Sunday, February 19, 2017

Rich and Educational

Last Sunday evening I went to the Thomas House potluck. I brought a little stack of Puffs with Lotion with me because I assumed that remembering F. would make me cry on the way in and out, but there weren’t any tears at all. It was great to see my soup kitchen friends. My walking friend gave a few of us rides home afterward. A year or so ago, I was in his car with a couple of people who really made me laugh, and last weekend, the same people were in the car and again made me crack up. It was the best laugh I’d had in weeks.

Last week at work we had didactics on assessing palliative care patients, treating Jehovah’s Witnesses (whose religion prohibits them from receiving whole blood transfusions), and working with patients with clinical depression. We also had a second session on transference, the psychological kind. Chaplains are frequently on the receiving end of this, and of course may fall into countertransference ourselves. These are exactly the same: mentally superimposing someone else on top of the actual person we are with and reacting accordingly, but when the care receiver / patient / client does this, it’s called transference and when the caregiver / chaplain / therapist does it, it’s called countertransference.

Tuesday was Valentine’s Day, and would also have been F.’s and my second anniversary. I was tempted to text him after work, but made it to the end of the evening without doing that.

I saw a patient this week whose wife left him in quite a cruel way after he became ill. He cried several times during our talk, and said he was thinking of reconnecting with his faith. I was impressed that in the midst of such a staggering amount of loss, he was able to come up with some sort of constructive plan for continuing with his life. The next day, he was sitting up in a chair and said he would be going home that afternoon. He was smiling, and I saw that someone had brought him colorful balloons.

A Code Blue occurred on my own unit Friday afternoon while I happened to be there. The patient was a man with Down Syndrome, who was soon stabilized. After a while, every member of the care team left the room and the patient was alone, so I went in, and the patient stuck his hand out to take mine. I sat next to him holding his hand for half an hour. He said two or three times, “I don’t want to die.”

This week we had our final session of presenting verbatims and last interpersonal relations group. The unit officially ends next week, when we will share our end-of-unit self-evaluations (not to be confused with our mid-unit self-evaluations) and have a party. I have arranged to take the test for the palliative care rotation next Wednesday. My statement of motivation is almost done.

There is a lot happening right now, including that one of my peers has developed health problems and has to leave the program. She works at the children’s hospital, so one person from my campus will move over there to take her place, and we’re going to get a brand-new intern who will do the second half of the year with us. So now besides the possibility of doing the palliative care training, there is the possibility of moving to the other campus for the rest of the year to work in the birth center and infant care nursery. I sent an email to see if it’s possible to apply for both or if they would prefer that we make up our minds up front and proceed down one path or the other.

In the past month, three interns who are doing an extended (part-time) unit of clinical pastoral education through June have joined us, and recently were able to start taking on-call shifts (so we like them very much, though we would, anyway; they’re all great people). It is our habit to say to each other before an on-call shift, “May your on-call be just what you need.” A co-worker once overheard me receiving this wish from our peer who is a rabbi and asked, “Educational, right?”

“No, no!” I said, before God could hear the rabbi’s prayer. “Restful.”

As it happens, that was a restful night, so the rabbi now has a reputation for magically effective prayers, and so we understood him to be undertaking a mild act of hazing when he said to one of the new students, “May your on-call be rich and educational.” Oh, no! Our colleague ended up getting two hours of sleep, partly due to getting a call at 3:30 a.m. from a patient who had had a nightmare—whose partner was right in her room!

So this is now a joke among us. One student who was pretending to be displeased with another said, “May your afternoon be rich and educational.”

More than one of us is a believer in the healing properties of oregano, but whereas I use it the way a normal, well-adjusted adult does—by applying the oil to my throat when illness threatens—one of our younger students eats huge quantities of the dried herb, and another drinks oregano tea. I think she may have influenced someone who is susceptible to peer pressure, because when we were recently together as a whole group, a foul miasma of oregano hung over the proceedings (oreganic miasma?).

