The Work of Intrusion

Death is such a private time; it is the only thing we truly do alone. Sure, if we’re lucky, we’re surrounded by people who love us, but the final trip is done solo. I’ve often wondered where the dying are during that in between time: when the body is still here but the soul (or whatever you want to call it) begins to fade away. I guess the answer depends on your own personal belief system.  I’ll spare you mine; it’s private and precious to me but also not the point of this blog post. This post is about feeling like an intruder.

So much of social work is about invading people’s personal space. We ask wildly personal questions of our clients: what kind of sex do you have, and with whom? How much money do you make? What religion do you practice? Where do you want to die? Imagine asking someone those questions in any other setting. I’m a real hit at cocktail parties, let me tell you.

And yet, this is the work: to build rapport and intimacy as quickly as possible so we can help people. It is a skill that we have to cultivate over time, acknowledging our own discomfort and moving through it. I sometimes feel like an intruder in hospice: when I walk into a home and someone is actively dying and I’ve never met the family before, for instance. Who am I, to invade this sacred space? People often come onto hospice very late in their illness—a topic for a whole different post, I can really rant about that one—so we don’t always have the time to provide the quality care that is the goal of hospice: the relationship building, the life review, the exploration of spiritual and existential distress. Often, I walk into a house and the patient is already halfway gone. The body is present but the person is not themselves, exactly. In those moments, I feel like an intruder, a voyeur. What can I do for someone who is mostly gone? What can I do for a family of strangers in their most intimate, private grief? Sometimes I have felt an urge to leave as quickly as possible, to spare everyone the awkwardness of my presence.

And yet, I have been invited to be present; that is the work I’ve agreed to do. That is what we have all agreed to do, as social workers: invite and share vulnerability, create intimacy and trust, sometimes over months and years and sometimes over just minutes. I can tell you that while I love having a patient for a long time—love hearing the stories and meeting all the family members—there is something special and sacred about holding space in the room for a stranger as they exit this mortal plane. I used to want to run out of the room, sure that I was already too late. Now I see the usefulness of my presence; I can be still and quiet and assure the family: you’re doing everything right. Thank you for letting me be here with you. It turns out I am not an intruder after all, but a source of comfort for the journey. Even if it’s only at the very end.

Image by Jose Pereira, Unsplash

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

White privilege, hospice, and a ton of unanswered questions

It doesn’t feel like the time for me to be talking; there are BIPOC voices that need to be elevated at this moment and I want to be someone who elevates those voices. That being said, it also feels important to interrogate the ways in which social workers work within a system of white supremacy. And it feels important to acknowledge how tricky it can be to balance the work of anti-racism and social justice while also building rapport and offering support to our clients with unconditional positive regard.

Easy stuff!

I’ve worked in hospice for six years in a city that is racially and ethnically diverse but also often clearly segregated. The neighborhoods I visit vary wildly, both socio-economically and racially. And the demographics have changed over the years, as all neighborhoods change. In fact, that’s the racism I encounter from my patients and their families. It’s not racial slurs or explicit hatred; that would maybe be easier to address. Instead, it’s the insidious, widespread, casual stuff. For instance, the white family who says, “We moved because the neighborhood started changing, you know.” The white patients and families I see feel safe using coded phrases like that because I’m also white. And in those moments, as an ally, as a social worker, as someone who wants to be Helpful and Brave, what am I supposed to do?

With a friend or a family member, perhaps I would be brave. Hopefully I would be brave and address those statements. But with a patient or their caregiver, I must confess: I am not brave. Instead, I am complicit. In six years I have not figured out how to manage the twin asks of doing my job and doing the bigger work of anti-racism. At best in those moments, I make my face go stone and change the subject. I don’t think that’s enough. But I honestly don’t know what else to do.

One of my supervisees and I spent a solid amount of time talking about this and we didn’t end up with the Big Answer. The closest I can get is that we have to work in the role we choose. Which is not to say there’s never an opportunity to push back in a therapeutic relationship. The questions are when and how to do it. As my supervisee wisely pointed out, is it fair or reasonable to ask a person to examine their racism and their prejudice as they are dying? Will it do any good? Further, do I do my Black patients a disservice by not acknowledging the racism they face in the healthcare system I represent? How do I start that conversation? And when? Will it be welcomed or will it also be considered harmful?

