Aug 08

Temptations in Clinical Encounters

By definition, a temptation is an individual inner urge to break an external community rule.  Our community of psychotherapists has evolved a set of rules for all its members, without exception.  These rules embody decades of clinical experience, the knowledge that has come from trial and error, and the overarching concern for the welfare of those we are treating.  While over time some rules do change a bit, mostly we can call ourselves professionals because we all recognize certain rules as inviolate, never to be broken.Counselor

The rule about having no sexual intimacies is a major one, but will not be part of this column.  Therapists face other kinds of temptations that may be less dramatic but are just as important to resist.

Certain clients/patients can be very upsetting to us, and we naturally try to reduce that unusual amount of stress, even as we are also trying to conduct psychotherapy. Occasionally the stress is so great that we find ourselves tempted by the possibility of seeking immediate relief through releasing our anger in some way, or in removing ourselves emotionally from the scene.

While a neophyte therapist may not know about, or fully understand, some rule about proper professional conduct, good supervision soon corrects that.  For the rest of us, a temptation may occur suddenly without warning, or on the other hand an attractive fantasy may start to develop in our minds about something we might say or do with a particular patient/client who, if we are honest, is arousing strong uncomfortable feelings in us that are pressing for release or relief.  For example, people who are diagnosed as having a borderline personality disorder are typically highly frustrating for all but a few therapists.

The temptation is twofold: to take an action, and to think approvingly about it. The rules of our professional ethics pertain to our behaviors. But under stress we also want to provide ourselves with a justification for why a certain risky bit of behavior on our part is really all right.  We try to rationalize that the rule can be bent in this situation, or that the rule doesn’t apply, or that this is “the (allowable) exception that proves the rule.”

Basically, every therapist has his or her limits, and certain clients/patients can push us beyond our normal competencies. We may suddenly feel provoked.  Such patients/clients can overstress us, and make us feel overwhelmed and uncertain about what to do.  This is when we get tempted, to find some quick relief.

Psychology tells us that when faced with some major threat, we shift from normal behavior into Fight or Flight.  We start to get angry, or we try to create some distance between ourselves and the threatening difficulty a client/patient is presenting.  This is the way our emotions have become programmed by evolution and the imperative of survival.

So it is not a sign of personal weakness or professional incompetence if we feel very angry at or scared by a particularly difficult patient/client.  We are not responsible for the emergence of such all-too-human feelings; we are held responsible only for how we deal outwardly with these inner stresses.

The temptation is to find some form of quick release of our inner tension. But the high standards of our profession remind us that a therapist’s self-discipline includes the commitment to suffer in silence, temporarily, and endure the stress. Meanwhile, in the extra difficult session, we must keep our mouths shut, and do nothing except to continue to listen, until we can come up with a response that is therapeutic in intent and not a form of self-serving relief, by releasing anger or creating distance.

Besides the obvious scolding, cursing, or shouting at a client/patient, there are more subtle forms of inappropriately showing  therapist anger: raising a disapproving eyebrow, pursing our lips, letting a grim look with clenched jaw show on our face, letting our hands or feet start to move in frustration, sighing audibly.  Abruptly getting up and walking about our office may bring some relief, but what does it communicate to the person we are trying to help?

The other defense against patient-induced high stress is Flight, which also can take various forms.  Getting sleepy is an obvious one.  Letting our mind shift to imagining more pleasant pastimes is another.  Fantasies of enjoying a vacation can take us far away.  Thinking about how we’d like to shorten the session, or checking the clock a lot, are other indications of the Flight temptation at work.  Focusing on our hands or shoes, or anything else other than the client/patient, also insulates us from experiencing the stress of the session.  Having repeated thoughts about money or food or chores we must to do – all these can create distance between us and the person we are trying to treat.

