Crash And Burn (To Stand Back And Watch In Slow Motion).
Christian Billington
What do you do when a client is apparently in a free fall? They report, of course, that “this time it will be different.” They will change, they are ready, and it is time. Then the next time you see them – usually just a few days later – they resemble the same blown out, angry wreckage that you spoke with just days before. How does this sit with you?
I currently work with chronically ill patients and I have watched them chomp down pain medications like they were Mentos, while I helplessly offer and make appointments with alternative adjuncts and therapies that may or may not help them. I have listened and watched them report that they are “…sick and tired of being sick and tired” and this time, they “really mean it!” Watching a client or patient get broken down by life, by disease, by stress, by addiction, by anxiety or whatever causation is one of the hardest aspects of being a health care professional and, I imagine, a counselor. This slow motion decent leads, from my experience, to one of two things. The first is that the client will truly hit rock bottom (wherever that is for the individual) and truly become sick and tired of being sick and tired. When this happens they mobilize all resources and help available, begin a comeback and eventually reclaim their life. The second and perhaps more common pattern is that on the way to hitting rock bottom, the patient dies. I have witnessed this second scenario at least three times over the past eight years and read or heard about similar cases too many times to mention. It feels like I lose something every time a patient dies and I am left with the remaining family and broken pieces of another needless death.
Especially painful is when a patient follows this tragic pattern and dwindles toward ground zero at a slow rate despite all my attempted interventions and resources. I find this brutal to behold. I feel especially challenged to just stand by and watch said patient’s demise. Sure, when a true rock bottom arrives I will be there as will all of my peers and every possible intervention that can help this person get their life back. But what to do now? And which of the two trajectories above will the free-fall take?
What to do in the meantime is where my challenge lies. What am I to do? How can I help the patient who appears unwilling to help them self? And am I alone in this dilemma? A further consideration is how can I raise the bottom, the point at which someone rebounds and is sincerely ready, willing and able to make significant changes. That is to say how can I lift up the lowest point that my patients fall to before they grasp life again? How long before they get so frustrated, angry and ultimately ready to turn life around and make the best of things? I have tried motivational interviewing and gentle counseling but have received significant push back. Often, the client angrily blames “the system’s” conspiring against them instead of helping more. Is this phenomenon that I am experiencing common, and is there anything we can do but wait and hope?
Personally, having established a therapeutic relationship with these patients and families over the past several years, I feel frustrated with the impasse. Adopting the observer role challenges the pro-active side of my being, which is a big part of how I practice. I want to respect that only the client can help themselves, initially, but I also want to honor myself and how I practice – and I want to help. But often I feel helpless to affect positive change, and this is an uncomfortable place for me to exist. As my title suggests, I often feel I am sitting back watching a slow-motion, life- changing crash. And I know too well that when the impact is over, either the patient will emerge ready to do some work or they will simply remain lifeless, trapped within the mangled wreckage, leaving the providers, family members and significant others with only the memories of a life that we all worry perhaps should have tried harder to save.
It is a mess and I am not sure what to do.
So what is a beginner therapist’s role in this instance? How can I utilize my new counseling knowledge working with the chronically ill? I am sure the majority will advise that there is nothing to do but wait until the one of two outcomes becomes reality. And when it does be present for those that remain. Others will caution me about boundaries and being weary of the role I am playing. I understand both ideals but is it really “business as usual” for me until that time?
Christian Billington is a counselor in training. He is passionate about end of life issues, grief and loss, trauma and the development of training to better prepare the emergency services for what they experience in the field.
Dear Christian,
I very much appreciate the struggle and wondering that you describe in this post.
I believe that we underestimate the profound effect that our respectful, empathic staying power has for individuals who are suffering. In private practice, only a small percentage of my clients are in the chronic, dire stuckness that you describe. But I am of the same opinion in both cases, with heartier, short term clients and with longer term, vastly more chronically critical clients. The respect and empathic understanding that we offer in relationship is too often not a part of regular life experience; it’s a sadly rare commodity. Even though, in a practical sense, as counselors, yes, we are helpless, I feel very strongly that your sturdy acceptance of this and every person as a unique human being with his or her own separate experience is a rare healing gift. But sometimes the course of healing takes years instead of weeks. And, as you describe, for some it is too little too late, or the weights and drags working against the person are just too much.