Lots of questions I don’t have any answers for. There’s more for me to learn, clearly: more reading to be done, more discussion with others, more self-reflection. One place I’ve started is with this Medium post by H. C. Dawes; I hope you’ll check it out: https://elemental.medium.com/an-invitation-to-white-therapists-a04cc93b1917

Thanks for reading.

Be my witness

I’ve had a lot of trouble writing this post. Not because I don’t know what I want to say; the words have been pouring out for days. It’s more that I can’t seem to get them into a coherent order. I’ve been struggling with my work—not my job, but the actual work of being with grief and illness and death. I’ve been thinking for weeks about what it means to witness the suffering of others.

It’s a heavy topic, and I’ve come to imagine it as an actual weight. When I’m with my patients and their families, I take their weight for a little while, to give them a rest. Then I hand it back before I leave the house. I literally leave, which helps separate me from the grief I’ve witnessed. But lately the weight has seemed heavier, not as easy to release when the visit ends. And because this blog has become a key part of my self-care, I’ve got to write it out so I can move on.

The other day, I mentioned to my husband that I had met someone who had lived the life of Job. He had never heard that expression before, which makes me think it’s an old-fashioned one (I have an old soul, you guys) so I will elaborate. Skip this paragraph if you’re familiar with our friend Job of Old Testament fame. Job was some poor soul that God used to prove a point to Satan. (Old Testament God made some upsetting choices, honestly). God not only stripped Job of his earthly possessions and killed off all ten(!) of his children, He also gave the guy a horrid skin disease. This was all to prove to Satan that Job would continue to love God under any circumstances. There are more details, of course, but you get the gist: Job’s suffering was incredible.

I sometimes meet people who have suffered so much that a part of my brain thinks, this cannot possibly be true. Their losses have added up so significantly that it is almost unbelievable that one person could have bad luck like that. There are times that I am faced with such tragedy and pain that it nearly takes my breath away. In those moments, I wish I didn’t choose to be a witness to suffering.

And yet, I did. Or it chose me, whichever. The point is, I am honored that people trust me enough to tell me about their trauma. I feel that it is a gift that I can bear witness to someone else’s pain and briefly hold it for them so they can get a break. I don’t have to live with it, myself (I have my own tragedies to carry). Anything is bearable for a few minutes and I usually can let it go.

But, like I said, lately I’m having trouble releasing the weight. I imagine myself being pushed down, little by little, as I hear sadder and sadder stories. Picture me up to my knees in the ground, carrying something heavy on my shoulders. That’s what it feels like: I’m standing upright but I’m sinking.

It’s hard to admit that. I pride myself on having excellent boundaries and solid self-care. It’s difficult to tell you that my usual stuff is not totally working at the moment. But the best disinfectant is sunlight; it’s better to admit that I’m struggling. So what will I do? In these times, which come along with the territory of the work, I allow myself to feel overburdened. I let my heart feel heavy. I go to church. I look into the beautiful, healthy faces of my daughters and try to be present with them. I read celebrity gossip. I take deep breaths. And I wait, as patiently as I can, for the weight to lift.

There is great tragedy in the world but also great joy. Even Job received his rewards (questionable whether the pain was worth it, but again, Old Testament stories are wild). I can still see the good. It exists in the warmth of strangers, in music, in bright sunsets, in my children’s laughter. It exists in my work, which can be deeply, profoundly sad, but also wildly, touchingly beautiful. It is heavy but I have chosen to carry it. I am still grateful.

Speaking of which, thank you for being my witness today. I hope you find an easy road today. Be well.

Not a rupture, but a tear

Over the years, I have grown comfortable with what I can and cannot do for my patients. I think often of my early hospice career, when I once called my dad after leaving a visit, sobbing because my very young patient was going to die. (I’m sure I’ve written about this before but it has shaped my practice so much in the past six years, I feel compelled to mention it again). The short story is, I told my dad that I couldn’t do anything for her because I couldn’t stop her from dying. And my dad kindly reminded me that I could do something: I could be with her.

