Parenting your adult children

My clients sometimes offer me this glimpse of the future: "your kids are little now, just wait." This is true; my children are still little enough that I’m a huge part of their day to day life and decision-making. Read: I have control over much of their lives. My clients’ kids are usually grown-ups. These grown-up children get to make their own decisions (and their own mistakes) without the very hands-on guidance of their parents. 

That’s how it’s supposed to be, right? Those of us who choose to raise children do so with the idea of launching them into the world as independent human beings. Once they’re launched though, they don’t stop being someone’s children. Parents of adult children generally don’t wish their kids good luck and stop being interested in their lives. When interest turns into interference, problems can arise.

Now listen: I’m not suggesting you can never again have an opinion about your adult child. I am, however, suggesting that the relationship between adult children and parents is different than the relationship with young kids or teens. Boundaries shift over time; not allowing those shifts to happen can lead to trouble.

So what is a parent of an adult child to do? Often a parent’s first instinct is to jump in and fix the problem. But if you’ve done your job and launched said kid into the world, you have to trust that they will figure out their own stuff. And if you really cannot stand idly by and not get involved, you can ask your kid what they need. This can look like, “I see you’re struggling; how can I help?” or “I want to help you but I want to make sure you want that from me.” The answer might be no but it might also be yes. We all need our parents sometimes, even when we’re grownups. But we also need to be given the grace and space to ask for help, rather than having it thrust upon us.

And if you really can’t keep your opinion to yourself, that’s what friends and therapists are for: vent away! Then you can maintain the healthy and happy relationship with your kids we all strive to have.

Say no: Setting boundaries when you're grieving

Therapists love to talk about boundaries and I am no exception. Boundaries are wonderful! There are so few things we can control in our lives; setting limits with others is one of them. That being said, knowing we can make our own rules in this way is easier than actually doing it.

Setting boundaries can be frustrating, to say the least. That’s because most frequently, the response you get from others when you set a limit with them is not ideal. It is not, “oh, thank you for telling me! I will honor your request with good humor!” Instead, setting a boundary or a limit with someone in your life often leads to hurt feelings and frustration. Asking someone to give you space or not bring up a certain topic or whatever can be difficult for a number of reasons: you’ve never said no before; or the situation has been the same for so long, it seems weird to suddenly ask for a change. Likewise, the person who is being asked to step back or stop a behavior often feels defensive: what’s wrong with the way things are? Why are you suddenly changing the game on me?

But life is always changing (which is out of our control) and we need to be able to make changes that suit us (which is in our control). This is especially true when we are grieving.

Grief is exhausting. It takes up so much of our energy, mentally, physically, and emotionally. In a grieving period, we need to be able to tell others (who may be well meaning) what we need. Most often, what we need during our grief is to say no.

I don’t mean you should hide away in a cave until you feel better (though there may be days when that sounds appealing). Rather, I mean you don’t have to go on as if everything is normal. It isn’t, for you. Your life has changed and you need time to adjust and figure out how you want to move forward. People in your life may not understand this; they may want you to show up in the ways you used to, at work, in your family, in your social life. I’m giving you permission to sometimes say no, without guilt. Your grief deserves your full attention. You deserve to honor it by asking for what you need.

What if I want to know about my therapist?

Once, during a job interview, the interviewer asked to describe my boundaries with clients. A pretty vague question, right? Like, it depends! But seeing as how I was in an interview for a job I wanted (and eventually got, thank you very much), I played along and responded: I answer the questions my clients ask me (within reason).

Because here is the thing: when you are sitting across from me in that first session, I want to know some pretty deep stuff right off the bat. For instance, do you drink alcohol? Use drugs? Are you religious? Have you ever tried to hurt yourself or someone else? Not exactly cocktail party conversation. So if a client has a question for me (like how old am I or how many kids do I have, etc.), I’m more than willing to answer.

Some things about me are already clear: I wear a wedding ring, for instance. I’m fairly young. I’m a woman. I’m white. For some therapists, this is about as much information as clients are allowed to know. There are different schools of thought and none of them are wrong; in some ways, it’s a personal preference. There are good reasons for a therapist to not spend a lot of time talking about herself. For one thing, that’s not why you’re paying me; we’re here to talk about you, my friend. For another, some clients use this tactic to deflect and avoid the stuff they need to talk about. But I think, especially in the rapport building phase of therapy, it’s normal for a client to wonder, who is this person I’m telling all my secrets to?