Our professional ethics and practice guidelines all convey essentially the same principles:  stay focused on the patient/client; use part of your mind to think ahead to your next intervention, or how best to complete the session; use another part of your mind to become aware of any mounting stress and then how to neutralize it.  We can use reminders such as: This is part of the client/patient’s illness, to make me, and others as well, feel so upset.  I’m certainly uncomfortable, but I’m not in any real danger – so I don’t have to go into action.  I can be proud of myself professionally, if I just hang in there, try to learn from this, and don’t try to do too much at this time.  My basic reminder: don’t get overly invested in trying to change the person, when the person seems highly defended or highly obnoxious.

In summary, our clinical temptations (other than sex) are primarily to find ways to bring us relief from the unusual stress of dealing with an unusually difficult client/patient. We get frustrated, which means we feel both angry and helpless.  The human psyche then seeks immediate relief in Fight or Flight, while our training and sense of professional responsibility have rules: Don’t show anger (with a few careful exceptions), and Don’t disengage.

A temptation is “bad” only if we continue to justify our indulgence in it.  Giving ourselves temporary relief is understandable, but rarely is it therapeutic.  The impact of our Fight or Flight behavior is almost always negative, and corrosive to the relationship.  But if the stress of a particular session becomes so great that a temptation is acted upon, and we experience a lapse in our professional conduct, then it usually deserves our compassion, followed by careful self-study.

 

David C. Balderston, Ed.D., LMFT

New York City

 

Aug 03

Fit Trainer Spotlight ~ Sandy Cochran

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Sandy Cochran is a Chicago based fitness trainer, motivational speaker, and nutritionist. Sandy is known for his work with celebrities including Beyoncé, Tyrese Gibson, Usher, and many more. As a Celebrity Fitness Trainer, Sandy would accompany his clients on tour, on movie sets, or wherever his services were needed. In addition, he was hired to be the on call fitness trainer for the set of Transformers 3 and The Fast and The Furious Part 2. During these projects, Sandy would work out with the actors as needed and would help with last minute filming preparations as well.  In addition to working with celebrities, Sandy works with non-celebrity clients throughout their entire fitness journey. He provides one on one training and small group fitness training. He also teaches cycling classes, which can contain larger groups of clients. After visiting Sandy in his Chicago studio, here is what I learned:

When did you start working in the field?

20 years ago. Sandy went to school for theatre and classical music, but somehow transitioned into the fitness industry.

What made you decide you wanted to pursue this career path?

Sandy was approached one day to be a model for a fitness magazine, and stayed in that industry for some time. However, people kept approaching him asking about how he got in such good shape, and he realized that he wanted to help other people reach their full potential as well.

What is your favorite aspect of your career?

Sandy’s favorite part of his career is seeing the change in each of his clients. He told me a story about a female client he worked with for a couple years, and she ended up losing over 70 pounds. She was at her ideal weight and had the body of her dreams. In addition, she got a promotion at work, and broke up with her boyfriend who was bringing her down emotionally. Sandy said that she turned her whole life around, and that he was honored to be a part of it. She also ended up becoming a fitness trainer, which Sandy thought was the coolest part of the whole story.

Sandy also competes in body building competitions, which he enjoys tremendously. He is in the process of becoming a professional.

What is the most challenging part of your career?

The most challenging, or Sandy’s least favorite part of his job, is when he has celebrity clients who just bring him along for the ride. He’s worked with celebrities before who are traveling around the world and ask him to go with. He doesn’t mind that aspect; he just gets frustrated when they bring him along and don’t genuinely appreciate his services. He likes the clients who appreciate the work outs and actually want to engage in them. In addition, he doesn’t always have clients who take interest in his life and that upsets him too. Sandy explained that one of his favorite celebrities he had the chance of working with was Beyoncé. This was because she would take the time to ask how his trip home was, ask how is family was doing, and to genuinely take an interest in his life.

What type of workout is your favorite to teach/do yourself?