It’s a lesson I carry with me into the saddest cases as well as the most mundane days. It’s how I do my work without being drowned by the suffering of others. Also, it’s true! I can’t stop people from dying but I can bear witness and be still and that is mostly enough.

But then, there’s this patient.

I’ve been seeing this lady every two weeks since July. She and her family were told by the doctor, in July, that she had hours to days to live. Another wise thing my dad has told me my whole life is that doctors don’t know everything and they definitely cannot accurately predict when death will come. Here, case in point: she’s still alive in November. And she’s not exactly thrilled about it. I can’t blame her: she’s mostly confined to her bed, she barely eats, and she feels like a burden on her children. When I visit, we talk about those things, but also about her life and her accomplishments and her family. We have a good rapport and I think she enjoys my visits.

Last time I saw her, she was having a particularly bad day. I used all my active listening and therapeutic presence skills and I thought, when I left, that I had been at least a little helpful. When I called this week to schedule our normal visit, she declined. This happens, don’t get me wrong; sometimes people aren’t up for a visit, especially if it’s “just to talk.” But there’s a little nagging voice in my head that is telling me she said no because I can’t do anything for her.

This isn’t a therapeutic rupture exactly but it does feel like a little tear, or a crack maybe. And again, I may be projecting, but I heard in something in her voice when she said “not today.” I heard, “you can’t do anything for me, so why bother?” And that’s the part of the job that scratches away at my confidence and my resolve. I can’t change things for her. What I can offer, she doesn’t want right now.

It’s taking everything in me to type the following: THAT’S OKAY! It is okay that she declined one visit, one time. It’s okay that she’s depressed. It’s okay that I have no magic wand. (Maybe if I write these words enough, they’ll come true). It’s okay to not be all things to all people.

This is mostly my stuff because I’ve been having a hard time getting people to agree to visits, especially new patients. That’s a thing that happens in this job; after six years, you would think I could sit comfortably with it. But at this moment, I’m struggling with it. And honestly, that’s okay too. It’s not a rupture in my work, just a stumble. Carry on, my grandfather used to say, and so: I will.

Photo by Namnso Ukpanah on Unsplash

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.

Living in the village

The other day, I just about ran out of a joint visit. It was a tough one: the patient’s caregiver is struggling, to put it mildly. His anger is palpable. He is hyper-focused on a story he tells every time I see him, of how the hospital and the doctors wronged him and his partner, and how he will get revenge (his words). It is a difficult house to be in, so the nurse and I have made a couple of joint visits.

As a rule, I love joint visits. This work can be isolating and lonely and it’s helpful to have someone else with you sometimes, if only to cut your eyes at when the family leaves the room. I’ve been lucky over my career to work with a lot of wonderful nurses who relied on me for my expertise just as I relied on them for theirs. I think of hospice—of all interdisciplinary work, really—as a village. At its best, the team functions as a mini village where each person has their own role to fulfill: the nurse, medical care; the home health aide, physical care; the social worker, emotional care; the chaplain, spiritual care. Beautiful, right? Everyone has their own set of skills in the village, which complement each other and serve the patient.

There’s a balance to village life: just as I’m able to give to others, I have to do some taking, too. Obviously it’s not always an even split; that’s life. But with this co-worker of mine, the split is so off that something has to change. And I’m struggling with how to set a boundary without derailing a fairly new professional relationship. This visit may be the straw that is breaking my back.

I don’t want to go into too much detail, because the minutiae is not terribly important. The gist is, this co-worker attempted to do some psychosocial interventions in a clumsy, overbearing, awkward way, that only set the caregiver off (I told you he was angry, remember) and took the oxygen out of the room for a few minutes. It’s not her fault that she did the interventions poorly; she didn’t go to social work school. Just as I would never take someone’s blood pressure or tell them how much medication to take, another discipline can’t do social work.

