CPE

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

/ scblair / Leave a comment

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?

Trusting the Process

/ scblair / Leave a comment

Not long ago I thought I’d be shutting this site down, as I wasn’t sure if I was going to be a chaplain anymore. I wasn’t sure I wanted to be one on one hand: I’d had about enough of the stress, the politics, and the poor time off. Hospice seems to breed burnout for precisely those reasons. However I was recently offered a full time job at a hospice that seems good.

Trouble is I have two other jobs waiting in the wings. The key word there is “waiting” however, as neither one has made an offer and have been slow – in one case extremely slow – in interviewing. Both of these jobs have their pluses and minuses as well. While it seems clear that I should go with the “sure thing” I’m hesitant.

As usual I’m overthinking things, I think. Commitment to a job does not slam the door on everything else forever, obviously. However I tend to think of these things as permanent. As my wife said, I can give this a trial period in the same way that they’re giving me one. Plus I have to recognize my hesitation is due to a fear of the unexpected, and also a fear of the expected.

One of the things you hear a lot in CPE is to “trust the process”, meaning that the CPE group is designed to raise problems and growing edges, and any quick solution to those issues is not going to help. They in fact hinder the process of growth, change, and self discovery. Here too I see that I need to trust the process, trust that God is in it, and care less about being sure about my decision.

I get too concerned sometimes about making the wrong decision, often where there is no wrong decision. Mistakes are survivable, and I have no idea what lies around the next bend in the road.

Know, Be, Do

/ scblair / Leave a comment

The biggest part of CPE is the process itself.  It’s not a matter of learning something new and then showing that you’ve learned it, as in a typical classroom.  You are the classroom and you are the textbook.

In fact, CPE and chaplaincy depend very little on knowledge.  Rather it depends on wisdom, developed over time and only through experience.  Many enter in to CPE thinking that either it will be like a college class or a small-group devotional.  In my experience, that couldn’t be further from the truth.  The CPE group develops in a dymanic way, with each member of the group giving and taking with the ultimate goal of building pastoral identity and wisdom.  That wisdom is not gained easily though, not just through navel-gazing or drum-beating.

John Patton in Pastoral Care: The Essential Guide writes “Pastoral wisdom involves our knowing, being and doing.”  Sound profound?  Yeah, did to me to.  However it’s true, but here’s how I understand it.

Knowing involves not simply knowing a fact.  In pastoral care, this knowledge is not just knowledge of scripture or doctrine.  It is the knowledge of your self – strengths, weaknesses, history, pain, story, shames, successes and so on.  CPE involves a great deal of this self-identification, which is sometimes easy and sometimes hard.  I think lots of folks have experiences in CPE because they try hard to maintain false selves while the group or supervisor try even harder to tear that false self down.

Being involves accepting those things we are aware of through self-knowlege.  Too often self-awareness leads to self-rejection, I think.  The hard parts of my life are just a part of me as the good parts, yet I find I tried for so long to judge those hard parts as things to be set aside or avoided.  I reject negative parts of myself as not really me, but that only sets up a false knowledge of who I really am.  However when I accept my past and my self and my past without judgement I can use them both to work with others in the midst of their own story and pain, and also help them to see their own true self without judgement.  This is not saying that sin isn’t sin or that “I’m all good”.  It involves seeing myself as I truly am, not how I view myself or how I want others to view me – it is how God sees me.  And in Christ, God sees me without judgement.  I think that’s what grace is.

Doing is the acting upon that knowledge of who I really am, putting my self fully into interaction with others.  This is the essence of pastoral care, but it can only happen after the knowing and the being.

Sample CPE Verbatim: A bit of what Clinical Pastoral Education does

/ scblair / 8 Comments

I thought I’d throw in a sample verbatim that I presented in CPE a few weeks ago.  These are presented in class and are a pretty significant part of what we do.  After a patient visit we write it up similarly to what you see below, although there are a lot of different ways to do it.  The main reason is to have the group look at what you did, ask questions, and look at the visit from a number of different angles.  Plus, the writing down of the visit and reflecting back on it afterward is very helpful in your own education.  I don’t write up every visit obviously, and while I used to look to try and find the “perfect visit” you can pretty much find something interesting in every visit you do.

Names and places have been changed obviously.  This references the Association of Professional Chaplains’ Common Standards, available here.  And pardon the weird formatting but I’m not fixing it on Monday morning.

Continue reading →