So ask away! If I don’t want to answer, I won’t. Part of this process is developing a relationship and setting boundaries within it. I’m happy to tell you that I have two kids and a little dog and a husband. I’m happy to tell you that I’m in therapy myself, and that it helps me be a better therapist for you. I’m happy too, to talk about why you want to know about me instead of telling me about you. Like I said last time, almost nothing is off limits. This is a road we walk together. So tell me, what do you want to know?

In defense of the six minute visit

This is in defense of the six minute visit.

There is a kind of cold call aspect to my job that has taken years for me to accept with grace and poise. When I explain to patients and families that I’m calling to offer emotional support, some people are immediately hesitant. I’m sure this is partly because of the way we view mental health in this country but that’s not the point of this particular post; suffice it to say, people are on guard when I explain why a hospice social worker is offering them a visit. The nurse, the home health aide, even the chaplain: their roles are very clear to patients and their families. But when I say that I just want to talk, that makes some people feel weird.

So over the years, I’ve become practiced in how to get people to talk to me, a stranger. (And, since the pandemic, a stranger wearing a mask, which really hinders the non-verbal cues. But again, I digress).  When I see a new patient, which I do once or twice a week, I have a kind of game plan: I start with an informal list of questions that I offer to my patients and their families. They range from the mundane (where are you from originally?) to the thorny (what are you afraid of?). Sometimes those questions lead to a lovely, rapport building visit and I feel I’ve done something useful. Other times though, I’m not welcomed to stay. I don’t mean I’m unceremoniously kicked out; it’s more that it becomes clear to me that the patient or the family do not want to talk to me. I am, after all, a stranger, if a well-meaning one.

At a recent visit, this exact thing happened: there were introductions, I explained the purpose of my visit, and the patient’s adult children very kindly thanked me for coming and then said they were fine and I should feel free to hit the road. So, after only six minutes of standing in the living room, I left. The patient was hours from death; the family was all present and all on board with hospice philosophy. They had funeral plans, they were following the medication regiment, they were making jokes about death (a very solid coping mechanism). They really and truly did not need social work intervention.

And yet! My critical inner monologue kicked in as soon as I began the walk back to my car: six minutes! That wasn’t long enough! I did something wrong. Maybe a better social worker would have pressed. Perhaps a better social worker would have explained in greater detail what the visit was for. Was I distracted? Burnt out? Having an off day? I could have asked to stay, I could have insisted on seeing the patient with my own eyes, I could have… completely alienated a lovely family who made their needs known to me the moment I walked in the door.

Because that is the thing about this job: you have to have an innate ability to both read the room and find the places to push. Sometimes there are no places to push. There are no weak spots or cracked open doors to lean against. Sometimes I have to trust my instincts that I am an unwanted guest and get out before I start to cause harm. That family did not need me. Six minutes was plenty of time for them; why shouldn’t it be plenty of time for me too?

Not a rupture, but a tear

Over the years, I have grown comfortable with what I can and cannot do for my patients. I think often of my early hospice career, when I once called my dad after leaving a visit, sobbing because my very young patient was going to die. (I’m sure I’ve written about this before but it has shaped my practice so much in the past six years, I feel compelled to mention it again). The short story is, I told my dad that I couldn’t do anything for her because I couldn’t stop her from dying. And my dad kindly reminded me that I could do something: I could be with her.

It’s a lesson I carry with me into the saddest cases as well as the most mundane days. It’s how I do my work without being drowned by the suffering of others. Also, it’s true! I can’t stop people from dying but I can bear witness and be still and that is mostly enough.

But then, there’s this patient.

I’ve been seeing this lady every two weeks since July. She and her family were told by the doctor, in July, that she had hours to days to live. Another wise thing my dad has told me my whole life is that doctors don’t know everything and they definitely cannot accurately predict when death will come. Here, case in point: she’s still alive in November. And she’s not exactly thrilled about it. I can’t blame her: she’s mostly confined to her bed, she barely eats, and she feels like a burden on her children. When I visit, we talk about those things, but also about her life and her accomplishments and her family. We have a good rapport and I think she enjoys my visits.

