In an opinion piece published in Sunday’s New York Times, researcher Leeat Granek shares the results of two studies that suggest to her that, “Not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves, as well as for the quality of care they provide.”

A different study released by the JAMA journal, Archives of Surgery, last week found that residents don’t get as much sleep as ordinary professionals get — which directly impacts their ability to concentrate and be mentally attentive.

Combined, these studies add to the picture that’s been painted for years by research — that doctors believe they are somehow “super human” and beyond the reach of normal human needs, for both their body and their mind. It’s a disturbing picture, and one that the medical education establishment needs to remedy sooner rather than later.

In the op-ed piece, researcher Granek summarizes the results of her study:

We recruited and interviewed 20 oncologists who varied in age, sex and ethnicity and had a wide range of experience in the field — from a year and a half in practice in the case of oncology fellows to more than 30 years in the case of senior oncologists. Using a qualitative empirical method known as grounded theory, we analyzed the data by systematically coding each interview transcript line by line for themes and then comparing the findings from each interview across all interviews to see which themes stood out most robustly.

We found that oncologists struggled to manage their feelings of grief with the detachment they felt was necessary to do their job. More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.

While I agree that there very well may be a “professional taboo” on professionals expressing grief — and this is true of virtually all health and mental health professionals — I’d argue that, in the U.S. anyway, expression of grief isn’t exactly something most people do well to begin with.

Visit anyone’s viewing for a snapshot of how Americans handle their grief:
some people cry, others nod in awkward silence, still others make small talk. Very few people feel comfortable in their grief, and fewer still in expressing it.

So maybe it’s not a surprise that doctors don’t do it very well at all, either.

But what makes it different for doctors is that their lack of skills in dealing with their grief could very well impact their job and decision-making — negatively impacting other people’s lives too:

Even more distressing, half our participants reported that their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients — leading them, for instance, to provide more aggressive chemotherapy, to put a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option. [...]

Unease with losing patients also affected the doctors’ ability to communicate about end-of-life issues with patients and their families. Half of our participants said they distanced themselves and withdrew from patients as the patients got closer to dying.

Doctors (and therapists, too!) have a responsibility to acknowledge and appropriately cope with their own grief reactions. And heck, if they don’t have the skills to do so, they should learn them.

In the second study, 27 orthopedic surgery residents wore a wristwatch-type of measurement to gauge how often they slept. The average amount of daily sleep for the residents was just over 5 hours, with individual amounts ranging from 2.8 hours to 7.2 hours.

This lack of sleep is not good for their mental attention span:

The authors found that, overall, residents were functioning at less than 80 percent mental effectiveness due to fatigue during a mean of 48 percent of their time awake. Residents were also functioning at less than 70 percent mental effectiveness due to fatigue during a mean of 27 percent of their time awake.

Most docs are good people trying to do good in this world. But the more they act like they aren’t human and don’t have the same human needs and feelings the rest of us do, the more harm they bring to their patients.

Read the NY Times article: When Doctors Grieve

When my supervisor gave me my end-of-the-semester review, she gave me a great compliment, saying that I “seem very comfortable in my skin” and how that is a great asset for a counselor. Of all the words of praise she had given me over the past few months, those meant the most.

Years of my own therapeutic work got me to the place I am today, a place where I can be of most help to others. It has been a long, often difficult, but also rewarding journey to reach the place I am today, and that has made me all the more empathetic to the struggles my clients face.

Although our essential issues may not look similar, the human condition of working to triumph over adversity is the same.

I was humbled by the trust my clients put in me, a perfect stranger whom they chose to sit with for 50 minutes once a week, for at least four weeks of their semester. They believed I would listen to them, understand their stories, and maybe help them in ways they had not thought of before. We had success, we had struggles. I truly believe we all learned from the experiences and are better for it.

If I had to pick one word to describe a main issue every single one of my clients presented, it would be “relationships.” Upon further reflection of that thought, it’s really not a revolutionary idea: if you have loving, supportive people surrounding you, there’s probably a good chance your mental health is pretty good. But if you throw even one person who causes angst into the mix, life can go downhill quickly.

I did a tremendous amount of interpersonal work with my clients, but never did I expect that would be the case. I’ll admit—in my DBT training, the module on interpersonal effectiveness was my least favorite, and yet, it was those skills I utilized the most for teaching my clients how to appropriately and successfully communicate.

