Therapeutic Relationships: How (and When) to Say Goodbye?

What do clinical boundaries really mean? Where does a therapeutic relationship end and a friendship begin? When we interact on deep and profound levels with clients/patients over long periods of time---sometimes for years---what does it mean to say goodbye? Is it possible to satisfactorily take one's leave of a long-term therapeutic relationship and feel OK saying "Have a nice life!" as the door slams on your way out

Having just emerged from a psychotherapy appointment wherein I was discussing just these issues, my mind and heart are simply brimming with thoughts and feelings about just such scenarios.

Leaving a job is (almost always) a process of letting go, of relinquishing the past in the interest of a newly forged potential future. When one leaves a workplace, there are the inevitable goodbyes to colleagues, "subordinates", "superiors", and others with whom one shared a relatively large portion of one's waking life. This is no small matter, and such a leave-taking is more often than not fraught with uncertainty, nostalgia, and a tinge of regret. It is an accepted and normal phenomenon that, when one gives notice and begins to prepare to leave a workplace, that workplace will suddenly seem more friendly, more amenable, and more comfortable. It's almost as if the Universe begins immediately to test one's resolve to leave just as one submits one's resignation. How maddening!

For myself, being on a leave of absence has allowed me more than sufficient time to process my decision to leave, and I have already begun the process of considering my patients and colleagues and what those goodbyes will entail. In a recent post, I began to delineate those challenges. As for colleagues, maintaining contact is simple. Phone calls, emails, dinner or lunch invitations, the occasional party or professional gathering---those relationships can be maintained like any acquaintance or friendship. Inevitably, time and lack of frequent proximity will preclude frequent contact, with many of those professional but collegial relationships falling by the wayside over time, some more quickly than others.

Now, when it comes to patients, that is another arena entirely, and a great deal of forethought must be given to a decision to offer to maintain contact following the end of a therapeutic relationship. Of my 80 patients, there are probably thirty with whom I feel a deep affinity and positive mutual regard, so much so that ending those relationships will be emotionally difficult. Amidst that group of thirty there are probably ten people to who I feel an even deeper connection, and saying permanently goodbye would be painful. Narrowing the field further still, there are most likely two or three people with whom I feel an intimate, almost familial bond, and these are the therapeutic relationships which I could foresee morphing into friendships, albeit friendships with strict parameters and severely limited scope.

Considering such an outcome, one must ask certain questions:

-Does the client want continued connection?

-Is the offer of a continuing friendship/connection in the patient's best interest?

-Are you pursuing this friendship out of guilt or true desire for such?

-How will the new boundaries of such a relationship be established?
-How would said individual contact you?
-Will expectations of frequency of contact be considered?
-Why not just say goodbye?

There are dozens of questions to consider, many of which perhaps you, esteemed Reader, could raise (and please do!). This is a conversation worth having!

Those of us in Human Services and the so-called "helping professions" constantly face the issues of boundaries, transference, counter-transference, and projection. When facing the end of a therapeutic alliance, all bets are off and the game becomes simultaneously murkier and much simpler. The path of least resistance? Say "goodbye, nice to know you, have a good life, and thanks for being you". The path of potential complication (but also of richness and authenticity)? "Let's stay in touch and see what our new relationship/friendship is capable of within certain parameters". In all likelihood, most connections made in this way will, like tangential friendships, fizzle out over time. People move, phone numbers change, lives develop through unanticipated twists and turns, address books are lost, and the frequency of contact gradually subsides. Still, the effort was made, and true authenticity was honored.

As Jerome Groopman, M.D. writes so eloquently in his outstanding book, The Anatomy of Hope (and please simply subsitute the word "nurse" for "doctor" as you read):

"There are some patients whom a doctor grows to love. It is a unique type of love, distinct from any other type of love the doctor has experienced before. It moves outside the bounds of the usual doctor-patient relationship; feelings and thoughts are no longer strictly professional and are shared among true friends."

If this area is simultaneously murky and simple, I am certainly still in the murk. And, as I do in many areas of life when I am faced with difficult choices, I remember that age-old adage that I have quoted here on Digital Doorway before: "Don't just do something, sit there." Thus I will sit with these feelings, with this sense of impending and inevitable change, and perhaps, if I am quiet enough, the answer will make itself known.

Nurses and Hell

Did you hear about the nurse who died and went straight to hell?

It took her two weeks to realize she wasn't at work.

Harm Reduction

Today in Ottawa, a rally will be held in support of Insite, the first supervised safe injection site in North America for individuals addicted to intravenous drugs. A blog specifically devoted to this issue is promoting the rally, requesting that Canadian citizens supportive of this successful harm reduction technique make their presence known in Ottawa today. 

As strange as it may seem to the uninitiated, providing a safe, clean and supervised environment for injecting drug users is in the interest of the safety and health of all citizens. According to the Insite website, rigorous scientific evaluation has shown that supervised injection leads to: reduced use of injectable drugs in public where children can be exposed to such behavior; reduced overdose fatalities; reduced transmission of blood-borne infections such as Hepatitis C and HIV; reduced injection-related infections; and improved public order. 