Despite this very large misstep, she had a good rapport with the caregiver so the visit didn’t end in a yelling match. The visit was over shortly thereafter and even though I knew she wanted to debrief, I had to get out of there. I just about ran to my car, angry with her for disrespecting my skillset, frustrated with myself for not cutting the conversation off the moment it began, and overall feeling horrible, about that particular interaction and about how poorly I’d set boundaries with this co-worker.

Luckily, I have good supervision at this job so I called my supervisor for some validation and guidance. She gave me both and helped me find a way to set some solid limits. I want to be helpful; I want to be emotionally present for my colleagues. At the same time, I can’t be all things to all people. I love the village concept but as I said, there is a balance. I hope this co-worker and I have found the right balance so that we can move forward. This job is easier when you’ve got other people on your side.

The perks of being grounded

Recently I got together with some of the girls I grew up with for lunch. It’s been more than fifteen years since we’ve all been together and I was expecting it to be a short little meetup. After all, what do we have in common after so much time apart? Instead, we chatted for more than two hours, until we all reluctantly had to get back to our families and our Sunday chores. I left feeling happy and surprised but also deeply grounded. These women know the most core parts of me. We’ve lived a lot of life in between our high school graduation and now, but still, they understand me; they brought me back to myself.

Since that lovely lunch, I’ve been thinking about that feeling of being grounded: namely how it makes this work easier. It’s different from self-care, a term which has been co-opted by pop culture so much I think it’s lost a bit of its meaning (a rant for another blog post). Being grounded is not exactly about self-care, though that certainly factors in. What I’m referring to is being strong in my own sense of self. So often in this job I’ve lost myself: because of difficult clients, micro-managers, my own counter-transference. There is often chaos in what we do, swirling around whatever the core of the issue is, preventing us from getting to the point. It’s easy to get drawn into the chaos. I think of family meetings I’ve been in where I was overtaken by stronger personalities or louder voices (hard to imagine, I know). Over the past decade of doing this work, I’ve replayed client interactions where I lost my patience or got over involved in the minutiae, missing the part I could actually help to change. At times I forgot how to listen, how to be still: core skills of our job.

I don’t recommend this strategy as a way to get grounded. As important as it is for us to examine our work, it’s even more important to walk in to the work confident in our strengths and aware of what we can’t offer. When we are grounded, when we know ourselves and feel strong in that sense of self-knowledge, that’s when our best work comes out. That’s when we are able to get to the eye of the storm and offer real help.

So. As you walk into your week, into the frustrations and successes and surprises of our work, I hope you are acutely aware of what it takes to ground you. For me, it’s being with old friends; watching my daughters play; and being outside. These are the ways I come back to myself. I hope you have a way back, too.

Photo by Deniz Altindas on Unsplash

A (small) ethical question

I’m in the midst of a lot of professional training, both for work and for my side hustle (“clinical supervision” doesn’t roll off the tongue as nicely “side hustle”). I love continuing education: I love being with other social workers; I love reading case studies; I love doing exercises about theoretical framework. (It turns out I kind of miss being in graduate school). Because clinical social workers are required to have ethics training every two years, a lot of my recent continuing ed programming has involved some ethics credits. We start, always, with the most egregious examples of social work ethical dilemmas: stealing from your workplace (BAD); falsifying documentation (PRETTY BAD); having sex with a client (SO VERY BAD). Those ethical questions have straightforward answers: don’t do that shit. It’s the grayer stuff that I like to turn over. And today I’d like to turn a personal one over with you.

Don’t freak out! I am not involved in any egregiously bad activities! It’s definitely one of the gray ones.

I have a patient I really like: she’s bright and funny and interesting. She has a fascinating career. I’m sure that if we met in a different setting, I would strive to be her friend. But we haven’t met in a different setting; I’m offering her counseling, not friendship. And sometimes I find myself forgetting that.

I write often about use of self and counter-transference but I don’t think I’ve yet touched on this: what happens when we really like our clients? Obviously we like most of them; social workers typically like people. I’m talking about the unique problem of liking a client personally, the way you would like a new friend for instance, and how to manage that.

