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.

CBT Yourself

I frequently use my dad as my ad hoc clinical supervisor. He’s a doctor (retired, he’d be quick to tell you) so it’s not quite the same as talking to another social worker. But he’s one of the smartest people I know and he’s also very Zen Master, which is sometimes just the combination I need. Recently I was complaining about someone I work with (I’ll spare you the boring details) and I ended with, “She just gets on my nerves.” To which my dad replied, “You could just… not let her get on your nerves.”

Oh.

I keep turning that over in my mind. This is what we ask our clients to do, right? This is some kind of cognitive behavioral therapy mantra: don’t let it get to you. That’s the strategy I go to with people who are experiencing stress that’s out of their control. I help them find a way to let it go a little, to react in a different way, to retrain their brains. But what if I can’t CBT myself? What do you do when you’re the one who’s stuck?

This is not a new feeling by any means. I’ve had bad jobs. I’ve had bad supervisors. I’ve been to bad therapists (or at least they were having bad days; I like to give my colleagues the benefit of the doubt). I was able to walk away from those situations and from those people. That’s not an option in this instance. I work with this woman and that’s just that. So what do I do with my feelings (which are not facts, as I remind my patients daily!)? How do I take my dad’s very fair point and not LET her get on my nerves?

I’ve written before about how important self-reflection is in this work. Faced with a patient that makes us cringe or a job duty we really don’t want to perform, we are tasked to look beneath it. Why am I feeling this way? Where is this coming from? What can I do about it? But all the self-reflection in the world only gets you so far. I KNOW why I don’t like this woman; it’s partly because she doesn’t like me! (A topic for a whole other post about my own insecurities and ego. I will spare you that particular trip into my psyche). I know why I’m struggling with this working relationship; it’s because I’m struggling with this whole job and this is just another symptom of my frustration. I know all this because I’ve talked with myself about it. The question is now, what to DO about it?

I suppose I know the answer already. It’s what this whole blog is ostensibly about: I have to go back to supervision. In the meantime, I can vent to friends; try to shake it off when I feel it; and, of course, not let her get to me. I’m the one in charge of my own feelings (as I tell my patients. Daily. I’m starting to see why they get frustrated with my helpful suggestions). I’m trying to remind myself, this is just a moment. And if I forget, my dad can put on his clinical supervisor hat to remind me. I’m lucky that way.

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.

Every conversation is clinical

My first experience with providing clinical supervision was about a year and a half ago, supervising an advanced-standing graduate student during her internship. The student's MSW program provided 6 sessions of training for new clinical supervisors (free CEUs!). One theme we kept returning to was the complaint from the student that their placement wasn't "clinical enough." I empathized with this; I recall expressing the exact same complaint as a grad student. I hated my first placement deeply, partly because I felt like it wasn't "clinical." (There were other reasons of course but that's a drama for another day). I was inclined then, at this training, to side with the students on this point. Some placements just don't seem to be given to enhancing clinical skills. But my trainors reminded me of a simple and true fact about being a social worker: every conversation you have with a client is a clinical conversation. Every. Single. One.

That was by no means the first time I ever heard someone make that point. But prior to that training, I didn't really believe it. When I was doing case management, for instance, it was easy to forget the clinical piece because so much of my job was about providing concrete resources to people in crisis. I often got caught up in the (sometimes very complicated) surface issues: pending evictions, drug or alcohol relapses, medication compliance. I sometimes forgot that I could utilize my clinical skills during these conversations because I was focused on what I could do right that minute.

I burned out of that job pretty quickly because I felt like all I did was put Band-Aids on broken legs. Now, several more years into my career, with different experiences and more education, I think about that job differently. Knowing what I know now, I think I could have been better at it. This feels especially true as I learn new skills, like motivational interviewing. When I was case managing, stuck in the weeds of constant crisis, I often forgot to use my clinical skills to tease out the underlying issues. Why, for instance, would someone relapse after a year of successful sobriety? Why did this one client, who seemed to have a reasonable income, constantly end up on the brink of eviction? Maybe I asked the client that, but not in a skillful way that elicited a thoughtful conversation. I focused on the resources I could provide and forgot, sometimes, the clinical skills I learned as a student.

It's easy to do that, when we are pressed for time and have limited tangible help we can offer our clients. But we have tools at our disposal that are unique to this profession: we know how to look deeper at what is said and not said in a client meeting. As soon as we start a conversation with a client, we are doing clinical work: assessing body language, physical presentation, affect, what they're saying and what they may actually mean. Don't be fooled by the weeds you sometimes get into: every conversation is clinical because this work is complicated. And your skills are growing every time you interact with someone. 

Happy Social Work Month! Do good work and be proud of it.

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.

Supervision after the MSW: Now what?