As a side note to that, I also never expected the role technology would play in how people communicate with each other. My blog earlier in the year on Facebook and process commentary touched on this observation, and this topic on how people (mis)communicate through technology is a subject that needs much more research in the counseling community. I was talking with my mentor recently, who also counsels adolescents, and we laughed about the idea of role-playing with a client how to have an appropriate argument through text messaging! As these young people get older, we will see more of this type of communication affecting the lives of young adults as they move into careers and family life.

To wrap up our semester, for our last group theories class, our professor and department chair brought in his wife, a registered art therapist, to teach us about art therapy techniques. By no means was a three-hour class long enough to impart even the basics to us, but it was an interesting experiential class nonetheless. For one exercise, she had all of us divide a sheet of paper into thirds. In the first column, we were asked to draw ourselves as counselors at the beginning of the semester. In the last column, we drew who we envisioned ourselves to be at the end of our careers. In the middle column, we drew what would get us from who we are as beginning counselors to who we will be years from now.

My first drawing was of a seedling, just poking its head above the brown, newly tilled surface of the ground. It had a tiny red flower with deep, thin green roots, and a bright sun overhead. My middle drawing was of a clock. The last drawing was of a mature tree, with lots of leaves to provide shade, and deep roots, but this time, the roots were strong and thick, and there was grass below the tree, where the open, exposed soil had once been. The sun continued to shine overhead.

I was not alone in putting a clock in my middle panel—the majority of the drawings I saw from my classmates indicated that time was the main element that will get us from the neophyte stage to seasoned counselor. My general theme of starting off as something young and perhaps delicate — as indicated by my flower — then becoming steady, strong and reliable — like a big oak tree — was also echoed by my classmates. Many of us recognized that we already have the core elements we need to become excellent clinicians, but time, training, and experience are what will get us from where we are today to where we hope to be in the future.

On that note, my first year as a Master’s student has come to a close, and it has been a pleasure sharing my journey as a beginning student therapist with the Psych Central audience. Fall brings my internship experience, and I hope to bring you stories from an intern’s perspective then. Enjoy the summer!

Technically, I did say goodbye to four clients earlier in the semester, but over the next few weeks, I’ll be saying goodbye to clients with whom I’ve worked “long term,” as in, longer than our four required sessions, and therefore, with whom I have built more of a relationship.

The client I said goodbye to today made incredible progress during the semester. She came in very closed off, afraid to show emotion, and dealing with issues that would be hard for anyone to deal with, let alone a 20-year-old undergraduate. During our time together, she worked hard and was a rewarding client. However, today during our termination session, I was reminded of what counseling is really about: the client and her needs, not my needs or expectations as a counselor.

Last session, I had reminded my client that today would be our last meeting, and she was fine with that. Today she arrived a little late for our session, which is unusual for her, and was obviously feeling flustered. When I asked my usual, “How are things going?”, she proceeded to answer my question as she would have during any other session. Normally, that would have been great, but I had expectations that today’s session would go differently. Here’s where my expectations and my client’s expectations diverged: For her, today was a “normal” day of counseling, with maybe a quick “thanks” and “goodbye” at the end. For me, I had (what I thought would be) a profound activity for us to do to wrap up our work together.

It didn’t happen. Not even close.

As my client talked, I found myself glancing at the clock more often than usual. I caught myself thinking, “When is she going to stop? What she’s talking about isn’t that important! I really, really want to get to what I want to do!”

Of course, she didn’t stop and I knew that interrupting her to “get to what I wanted to do” was not appropriate. When we had about 10 minutes left in the session, I took the opportunity during a break in her speech to remind her that this was our last session and to start reflecting the themes of the topic at hand to all of the work I’d seen her do this semester in counseling. Ultimately, I was able to praise her for all the progress she had made and to encourage her to keep building on her strengths and successes. When I was done, she sincerely thanked me for my help and said that both she and others had noticed a change in her, which was gratifying, and more than I expected.

Still.

After I walked her out the door of the clinic for the last time, I could only manage a half-smile. I know we did great things together. I know she feels better about herself and her life than she did three months ago. She has changed tremendously. This was a successful counseling relationship. And still, I’m upset that I didn’t get to score a touchdown in the final session. What is that all about?