Last time I saw her, she was having a particularly bad day. I used all my active listening and therapeutic presence skills and I thought, when I left, that I had been at least a little helpful. When I called this week to schedule our normal visit, she declined. This happens, don’t get me wrong; sometimes people aren’t up for a visit, especially if it’s “just to talk.” But there’s a little nagging voice in my head that is telling me she said no because I can’t do anything for her.

This isn’t a therapeutic rupture exactly but it does feel like a little tear, or a crack maybe. And again, I may be projecting, but I heard in something in her voice when she said “not today.” I heard, “you can’t do anything for me, so why bother?” And that’s the part of the job that scratches away at my confidence and my resolve. I can’t change things for her. What I can offer, she doesn’t want right now.

It’s taking everything in me to type the following: THAT’S OKAY! It is okay that she declined one visit, one time. It’s okay that she’s depressed. It’s okay that I have no magic wand. (Maybe if I write these words enough, they’ll come true). It’s okay to not be all things to all people.

This is mostly my stuff because I’ve been having a hard time getting people to agree to visits, especially new patients. That’s a thing that happens in this job; after six years, you would think I could sit comfortably with it. But at this moment, I’m struggling with it. And honestly, that’s okay too. It’s not a rupture in my work, just a stumble. Carry on, my grandfather used to say, and so: I will.

Photo by Namnso Ukpanah on Unsplash

Who's in charge here?

I never know what I’m walking into when I have a new hospice admission. Likewise, my patients and their families don’t always understand why I’m there. The nurse and the home health aide, even the chaplain, have very clearly defined roles. When I tell people I just want to talk, it can make them nervous.

At that first visit, death doesn’t always come up in the conversation. It’s a delicate balance: building rapport and offering education and being present without pushing too hard on the door to deeper issues. However, sometimes the patient opens the door for me. Take, for instance, the other day: I visited with a new patient who almost immediately wanted to talk about her impending death. She wanted to know how much time she had left (can’t tell you, sorry); how involved she could be in her funeral planning (as involved as you want!); and how it was possible to feel physically ok and somehow still be dying (take that one as a gift, my friend). We had a difficult but very nice conversation and I think I was helpful.

The next day, the nurse called me to tell me that the patient’s sister didn’t want me to talk to the patient about end of life issues. (Imagine me rolling my eyes).

Luckily, the nurse is no shrinking violet; she informed the sister that the patient is alert and oriented times 72 and gets to be a part of her care planning. In fact, the regulations (if you, like me, are a rule-follower) insist upon the patient being involved in her own care.

But families don’t care about the regulations; they care about their loved ones not being sad, or scared, or “losing hope.” I can’t tell you how many times a (well-meaning) family member has said to me, “We don’t want him to know he’s on hospice” or “we didn’t tell her that she’s dying.” (Spoiler alert: people typically know that they’re dying). And truly, I get it: we don’t want the people we love to be afraid or feel sad or suffer. But, as I always remind those family members, we don’t get to make decisions for other people as long as they’re capable of making their own. We can be tactful; we can be kind. But I will not lie to a patient who asks me a direct question. I will not change the subject when a patient wants to talk about her death. It’s easier sometimes, as I tell my patients and their family members, to bear one’s soul to a stranger, if only because they don’t have to be careful. I won’t start crying or tell them it’s going to be ok; they don’t have to protect me the way they want to protect their loved ones.

In my most gracious moments, I can acknowledge that protection is what people like the afore-mentioned sister are after. In my more annoyed moments, I start crabbing about how it’s all about control and who wants it and who has it. Both can be true! What’s important is to focus, once again, on the person we are serving and to (kindly, firmly, lovingly) set boundaries with everyone else. Advocating for patient choice is foundational to this work; what a joy when it is so easily done.