Since I believe that our reception of our client’s humanity is healing in itself, the challenge for me is to find a way to stay fresh, open and present in relationship with each person for each meeting.
Kathryn Moon
Chicago, IL
I was really moved by this post. I completely identify with feeling frustration over having to watch the client self-destruct before you feel like you can help. I agree with you that you run a high risk of weariness (aka compassion fatigue or burnout) if you continue to feel ineffective in your role, especially this early in your career. First I want to support you and say that I believe every beginning therapist has been there to some degree. Second, I hope to offer something else to try: my supervisor told me that when a counselor has a strong feeling in session, that’s something you need to pay attention to. I don’t think it’s necessarily your job to ignore it at your own risk.
I wonder if you’ve tried a bit of honest self-disclosure already with the client. Sometimes they think of us as automatons, and saying something like this could really make a difference: “You know, I’ve spent a lot of time working with you and come to really care about your well-being. I know I can’t imagine what you’re going through, but from where I sit it’s really hard to see someone I care about in such a bad spiral. I can completely understand you feeling like you want to give up…but can I ask you to try again for my sake?” What do you think about trying something like that? Would love to hear if you think it would work for your clients.
Christian, you have written your heart felt desire to help and the frustations that come with that very well. You obviously have brought this to others as you also state what others will say and maybe they are right but for me, being a counselor is a life of deep caring and sadness when your client doesn’t seem to move, even slowly, in a productive direction. It sounds like you might be seeing clients late in their illness. Understanding mental health issues and dealing with them earlier would be nice but as a society, we are not there yet. So we are left with deeply wounded souls who have little to no trust in what is possible. If you can’t remember a healthy life, it is hard to fight to acheive it or even believe it is possible. Maybe part of our job is to help them see potential. As far as blaming the “system”. I understand that to some degree. The “system” is broken and is very depressing in itself to try and get through.
Well, I guess I have no answers and have just commiserated with you but keep you heart open but…BUT make sure you walk out of their world and back into yours and have the fun that you know how to or it will be too much to bare.
All,
Thank you for your comments and support. I feel like a couple of items are in play. The first being the recognition of the dire situation that is not as remarkable or isolated as some may well think and this scenario can play out in a number of different settings. The second is that I just want to be clear that right now I am moving into internship. I have worked with chronically ill patients for the past seven years and have become well accustomed to burn out and compassion fatigue, in fact I have worked really hard to guard against it. The ‘tough skin’ is a work in progress, but there will always be cases and clients that affect us. I just wanted to underline that I have accepted that currently the client is not open to help and is freefalling in the ways previously described. My issue is perhaps more personal, it is the sitting, waiting and helplessness that is my issue to deal with for true acceptance. Just being a bystander watching this all unfold knowing from previous experience the outcomes with similar cases is a true test of patience.
I want to reassure you all that I continue to do my own work as I attested too in a previous post (please see ‘Do your own work’). I recognize the feeling of being helpless is not sustainable and not productive in the long term. I love the idea of just sharing with the patient, self disclosing that I am concerned about the direction she is heading. I move from a clinical role to that of a concerned human being as have the nurses that have worked with this particular case and others. It is tough. The impact has not been as great as I would have hoped in fact it has created an even bigger push back from the patient. I strongly believe in coming from a very personal place in my clinic work and as a future therapist, which has played out in this case with limited effect.
I have worked in health care for over twelve years and have become pretty resilient, but it still effects me. I feel like the client is moving and is being productive it is just, in my opinion, in the wrong direction. I believe the patient has forward momentum, but in this case it is towards an undesirable outcome. As far as removing myself from the situation back into my own world, that is massive and I appreciate the reminder and your concern. I have my own life, I think it is just the human condition to not feel comfortable watching another human being implode in slow motion. I want to mention mandatory reporting here because it is on my mind. We report imminent harm to self and others because there is immediate effect and impact. We are legally and I hope as a society obliged to intervene and take action. The case I have described is happening in such slow motion that interventions are harder to implement and not as obvious to the untrained eye. It is just the time line that is different, but what can be done? (I will leave you with this contemplation)
Thank you all again for your thoughtful comments and concerns. I truly appreciate them very much.
Christian.