I’m actually surprised at my strong reaction to “not getting my way” in a session. I think I’m pretty well grounded in the philosophy that the counseling relationship is not about me and my needs and wants. One of the items we have to evaluate about our sessions is “Keeps the focus of the session on the client,” and I’ve always rated myself highly. As a former teacher, I came into counseling at the beginning of the semester with a “lesson plan” of sorts about what a client and I would talk about that day, but quickly learned that what was relevant for a client last week is often not this week, and therefore, the best laid plans often were not used. Some counselors might be more directive and steer the session the direction they wanted anyway, but I chose to try the approach of letting the client guide the topic of the day, while still being mindful of client resistance and avoidance of previous topics presented.

But I wanted this last session with this client to be memorable for her. And if I’m going to be honest, for me as well. What I had planned really seemed like the “perfect” ending, but that’s my bias about what the client “needed.” I have to trust that what the client “needed” is what she presented in the session today, and if it just so happened to coincide with this being our last session, I need to accept that. For all I know, something I said to her today was the most profound thing I’ve said all semester. Or maybe the “perfect” final activity I had planned would have turned out to be the most disastrous choice I’d made all semester.

I’ll never know. And I need to be okay with that.

The Blackberry on my client’s lap was signaling a message. Usually, this client silences her phone and puts it away before our session, without any prompting from me. This time, she glanced down at it, pushed a few buttons, and resumed our conversation. I let it go.

Two minutes later: buzz…buzz…buzz…

My client looked down again and started pushing buttons. I called her out.

“What’s up with the phone today? Usually you put it away. Is something going on?”

“It’s just Facebook updates.”

She pushed a few buttons again and put the phone in her pocket. I didn’t hear it vibrate again during the rest of the session.

In my group theories class, we’ve been discussing the concept of process commentary, which Irvin Yalom described in his book The Theory and Practice of Group Psychotherapy as “taboo social behavior” among adults. Process commentary can be defined as comments on here-and-now behavior and the immediate relationships between people. It’s associated mostly with group therapy, but therapists use it to bring attention and immediacy to individual sessions as well. In therapy, process commentary is a powerful tool; in the wider world, they are the type of comments that we sometimes attribute to people who are less socially adept: “Can you believe he actually said that out loud?”

Adults often use process commentary with children, saying things such as, “Look at me when I’m talking to you!” Using process commentary can also seriously get you in hot water with a significant other: “Hmmm, honey, I’m sensing resistance to my request to take the garbage out” might be met with, “Excuse me, counselor, but I am not your client!”

Yalom put forth his ideas about process commentary long before Facebook was an imaginable concept. I’d be curious to know if his ideas about process commentary have changed now that people are posting millions of status messages a day that answer the question, “What’s on your mind?” That very question invites users to tell the world what is happening in the here-and-now. In fact, “Facebook friends” might even get upset if you don’t keep your status updated or you—gasp!—dare to let any significant amount of time pass before posting a status message about an important life event. A friend posted—on his Facebook page, of course—a picture of a bride walking down the aisle, looking at her phone, with the caption: “Facebook Status: Because it isn’t official until you update it.”

Yalom (1995) gives four reasons why process commentary is taboo: socialization anxiety, social norms, fear of retaliation, and power maintenance (p. 137). Facebook by its very construct has blown all of these fears out of the water, and process commentary has become front and center in our lives and the lives of our clients who use Facebook. This powerful program has changed the face of “social norms” for communication and is increasingly harder to ignore, especially when what is said on a Facebook page can negatively affect clients and their relationships, self-concepts, and interactions with others and the world.

If you are on Facebook, you might have had the experience—as I have—of reading a string of comments about a friend’s status that made you blush because of their boldness (of the comments, but maybe the status itself as well). While of course someone has to be a “friend” to comment on someone else’s status, and your name and picture is posted with every comment (assuming you are using your real name), there is still a sense of safety from being behind a computer and not face-to-face that allows people to feel as if they can say—literally—what’s on their minds, without a lot of censoring or thought about interpretation. I have been continually amazed at the depth of self-disclosure of status messages and the sometimes brash, rude, and cruel humor of ensuing comments. In addition, I have witnessed awkward interactions among my classmates that are carried over from crude humor that was posted on Facebook pages. Clients have come to me with stories of “friends” posting hurtful or embarrassing comments on their pages. Anyone who has a Facebook page and “friends” linked to it is susceptible.