I love meeting other social workers in the wild. There’s a real benefit to belonging to a kind of community. I’m not sure how it is in other professions but when I meet another social worker outside of work there’s an instant camaraderie. We get each other. We may come from different agencies or work with different populations, but we will immediately have a strong bond because we have almost certainly had some shared experiences. I’m lucky to know a lot of other social workers and to count many of them as my real life friends as well.

Photo by Zoran Nayagam on Unsplash

Today’s blog post was inspired by one of those social worker/IRL friends. She’s been considering the lack of formal supervision in our profession after the Master’s program is over. As graduate students we are supervised intensely, with individual and group supervision, process recordings, class discussions etc.  We are constantly writing about and reviewing our clinical work as we learn how to do it. Then we go into the professional world and it just… stops. My friend made the excellent point that we’re required to have 30 hours of continuing education to renew our social work licenses but we’re not required to have any supervision hours once we obtain an LCSW. We don’t stop requiring supervision when we become LCSWs; and yet, for many of us, supervision stops being a priority after we reach that professional milestone.

This is not to say that there is no supervision in the real professional world for social workers. For instance, in my last job we had group supervision once every month or two, which was tremendously helpful. But that was pretty much it and it was definitely not enough. In fact, part of the reason I left that job was because there wasn’t a lot of support. I was mostly alone in my car, going from house to house, from sick person to sick person. The only contact from the office came in the form of emails throughout the day asking for consents to be signed or fires to be put out. Certainly my supervisor was available for questions and dire situations. But that didn’t replace an ongoing supervisory relationship. And ultimately I wasn't able to continue at that job.

So why don’t all agencies require clinical supervision? Why doesn’t our licensing body? I’ve been considering these questions and I’d venture a few guesses based on my own experience. One is that it costs both money and time; this is not a field that has a lot of extra of either. On the long list of things we’re required to do, supervision can seem like a lowly priority. Then there's a question of what kind of supervision is available in our agencies. Agency supervisors have their own agenda as representatives of the agency. They can’t be truly impartial because they have a stake in the game. So supervision may exist but it fulfills a different goal: namely that the agency’s standards are being met and not necessarily that the clinician is growing professionally.

I think professional growth is actually another reason we tend to view supervision as less important post-Master’s: as we get more clinical experience, we tend to think we don’t need formal supervision anymore. I spent five years at my last job; I felt like an expert most of the time. Sure, things came up, but not the way they did when I was a new social worker. So although I felt unsupported at times, I didn’t seek out additional supervision because I felt like I had it pretty much under control. By the time I realized that I was burnt out, I was ready to move on. Maybe formal supervision could have helped me recognize the signs of burnout before it became overwhelming.

As social workers, we are advocates. But how often do we advocate for ourselves? Are we getting the supervision we need to keep us working in the field and working effectively? My fellow social worker/mom/friend brought up a good point when she gave me the topic for this post. The question I’m left with is, what should we be doing to change things?

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

Crispy around the edges: Avoiding and recognizing the dreaded burnout

I have started this post about burnout about five different times. I'm having a hard time figuring out where to begin, partly because I've been considering burnout since before I even became a social worker. In fact, I sort of decided to become a social worker because I read an article about burnout when I was fifteen years old. Seriously.

The internet was such a new thing when I was in high school that an offered elective was something called "Electronic Fiction." For real. The basic point of the class was to look things up online and write about them. (This seems hilarious now but it was the late 90s!) One of our assignments was to pick a future career (a daunting task for a 15 year old, by the way) and do some research about it. I took this task way too seriously. In fact, I distinctly remember a classmate telling me it was just an assignment; I didn't have to make a lifetime decision in that moment. But apparently that was lost on me; I had to decide right that second what I wanted to be when I grew up. I put a lot of consideration into what kind of work would appeal to me. As I mentioned last week, doctoring was not for me; too much science. Professional acting seemed good but, you know, really hard. My teacher asked me what I thought I liked doing and I said, earnestly and honestly, "I like to help people." She told me to look up social worker.

It is very telling that the first article I came across after I searched (I swear this class was even pre-Google, I think I used Lycos) was an article about burnout. I was immediately drawn to this concept. It hadn't occurred to me that doing something good could make you feel bad. I was enthralled by this article. I printed it out and highlighted it. It stayed in my mind for years. And so, I started my social work career thinking I had all the tools to combat burnout. I read an article when I was 15! I'm ready!

There are many ways to combat burnout. Blind optimism is not enough, it turns out.

Part of the reason burnout creeps in, despite the walls we build as professionals to keep it out, is that it's systemic. As social workers, we work within systems that are lacking: lacking in funding, in staff, in resources. We spend a lot of time, no matter if we work in a big health system or for a small non-profit, struggling against a system that mostly says no. That is exhausting.

Add on to that the stresses of bearing the weight of other people's struggles. It is virtually impossible to spend all of your working day listening to people explore loss and pain and sadness without starting to feel like you have heard enough. I can always tell that I'm getting crispy around the edges when other people's emotional pain starts to seem... irritating. Like, I get it, you're sad. I am always startled when I have that thought but when I do, it's an eye opener: I am tired. I need a break.

