Behind the Human Curtain: The Courage to Look

2 11 2014

Wow…I was blown away when I read In the Ogre’s Lair: Seeing Light in Shadow by J. Scott Janssen, LCSW, in The New Social Worker Magazine. Scott tells a powerful story of helping a challenging client who was hiding behind his ‘curtain’, behind a very big and intimidating wall. What a blessing it was for this man’s life and for his transition into death that Scott persisted in providing support, even though it was a very stressful relationship. So much of what happens to our clients remains hidden. Sometimes when we consistently present ourselves as compassionate, sensitive and trustworthy people, the curtain will slowly move away-  just enough to allow room for hope and help to slip in.

Through his skillful storytelling In the Ogre’s Lair: Seeing Light in Shadow, Scott shares his experience with us and I included an excerpt below.

Read the full online article here.

I should have seen it coming when I slipped on the bullet casings strewn across the front steps. Or when I rang the doorbell and heard an angry-sounding voice bellow, “Who are you and what do you want?” I identified myself as the hospice social worker and waited…

“I don’t need a social worker,” he growled.

I’d read his medical history—respiratory disease, diabetes, hypertension, skin ulcerations that just wouldn’t heal, a long history of uncontrolled pain. And a single line entered under “Social History”—patient can be hostile and combative.

Our visit that day consisted mainly of him telling me what a bunch of incompetents his medical team had been and why it was their fault he was in such bad shape. He alluded to talks he was having with his lawyer and how he would “settle with those cranks” before he died. He came across as angry, self-righteous, and abrasive. And, yes, hostile and combative…

The visit tension hit its high note when I asked if he was having any suicidal ideation. It was a reasonable question—an ex-cop with guns, over sixty-five, male, socially isolated, terminal illness, secretive, hyper-vigilant, apparent anger issues, wanting to be in control but facing increasing physical decline, protective of his privacy but needing help, possible impulsivity, possible depression, possible aggression, possible PTSD—but Jack didn’t see it that way. He hit the roof.

Over the next many months, I called him regularly and offered visits, bracing each time for rebuff and/or complaint…No conversation, however, remained civil for long. He always found his way back to things about which he was angry, always went back on the attack…

Funny thing was, despite his sarcasm, complaining, and opposition to almost everything our nurses suggested, Jack’s medical condition was stabilizing. Steady care from our staff and Jack’s reluctant willingness to listen to a few recommendations here and there allowed his wounds to begin healing. His blood sugar was controlled, and so was his blood pressure. He even began taking more pain medication and getting more sleep at night. Taken together, his underlying respiratory disease began appearing more chronic, less terminal…

When Jack was finally discharged from hospice service because of this stabilization, I was relieved. I walked away thinking I knew him, thinking I’d seen him, and glad to be done with him. As far as I was concerned, he was an egotistical bully. He was insensitive, foul-tempered, devoid of empathy as well as the most remedial signs of social or emotional intelligence. Although I admired the determination and discipline it took to live alone with all the challenges he faced, these were no excuses for being a mean-spirited, anger-addicted pain-in-the-neck…

Sometimes I felt relief that I’d never see him again. At other times, I had a sense of dread that sooner or later, he’d be back…

On the morning I saw his name once again listed under the previous day’s new admissions, I swallowed hard…

The visit was to be our last. I walked in, and Jack was awake. He smiled wide and held out both arms as if to hug me. My first thought was that he was confused. “Hi, Jack. Remember me?”

His smile broadened (something I’d never seen before), and he said, “My social worker.”

He clasped my hand and continued holding it throughout the visit as I sat beside the bed. “I feel so much better now that you’re here,” he said.

Masking my surprise, and wondering if he was being sarcastic or setting me up, I asked him about what had been going on recently.

“It’s been a hard time.” His eyes appeared to water slightly, “I think I might be dying.”

No secretiveness, no defensiveness, no complaints, no blame or attacks… His memory and concentration were taxed, and he had a hard time finding words, but slowly, methodically, Jack searched for language to describe and process what he was experiencing…

Read the full online article here.