Sandy’s favorite types of workouts are anything that strengthens the upper body. More specifically arms and chest focused workouts.  When it comes to cardio, Sandy prefers to switch up his method. He enjoys cycling the most, but also thinks that the stair master is a great way to burn a large amount of calories. Sandy also enjoys riding his bike, running, or going for walks downtown Chicago!

When it comes to nutrition, what are some examples of healthy food you suggest to your clients?

When it comes to nutrition, Sandy is very strict with his clients. He urges them to log their daily food intake and report back to him as well. In addition, when working out without him, he asks for photos of their accomplishments on the treadmill, etc. However, Sandy suggests that his clients eat smaller meals more often throughout the day. For example, he would suggest a client to start their morning off with oatmeal. After a workout, Sandy recommends a protein bar. He really stressed the importance of eating something after a workout, and he said a protein bar is the best option. For lunch or dinner, a salad or wrap with kale, spinach, and a source of protein (chicken, turkey, tuna, etc.) would suffice. He believes that carbs are important, but shouldn’t be eaten during the late evening hours.

Jul 28

July is National Grilling Month: 5 Ways to Eat Healthy during Barbeque Season!

 

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From July 4th all the way through the month (and the summer!) grilling out is a staple of American life. Backyard barbeques, fire pits on the beach, hibachis at campgrounds all become a place to create delicious meals over a coal bed or wood fire. But too much red meat can be bad for you, and brats and burgers (and even hot dogs) can lose their appeal after too many roasts.

Here are five ways to make your grill-outs healthier and more interesting:

  1. Consider beef and pork alternatives. Grilled chicken is delicious when you make sure to soak it in marinade first and keep basting it so it doesn’t lose moisture. Breast pieces can be sliced horizontally to yield a more even thickness and then cut in strips for fajitas and shredded and doused in BBQ sauce for health sandwiches.
  2. If you haven’t tried grilled fish yet, now is the time. Large steaks can be cooked directly on the grill or planked for delicious smoked flavor, and smaller filets can be grilled in a wire trap to keep them from disintegrating. A little lemon juice, basil, and olive oil can help keep your fish moist and flaky.
  3. Mushrooms are the new burger. A huge Portobello makes a fantastic meat substitute, perfect both for the vegetarians in the family and the health conscious as well. Sprinkle some mozzarella cheese on top during the last few minutes of grilling and don’t forget to season well.
  4. Kabobs let you have a small amount of meat while doubling down on veggies. Cherry tomatoes, bell pepper chunks, button mushrooms, and pearl onions are traditional, but consider adding fresh pineapple or mango, chunks of zucchini, and even sweet potato cubes as a way to brighten the meal and add much needed nutrients.
  5. Pizza night can be healthy and fun on the grill! Throw your crust in a pan and sling it on the back of the grill with a layer of sauce to start cooking while you grill veggies to put on top. Small meat cuts can be quickly cooked then cut up as toppings, then you can cover the entire thing with cheese and close the lid of the grill to finish it off. Try a whole wheat crust brushed with olive oil for a healthier twist.

Your grill outs can be fun and healthy, leaving room for the occasional guilty s’more. Find out what your client’s love to grill and suggest ways to make their own backyard barbeques a little better for their health. Nutrition advice is one of the things trainer insurance is designed to cover, so make sure you have a good policy in place!

Jul 26

3 Amazing Smoothies to Fuel Your Summer Workouts

 

fresh vegetarian smoothie witn oat flakes and blueberry

A smoothie is the go to of any true fitness aficionado – right? But the routine can get boring quickly if you don’t mix it up with different styles and flavors. Here are 3 tried and true smoothies that will get your morning off to a great start.

Delicious Protein Powder Smoothie

Start with a high quality protein powder, Add milk – dairy or non-dairy; almond milk or coconut milk is fantastic. Dump in nut butter of your choice, a banana if you like, or some fruit yogurt. Chocolate is good – go for dark for better antioxidants and less fat. You can mix this kind of shake up in a Bullet blender, food processor, or other mixer and it will be delicious. For best results, keep the milk chilled as cold as possible and use frozen peeled banana chunks for a creamy, smooth taste. You’ll think you are having an ice cream shake. This site has great protein powder smoothie recipes to try.

