Up for comment: when is doing “enough” too much?

I have a particularly hard case that I wanted to share. It’s hard not only due to the nature of the disease but to the difficulty of how to approach it. I thought it would be a good ground for discussion.

This particular case is a man in his with Huntington’s Disease who lives in an assisted living community, which is comprised of much older adults. He has adult children and is married. He has a history of some suicidal ideation and has had two attempts that both failed. This disease claimed his father so he is well aware of what is in store for him. He is currently receiving medication to help with his depression and this seems to be helping. I see him twice monthly and our hospice social worker visits regularly for support as well. His wife is recovering from a traumatic injury that nearly killed her. He tends to keep to his room watching TV and movies most of the day. He doesn’t go to activities and has few if any friends at the facility.

The disease is the big elephant in the room. He refuses to talk about it and the family refuses to talk about it. They acknowledge it but it is not a topic to be discussed. This gentleman also never really opens up about anything. For some time I felt that it was me, but after a conversation with his wife this is his norm – he has never been that open about his feelings or thoughts. In fact neither has she or anyone else in the family. During most of my visits we sit in his room and watch TV or movies, maybe talk a little sports. I brought him some Christian music once and he gave it back to me the next visit. My thought was that he didn’t like it, but his wife told me he loved it.

I spoke with his wife yesterday to follow up on a visit and to check in as to how a visit with his psychiatrist went. It didn’t go well at all. The psychiatrist wanted to talk about the “elephant in the room” which was the disease and this man’s eventual death, and he wanted everyone to talk about it. Nobody did of course, and the end result was that everyone left angry and offended, and this man’s children felt even less like going to see him (as they are also prone to the disease). His wife told me that nobody in the family talks about things, especially their feelings, and that they are fine with this.

Hearing this was a bit difficult for me. I agreed with the psychiatrist that the family did need to talk about the elephant in the room! However the push-back made me rethink this position.

Personally this reminded me of the fine line we walk sometimes between managing our own agendas against – or along with – our patients. Even when my agenda is valid and helpful, at least as I see it, it’s important to remember that it is still my agenda. This psychiatrist wanted to use a more Rational-Emotive methodology to break through barriers that he saw and bring the family to his own picture of health. Is this family healthy? Well that depends on your picture of health. Is it functioning? That depends on your picture of functioning.

This story also touches on a key element of chaplaincy – that the chaplain both is and isn’t a psychotherapist. As I have a background in both psychology and ministry I feel this tension strongly. In chaplaincy, the primary agenda is set by the other, where as in psychotherapy it is often set by the therapist. In my own experience of receiving counseling, I’ve had periods of strong resistance and anger that I had to work through, and my therapist (as well as my CPE instructors) had to hold my feet to the fire while holding me up at the same time. I understand the resistance to resistance this family feels. I feel my own resistance as well, and question my motives as well as my actions at times. Am I doing enough or is my version of “enough” too much? I feel that I want to be helping, but it is hard to know when you are helping in this situation. It makes me feel caught in a bind, sad and frustrated. Plus this man’s life stage is much closer to my own than are my other patients’!

So let me know what you think. Use this as a jumping off point for discussion. Feel free to comment below and see where this goes. What do you see here? What would you do? Was the psychotherapist wrong, right or neither?

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