The following is an excerpt from a Level II verbatim I did several years ago to give you an example of how I wrote toward the Level II standards.
This case ended up being one of my most difficult, in that the patient was a child and I was good friends with his mother. His death was hard on all of us. As I have children this child’s age, it cut very close for me. Perhaps a bit too close. This visit is a follow-up regarding her son’s death. I think you’ll see several themes at work:
- who is caring for whom?
- recognizing defensiveness
- allowing space for authenticity and giving permission to be authentic
- theodicy – how does God work things out for the good when a child dies?
- self care
While I see these themes at work, I don’t think I touched on all of them in the conversation.
Feel free to comment!
Background: This visit in particular is significant in that involves the mother of a young patient we had on hospice with us who died a year ago. She is my age and she often came to me with theological questions she was struggling with. When her son Ben came on hospice, she left work but asked me to be her chaplain. This felt honoring to me, but at the same time I felt quite overwhelmed and anxious. It was one thing to work with the elderly dying and their older children, and quite another to care for a child close to the age of my own whose parents I knew very well and who I was close to.
After Ben died Eliza didn’t work for a few months. Originally she came back into marketing but found it horrible as she felt that she was going through the whole initial process of bringing Ben onto hospice over again. She felt more drawn to bereavement, but our management was concerned about how this would affect her own grief. Eliza then settled in to a part-time position in human resources, which has become more full-time.
Eliza is white, middle-class, about 38 with a thin, athletic build. She has always been focused on health and exercise and routinely runs in races and marathons. She and her husband Dave have two surviving children, the oldest being Tanner (about 14) and the youngest being Tia (about 8). Tia is an African-American girl whom they adopted after having her as a foster child.
I initiated this visit because I’ve seen that Eliza has been struggling more, at one point saying that she thought she might quit. She said this in an informal context so I didn’t know if she meant it, but it made me concerned. My initial concern is her stress level, and I’m not sure if this might be due to some grief issues, stress from work, or both. But I want to make sure that I address what’s going on and let her know that I’m concerned and available. I asked her earlier that morning to meet with me at the end of the day.
This visit lasted about 20 minutes and we met in my office. We met at the end of the day, and I was feeling a bit tired and ready to go home. However this visit was important and I was looking forward to it. I was at the office and Eliza sent me a text that she was running late. We had canceled once already and I didn’t want to cancel again so I encouraged her to get here whenever she could.
Visit Narrative & Comments:
|Interpersonal Process||Internal Process|
|P1||Hey, how’s it going?|
|I immediately notice that she looks tired and depressed. Eliza’s body slouched, eyes are droopy and dreary. She falls into a chair, on leg crossed under her and leans back away from me, head propped up on one arm.|
|C1||OK, how’re you?||I feel my own tiredness when I see hers.|
|She probably thinks that I’ve a problem or a complaint. I hadn’t told her specifically about why I wanted to meet with her, but I did say that I wanted to see how she was doing. But she also seems to be wanting this to be about me and not her.|
|C2||No – I’m fine. Don’t worry. I just wanted to check in with you. We haven’t talked in a long time.|
|P3||I’m OK (long pause, deep sigh, laughs and slouches in her chair)|
|C3||You look exhausted.||I don’t believe her, and I think she knows that.|
|P4||I am. How are you?|
|C4||Tired. Glad this week’s almost over.||I do feel tired. But I also feel like this is a diversion and feel a little frustrated.|
|C5||I wanted to see how you were. You’ve been flying around here like crazy, and you just haven’t seemed like yourself. You seem more stressed out.|
|P6||I have been. What made you think about that?|
|I could have gone two different directions here. One direction was to talk about the death of her son a year ago. That is what caught my attention initially. But I think that’s only part of the issue. Eliza has always spoken about being at peace with Ben’s passing and I think she’s being honest about her feelings. We’ve talked several times about his dying in the past and I think she’s been doing relatively well. But something in her life just seems out of congruency right now, and I think it’s coming out in her job. I didn’t think she ever wanted to do what she’s doing now in the company, and I wonder if she’s doing what she thinks she has to do or should do, or maybe she’s avoiding something. I’m not sure, but I think her job is the bigger problem right now. Her job and her grief are inextricably linked though, as her son died under our care. Touching on her grief touches on her work and vice-versa.|