Yummy Veggie Smoothie

You don’t have to use powder to get protein into a shake, veggies like spinach and kale work wonders, and if you buy these fresh and make sure they are chilled and dry, the texture and taste will be great. Try mixing either green vegetable with a strong tasting fruit like a mango, and add smooth consistency with chilled coconut milk and some frozen banana chunks – or go full mojito with pineapple and mint blended in along with ice cubes for a delicious green drink. Try more green smoothie recipes to find one you can’t live without.

Terrific Fruit Smoothie

Everyone loves a quick fruit smoothie, Washing, peeling (if necessary) and chopping fruits to pop in the freezer can provide a base – or dump your chosen fruits in a blender, puree, and pour into ice cube trays for a jump start. Add yogurt, milk or non-dairy milk, a little cinnamon or vanilla, and garnish with a lemon slice or berries for a boost to your morning that tastes and looks great. Feeling brave? Avocado makes smoothies smooth as silk and the flavor is subtle under the fruit. Try these fruit smoothie recipes and get creative!

Ask your clients about their fave smoothie recipes, and think about holding a smoothie experimentation day with a huge variety of ingredients and BYOB (Bring Your Own Blender). You’ll be amazed at how many variations you can come up with.

  • Don’t forget to keep your fitness trainer insurance up to date. Nutrition advice counts when you are a personal trainer, so ensure you and your smoothie day are covered!
  •  Discuss how to get protein from fruits and/or veggies for your smoothies – that not all smoothies have to have protein powder. (spinach and kale are high in protein,
  •  Include one smoothie using fruits, one using vegetables and one with a protein powder. Discuss how chia seeds are packed with protein – good to add to fruit smoothies.

Jul 22

Fruit and Hydration go Hand in Hand during the Summer Months

Sliced juicy watermelon on wooden chopping board in kitchen

Fruit and Hydration go Hand in Hand during the Summer Months

It’s summer time and that means heat and sweat which means hydration (always important) is even MORE important. Are you drinking enough water? Getting your electrolytes? Making sure your blood sugar doesn’t tank?

Fruit can be your friend all summer, with high water content, natural sugars for better glucose control, and the ability to be easily grabbed on the go. Summer is the best time for high water content seasonal fruits, so start hitting the produce section whenever you go to the store.

Many fruits have additional benefits beside their hydration properties. For example:

Watermelon

Besides being 92% water, watermelon is packed with nutrients, antioxidants, amino acids, vitamins (including Vitamin A, B6, and C), potassium, magnesium, lycopene, and free radicals.

Cantaloupe

A denser but just as delicious melon, the juicy cantaloupe also has potassium, Vitamin A, choline, and fiber – all important to heart health. In addition, you get a healthy dose of antioxidant and anti-inflammatory phytonutrients.

Honeydew Melon

Another winner from the melon family! Honeydew delivers iron, potassium, fiber, and copper, plus a healthy serving of Vitamin C and 2 different B vitamins. It can aid in collagen production and tissue repair.

Kiwis

Vitamins C, and K as well as potassium, folate, copper and manganese all hide in the green flesh under the kiwi’s furry brown skin.  These gorgeous little serving sized fruits also contain a rare fat-free version of Vitamin E for added power.

Grapefruit, peaches, berries, oranges and pineapple are also great ways to “eat your water” for the day, so plan on plenty of fruit salads and fruit smoothies as well as munching down on whole pieces of fruit at snack times.