Other Resources

Janssen, J. S., (2004) Dawn is Never Far Away: Stories of Loss, Resilience, and the Human Journey

Janssen, J. S., (2013) Locked in the Vault — Survivor Guilt in Combat Veterans, The New Social Worker Magazine

Janssen, J. S., (2012) Just Plain Stephie: Conversations at the End of Life, The New Social Worker Magazine

The New Social Worker- free e-magazine www.socialworker.com

Lacay, S. (2013) Breaking Boundaries With Empathy: How the Therapeutic Alliance Can Defy Client/Worker Difference, The New Social Worker Magazine

The Therapeutic Alliance: An Evidence-Based Guide to Practice (2010)

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Creative Commons Attribution: privatenobby flickr.com




Therapeutic Relationships: What more do you need?

17 09 2013

Help puzzle freeditigalphotos.netID-100124223

I spent a day with Scott D. Miller, PhD, watching him training people on the power of the therapeutic relationship and how to assess client satisfaction and outcomes with performance metrics for session and outcome rating tools. Since then,  I have been fascinated by the healing power of the therapeutic relationship and its relationship to treatment. There are  evidence-based practices related to establishing therapeutic relationships at the SAMHSA Evidence-Based Therapeutic Relationships page. Yet at the same time, there needs to be a solid treatment approach. I have seen people not heal even though they had a good relationship with their therapist. And I have heard therapists say that they don’t like evidence-based practice because it takes away from the relationship and choice of the client. Perhaps fear of the unknown talking.

Good therapeutic relationships + effective treatment approaches + assessment of sessions and outcomes by the client=  the road to success and healing. And these are all essential in a trauma-informed service environment so that clients receive services within the the five-guiding principles of Trauma-Informed Care (Fallot, 2006): safety, trustworthiness, choice, collaboration, and empowerment.

Recently, trauma therapist  and founder of the Trauma Institute and Child Trauma Institute, Ricky Greenwald, PsyD, wrote a great blogpost about the  Therapeutic Relationship vs. Treatment Model. Here is an excerpt from the post that has already received 147 shares to date from his blog site.

“When I call therapists in other locations to check them out for a referral, I briefly describe the case and ask what their approach would be. Quite a number of these therapists have said something like, “I mainly focus on the relationship, since that’s where the healing comes from.” In a recent survey I saw a number of similar comments. One question focused on choice of technique in a particular context, and a number of respondents wrote some version of, “The technique is irrelevant – it’s the relationship that heals.” Based on my nonscientific sample, I suspect that this position is not uncommon among therapists.

The way it is expressed indicates that this view of the relationship’s primacy is not about psychodynamic theory – in which the therapy relationship is systematically utilized for healing. Psychodynamic people tell you that they’re psychodynamic; they’re clear about what they’re doing, and about the role of technique. No, these therapists are saying that they’ve extracted the essence of the so-called “common factors” research, and concluded that as long as they develop a good relationship with their client, everything else falls into place.

The common factors research – focusing on factors such as empathy, warmth, and positive regard, that may be common across treatment approaches – is quite important, and the centrality of common factors to therapy’s effectiveness has become ever more widely recognized and embraced (e.g., Duncan, Miller, Wampold, & Hubble, 2010). However, this valuing of the relationship over treatment approach reflects a profound misunderstanding of the common factors research.

Duncan & colleagues’ (2010) recent synthesis of the common factors research emphasized the integration and inextricability of the various factors. That is, you can’t just add more empathy or therapeutic alliance to an otherwise non-viable treatment approach and suddenly have a viable treatment. Rather, the common factors are necessarily grounded in a coherent and credible treatment model – itself a common factor – that is embraced by therapist and client. Such a treatment model serves as the foundation for the explanation of the problem, the plans for rectifying the problem, and the hope for successful change. These constitute much of the basis for the therapeutic alliance, the most important predictor of treatment success (Norcross, 2010).

Although it is heartening to see that the common factors literature has reached the practice community, it is concerning to see that it has been commonly misinterpreted in such a way that many therapists may be disregarding the importance of using a coherent treatment approach.”

via Ricky Greenwald, PsyD, Once Upon A Time… TI/CTI Blog–  Therapeutic Relationship vs. Treatment Model, August 6, 2013.

Like this post? check out our other posts on Behind the Human Curtain.

Author for the introductory paragraphs: Lesa Fichte,  LMSW, Director of Continuing Education

Photo Credit: Help Puzzle by Stuart Miles, www.freedigitalphotos.net








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