|C6||I was working on letters for bereavement and your name popped up. It was the one year letter, and I thought “wow, has it really been a year?” I realized I hadn’t really talked with you to see how you were with everything. You’ve had a lot of changes and you just don’t seem happy. Is this what you planned on doing?|
|It’s hard for me to talk about Ben dying, because that was a particularly hard death for me. He was not much older than my oldest son, was extremely sick, deformed facially from his cancer, and scared to pieces. I felt scared and helpless myself, and I don’t like going back there. Work-talk felt safer for me. Not sure in retrospect if this is the primary issue, but it was my initial question going in.|
|P7||Well it’s what my degree was in. I want to get certified in human resources, and it won’t take me long to do that – I think I told you about that.|
|P8||I’m good at this, but it’s just so much.|
|C8||Aren’t you sharing your job with Suzie?|
|P9||I am, but she’s not in that much. It’s mostly me. How’s your job going?|
|C9||Don’t put this on me – we’re talking about you…So the hiring, the training, the problems, the applications…||That prior frustration makes me want to affirm that this isn’t just a chit-chat. I feel strong and confident.|
|C10||You don’t seem happy. (pause) How are you doing spiritually?|
|I feel she’s either sad or angry, or both. Eliza’s faith is extremely important to her. We’ve had very candid and lengthy conversations in the past about faith, religion, God, heaven, you name it. I think she has a very strong faith, but I wonder where that is in her tiredness and anger.|
|P11||Spiritually I think I’m doing ok…Dave is really doing a lot better. Before Benny died he was really on the fence with God. Now he’s going to church and I finally feel like we’re on the same page.|
|She’s still talking about other people – not herself. I didn’t pick that up at the time. But this is important for her and something she has mentioned in the past.|
|C11||That’s great – a lot of times when someone loses their child that drives them away from God.|
|P12||And he’s gotten a lot stronger. It’s great!|
|C12||So where are you in all this?||I feel a little puzzled. She’s more defensive than usual. I want to challenge her a little.|
|P13||I’m not angry. People keep expecting me to be angry and I’m not. How can I be angry at God when Bennie’s up there with him? He’s rejoicing – and yes I miss him terribly, and I’m sad about it, but I’m not angry. I get tired of telling people that I’m not angry at God.|
|C13||You don’t have to be angry at God, but you are angry. Sounds like you’re angry at those people telling you that you shouldn’t be angry.||Eliza immediately starts talking about what she isn’t, and I feel that’s exactly what she is. I think from her talk that she’s limiting herself – “I’m not angry about that so I’m not angry.” Her demeanor and speech say the opposite.|
|C14||And you got pretty mad when people brought up the whole St. Jude thing.|
|P15||Yes. That really makes me mad.|
|A few weeks prior someone had suggested having our company support a fundraiser for St. Jude Children’s Hospital and Eliza became very upset. She said that they had gone there to try and get some help for Ben, but they turned him down because he was terminal. She said that they told her that they didn’t want children to die on their service because it made them look bad – that not everyone got better or went home.|
|C15||I remember you saying how unfair it was, and maybe that hits at what you’re angry about. This whole thing is unfair. That Bennie died, that people don’t get you, and that people didn’t treat you or him fairly.|
|P16||I just don’t know how people can do that.|
|C16||And that’s what you’re angry about. And that’s fine that you’re angry. You need to be angry.|
|P17||It’s just hard.|
|C17||I know. It is hard. (long pause)|
|P18||Do I come off as angry and bitchy?|
|C18||No, not really.||I’m a little surprised by her question.|
|P19||Because if I ever get bitchy you have permission to tell me off. I don’t want to be one of those people that’s just crabby all the time.|
|She’s laughing as she says this. I think she sees that she is angry and doesn’t want to become an “angry person”. I also feel that this is her way of saying that I have permission to confront her, and also that she’s done talking about it for now.|
|P20||Promise you’ll tell me!|