Sunday, February 12, 2017

Full of Possibility

In case you don’t happen to be reading eight articles about palliative care, here’s a brief overview. Palliative care is often confused with hospice or with comfort care, but while a given patient might be receiving all of them, they refer to three different things. Comfort care is in turn sometimes wrongly characterized as withdrawal of care, but we were instructed never to put such a phrase in any patient’s chart. (Let alone say anything about “pulling the plug” on a patient, which one of my young colleagues actually did write in a chart. Come to think of it, it was not long after that that we had the didactic on charting, so the two were probably not unrelated.)

Anyway, we never withdraw care. Patients might “transition from cure (or curative care) to comfort care” or they might “transition from intensive interventions to comfort care.” “Compassionate extubation” might occur, or “withdrawal of interventions.” We might, per the patient or his or her decision-maker, “allow for natural death.” Comfort care is focused exclusively on making sure the patient is clean and warm and free from pain and discomfort.

Many patients on comfort care might indeed be hospice patients—people with terminal illnesses who are expected to die within six months. Curative care is no longer provided, a do-not-resuscitate order is almost always in place, and the focus is on helping the patient to live as full a life as possible.

And certainly a hospice patient on comfort care might also be receiving palliative care, which focuses on relieving suffering and providing the best possible quality of life for the patient, who might have a terminal illness and be expected to die within six months but who also might have a condition that can’t be medically cured regardless of life expectancy. Sometimes people begin receiving palliative care immediately after diagnosis, long before becoming a hospice patient.

Quoting from “Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference,” from The Journal of Palliative Medicine, Volume 12, Number 10, “Healing is distinguished from cure in this context. It refers to the ability of a person to find solace, comfort, connection, meaning, and purpose in the midst of suffering, disarray, and pain. The care is rooted in … the recognition that, although a person’s life may be limited … it remains full of possibility.”

That means that even though I might never see F. again, my life remains full of possibility! I felt happy when I read that, and I generally feel happy today because the sun is out, and I got my laundry done, and also my weekly trip to Rainbow, and my periodic giant delivery from Pet Food Express, and later I’m going to the Thomas House potluck.

My shopping list now says “IOS” all over it—buy this thing if on sale. I’m also planning ahead in order to take advantage of various discounts Rainbow offers if you spend a certain amount in a couple of different departments, one being bath and body. Today I got to buy, among other things, six bottles of fluoride rinse, so I certainly felt happy about that.

I also bought chocolate! I have not eaten sweets in more than five years—an even more remarkable feat these days, as the student table at work is always groaning under the load of doughnuts, cookies, candy, cake and pastries. (Actually, I am not at all tempted.) I read in the AARP magazine this week about the health benefits of chocolate, and at Rainbow, I got a bar of Pacari Raw Organic Chocolate, 100% Cacao, socially responsible, no sweetener at all. The only ingredient is cacao. I thought it would taste just like baking chocolate—bitter—but it somehow is not bitter, and it does that nice chocolate melting thing, so life is good.


If you want to read just one extremely excellent article about palliative care, read
“Letting Go: What should medicine do when it can’t save your life?” by Atul Gawande in the August 2, 2010, issue of The New Yorker. I had read this before and it is also one of the eight assigned articles. It is superb.

Saturday, February 11, 2017

F.

I was on call at the other campus starting on Friday. Today was the first day it hasn’t rained in what seems like weeks. It was nice and clear and I was stuck inside the entire day, because the phone that is used to contact the on-call chaplain doesn’t work outside the building, but I still enjoyed looking out the window at the blue sky.

It was a quiet evening last night, greatly aided by the fact that I didn’t do any of the rounding we’re supposed to do. Am I going to become one of those chaplains who sits in the office eating doughnuts instead of seeing patients? I was forced to see two patients today, and felt somewhat joyful after seeing one of them, a young woman with an eating disorder. We talked for quite a while.

Tom and I were thinking of going to another movie next weekend, but I decided I can’t, because I have to do palliative care reading, and write my end-of-unit self-evaluation, and prepare for my mid-year consultation, not to mention other assigned reading that is piling up, and some reading I was going to do of my own accord to better understand the group dynamics model one of our supervisors favors.

I was also going to go to the Thomas House potluck tomorrow evening for the first time in months, and then decided not to do that, either, for the same reasons, or so I thought. Then I realized it’s because going somewhere with someone other than F. doesn’t sound fun. He and I used to go to the potlucks together. I can still clearly remember the last one we attended and something he said while he was there. Nothing major, just something that sticks in my mind, in the voice I’ll probably never hear again.

