When your hands are tied, reach out with both.

By Nick Perry, M.S.

puzzle

Just the other day, I sat in an attending room with my supervisor and the attending for the day discussing available resources for victims of intimate partner violence.  How can we best counsel patients living in a violent home? Where could we tell them to go? What should we tell them to do?

Katie and I bemoaned our training model as clinical psychologists.  As psychologists, we are trained and skilled in working with the “person” and, in therapy, largely set aside issues of “the system.”  Social concerns are left in the hands of social workers, which we are not.  And yet, this is a critical limitation of our very thorough training in intervening with “the person”, which becomes uncomfortably real in everyday practice.  Despite Katie’s wealth of experience and my own, small but growing, years of experience, we were stuck in the worst possible way.

Several weeks ago, I met with a patient for an intake visit.  These initial visits are used to determine the primary psychological complaint, conduct a thorough psychosocial history, assess for any comorbid conditions, and establish a clear plan of treatment.  In spite of having a leisurely hour to do so, the minutes move by quickly and I am often forced to set aside important concerns that are not the primary complaint, which, in a better world, also need to be addressed.  The patient sitting across from me was a young woman with a history of serious depression, non-suicidal self-injury, and suicidal ideation.  These were pressing, urgent concerns.  She was also, at the time we met, couch-surfing. I likely included this in my note by simply stating she was “marginally housed”, a pat, boiled-down version of something in her life that loomed large.  This issue of homelessness was “outside my scope of practice”; I had limited training or experience in handling it. I consciously set it aside to focus on where I knew I could be helpful – setting her up with good therapy in the community and establishing a safety plan for her suicidal thinking to help her keep herself alive.

Over the months in our primary care clinics, where I have been seeing patients for brief therapy or rapid interventions at their medical appointments, I have run into the walls of my training time and again.  I have met patients needing public assistance with heating, needing food stamps, needing transitional housing for substance use problems, needing help with immigration paperwork.  Each and every time I have been frustrated by my lack of ability to help in these situations. If you need help with your depression, your OCD, your PTSD, or your smoking cessation, I am here and I have tools for you.  But where is my evidence-based practice to lean on when my patients’ lives are unstable?  “We need a social worker” has been my inner mantra in all of these circumstances.  However, with the clarity of hindsight, my inner mantra has been my way of railing against things I feel I can’t control.  We, my patient and I, are both stuck.

But, have heart. Because just the other day, with some sorely needed insight from much more experienced providers, I found a better solution.  By putting our heads together, Dr. Fortenberry, Dr. Cochella, Google, and I, identified partner violence resources for patients.  Even more powerful for me personally, was a conversation about what to do with our patients when we feel our hands our tied.  The gist was this – be smart, be thoughtful, and be kind.  Even when we don’t have the exact tools we’d like at our disposal, we can still be helpful, we can still be concerned, and we can still care deeply.  So, the next time your evidence-based training falls away or fails you and you are stuck, do this – keep going.

Nick Perry, M.S. is a Clinical Psychology Doctoral Student at the University of Utah.

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