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.