How long before this type of discourse finds its way into the counseling session, coming from the client? I can tell you that text messaging shorthand has already found its way into academic writing, everyday speech, and even memorial services (yes, I experienced that firsthand.) How many times have you heard “WTF?” or “TMI!”, stated just as I typed them? One of my clients described her sibling as “Not my BFF,” and expected that I would know what that meant. (I did.) Process commentary as a regular way of communication is probably not far behind.

Yalom (1995) stated, “If individuals felt free to comment at all times on the behavior of others, social life would become intolerably self-conscious, complex, and conflicted” (p. 138).

Well, that time is here. And now. Process commentary is no longer something that just happens in the therapist’s office, delivered by the therapist for growth and awareness purposes. Millions of people engage in it all day, every day. It’s not just changing how people interact with each other in the real world, but it’s also sure to show up in your office, coming from the client, soon.

Reference

Yalom, I. D. (1995). The Theory and Practice of Group Psychotherapy (4th ed.). New York: Basic Books.

During my supervision session prior to break, I expressed frustration to my supervisor about a client who had asked to continue counseling beyond her class requirement. I questioned this client’s commitment to counseling and whether her problems were significant enough to warrant additional sessions, especially since I had been assigned six new clients, and therefore, continuing counseling with this client would mean extra work for me. My supervisor reminded me that I had been very excited to work with this client initially, and gently encouraged me to keep working with her for a few more sessions.

Then my supervisor did her job: she suggested that my client might have a serious disorder, one I hadn’t even considered, or honestly, would have even occurred to me on my own. Since I knew basically nothing about this particular disorder, I decided to take my supervisor’s suggestion under consideration and do more research while on break.

So I did. I looked online for information, read the DSM-IV-TR criteria, talked with my mentor, emailed a fellow Psych Central blogger about her articles on this topic, and ordered, received and read an entire book about the disorder. I now feel much more educated, enough so that I feel like I would be able to have an informed discussion with my client about a potential diagnosis.

However.

Diagnosis is a tricky, controversial subject. I have several reservations about it, including my lack of experience in making diagnoses (I’m in the diagnosis class currently, and we have not covered this disorder yet) and whether having a diagnosis helps or hurts a client, especially since once a diagnosis is in a medical file, it’s there permanently and can have profound effects for a client’s future. Even though we’re a training clinic, our clinic director told us a story about a former client applying for an FBI position, and having to turn over the client file for a background check. At this stage of the game, given my level of experience, I don’t want that responsibility on my shoulders.

Of course, once I have a discussion with my client about my thoughts, she may tell me I’m full of it, and that will be the end of the discussion. (Maybe. Client denial is a topic for another post.) But what if she says, “Yes, that’s me!”? I can’t anticipate what comes next: “I’m so glad to know I’m not alone and what can we do about it?” or “And so you’re telling me I’m defective?”

So here I am at a crossroads. Now that I think I have a name for my client’s expressed feelings and behaviors, I want to share them with her and formulate a plan to help relieve her distress, based on the empirical treatments for her problem. On the other hand, I fear making the problem worse by subscribing to the medical model for addressing her issues and “labeling” her. Also, I only have four sessions left with her, and if she indeed does have this disorder, it won’t be resolved by then. She would need to see someone in the community to continue treatment, therefore carrying this diagnosis beyond a month’s time and outside of a training clinic.

Thinking ahead to being in professional practice in the real world, I had only briefly thought about what I would do if a client seemed to clearly fit a diagnosis. There are some behavioral disorders that seem to be fairly clear-cut, although that’s probably an inaccurate statement in itself. In this case, diagnosing a disorder that is more about cognitive functioning feels much more subjective. In addition, this particular client also seems to have a very mild form of the disorder I have in mind, which makes diagnosing it feel even more precarious. I fear damaging the relationship if the client tells me I’m wrong.

However, I wonder if, after I present my hypothesis and share what the usual symptoms of this disorder are, she will disclose further symptoms that she either hasn’t thought to share or was too embarrassed to share previously. Will this be a breakthrough in our relationship and work together, giving us direction and purpose that was starting to elude us?

Despite my reservations, this is my time to experiment. I think by prefacing the conversation with “I am new to making diagnoses, but after talking with my supervisors and doing research, I think you might have [this disorder]. I’d like to share what I’ve learned with you and see what you think,” would help soften any potential blow. I very much want to make this a dialogue between the two of us. That way, not only will I get feedback about whether my clinical judgment was correct, I can learn about the effect of having a diagnosis.