Nor will I ever do anything with him again (unless a whole set of small miracles occurs), and I guess I can’t not ever go anywhere again because I don’t get to go with him, so I called Tom back and said I would like to go to the movie, and I might even go to the potluck. Though I really do have palliative care reading to do.

Death Doula

I saw one of the doctors at the student health service a week ago and was pleased to learn that my blood pressure is nice and low, and my resting pulse is 53. Since I was there to discuss a tiny but nagging pain in my abdomen, I was also pleased to learn that pancreatic cancer doesn’t normally present with pain. I liked this doctor, who said minor things tend to get better and major things tend to get worse, so we made an appointment for a month from now, just in case, and I’m going to keep a log. Whatever this was already seems to be lessening.

It is a well-known fact that doing a year of clinical pastoral education causes a 20-pound weight gain, so I was also happy to discover that, at the halfway mark, I have lost 3.5 pounds. Since I should have gained 10 pounds by now, this means I have lost 13.5 pounds. (Right?)

In the past week, Tom and I went to see Hidden Figures, which I enjoyed, and my friend Karen, having come by free tickets, treated me to the San Francisco Symphony’s Lunar New Year concert, preceded by pizza on Hayes St.

I’ve been kind of down lately. I think three units of clinical pastoral education in a row is catching up with me. I’m still allowing nine hours nightly for sleeping, which is normally enough, and my schedule doesn’t allow for any more than that, but every morning, I feel as if I could easily sleep for three more hours.

During units three and four, one lucky student apiece will get to do a palliative care rotation and be mentored by TWMC’s main palliative care chaplain. This was mentioned at the beginning of the program, and I immediately assumed I would want to do this, with my background as a hospice volunteer. We learned in the past week that in order to apply, we would have a giant pile of reading to do, and then take a test based on the reading. The first five people to take the test would be invited for an interview. Stress ensued, as we were now in direct competition with each other. One of our three peers whose first language is not English expressed discouragement—she said it takes her twice as long to read in English—and another person for whom English is a second language said he would not bother to apply at all.

I guess enough people complained that our supervisors decided to revamp the process, and now we simply have a deadline for finishing the reading and taking the test, and the five people with the highest test scores will be the ones to interview. I mention all of this in part because I think my gloom started right around the time this was announced.

I spent an hour with Patricia (the chaplain who led the enneagram session) this past week and she said she thought I’d be an excellent hospice chaplain. I mentioned that I’m thinking of pairing that with being a bereavement counselor and she said those fit nicely together, and if I have an entrepreneurial streak (which I really don’t), I might think about being a death doula in private practice. A doula provides physical and emotional support during and after childbirth. A death doula would accompany a person who’d gotten a terminal diagnosis. I could totally see myself doing that.

I mentioned that once CPE is over, I’m planning to do the two-year program at Upaya Zen Center (in New Mexico, where it’s sunny!) and I hope to work two days a week as a chaplain. Upaya requires volunteering, so I thought I would do the Sojourn chaplaincy training at Zuckerberg San Francisco General Hospital and volunteer there, but Patricia mentioned the Zen Hospice Project, lately enjoying a higher profile due to an article in The New York Times Magazine about B.J. Miller (“One Man’s Quest to Change the Way We Die”). (Also probably now thousands of people want to marry B.J. Miller, who is extremely attractive.) (One of my peers used to work at Zen Hospice and can text B.J. Miller at will.)

Patricia said the Sojourn program is excellent, but noted that the Zen Hospice Project has a national reputation, and the lights in my grasping little brain lit up: ZHP will look great on my resume! Doing the palliative care rotation ditto! But right after that conversation is when I started to feel gloomy, and more so when I heard about having to do hours of speed reading in order to try to beat my colleagues to the finish line. I was very glad when I found out that won’t be necessary, but I still feel that something is not right here. Do I actually want to be a palliative care chaplain, let alone a death doula? Or even a chaplain at all?