A smoothie for breakfast will hydrate you in a way that coffee, tea, or soda simply can’t. A smoothie that also gives you fiber, protein, and a super punch of flavor can be made quickly by following this easy formula:

  • 1 cup fresh fruit (you can also add grated or chopped veggies)
  • 1 cup base: milk, yogurt, kefir, or non-dairy milks like almond, soy, or coconut
  • 1-2 tablespoons of healthy fat (nut butters, flax / chia seeds, or avocado)

You can add protein powder or additional flavoring as desired. Think about sharing this simple breakfast tip with your clients, encourage everyone to eat more fruit this summer, and don’t forget to make sure your fitness trainer insurance is active and covers nutritional advice!

Jul 20

Educating Your Clients on How to Work Out During Their Vacation

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Even when you are on vacation and away from your gym or fitness studio, keeping up with a workout routine should be a priority. Your clients will be planning their summer vacations for this month and the next, so now is a good time to ensure they come back well rested but still in step with their fitness program.

Five ways you can encourage your fitness clients to work out on vacation include:

  1. Discuss the importance of maintaining a consistent work-out regimen while traveling. It keeps mind, body, and spirit in synch when the rest of a daily routine is disrupted. Sleep patterns will be more normalized, energy levels will be higher, jet lag will be minimized, and the chance of exhaustion upon return from the trip will be lower.
  2. Remind them that they can find simple outdoor activities like a long walk, jog, or run outside if the weather permits. Local open classes in public parks can often be found – consider a calming yoga meditation class, or seek out a group that runs together and join them on a local trail.
  3. Encourage your clients to look into any reciprocal programs offered by sister gyms in the location they will be in. Make sure they have a t-shirt or members card if you own your own gym and have secured reciprocal privileges with others. If not, tell them to check out sites like Groupon or Living Social to check for special on classes in their destination area.
  4. If the weather may be inclement, suggest that they use a hotel fitness center or pool – these are often free or very inexpensive to use and can allow a quick swim or treadmill workout at the start and end of each day.
  5. Finally, teach your students well enough that they can do routines on their own while on vacation! You can even sit down and come up with a DIY workout schedule for them to follow while they are away and this will provide them with motivation to get up and get exercise in every day.

You can also give some guidance to your clients about remembering their nutrition plan while they are on vacation. Setting goals with your clients will help them stay on track and they’ll return rejuvenated but still psyched about their normal routine.

Don’t forget that all advice can be considered part of your fitness trainer scope of influence, and ensure your fitness trainer insurance is up to date.

Jul 20

5 Ways to Stay Healthy while on Vacation

 

Family of five running on the wooden bridge, outdoors

It can be tricky to stay healthy on vacation, but sun and sand or the wide open road doesn’t mean giving up on your nutrition and fitness plan. Whether you plan to travel by car or plane, will be staying in a chain hotel or a campsite, expect a family reunion or a singles getaway, there are things you can do ensure the pounds don’t pile on this summer.

These tips can help you stay healthy and feel great all summer long:

  • 4th of July and Labor Day are events where food is everywhere and most of it can be pretty bad for you! Plan ahead and don’t show up starved. Portion control is your friend, so eat just one hot dog and one s’more, and fill up on healthy treats like watermelon instead.
  • A beachside vacation can mean temptation in the shape of a coconut shell and a flowered umbrella. Alcohol is empty calories, so ration your intake and consider fruit juices and frozen fruit slushies instead.
  • Being in the car for hours leads to boredom and boredom leads to hunger. Pit stops for snacks can lead to a choice between a Slim Jim and a Twinkie at most gas stations, so prepare some healthy snacks and pack them for your trip – granola bars, apples, and home-made trail mix are awesome for car rides.
  • Plane trips can be just as exhausting and in-flight meals are becoming rarer. Instead of being forced to scavenge for extra packs of stale peanuts or munch on dry biscotti, pack some nutrition in your carry-on and enjoy a piece of fruit and a protein bar to keep your blood sugar from dropping.
  • In restaurants, if dining alone, consider asking for a to-go box at the start of your meal and placing half of your food in it. When dining as half a couple, order an appetizer, entrée, and dessert – then share. Groups can order plates for the whole table and eat family style. Portions are usually twice as much food as any one person needs.
  • Look for hotels that offer a hot breakfast and increase your chances of some eggs or oatmeal in place of a sweet Danish. Alternately, plan on hitting a diner and ordering something with vegetables and a lack of deep fried food.
  • Frozen cooler packs come in foldable styles now and can be easily tucked in a lunchbox or shoulder bag with some yogurt to provide a healthy snack on the go.
  • Have trouble drinking water away from home? Carry a small bottle of lemon juice, or carry a water bottle with a built in filter. This will help you get your 8-10 glasses a day.