I realize every client will react differently to receiving a potential diagnosis, but I can’t learn what happens if I don’t try. I feel comforted by having the backing of my supervisor, the safety net of still being a student, and knowing that I have done research, so this is not just me taking a risk for the sake of having the experience. My intentions are pure and good, and my desire is to help this client to the best of my ability. If having a diagnosis to help shape our time together is the way to do that, then that’s the direction we’ll go.

Last semester, I pretty much agreed to participate in everything. My helping nature made me think, “You might be asking others to do this someday yourself, and good karma comes around.”

This semester, I am way more protective of my free time and available brain cells.

However, a survey landed in my inbox on Thursday morning, and since the caffeine hadn’t connected with my brain just yet, I decided to fill it out. The first half of the survey asked me to assess my counseling skills within a range of “strongly disagree” to “strongly agree.” As I went through the questions, several stirred memories of experiences I had with clients this past week.

3. When I initiate the end of a session I am positive it will be in a manner that is not abrupt or brusque and that I will end the session on time.

This is one my supervisor and I have identified as a growth area for me. I am conscious of the time in my sessions, and at about five minutes before the end, I say, “We’re about out of time—is there anything else you’d like to discuss?” Two of my clients have waylaid me by bringing up topics that need more than the time we have to discuss—classic behavior my instructors warned us about. I have managed to end the sessions on time, but haven’t always done my best of reflecting content and feelings as I should since I have been trying to be respectful of my time, the client’s time, and the fact that one of my classmates is probably waiting impatiently for me to get out of the office I’m using so they can start their session.

Answer: Slightly disagree

11. I feel confident that I will appear competent and earn the respect of my client.

I am always on time. Early, usually. My planner is my lifeline. I generally check my planner several times a day, even though I’m pretty good at remembering when things are scheduled. One day this week, I had individual supervision from 1-2 p.m., a client at 5 p.m., and a midterm review at 6 p.m. It was mid-afternoon, and I had tucked myself away in a corner office in the clinic to catch up on some paperwork. A classmate came in and said, “Kate, your client has been waiting since 3:30.” I replied, “Uh-uh…must be the other Kate.” (There are two “Kates” and a “Katie” in my cohort. Mix-ups are not unheard of.) I pulled out my planner, just to check…oh, $%@^! It was 3:47p. My client had indeed been waiting twenty minutes for me. I apologized profusely to him and he was gracious, but geez. Talk about conducting seat-of-your-pants counseling—I felt totally unprepared and unfocused, and hoped the videotape was not rolling since my tardiness also resulted in a clinic office change from where I was originally scheduled.

Answer: Moderately disagree (That day, anyway. In general, I would answer moderately agree.)

24. I do not feel that I possess a large enough repertoire of techniques to deal with the different problems my clients may present.

Last semester, my Helping Relationships professor asked a question similar to this on a take-home exam: “Do you feel that employing the core conditions are sufficient for counseling a client, or does there need to be more?” My answer at the time was that the core conditions are necessary in the counseling relationship, but other techniques in addition are essential for really addressing the client’s issues.

It would be great if some of those techniques would come to me when I’m in the thick of a session.

One of my goals this semester was to employ techniques from at least four different theories with my clients. I did fairly spontaneously use the empty chair technique with a client. It went well. Gestalt: Check! I tried the miracle question—wasn’t thrilled with the results—but that was a solution-focused approach. Check! I do use CBT and DBT techniques regularly: Check!

I’ll be pulling out my theories book and refreshing during spring break.

Answer: Moderately agree

35. I feel I may give advice.

So far, so good with this one, though it’s been close a few times this week. We were told that our clients would come to regard us as experts, despite our status as students. I have several clients who are very cognizant of and articulate about their issues…and they really hope I’ll give them a verbal prescription for how to make everything better. I won’t deny that advice is rolling around in my head, but none of it has spilled out of my mouth. Yet. My career is young.

Answer: Slightly disagree

This week, I will send three more clients back into the real world, wishing them well on their academic careers and young adult lives, and thanking them for the opportunity to glimpse into their inner lives and see how I could help.

Next week = Spring Break! It will not be nearly long enough.