Clinical Intersections: Practicing While Grieving

by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field 

     I was originally planning on writing this post on December 13, 2019. I even have the document saved with the date and title on it, but no content. In December, I was reflecting on a year of practicing since my father died of lung failure. Some of my patients know; some don’t. I forget who does and who doesn’t at this point. I forget if I am sitting with someone who knows that my heart hurts a little extra lately or if I am sitting with someone who doesn’t realize that I just went through a real emotional wringer. It gets confusing. Yet, here I am, four months later, really practicing while grieving; alongside all of you with not a lot of smart things to say but the same deep wish to connect.

     Here are some things that I am thinking might be worth sharing as I sit with clients, or across from them on my computer screen, and try to piece together what the hell is going on in the world.

We are grieving.

     I went out for an Italian ice with my son and the world was so quiet, just eerie, eerie quiet. We stood six feet behind the person in front of us, but it wasn’t crowded anyway. We were served our treats and both quickly realized that it felt like they just didn’t taste as good as they did last year. We shrugged and said it was worth it anyway. Which was true. It was also just so sad. The quiet was sad, the empty roads, the gloves, the masks, the gorgeous sunset. There is literally no way to be navigating this moment in time without a broken heart. And if you already had a broken heart, like I did, I can tell you, it hurts even more. The fault lines were already in place for the impact that this world shift is having on our internal worlds. So, if you are hurting a little extra, it’s okay to be still soaking in the grief that preceded the world tilting in this exact way. And if you feel a little extra persecuted by it, maybe that’s because you had the flu before the coronavirus (metaphorically), and you just can’t imagine trying to rebuild yourself again.

The advice doesn't fit.

     All of the advice I read about how to take care of ourselves right now makes me feel like I am alien. The big ask from self-help guides right now seems to be: look away from the news, maintain your relationships, maintain routine, take a shower, don’t expect yourself to be too productive, keep working, exercise, get dressed in the morning, don’t over-fantasize about the level of control you have over how this will all play out.

     The problem with all of that advice is that it is suggesting that we don’t rely on our entire neurobiological system, which has been largely trained and bathed in trauma (because I don’t know any social workers who haven’t experienced trauma). Our neurobiology is in a fight or flight mode. We are either obsessively collecting information or crashing. And THAT is how we are taking care of ourselves right now. No, it doesn’t fit the advice, but it is instinctually real and the well-worn pathway that most of us are taking.

     Please don’t be ashamed if you can’t follow any advice right now outside of putting one foot in front of the other. Please don’t be ashamed if your trauma symptoms are highly activated right now, and please don’t be ashamed if you feel oddly calm - because many of us feel that what is happening in the external world is finally mirroring what we have long been feeling internally, and the symmetry is deeply relieving.

     I had a client say to me: “PTSD for me right now is like the sand that is omnipresent after a day at the beach...enough to annoy and remind but still able to move about.” Our histories of trauma are backdrops to what is unfolding right now. The past didn’t go anywhere; it is just intertwining itself with the present and reminding us of its existence.

There is no one in charge.

     I am in around 100 listservs for clinical social workers. I am downright fascinated by how many people keep asking each other what the “rules” are. By rules, I mean licensing regulations, what the insurance says, what is telehealth, what is HIPAA compliant, what are the right billing codes. I, of course, understand the importance of this information sharing and anxiety. And, at the same time, all of this searching for information about how to do this “right” makes me think that there is a wish that someone is in charge who knows what they are doing. There isn’t. The legislation around telehealth changed almost every day last week in Pennsylvania.

     I don’t know what next week will look like. What I do know is that it is more important to honor our code of ethics right now than any set of evolving regulations. If someone loses their health insurance because of their job, they still need a proper termination session. If you are terminated from your job, you are owed space and direction around closure with your clients. We have to resist how the system is pulling us toward traumatic ruptures as things spiral in ways we never imagined. Yes, the coronavirus is an illness that can strike anyone. But it will affect different clients unevenly because of socioeconomic brutalities. We need to activate ourselves around not letting problematic structures ruin the attachments with our clients that we have so carefully tended to constructing.

There is no training here that works.

     I hear so many supervisees talking about how they don’t know how to properly hold the therapeutic frame right now. They also feel as if they don’t know what to say or how to act or how to shift to telehealth overnight. None of us knows what we are doing right now. There is no technique or strategy that will make us feel more prepared right now. We are all winging it, and the feelings of incompetence are utterly exhausting and confusing.

     I had a patient tell me that this is what has finally made her realize that no matter what, she will die alone. Even if people are around her, she will ultimately leave the world alone. She’s right. That’s the kind of existential reality we are seeing our clients respond to, and we are no experts on how to make sense of that except to allow ourselves to bear witness to it, not try to fix it, not try to pretend that this is any more okay than it is. It isn’t. Our singular responsibility is to verify and acknowledge reality while remaining connected to others. There is nothing easy about that, and there is no technique for it, either.

We are all in our earliest stuff.

     I have been asking my clients what crisis was like when they were growing up. Almost uniformly, their response to this question helps them understand how they are currently coping. If you grew up in a family that acted like nothing was happening, you might have been shocked when schools closed indefinitely. If you grew up in a family that was always on the edge of chaos, you might feel right at home in this moment - or as if you are drowning in the same cortisol that you were raised on - and it has triggered every early defense you ever had. We are all both our youngest, most scared, selves right now while also having to perform the task of helping others to see how their pasts and presents are colliding to make this moment in time feel unbearable. This is deep work, and if you find that you are back to biting your nails or smoking cigarettes or clinging to a transitional object, there is no surprise in any of that. We are on high alert and have also been gaslighted about the severity of this pandemic for months. The confusion we are feeling is real and truly disorienting.

We really need each other right now.

     We are going to lose lives in this. It might be the lives of our clients’ parents who we have come to deeply know and understand, or it might be the lives of our own families, our colleagues. The only goal, really, is to get through it connected and open and in relationship.

     Trauma and the ways in which social work has indoctrinated us with the belief that we are superheroes will come together to trick us into not asking for help. I am telling you: I need help, and so do you. We need to ask each other for it every single day moving forward. If asking for help is like a second language to you, like it is to me, I hope we can practice together.

Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).