However, one of our supervisors pointed out that we can be accepted into the palliative care rotation but decide not to do it, and it seems silly to close that door prematurely, so I am planning to do the reading (much of it the kind of dense academic stuff I normally avoid) and to take the test, and we’ll see. We have already had a couple of sessions on palliative care and will have at least a couple more, so it’s not like we’re not going to learn something about this. If my test score is not among the top five, at least I will have learned something by doing all that reading. We have to write a one-page statement of interest in the training, as well, so I’m also working on that.

Tough Row to Hoe

At work I saw a patient who took a seemingly minor fall nearly a year ago which caused a spinal cord injury and changed him from a strong, healthy person to one who hobbles about with a cane and is treated like an invalid. He asked several times why God was angry at him: if God is in charge of everything and I have a terrible situation, God must have done this to me on purpose. I am hardly a master of theology or theodicy (sticking up for God even though he does bad stuff to nice people), but my approach to this was to find out how he would treat a friend who was dealing with difficulties. It turned out the patient doesn’t have any, but he does have children, so I asked him to imagine how he would comfort a tiny child who had fallen and skinned her knee, and tears came to his eyes.

I returned to that idea a couple of times during our long visit, and toward the end, I led him in a guided meditation starting with mindfulness of the body, followed by loving-kindness (metta) for himself, and concluding with a bit of gratitude practice: cultivating the prosocial emotions that build resilience and are protective against debilitating stress. He became teary again during the loving-kindness part, as people often do.

Just before leaving, I again mentioned the idea that perhaps God loves him very much and is in fact sending kindness and comfort, just as he would have offered to his own young child. To my surprise, the patient smiled and said gently, “Well, maybe I’m supposed to learn something from this.” And then, sounding almost jovial, “He’s certainly given me a tough row to hoe.”

The next day, I encountered a patient with terrible abdominal pain and tried my first guided meditation aimed at coping with pain. I did the same thing as described above, except that after mindfulness of the body and before loving-kindness, I asked the patient to let his attention rest on the painful area. He winced, so I said, “I see your wince. Let your attention move out to the edge of the painful area, to the border between where it’s painful and where it stops being painful.” This idea came from my own hours spent sitting with physical pain on meditation retreats. I suggested that he cultivate a sense of allowing the sensations he was noticing to be present and explained that it is natural for us to resist pain, but that pushing it away makes the whole experience more miserable.

Then I asked him to identify a part of his body that didn’t hurt—a foot or hand—and let his attention rest there. After a bit, I asked him to notice the edge of his pain again, and then the pain-free area again. I borrowed this from Somatic Experiencing, which I took a class on at the Zen Center. Then we went on with loving-kindness and gratitude.

For gratitude practice, I might say, “Thinking now of something we’re grateful for, even just a small thing. Maybe your nurse smiling at you or a pleasant conversation with your nurse, or maybe something delicious you had for breakfast. Remembering that pleasant moment and noticing how it feels in your body to remember this.”

At the end of the meditation, I thought the patient was going to say, “My abdomen still is killing me, but I feel a little more relaxed.” But he said, “That was really nice!” and when I asked how his pain was, he announced that it was gone! I’m sure it was back soon enough, but I’m glad he had some moments of relief. The whole meditation took less than ten minutes, and consisted of simple steps the patient can easily do on his own if he feels like it.

Another day, a nurse asked me to see a patient in an overflow pre-op area that I didn't even know existed. The patient was deaf and a sign language interpreter was present. The patient understood the interpreter so readily and responded verbally, in perfectly smooth English, so quickly that I could hardly believe she was deaf. I stopped by the front desk to get the patient's record number so I could chart the visit. The woman who works there, who is a character and who often makes me smile, checked to see if I could access a system that tracks surgeries and we found that I could.

Poking around there later, I noticed two patients whose records were adjacent to each other and who had the same last name: what are the odds? But then I took a closer look and saw that one was donating a kidney and the other receiving one.

I also saw a man of less than retirement age who came down with a mild case of flu and was dead less than two weeks later, his final few days spent in the ICU, with his children and wife at his side.

Self-Portrait


(Click photo to enlarge.)