In my current job, I’ve met almost 300 different patients. Of those, there are maybe 3 that I’ve bent the rules for: seen them for a whole hour instead of the usual 30 minutes, provided a few more personal details than I normally do with my patients. See? Nothing egregious. But definitely gray.

I had a colleague once who told me, when I worked in hospice, that if you get attached to one out of every one hundred patients, you’re ok. Any more than that and you should take a good hard look at your practice. I’ve passed that advice along a dozen times, at least; it makes sense to me. I’m not causing any harm here, to my patients or to myself. I won’t overstep any boundaries: we won’t meet for coffee or see each other outside of this professional setting. But I do want to pause and consider what it means that these people get a little more from me than my other patients get. Being mindful of how much of ourselves we give is one of my favorite ethical questions. Do I give less to the patients that make my skin crawl? Do I give more to the ones that are pleasant and friendly? Do I give too much or too little based on my own feelings? And, ethically speaking, is it ok if there are (small) differences in the care I provide?

The cool and also deeply frustrating thing about ethics is that there are often no clear answers; there are multiple scenarios and variables to walk through. In this case, I lean towards the side of giving myself permission to be a human person who sometimes gives a little less or a little more, depending on the circumstance. Of course I’ll always examine my practice and look closely for signs of trouble. But I also want to allow myself that one in a hundred; it’s part of what makes the work worth doing.

Photo by Dil on Unsplash

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.

The gift of the work

I started off my day already over it. Yesterday only one of my five scheduled patients bothered to show up. This day was starting with a patient I had seen a year ago who told me the exact same story she was telling the first time we met. This was followed by another no-show and yet another frequent flyer patient who never wants to do anything to change. Overall, I was ready to leave the building.

My last scheduled appointment was a lady who didn’t really want to see me. Her son had cajoled her into coming and she went along with it because she’s a mother and sometimes we do things we don’t want to do. Granted, this woman’s son is in his 60s but still: you never stop being a mom. And your kids never stop wanting you to be well.

Still. This lady wanted no part of it. And I really couldn’t blame her. She’s depressed because she’s basically just waiting to die. She’s had a lot of loss, more than her fair share, as she says. And for awhile we just sat there staring at each other because she didn’t know what I could do for her. “Nothing’s going to change,” she kept saying. “What’s the point of talking about it?”

I was mentally cursing her son for not hearing his mother clearly say she didn’t want to come when suddenly something did change: she started to talk. We talked about what it means to get older, how much loss there is and how lonely it is. She talked about how even in her depression, she’s content with her life. She talked about the child and husband she’s had to bury and how she’s kept those losses tucked away in a little box that she hides from the outside world because she doesn’t want to disturb them. Then she talked about climbing trees when she was a little girl. She smiled. I did too. She said she’d think about coming back.

The rest of the day shifted in my mind. It’s been a long week and I was feeling useless and out of my depth and frustrated. I could hear myself being impatient with my other patients, wanting to rush them out of the office because I didn’t know what they wanted from me. I know what burnout looks like and I could see myself gliding towards the flames. This lovely lady brought me back, just by opening up a little bit and allowing me to listen.

Now I’m not saying that we should rely on our patients to keep us engaged and upbeat about our work. But I also can’t deny that success with one patient at the right time can make a world of difference. It is, I think, what keeps us in the work: watching people be helped, even just for a moment, and knowing that we are the helpers.

I’m also not denying that I’m nearing a burnout point; it’s time for a vacation, clearly. But I am relieved to know that I haven’t completely checked out. This is another gift of this work: the reminders that come from the grace of others, in letting us bear witness to their pain, even though we don’t have any magic answers. How lucky for me that this lady came along today, to remind me.

Photo by Leone Venter on Unsplash

The wave of grief

My referrals seem to come in waves: one month it will be folks who need help managing their diabetes; the next will be a wave of young patients with anxiety. This is only anecdotal evidence of course, but it was like this in hospice too: you begin to notice some trends. This particular month, it’s grief.

