver. But he wasn’t having it. The session can be boiled down to me saying, “So what about…” and him saying, “nope, won’t work.”

In the end, we were both frustrated. He had started the session telling me that he didn’t think I could help him and honestly, my delicate ego had been marching around my mind the entire time, telling me I COULD help him and I WOULD! But at the end of it, we hadn’t moved much. He was resistant to me and I was resistant to him and we were both stuck.

This is one of those things that keeps coming up for me, however many years into my social work career: dealing with the impulse that screams PLEASE LET ME HELP YOU. It’s disappointing to me when the patient doesn’t want to do anything to change their circumstances. But why is that? Why do I want it more than the patient? Why do I measure my competence as a clinician through how a patient responds in one half hour session? If I’m being generous to myself, I can say it’s because I became a social worker to help people; I want people to leave the session with a plan to feel better. Less generously (but no less true), I let my delicate ego make me think I can save everyone, even people who didn’t ask for it. I’m resistant to their resistance and that’s just not going to work.

So I’m taking a deep breath and stepping back for a second. Pre-contemplation just is; same with resistance. I don’t have to move anyone forward. I don’t have to have any goal except for the goal the patient has given me. I can let my expectations go and get back to hearing what the patient in front of me is saying. And sometimes it may be, “I’m not ready.” And my response has to be, Ok. Tell me more about that.

The gift of counter-transference

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

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

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

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

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

Recognizing our own shit

I was not at my best the other day. I met with a patient I’ve seen a handful of times who is struggling with managing her depression. I won’t lie, I was feeling frustrated. This was our fourth meeting and it was almost verbatim the same conversation we had had in our three previous sessions: her son is annoying, she hates getting older, she wants to meet a man, the people in her building are awful… Every single thing in her life is terrible as far as she’s concerned. It’s an exhausting conversation. Today I just couldn’t take it anymore. So I said (gently), “We’ve been having the same conversation every time you come in.” To which she answered, “Should I not come back?”

I can be honest here, in my safe space, the blog that a half dozen of my lovely friends read: I was briefly tempted to say, yep, don’t come back. But I’m a professional and I can’t give in to my baser instincts. Instead, I silently checked the feeling and took a breath. “That’s not what I meant,” I clarified. “I just meant: I can’t change the way you feel. What I can do is help you figure out how to make changes to try to feel better. And if you don’t want to do that—which is your right!—that’s fine. But if that’s the case, then I don’t know how I’m going to be any help to you.”

Her reply was, “It’s hard.”

Just like that, my compassion came rolling back to me. My shoulders dropped a little (I hadn’t even realized how tense I had been, how physically rigid in reaction to my frustration). She was right: it is so hard. It is hard to feel stuck and depressed and lethargic and not be able to see your way towards the light. It feels permanent, even though it’s not. It feels like shit.

In that small sentence she reminded me of two things: one, it is hard and I should not forget that; and two, it’s not my problem to fix.

I don’t mean to sound cold. But here we are again at another truth of The Work: you cannot do it for someone else. I can’t wave a wand and have this woman feel better. I can only lead her to her own conclusions. And the right thing to do when faced with the frustration I felt is not to say, yeah don’t come back; instead, it’s to push through the ambivalence and the frustration that she is surely feeling and help her decide to make a change.

I don’t know if she will come back; I may have messed up enough that she seeks help elsewhere. I hope that’s not the case. Either way, another learning point for me: check that counter-transference before it interrupts the relationship! This is part of the reason we continue to have supervision throughout our careers: to manage the feelings that bubble up and interrupt. After all, we’re only human.

Racism, anxiety, and discomfort

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

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

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

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

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

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

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

The case for cutting someone off

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

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

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

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

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

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

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

Replacing "I'm sorry" with "Thank you"

Photo by Nicole Honeywill on Unsplash

I went to a Motivational Interviewing training the other day (highly recommend; it was super helpful and engaging). Lots of pieces of the training struck me but the one I keep thinking about is the power of saying “thank you” instead of “I’m sorry.” Let me explain: a big tenet of motivational interviewing is reflecting what a patient has said to you, the practitioner. Sometimes we misunderstand our clients, since we’re only human, and our reflection is off base. When this happens to me, I typically apologize. This trainer explained that when she misunderstands a client and they correct her, she likes to say “thank you” instead. That really stayed with me.

It reminded me of something I read on Facebook a while ago. (I usually ignore those positive meme/message things but this one caught my eye). It said, to paraphrase, “Instead of saying I’m sorry to friends, I’ve started saying thank you. If I’m late for instance, I’ll say, thank you for waiting for me.” I find that idea so powerful. It takes away the blame factor and invites the person on the other side to feel appreciated for being gracious rather than annoyed. And that’s important both in our professional and our personal lives. So much of this work is about relationship building. Won’t it build a stronger relationship if we foster graciousness rather than blame and apology?

There is a time, I believe, to apologize in therapy. Sometimes we unintentionally offend our clients. I, for one, am sometimes guilty of making a joke that doesn’t land very well that I have to walk back. In those moments, apologizing seems like the right thing to do. But if we reflect something back to a client and we just misunderstood, saying “thank you for clarifying that” seems like a more helpful response. We’re inviting our clients to continue to be honest with us. We’re encouraging them by thanking them for their vulnerability. Saying sorry can make things awkward; saying thank you is like opening the door a little wider.

Ultimately that’s what we want to do, whether we meet with a client one time only or once a week for a year: open the door. Invite honesty. And being grateful rather than apologetic may be one good way of doing that.

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

Relearning the work

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. 

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?