Breaks are good! They are a vital part of preventing burnout and recovering from the stress of this very difficult work. But if you don't have any precious vacation time right this second, there are other options. You can Google (we've come a long way from Lycos, guys) tons of lists and articles about how to avoid burnout. What follows are some of my favorite tips.

One is to have a real life. I've been asked many times over the years how I do this job and one answer is that I have created a beautiful life outside of work for myself. I learned how to cook (do not listen to my old roommates about my culinary abilities, please. I've gotten much better!); I have lovely friends who live all over the place and are happy to have weekend visitors; I like to read and still go to the library to borrow books. There are lots of ways I spend my time that have nothing to do with social work. 

Burnout needs to be combatted at work as well. To that end, another invaluable way of keeping yourself sane is having a work best friend. It is imperative that you have someone at work you can call or someone whose office door you can close and say, "holy shit, this day." Having a partner you can share your frustrations and successes with is key. When I worked in hospice, I did a lot of joint visits with nurses and developed some great friendships. They helped me feel less isolated when I was driving all over creation. I also appointed myself as the social chair of the social workers and demanded monthly happy hours. Amazingly, this worked, and a good sized group of us got together monthly over drinks. We even managed to talk about stuff besides work a lot of the time! Thus I managed to combine having a life with having work friends. 

Finally, another very important tool to combat burnout (and also the whole point of this blog): supervision. Sometimes we don't have the answers, especially when it comes to ourselves. We can't see what's holding us back with a particular client or why we're so frustrated with our work. It takes the objectivity of a supervisor combined with a good working relationship to help us clarify not just cases but our own feelings and struggles at work. Something I've always valued in supervision is having someone say to me, "Yes. These are valid feelings. You are entitled to them. Now what can we do with them?"

There are so many articles like this blog post, that give you advice on how to avoid, recognize, and address the symptoms of burnout. I added to them because I believe it's important to keep talking about it. But the fact of the matter is, you have to find the tools that work for you. And you have to do that work so that you can survive doing this work. Take care; it's the best thing you can do for yourself and for your clients.

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. 

Who I am/What I do/Is there a difference?

My dad is a doctor. So is his brother and so were both of their parents. It's probably part of the reason I'm drawn to medical social work. I never wanted to be a doctor; I don't have the interest or the aptitude in science. But I did want to somehow be a part of the medical field. I was always drawn to my family's stories about illness and disease. It's just that I was more focused on the story part: what was the family doing? How were they behaving? Had I known then about genograms, I probably would have convinced him to draw me one for the more interesting cases (sans names and identifying details, of course). The point is, I was fascinated by the people part of his work. That's a big part of how I got into this part of the field.

Photo by Hush Naidoo on Unsplash

Growing up, my dad's profession was so much a part of our lives: his call schedule, stories about his patients, pens and notepads from the drug reps. He loved being a physician (he's retired now, though he volunteers so he's still doctoring) but I don't think he ever felt that it defined him. If you asked him about himself, I don't think "doctor'' would be the first word that came to his mind. Whereas I feel that so much of my profession is a part of my identity; I can't turn it off.

Still, we're actually not unlike each other in that respect. He may have wanted to turn it off at times but I have a lot of memories of his various in-laws and friends starting a sentence with, "I have this pain" or "can you look at this?" He would always oblige (because he's a kind human) and I don't know if it ever bothered him. For him, I suspect it was just that he had all this knowledge and he was happy to share it if someone asked. 

For me, it's a little more complicated. I find myself unable (unwilling? Something to explore in supervision!) to turn off the social work part of me. It's like having antennae that pop up when someone starts telling me about their complicated family dynamic or their aging parent. I have to stop myself from giving unsolicited advice at times, or even accidentally blurring the line between friend and therapist. My girlfriend calls me a friendapist. It's a very cute nickname but it gives me pause; should I be more careful about turning off the social worker when I'm with the people I love?

Photo by Will Oey on Unsplash

This is partly in the forefront of my mind because I just finished an ethics CEU. As you can imagine, there was a lot of talk about boundaries. In my practice, they're easy to set: I'll meet with a client for 30 minutes, tops, talk about short term goals to help them, and then send them on their way. There won't be time enough to blur the lines between the professional and the personal. But with my friends and family, do I sometimes blur the lines between personal and professional? And if I do, so what? 

I am a social worker; it's not just something I do for a living. I can leave my actual work at work; it's imperative, in fact, that I do so I don't get burnt out. But I can't detach myself from the part of me that is empathetic and sensitive, that wants to both validate feelings and find solutions to problems. And I think that's all to the good. I'll keep examining my boundaries and my sense of self because that's what my profession asks me to do. But I will also find joy in the fact that who I am and what I do intersect so well. I hope you're that lucky too.