Saturday, January 28, 2017

THE Hospital Chaplain

Doing joint visits with a peer proved to be so illuminating that many of us have gone on to do others voluntarily; we don’t need to provide written feedback on these. Tony and I did this yesterday and it was hugely educational. That same day, I’d had a brainstorm about my opening question. When I began this year of clinical pastoral education, I would ask patients, “How are things going?” The answer to that is often, “Fine,” or “OK.”

Then I started asking, “How are you doing today?”, which is slightly more personal and sometimes leads to a longer answer. Yesterday I started asking people, “Can you tell me a bit about your experience in the hospital so far?” Bingo! Every single time I asked this, I got a very long, detailed answer.

I keep falling into wanting to fix patients: to rid them of their uncomfortable feelings or somehow resolve their difficult situations. This urge is stubbornly persistent, even though it is contrary to my caregiving philosophy and even though I know perfectly well that it is not helpful (and also impossible). I do believe that it is the relationship that heals, and that it is attuned conversation that helps create a relationship that feels trustworthy, so I’m excited about my new opening question.

Tony pointed out that most people mention their biggest concern within ten seconds of starting to speak, and said I did a good job of remembering these statements and returning to explore them later on. He advised that, instead of saying, “I’m the chaplain for this unit and I visit everyone who is here to let you know that we offer spiritual care and emotional support while you’re here in the hospital,” I might announce grandly, as he does, “I’m the hospital chaplain.” He thinks that makes the patient feel special: the hospital chaplain has come to see me! He doesn’t say the whole thing about spiritual care and emotional support. He says, “We are here to offer care and comfort. That could be prayer or meditation or just talking.” More concise, and also offers some possibilities to choose from.

I explained that Samantha told me to say I visit everyone on the unit after I saw a woman who seemed disturbed by my visit. Samantha suspected that I had scared her: “A chaplain is here? Am I dying?” Explaining that I visit everyone prevents this misunderstanding, but Tony said I can always add that if the patient seems perturbed. Tony said that if it seems necessary, he adds, “I’m the unit chaplain and visit all the patients on this unit. Most will go home happy and healthy, and hopefully you will, too.” That latter is a nice touch.

He advised that if a patient appears to be having a lot of emotions or looks like she is about to cry, I could say, as he does, “Wait, hold on just a second. I want to let that sink in for a moment. You just said [whatever]—that makes me feel really sad [or angry].”

He said that he tells people, “One of the benefits of having a chaplain come is that we hold space for you to tell someone things you might not feel comfortable telling others. With me, social niceties are off the table.”

He told me that he makes a point of offering his hand to every family member who is in the room, starting with the patient’s mother, if she is there, and he said that before he leaves the room, he stands near the door for one long, uncomfortable extra moment to inspect everyone and take in dynamics. He said it took a while for him to feel comfortable doing this. Since being aware of interpersonal dynamics is the one outcome I still have to meet before advancing to Level II CPE, I am going to give this a try.

While I was observing Tony in action, he visited a patient who, upon learning that a chaplain had entered his room, said in an emphatic way, “I’m fine.” When that happens to me, which it does often, I say, “OK. Well, if you ever want to talk to anyone, we’re here 24 hours a day. Just let your nurse know. It was nice to meet you.”

Tony, however, did not take that for an answer. He said, “Strong agnostic/atheist?” When the patient confirmed this, Tony said, “Me, too.” At this, the patient looked slightly surprised. Tony went on, “I’m not here to preach or teach—just here to hold space for you to talk about what matters to you.” It is considerably more likely that that patient will feel like talking to a chaplain than one who hears what I usually say, so I’m definitely going to steal that approach.

Tony invited all of us students to his place after work last night. Two of us were on call, as always, one at each campus. Besides Tony himself, that left 11 potential guests. Six of us showed up at his place, where we ate burritos and met his wife and darling two-year-old little girl. After dinner, we played a game that involves drawing pictures and describing in words the pictures drawn by others; that was fun. I have known these people since early September and we are already, with pleasure, socializing outside work. I worked for 18 years at a large corporation and knew many great people, but did not make one single friend there that I saw outside work, other than for weekday lunches. This corporation sent me my last paycheck on Friday: a year and two weeks of my full salary as severance pay. I will always be grateful. I happened to bump into this corporation’s CEO not long ago and took the opportunity to thank him in person.

