Uncategorized Jan 06, 2022

Your clinical shield

The most important part of the first time you see a patient is communication and listening. But what happens when we're doing all the right things, we're really present for our patients and doing a great job. 8 hours a day. It's easy to get burnt out. Building your therapeutic alliance can be hard work, ensuring trust, that you're listening and you're with them through the body language you use and how you question.

If you've been on my live courses you know I'm passionate about getting this right at the start. If you haven't seen Mark Bowden's Ted Talk it's a great place to start (followed by his books). 

Meeting the person with an open, "I carry no weapons" pose, using a upward eyebrow movement of positive interest, focus, and welcome. Making sure you set up your clinic room to dethreaten the situation as much as you can by placing the patient closest the door, without obstructions. If you can brighten the room with things that make it less clinical, enhance good lighting and even add some other sensory triggers like soft smells or music in the waiting area - all of these little clues to safety will help that person to relax enough to be able to tell you what they need to.

Many of us will have been on communication courses where we're taught interviewing techniques that include repeating back what the person has said to ensure understanding as well as show your listening, and open ended questioning to invite collaborative exploration of their issues. Great. We work So. Hard. on giving our patient the best opportunity to tell us their story. What happens when it works?  When you're doing really good, empathetic work for 8 to 10 hours a day?

Early on in my career I found that I needed to rest after seeing someone with pelvic pain. It took too much out of me. I'd give them my all and come out of that session feeling like my head was about to explode with all the emotions. Then I'd have a swift gulp of EGD (Earl Grey Decaf, drink of heroes) and head to get my next patient, emotionally spent. I worked with my mentor to limit my pain patients until I'd "built up my tolerance". I don't think this was the right way of thinking about it. Certainly exposure to hundreds of people with pelvic pain meant that I was less startled by some of the common things they reported, but I wasn't less moved. So I had to move my body and my mind, hitting the gym most nights a week and studying for my masters after that to keep my brain occupied. It was too hard to dwell on some of the stories that live with me to this day. It felt like a small price for helping them, when they had to live with the result of things that had really happened to them. Every day. Within clinical circles it was always spoken about as a "story" and something you were meant to find sad but dissociate from before you'd finished the session, and then online in more therapeutic circles I'd find conversations about "emotional energy transfer" and "auras". Neither was a good fit for what I was feeling.

Until one course where we discussed empathy in comminication, sitting alongside and within their vulnerability and the emotional toll it takes on the therapist. It's why counsellors have counselling... 

Then I was taught a few skills I thought I'd share:
- It's really important to create that comfortable, supportive, open space for your patient, but you get to choose where you sit within it. If you imagine it as a bubble, you can sit inside that bubble as someone tells you their story, expressing and mirroring thir emotions (a good sign of communion and deep listening).
- But it's important to take a quick moment to notice how you feel, really take note of how you are within your body. If you find you're getting too emotionally involved in the conversation then you can imagine making the bubble smaller, just surrounding the person.
- Just that small visualisation helps you to get a little distance from the emotions
- I'm blessed with a great memory, but that means I can remember almost every time someone's told me about their rape or abuse. Again, it's a small wound compared to theirs, but in a long career these small cuts build up and we burn out. Sometimes a story is so awful that bubbles dont work. It's ok to note that, so take a moment with your patient to take a breath and reset. And when things are really tough for us empathetic therapists you can imagine a shield in front of you between you and the patient.

Keep your active listening tools and communication open, but in the moments you find difficult having a mindful moment can help. I've used this more often than I thought I would. Take a breath, notice the breath, feel the chair underneath you and your feet on the floor. Imagine the shield in front of you between you and the patient. Then write notes.

Once I've listened, repeated salient points and written it all down I find it much easier. Sometimes thinking about someone's story as a jigsaw puzzle problem on the page can help me to stay focussed and not become overwhelmed with the emotion of what they've told me, which is what it's all about. They're there to get help, not have their therapist collapse as well underneath the weight of what they're carrying.

Debriefing with a mentor is absolutely key in these cases. You don't need to pass on specific information, but just let them know how you felt and that it was a tough session for you both. Lean on someone to help guide you in that aftermath, and find positive steps in moving forward in a healthy way. I hope these tips can help.

I'm so happy to have mentoring slots now available online at a sliding scale - pay what you can. If you're able to pay for the full session you'll be supporting your colleagues from around the world who may not be in the same economic position, but need that debrief as much as you. You can book direct online. I'm looking forward to chatting to you!


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