|C20||OK, OK I will!||I feel some relaxation as the mood lightens a little.|
|P21||I think part of the problem is that I’m not running anymore.|
|P22||I just don’t have time now. I get up in the morning, take care of the kids, run to work, run back home, run the kids around, and by that time I’m too tired to do anything.|
|C22||Hm-||I feel the same way – so busy that I can’t do anything.|
|P23||Dave’s noticed it too and wants me to get running again.|
|C23||Do you think this new employee health program will help?|
|P24||They’ve been talking about it for years. I’ll believe it when I see it.|
|C24||Hm-||I’m feeling like it’s time to be done. I’m tired but I also feel like I said what I wanted to say.|
|P25||Well I need to go pick up Tom from school and get him home.|
|C25||OK. Hey – I’m really trying to be around more for people. I’m hoping we can check in a bit more often. If you want we can go off-site too.||I want to make sure this door remains open, and that this wasn’t taken as just a gripe session.|
|P26||Yeah, thanks. We’ll have to do that sometime.|
Clinical Assessment: The visit went well for both of us. I was a little bit surprised at first in thinking about how Eliza reacted to my questions. She deflected and diverted quite a bit, and she’s usually very up-front. However I initiated the visit and so this might account for at least some of the defensiveness. I also think that by keeping most of the talk focused on feelings and not facts this also made her a bit defensive. Usually when she brings up a question or problem, it’s more of an academic discussion. So keeping this on the feeling level was new for both of us.
I noted several times how tired I felt, and this seems to be common with me a good deal of the time. However I didn’t feel discouraged and was able to stay with the visit until around C24. I felt some frustration and confusion when she tried to turn the topic away from herself, but I used that frustration to take some control and authority over the situation. Had this been in a different context, say just a chance meeting or some other unstructured visit, I would not have done the same. I was very hesitant to talk about her son’s death, which was the initial trigger for the visit. It is a very sensitive subject for me, but I did not avoid it for fear of upsetting her. My own perception has been that she is dealing with her own grief well, and we have had very open discussions about him in the past. I think that grief was there obviously, but it wasn’t my main concern. Whether this is my own avoidance or not is unknown but is a direction I could have gone. However I did bring it up in discussion of her anger and how unfair his death was.
I felt pastoral during this visit, not because I did anything necessarily religious or because I was dealing with an overtly spiritual issue, but because I felt that my role was very much that of a shepherd. I felt like I was going after one of my sheep that was sick and needed help. I didn’t use any of the resources I typically use: touch (which I don’t think would have been appropriate in that context), prayer or scripture. But I did listen and offer support, and tried to show her what I saw.
I felt like my initial concern was on target. I didn’t get a whole lot of clarity as to whether the underlying pain is due to grief or work, but at this point I think that is secondary. I identified anger and I think that was on target. I don’t think Eliza wanted to admit she was angry, but I think she did more toward the end of the visit.
I felt that the visit ended well, in that I didn’t just say “bye” when Eliza ended the visit. I left the door open which was one of the things that I’ve intentionally been trying to do now as I work in to my new role.
Theological Reflection and Learning Issues: Theologically this touches a very difficult issue, the apparent unfairness of the world, which is mentioned in Ben’s death. Does God work all things out for the good? How do we respond to evil and unfairness? Sometimes our only response is to be angry and to vent that anger. The Psalms are an excellent reflection of this, as David contemplates the apparent triumphs of the wicked and their eventual downfall. However the “eventual” is the pregnant word here: we often have to hope and trust in the eventual triumph of God’s justice without having that justice apparent. Some wrongs are never righted on this side of eternity. How we carry that with us is an important part of our walk with God.
This visit was an experiment of sorts and one that I found to be more fruitful than previous, recent visits. I felt more engaged and more “in the moment”. It was a different role for me to take and one which I am continuing to work in to with Eliza and others. However I find that my feelings were more positive during and after the visit.