Last night was also an open mic at the soup kitchen. It was at such an event that I first laid eyes on F. He no longer hangs around the soup kitchen much, but it had occurred to me to go to the open mic just in case he was there. When I got home from Tony’s, I called my walking friend, who runs the soup kitchen, to see if F. had been there. My friend said that he had indeed been there, and had performed in top ranting and raving form, and had “seemed to be in a good space.” For some reason, that was terribly painful. Even though I officially want him to be happy, knowing that he actually is cheerfully going about his business gave me a tremendous pang.

It was a hard night, but I did not call him. It helped (a lot) that I know he would not answer my call nor call me back. He has closed the door and I am sure he will not open it again. This is just as well. It was the closest thing to an abusive relationship I have ever been in. I don’t want to be the person whose partner loses his temper with her all the time, nor the person whose partner hits her so hard and so often that he drives her brain stem several centimeters into her spinal cord. This is much farther down the continuum than the harsh words I received, but it is the same continuum.

Fearless Cleanliness Captain

This past Thursday I did joint visits with a peer, observing him as he interacted with patients and writing down what I thought he did well and any suggestions I had for improvement—and in CPE, you can never get away with saying you don’t have any of the latter—and then he did the same for me. This peer is a Catholic priest, and therefore has formidable resources in the area of prayer. I could see how much that was appreciated by a Catholic family.

We also had a class that day on group dynamics, and one on conflict mediation, which involved interactive exercises that made us laugh. We heard about active listening and various styles of dealing with conflict. I’d gotten to practice the latter earlier in the day, when I went to speak with Patricia, who led the session on the enneagram last week that so inflamed me. Anita, my supervisor, was present as well. We sat down in a dimly lit small office and Anita said she was there to be our mediator. I said, “I thought you were here to be my attorney.”

I’d written out what I wanted to say and thought it over for a week, and, using “I statements,” I told Patricia about what I’d experienced. Regarding the “I statements,” there is definitely some grey area. “I feel that you are a jerk” is certainly out of bounds. “I feel angry” is always within bounds. “I felt shamed, humiliated and intruded upon” is iffy—it expresses that you shamed, humiliated and intruded upon me. I.e., that you are a jerk. On the other hand, those are specific experiences and maybe there is no better way to say it. Anyway, that was among the things I said, and Patricia’s response could not have been more wonderful.

She was completely open and undefended, and responded straight from the heart: perfect. She expressed great sorrow at having had this impact on me. She did say she thought the mood between us on that day had been “playful,” and I can easily see why she thought that. I acknowledged that my words and affect had not matched, and that I had used humor to mask my feelings. As for her not hearing my “No,” she literally did not hear it. She said she would never, ever push past a “No” and that she did not hear me say that. I was relieved to learn that.

I confessed my lie and apologized to her and she generously said it was a necessary form of self-care in that moment. The whole conversation took no more than 20 minutes, and Anita looked delighted at all this clear, heartfelt communication and mutual taking of responsibility. Patricia and I parted with a hug, after she told me how much she respects me and that I can always count on her support.

++

We tidied up the student office recently and were rewarded immediately with pizza and later with one of the spiritual care manager’s cheery emails, in which she said, “And thank you, Jodie, for serving as our fearless cleanliness captain!”

++

I don’t know if you’ve ever given any thought to what might happen if you get a heart transplant and then the new heart stops and you are the subject of a Code Blue and compressions are performed on this new-to-you heart, but I had occasion to ponder this this week and learned that they use a portable ultrasound machine at the bedside to confirm that the heart hasn’t been damaged.

Well, Well, Well

I recently received two books I’d ordered and realized, when I saw them together, that there is a glaring similarity in their titles: Remembering Well and Dying Well.

The former is by Sarah York. The subtitle is Rituals for Celebrating Life & Mourning Death. I have this idea that I might like to be a part-time chaplain and a part-time bereavement counselor, maybe just because I know someone who does both these things and who is overflowing with good cheer. Being a bereavement counselor sounds nice because, presumably, most clients are not themselves ill, probably not going to die anytime soon, and what ails them will in most cases eventually pass and they will feel better. One of my peers was in a bookstore looking for a book about memorial services or something, and someone sidled up to her and recommended this one, which is out of print, but Amazon seems to have plenty of them.