Staying healthy on vacation isn’t hard if you plan ahead and think about your nutrition. Don’t forget to care for your physical health (seek out opportunities to exercise daily) and your mental health too (fitness trainer insurance can give you peace of mind about your career!)

Jul 20

Insurance Company Records Request

It seems that requests by insurance companies or contractors for insurance companies for copies of client records is on the uptick.  More providers of mental health services are receiving letters from these entities requested copies of records for one or more identified clients.  These letters are not accompanied by signed written authorizations from the clients whose records they seek to access.  Providers receiving these letters have uncertainty about how to respond and what information they can or are obligated to provide.

The HIPAA Privacy Rule gave health plans and self-insured employers regulatory permission to obtain information without client consent for billing and health care related matters.  The Amended HIPAA Privacy Rule expanded the uses for which these entities are authorized to obtain, use and disclose protected health information (PHI) without client consent to include the following:

  1. Due diligence in connection with the sale or transfer of assets;
  2. Certain types of marketing;
  3. Business planning and development;
  4. Business management and general administrative activities; and
  5. Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance. Section 164.501

Treatment of clients for long periods of time or beyond a recognized average time period as experienced by the health plan seems to be a trigger for a review of records.  These requests often seek copies of session notes or progress notes.  I have talked to providers who received requests for copies of a client’s entire file.  The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose. However the minimum necessary standard does not apply to disclosures to or requests by a health care provider for treatment purposes.  

It is important to remember that if a provider maintains psychotherapy notes as defined by the Privacy Rule those notes are not subject to access by an Insurance company.  It is also important for providers to know if they are covered entities under the Privacy Rule.

So, if the health plan has concerns about the quality of services or the length of time services have been provided it would appear to have a right to access the entire client file.  If the requested use were for a billing question or issue the minimum necessary standard should apply.

Upon receipt of one of these requests I usually advise contacting the client to determine if they will provide written authorization to disclose the information requested.  A provider might consider including a broad consent in their intake forms clients execute on the front end of treatment authorizing the release of any and all information requested by the client’s health plan or payer of benefits.  If the client’s authorization for release of the information sought has not been obtained and the letter received does not make clear the use for which the information is being requested I advise getting clarification of use from the health plan or self insured employer before determining how to respond.  That information will inform whether or not the minimum necessary rule is in effect and how much the provider should release from the client file. Some times the requesting entity will agree to accept a summary of treatment and it is worth pursuing this option.

At end of the day it is the provider’s decision on providing PHI of a client and forced with the choice of being denied payment or future inclusion on a provider panel the decision becomes personal and difficult.  From my perspective more needs to be done to challenge and limit an insurance company’s access to personal and sensitive client information.

Written by Tom Hartsell

Jul 19

Putting the “Fun” in Functional Training: Getting Clients on Board and Enthused

Dumbbell push up group functional training circuit at fitness gym

Have you been trying to introduce functional training to your clients, but they just don’t “get” it? Functional training is one of the most versatile types of exercise, and almost anyone is capable of doing it – even clients who are obese, out of shape, partially disabled, or who have medical issues that preclude high impact or high heart rate exercises. Functional training is also extremely beneficial for clients recovering from injury or illness, who need to work their way back up to a full workout routine.

The core concepts of functional training are:

  • Use all 3 planes of motion.
  • Integrate the entire body.
  • Enrich the mind.
  • Make the workout fun!