I’m quick to say I lead a blessed life, but it has not been without great losses. My mom died three and a half years ago when I was pregnant with my older daughter. It was a terrible time, of course, but her death was not unexpected. In some ways it was a relief; she suffered for a long time. And since I was pregnant with a very wanted baby, there was a lot of joy intertwined with my devastating loss. When she first died, I still worked in hospice and I found that I was able to use my grief to help patients. Not every day of course, but sometimes the conversation opened the door to self-disclosure and it felt both clinically appropriate and personally beneficial.

More time has made it both easier and harder. Lately, the patients I’m seeing who are struggling with their grief are focused on how much time has passed. “It’s been two years,” one told me, “I should be better.” Should is a useless word, especially when it comes to how we feel. I describe grief to those patients as ocean waves: you can be standing at the shore for a long time and not notice them. Then suddenly one knocks you over without any warning. I know this as a clinician and I know it as a daughter without a mother, but still. Still. My own grief sometimes sits on my chest like a weight, making my breathing a little shallower. There is a pricking feeling behind my eyes that signals tears. In those moments, I am afraid that I won’t be able to hide it. I haven’t lost it yet but recently I have felt very close.

This is grief, I remind myself. This is a big ocean wave. This is because I had a baby recenty and my 3 year old only knows my mom through pictures and because the holidays just passed and because now that I’m a mother, I understand her so much better but I can’t tell her that and because… Because. This is grief.

The question now is, what will I do with it? I’ve been guarding it like a secret but I know that sunlight is the best disinfectant. So here I am, bringing it into the light: I’m having a hard time. Now I’m going to be mindful and intentional and not let myself be swallowed whole. Self-care is sometimes stepping back and being well. And the occasional afternoon hot chocolate. I learned that one from my mom.

The body knows

I had a tricky interaction with a patient a couple of weeks ago. A patient of mine (who has an extensive trauma history) made some comments about my children not being safe in daycare. She knows I have kids because she asked once and it’s such an innocuous question, I didn’t even think about answering it. In fact, I don’t generally have strong feelings around self-disclosure; sometimes I think it can be helpful to build rapport and trust so I don’t worry about answering mild questions from patients. This is all to say, I had no problem with this particular patient knowing a little personal information about me. That is, until she hit me with this nonsense about my kids being in danger because I’m not at home with them full-time. This is a touchy subject for me, because it’s a deeply personal choice that has several variables and the judgement around it feels absurdly sexist. When she said that I should be careful, that bad things could happen to them because they’re with strangers most of the day, I had to work very hard to be still and not let my face betray my internal, white-hot rage.

In the actual moment, it passed fairly quickly. I squashed it down and told myself that this woman thought she was being helpful; she wasn’t intentionally being cruel. (She even told me that she was being grandmotherly with her concern. Ok, lady). It was later, when I brought it up in supervision, that I realized just how very upset it made me. Telling my co-workers about the experience, my hands started to shake; I felt my breath quicken and my face get hot. And I realized, I was still really worked up about those few minutes!

It got me thinking about how we listen (or don’t) to our bodies when we’re working. I’ve written before about working with frustrating patients and suddenly becoming aware that my shoulders are up by my ears and my fists are clenched. How does it sneak up on me? Because I’m not really paying attention to my own body. There’s a lot we have to do when we’re with clients: listen actively, reflect back, read their body language, etc. But we also have to listen to what our bodies are telling us; often we react physically before we’re able to name what we’re feeling.

Personally, I especially struggle with being in touch with my physical self when I’m uncomfortable with the energy in the room. Give me someone on a crying jag any day; I can sit with that heaviness and have no problem being in my body: breathing deeply, being still, creating a space for vulnerability. But when a patient touches a nerve (usually unknowingly), my fear or discomfort or anger arrive first in my body, try though I may to ignore those feelings. In those moments, I’m trying so hard to reserve judgement and be still and present that I ignore the warning signals that I’m about to emotionally check out. When I feel my toes curl in my shoes and my hands grip the sides of my chair, it’s usually a sign that I’m not going to be at my best, clinically. In those moments, I have to recenter: I take deep breaths; I practice stillness. Then I take my ass to supervision, because clearly I have some things to work out!

The body knows; we do better when we remember that and listen to what we’re being told: to slow down, to reflect, to breathe. And to utilize supervision!

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??