The latter is by Ira Byock, M.D. The subtitle is Peace and Possibilities at the End of Life. There is a copy in the student office at work, and another of my peers said she thinks it’s very good.

++

We have inaugurated a 15-minute midday mindfulness session in the meditation room at the hospital on Mondays and Thursdays. I led the first one, which attracted 1.5 participants—a patient awaiting surgery, plus a staff member who came in toward the end, but seemed to appreciate her short time there. She thanked me when she left.

One of my goals for this unit of clinical pastoral education was to offer care to staff members, so I have gone to three of my five areas to let them know that I am available to speak with people one-on-one and also to lead meditation sessions, if desired. Two of the areas, which are on the same floor and often share personnel, said they would like weekly meditation, so that began this past Friday. It will always be led by me, unless I’m not available. I will now go to my final two areas and say I am available to care for staff, and tell them about the mindfulness sessions in the meditation room.

There are nine ACPE (Association for Clinical Pastoral Education) “outcomes” that must be met before one can advance to Level II CPE, hopefully after the second unit, halfway through the year. By the end of the first unit, I had met all but one of them, so I am trying to take care of that in the next month—the second unit ends February 24! This year is flying by. The outcome I still have to meet is to “Recognize relational dynamics within group contexts.” (I did actually complete this in my first unit of CPE last summer, but that probably doesn’t count at the Truly Wonderful Medical Center.) To this end, I will write about family and/or staff dynamics in my “weekly reflections,” which I discuss with Anita, and for the remainder of this unit, I will make sure my verbatims—transcribed conversations with patients—feature group dynamics.

We also have a mid-year consultation to arrange and prepare for. This is required before we can go on to Level II but isn’t something we have to pass or get a certain score on; we just have to do it. This is a discussion with a group consisting of my own supervisor, me, a member of my sangha, one of my peers, and a member of the Professional Advisory Group. Two weeks before our meeting, I have to provide a short autobiographical statement, my most recent self-evaluation, my supervisor’s most recent evaluation of me, a write-up on my goals either for the unit just finishing or the next unit (preferably the latter), and a document explaining what I want consultation on.

Finally, our self-evaluations for the second unit are due a little before February 24, and tax season is rolling around, so there is a lot to do.

++

I went to see the surgeon who took over when my breast cancer surgeon retired, and she said everything looks good to her, and now that it has been five years, there is very little chance of a recurrence. She also said she takes pretty much every kind of insurance, including Medicaid and Medi-Cal, and even if I don’t have insurance next year, we’ll work something out. That’s what my eye doctor lately said, too. Reassuring. For many years, I let fears about money and health insurance paralyze me, but I am not scared anymore.

After I saw my doctor, I stopped by the place where I did my first unit of CPE to see if anyone was around. One of the yearlong residents was there—the one who thanked me for being the only person who was nice to him when he started—and the administrative assistant and a woman who works in finance. It was good to see all of them, and I had a lovely chat with the resident. We agreed that one of the great things about being a chaplain, or training to be a chaplain, is that it forces you to practice excellent self-care and also to prioritize your spiritual practice. I now consider the time I spend sitting in meditation at home to be a part of my job, just as important as reporting to work and seeing patients.

You Can Do Good Work While You’re Doing Your Own Work

A week ago Saturday, I had breakfast and a nice long chat at Santaneca de la Mission with one of my peers, Marian. We have clashed slightly several times, but have easily discussed each instance and worked through it. Alas, this week at work, I got mad at her yet again and, while part of me dreads having to announce that I feel angry with her, I am increasingly convinced of the value of this kind of effort.

We were lately assigned a reading called “Functional Subgrouping and the Systems-Centered Approach to Group Therapy,” by Susan P. Gantt, from a book called The Wiley-Blackwell Handbook of Group Psychotherapy, edited by Jeffrey L. Kleinberg. It has proven to be utterly riveting, because it describes many of the things we have been encouraged to do in our interpersonal relations group, and why. I encouraged my peers to read it and one of them reported that he was enraged before he got to the end of the first page: “If these are the rules, why didn’t they give them to us sooner!?”