The only point of contact with the ground during functional training is the bottoms of the feet, so the goal is to remain stable at all times. Functional training can improve all of the following:

  • Strength, power, and speed
  • Flexibility and range of motion
  • Muscular endurance
  • Cardio vascular fitness
  • Prevention of and rehabilitation for injures
  • Posture and balance

The body itself is the prime workout accessory, but you can make functional training more interesting and fun by introducing props such as kettle balls, dumbbells, medicine balls, core boards, Indian clubs, and more.

Functional training can include one on one and group exercises – and encouraging “play” scenarios isn’t just allowed, it’s encouraged. So are seemingly silly “kid style” moves that you may not have thought of in years, including:

  • Crab walking relay races – you might be surprised when it’s not the leanest, fittest members of the class who win.
  • Time competition – who can cross one foot over the other knee while standing (as if attempting to tie a shoe) and keep it there the longest?
  • Speed competition – set a number of objects on the floor and have class members bend at the knees to reach them and straighten to place them on a high shelf.

You can make functional classes fun, and turn them into gateways for new clients to work up to joining more advanced or complex focused classes. As always, ensure your fitness trainer insurance is up to date, especially when working with those who are out of shape or recovering from an injury.

Jul 11

When Death Threatens Someone Close to the Therapist – What to Expect – Really, not Ideally

We know how to deal with grief in our clients/patients.  We know how to help someone who is very ill go through the various stages and feelings about their own approaching death.  Our professional knowledge helps us to anticipate our own feelings, as well as help our patients/clients deal with their feelings, which naturally can be intense or defended against.

But when it comes to someone close to us, it may not be easy to deal with this final fact of life – its ending.  We can’t be strictly professional about a personal situation.  And we may be surprised by our own reactions, even though we’ve seen them occur in those we have a professional relationship with.    Some of us may discover that we have wonderful, creative responses emerging to deal with this intimate exposure to death. In others, this event may not bring out our best responses.  As usual, there is a wide range of individual differences.

This column is NOT about the unusual death of a child or young person, or a suicide or homicide, but about a mature person’s demise.  Now, when a slowly dying person shifts into hospice, whether at home or in a facility, there is some extent of time to allow all the mixed feelings to emerge gradually into your consciousness, and while some of the feelings may be upsetting, there is no sudden surprise.  Over time, you grow to understand and accept them better.  (If, however, part of your reaction should be deeply troubling, then you may find it useful to have a consultation with a mentor, or a grief counselor who specializes in such feelings.)

Also, we have all read about, and perhaps participated in, a structured gathering of friends and close family at the bedside of someone who is dying, and who may have even chosen the date.  These  events are typically consoling as well as uplifting; sorrow is mingled with appreciation and love is freely expressed in the room.  Therapists may participate as private persons, but this kind of situation does not generally challenge us, for the simple reason that it is anticipated.

Then there are the other situations. We may watch TV hospital dramas and gain some awareness of what happens in extreme or mortal situations.  But mostly we are inexperienced with death at close hand; we don’t know what to anticipate, emotionally.   Not so, a century or two ago, when many young adults died of “consumption” (TB), when typhoid fever and cholera were common, and most deaths occurred at home.  Today, we may understand intellectually what is happening, but each of us is pretty much on his or her own when it comes to our private emotional reactions. Various religious and ethnic groups have their traditional ways for observing the passage from life to death, but what if your own feelings do not fit into those prescribed formats?  There are the usual feelings of painful sadness and loss, but what about “inappropriate” feelings of anger, relief, helplessness, disgust, or a numbing of all feelings –- reactions which are not so easy or acceptable to express?