Living in the village

The other day, I just about ran out of a joint visit. It was a tough one: the patient’s caregiver is struggling, to put it mildly. His anger is palpable. He is hyper-focused on a story he tells every time I see him, of how the hospital and the doctors wronged him and his partner, and how he will get revenge (his words). It is a difficult house to be in, so the nurse and I have made a couple of joint visits.

As a rule, I love joint visits. This work can be isolating and lonely and it’s helpful to have someone else with you sometimes, if only to cut your eyes at when the family leaves the room. I’ve been lucky over my career to work with a lot of wonderful nurses who relied on me for my expertise just as I relied on them for theirs. I think of hospice—of all interdisciplinary work, really—as a village. At its best, the team functions as a mini village where each person has their own role to fulfill: the nurse, medical care; the home health aide, physical care; the social worker, emotional care; the chaplain, spiritual care. Beautiful, right? Everyone has their own set of skills in the village, which complement each other and serve the patient.

There’s a balance to village life: just as I’m able to give to others, I have to do some taking, too. Obviously it’s not always an even split; that’s life. But with this co-worker of mine, the split is so off that something has to change. And I’m struggling with how to set a boundary without derailing a fairly new professional relationship. This visit may be the straw that is breaking my back.

I don’t want to go into too much detail, because the minutiae is not terribly important. The gist is, this co-worker attempted to do some psychosocial interventions in a clumsy, overbearing, awkward way, that only set the caregiver off (I told you he was angry, remember) and took the oxygen out of the room for a few minutes. It’s not her fault that she did the interventions poorly; she didn’t go to social work school. Just as I would never take someone’s blood pressure or tell them how much medication to take, another discipline can’t do social work.

Despite this very large misstep, she had a good rapport with the caregiver so the visit didn’t end in a yelling match. The visit was over shortly thereafter and even though I knew she wanted to debrief, I had to get out of there. I just about ran to my car, angry with her for disrespecting my skillset, frustrated with myself for not cutting the conversation off the moment it began, and overall feeling horrible, about that particular interaction and about how poorly I’d set boundaries with this co-worker.

Luckily, I have good supervision at this job so I called my supervisor for some validation and guidance. She gave me both and helped me find a way to set some solid limits. I want to be helpful; I want to be emotionally present for my colleagues. At the same time, I can’t be all things to all people. I love the village concept but as I said, there is a balance. I hope this co-worker and I have found the right balance so that we can move forward. This job is easier when you’ve got other people on your side.

Boundaries

I think (and write) a lot about boundary setting in my work. It was a thornier issue for me when I worked in hospice; being in people’s homes makes the lines all the more blurry and the boundaries rather flexible, in my experience. Now that I’m in a doctor’s office, it’s easier to draw some firmer lines. No one is offering me food, for instance. I’m not sitting on the edge of someone’s bed. I visit with patients in empty exam rooms; there aren’t any pictures of my family or any personal artifacts. Still, the balance of building rapport while keeping firm boundaries remains.

Take, for instance, a regular patient of mine. We’ve seen each other off and on since I started this job a year ago. We’re actually nearing the termination process now, much to his chagrin. He’s a nice guy; I like him a lot. But lately he’s been a little more familiar with me and I’m struggling with whether or not to push back.

Familiar feels like an odd word to use here but it’s sort of the only way to describe it. He’s not outwardly inappropriate; there’s nothing he’s said or done that I could point to and tell him to knock it off. It’s been an insidious little bit of boundary pushing. It started with an increase in cursing during our sessions. (Which honestly, if you’ve spoken to me for more than five minutes, you know that I have a foul mouth. I come by it honestly: my mother swore like a sailor). The words don’t bother me per se; it’s more that he used to watch what he said. My patients often apologize for swearing during a session, to which I answer that I’ve heard all the words before. I even allow myself the occasional “this is shitty” or something to that effect, if the relationship is there. But this patient’s frequent use of heavy curse words feels more boundary pushing than before.

Maybe I wouldn’t even have noticed except that the swearing comes along with a little more… flirting, for lack of a better word. Again, nothing so outrageous that I could give a firm, “not appropriate, knock it off.” More a subtle change in his tone of voice, a casual remark here or there. I have a feeling my female friends know exactly what I’m describing. If I mentioned it to him, he’d surely say he didn’t know what I was talking about. It’s subtle and honestly, I’m not totally sure he realizes he’s doing it. Which is partly why I’m struggling with what to do about it.