I consider being easily angered (just like F.) to be one of my two most destructive personality traits, and can report that pretending not to be angry and/or refusing to express it has not resulted in the magical eradication of this tendency. And now that I’m being very explicitly encouraged to know when I’m angry and to say it, I’m starting to feel pretty sure that it is precisely the inability to express anger directly that leads to it bubbling up left and right. When I don’t trust that I can say, “When you did that, I felt angry”—when I don’t trust that I can speak up for myself in an appropriate manner—I feel I am at the mercy of whatever may happen to arise: a chronic victim, who broods over grievances and easily notices additional ones, but doesn’t do anything constructive about them (just like F.). I think being overly self-effacing is the flip side of being overly quick to take offense.

One of our supervisors pointed out that clinical pastoral education is the very rare situation in which we are invited, encouraged and supported to tell seemingly antisocial truths, and that we should take advantage of it. The learnings this affords will be invaluable in our work as chaplains—I am fooling myself if I think that I’m only ever going to get angry with peers and never with any patient in the hospital—and in our personal lives.

I met a patient this week who was horrendously injured by her ex-husband. She is in chronic excruciating pain about which nothing can be done. For reasons pertaining to her children, she declined to prosecute her abuser. I noticed during our conversation that she had a definite and seemingly quite unnecessary apologetic air. I’m thinking that the first time this person disrespected her, she did not say, “That makes me angry. I will not be treated that way, and I will not spend any further time with you.”

F. never laid a hand on me in anger, but I had to notice, with some discomfort, some ways my behavior parallels this patient’s—not being sure I deserve to be treated well, not being comfortable expressing anger, sometimes (though not always) backing down when others are angry, prioritizing what others want over what I want. I knew that F. was not a good person to date before I got involved with him. I knew he was angry. I knew he had substance issues. I was very attracted to him and know I am far from the first person to be unduly influenced by a pleasing face, but I also let his extreme enthusiasm override my own misgivings. Why was I not able to say, “This is not a good idea. I will not do this”?

I think that learning to say, “I am angry about this” is going to be excellent for me personally, whatever work I end up doing, and so I am now almost looking forward to telling Marian next week that I’m annoyed about yet another thing.

The other thing that has caused me severe difficulties in relationships is basically being unable to tolerate intimacy, which manifests as changing my mind all the time about whether I want to be in a given relationship. Often I push people away just when they are expecting a friendly response. I imagine they think of me as being moody, and I am sure it is baffling and hurtful. I’ve known this about myself for a long time and have never really found an effective way to counteract it. When I’ve announced to people up front that I do this, it gets even worse.

Anita lately asked gently, in one of our weekly conversations, “Do you think you push people away before they have a chance to push you away?” I’ve been pondering that. I know that I experience intimacy and connection as a demand of some sort, against which I must vigorously defend. For instance, by barely greeting someone with whom I had a nice breakfast not three days earlier.

But maybe that eventually does come down to fearing not that there’s something wrong with the other person—he or she wants too much!—but that there is something wrong with me. I will not be surprised to discover that at the core of this. Or I may not have the sense that the other person wants too much but that this, that or the other is wrong with her. But what has changed? The other person is just as she always was. It is my mind that changes.

Now, what to do about it? Well! The aforementioned reading talks about “driving” and “restraining” forces. At the end of each interpersonal group, we list what was driving and restraining during the group. For instance, it was driving that such-and-such person shared so honestly about what was going on with her, and the kindness with which this was received was driving. It was restraining that just as we were starting to talk about emotions, another person told a long anecdote about what he had for breakfast. One surprising thing it said in this article was that it is more effective to weaken restraining forces than to try to strengthen driving forces. It said that if group leaders attempt the latter, it is like Sisyphus and the rock; they have to do it over and over. But if restraining forces are identified and weakened, growth bursts forth on its own. Isn’t that interesting?

In all this, have I concluded I’m just too psychologically damaged to be a chaplain? Certainly! But then I remembered Samantha, my supervisor in my very first unit of CPE, saying, “We can do good work while we’re doing our own work.” Everyone has his or her psychological crud. I am profoundly grateful for the chance to examine mine closely with people who are doing the same, under expert guidance.