Especially when a loved one suddenly has a bad accident or unexpectedly becomes seriously ill, our personal reactions may surprise us.  We hurry to the bedside, our anxiety inevitably elevated.  We hope for the best and fear the worst.  We look for small signs of improvement.  We ask the doctors and nurses for the latest condition of our loved one, and we seek their explanations of many medical details.  We may ask a lot of questions:  what are the medications, what are the procedures, what will this or that do, how long will it take, when will we know the results?????  We try to communicate with the person, and it may feel awkward: what do we say — do we mention death?  Depending on the particular medical personnel involved in the situation, we may feel reassured by the sensitive ones, intellectually satisfied by the impersonally competent, or alarmed and annoyed by what seems like indifferent or incompetent treatment.

Sometimes, good hospital care leads to a recovery, and we can breathe a sigh of relief, literally  – for we have probably been “up tight” in our breathing as well as in our feelings.  Other times, the patient’s body is more seriously challenged and they need the extra supports of an Intensive Care Unit, where blood pressure, pulse, temperature and other bodily indicators are continuously being registered and shown on a monitor.  Intravenous drips of nutrition and enriched fluids are inserted.  Medications may be delivered by IV, or a more efficient central PICC line into the body.  Supplemental oxygen may be supplied.  If lung functioning is more compromised, our loved one may have a ventilator tube put down the throat to enable a machine to assist with breathing.  Bladder and bowel elimination may have to be via tubes.  With entubation of the ventilator (and some other conditions), sedation may be required, and this lessening of full consciousness can to lead to more frustration for all about inadequate communications.  Sometimes dying people follow a steady downward path.  With others, there are false alarms, rallies that don’t last, various uncertainties – all causing more anxieties, more stress.  Some people die quickly, even easily, while with others it is an exhausting marathon for everyone.

We approach the bed and, having first sanitized our hands at the door, we reach out to touch this struggling person so dear to us.  Time passes – time stands still.  All the modern medical technology is doing its job, steadily, quietly, helpfully.  Some of us can ignore these intrusions and focus just on the immediate relationship.  Others may be overwhelmed by the sight of all these tubes and the strange fluctuating lines and numbers on the monitor.  We offer what comfort we can, but we ourselves are often in need of comfort too.  Our emotional reactions may be all over the map, registering desperation and fear at one moment, anger and frustration the next, always some helplessness, with “inappropriate” thoughts about impending death and the changed future afterwards, and the messages of our own bodies about urgent needs to use a bathroom or find some food.  We want to be close to the person, or we want to get away and find relief from the tension, or perhaps a bit of both.

We may be able to rise to the occasion and produce wonderful words of comfort, and bring in meaningful objects to surround our loved one with reminders of special people and pets in his/her life.  On the other hand, we may be so overwhelmed by the enormity of what is happening right before our eyes that our responses may become emotionally numbed and perfunctory, just going through the appropriate motions, while our heart seems locked up and unavailable.  All this is mostly unforeseen and entirely human.

In the period after death, the meaning of “loss” becomes painfully real.  You think of things you would ordinarily discuss with the person, or ask about, or gossip about.  You see a news item or magazine article you would ordinarily clip and save for the person.  You see a movie or TV program but can’t comment on it any more.  Or you enjoy a certain restaurant you both used to go to, or you go to a special spot you used to share together – but not anymore.  You see that your phone has a message waiting for you, and spontaneously you think – but then you remember.

Later, also, following the person’s recovery, or death, we often think of things we should have done or wish we had said.  But our guilt about this, while inevitable, is a misplaced judgment, for we have done the best we could, period.  We showed up, we were present and hence a comfort, we stood at the bedside, we held their hands.  Whatever our feelings happened to be, our actions were the important thing.  We can’t predict or control what our feelings may be in an extreme situation like this, when the life of a loved one is in the balance, but our actions, to show up and offer comfort and closeness, reflect our maturity under duress.

In short, there is no one way of dying, and no one way of reacting to another’s death.  All this is common knowledge for mental health clinicians, but when faced with the stark reality of a loved life threatened with immanent ending, we can often use some reminders.

 

David C. Balderston, Ed.D., LMFT

New York City

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