I should state here that I don’t feel unsafe; that’s a different topic for a different day. My discomfort is more about how I’m reacting to his boundary pushing. I’ve found myself coming back with a little attitude. For instance, he asked why I won’t be at work on a particular day (we were scheduling an appointment) and I jokingly replied, “None of your business.” We have a good rapport, so he laughed and said he was only kidding. It was a deeply awkward moment though. It’s the kind of response I’d give to a guy in a bar, not to a patient. But because I kind of let the boundaries blur, I let things get away from me.

That being said, this is not unsalvageable. And it’s possible that some of the over familiarity on his part is because we’re terminating our relationship soon and he has some feelings about that. Whether we’re going to address them the next time we meet really depends on how the session goes. I can consider different reactions to different things but I cannot predict the future (sadly) so I’ll just have to wait and see how it all shakes out.

In the meantime, I’m considering how I relate to my patients and if I need to take a more clinical approach. I don’t think there are any hard and fast rules here; it’s a case by case approach. I think what’s really needed is a little more self reflection and maybe a little pulling back. I guess we’ll see how hard he pushes and therefore, how hard I’ll have to pull.

Ah, clinical social work: where every interaction is deeply weighted! I guess it’s part of the charm of the work. Right??

Use of Self

I am kind of an over sharer. I have a tendency to spill out my life story when someone asks me a fairly benign question. For instance, a question about what brought me back to Philadelphia after going to school out of state sends me into a long, complicated tale with details about a protracted break up and a deep sense of homesickness (in case you were interested). I will tell almost anyone almost anything. My co-workers know far more details about my personal life than I think they want to, but that's just the way I am. 

Photo by Matteo Vistocco on Unsplash

With my patients though, I often wonder how much to divulge. I want to recognize and respect that I'm meeting people in their bedrooms, at their kitchen tables, in their intimate spaces, and asking them deeply personal questions. It's only natural that the boundaries between us are a little blurrier than they would be in an office setting. I don't mind answering a few personal questions: am I married, do I have children? I ask these of my patients; they're fairly benign. What gives me pause is when people hit a nerve they don't realize they're hitting. 

Now I have to give you a little more information--I'll try not to overdo it but it's important to this particular post. My mom died on hospice two years ago. She was comfortable and we had an enormous amount of support from the staff and from our friends and family. All that being said, I am still grieving and maybe will be for the rest of my life. 

I'm sure it's clear to you how this effects my clinical work, in this particular field. I frequently meet families that struggle with making end of life decisions. They hesitate to give medication or sign a do-not-resuscitate order or choose hospice at all. I have been asked sometimes, "What would you do, if it was your mom?" That's the nerve they (unknowingly) hit.

This is where I struggle with use of self. I have to ask myself, in the brief moment I can pause before it becomes too pregnant a pause, what am I willing to divulge? What will be therapeutic? What does this family need to hear? Sometimes I simply say, "If it was my mom, I would want her to be comfortable." Only recently have I been able to say, "I have been through this and I know it is incredibly difficult." And you know what? I don't know if that's the right thing to say. That's the thing about use of self, or about any part of therapy: one size does not fit all. There are so many variables.

This work has a science to it, of course. We use evidence-based theories to help people. But there is also a true use of instinct and intuition. We would not have become social workers if we weren't sensitive to other people's moods and body language. And so, when faced with this question that tugs at my heart in a very profound way, I must rely not only on my training about use of self and the therapeutic benefit, but also what my gut tells me. Sometimes it's wrong. Sometimes people's compassion for me derails the conversation and it's hard to get it back on track. But sometimes they are able to see the bridge I've laid out in front of them and thank me; they can trust what I'm telling them.

As always, I end this with no real answers. (Notice a theme here?) But I do believe it's an interesting question: how much do we divulge? How sharp should our boundaries be? What is self-serving and what is client-centered? Food for thought. Or, better yet, tell me your answers! I love to hear your feedback and look forward to it. Until next time, let's keep talking.