From my own experience participating in street outreach to IV drug users, teaching regarding clean injection technique, the availability of needle exchange programs, and medical oversight of IV drug use significantly impact public health and actually reduces the economic burden of drug use on the taxpayer by reducing ER visits, avoidable injuries, unnecessary hospitalizations, infection with blood-borne pathogens, and death rates from such behavior.

In terms of the philosophy of harm reduction, we meet the addict where he or she is, and we provide education to reduce the risks incurred through such behavior. We understand that the behavior is harmful, yet we also recognize that many individuals are not ready to address their addiction through treatment, thus we seek to mitigate the deleterious effects of their behavior. In so doing, we demonstrate to the addicted individual that we understand the difficulty of quitting and that we will support him or her in that process according to their readiness to pursue treatment. The trust created through such interactions has been documented to have a greater success rate in bringing addicts into treatment for addiction, as opposed to "tough love" interventions which preach or force a particular set of values upon the target population. 

Form more information regarding the philosophy and practice of harm reduction, The Harm Reduction Coalition's website is an excellent resource. If your community does not allow needle exchange or other harm reduction techniques, consider contacting organizations in your area that advocate for such interventions, and discuss the issue with local and state legislators. 

Addiction is, for better or worse, here to stay, and even the addicts amongst us deserve a chance to stay healthy, be supported, and seek treatment when they are ready to do so. 

Attachment, Anticipatory Grief, and Goodbyes

Faced with returning to my full-time job in mid-December following my six-week medical leave-of-absence, it has become painfully apparent to me that my days there are numbered. With the prospect of a job-share having fallen through, I face a slew of choices vis-a-vis my employment status, and the possibilities, while exciting in their potential, also open up tender emotional areas of attachment and anticipatory grief.

Having worked in my current position for seven years, a great deal of my identity as a nurse has revolved around serving low-income, inner-city populations whose vulnerability to disease and psychosocial dysfunction makes them ripe for our services. An endless well of need and dependence, my group of 80 patients have lived in my brain and heart for all of these years, and my emotional closeness with a number of them makes it most difficult to consider leaving my position for new horizons.

I have practiced nursing in a manner in which "therapeutic use of self" is a frequent technique of connection and teaching, using examples from my own life and struggles with chronic illness and depression as teaching tools and methods of expressing sincere empathy. Such disclosure, as well as my very personalized approach to nursing practice and therapeutic relationships in general, engenders an emotional intimacy that is slightly outside the norm for medical and nursing practice. For this reason, I have become quite invested in the lives and well-being of some of my patients, and I fully realize that this is a potential factor in the eventual development of burnout and compassion fatigue over time. I recently wrote a blog entry about vicarious traumatization, a phenomenon which is more than theory for me. It appears that my patients' trauma and traumatic histories have also begun to trigger my own personal trauma history, further exacerbating my feelings of burnout and compassion fatigue.

With time on my hands during this leave of absence, I have had opportunity to reflect on my relationships with a number of patients, and the notion of saying goodbye and terminating said relationships brings me great pain. As I conjure a mental image of this patient or that patient, I experience a wincing sensation wherein I think, "Oh, no! How will I say goodbye to him/her?" And the thought of each patient of whom I am fond evinces yet another uncomfortable sensation of loss.

This workplace where I have given my all for seven years is like no other I have experienced. United in our mission to serve the poorest, sickest, and most dysfunctional sub-populations, we are also united in a day-to-day feeling of being overwhelmed, of swimming against a steady current of unquenchable need, and of knowing that our collective and individual levels of stress are potentially hazardous. As much as we complain about our patients and their neediness, there must also be an aspect of attachment and addiction to such drama on our parts as well. There must be some secondary gain for us as we slog through the challenges of our days, striving to keep our heads above water in a current which changes directions---and depth---without notice or sympathy for our collective and individual plight. The undercurrent of family and camaraderie under duress keeps us afloat, even on the worst of days.

Within the adjacent inner-city community health center with which we partner to care for our patients---and where our patients receive their primary healthcare---there is a team of doctors with the majority of whom I have developed stellar working relationships. These doctors, all of them very committed to the care of the disenfranchised, poor, and chronically ill, have consistently treated me with a level of respect and professionalism unparalleled in my experience as a nurse. This sentiment is echoed by most of my nurse colleagues, and the learning and teaching which these working relationships engender is priceless. On a first-name basis since the beginning, my opinions and suggestions are taken seriously by these docs, and our discussions are never one-way---rather, there is an exchange of ideas focused on the ultimate goal of improved health and function for our mutual patients, although I frequently do feel that I am left with more responsibility than I can handle. Still, I see that my efforts are recognized and appreciated, and that my opinion is thoroughly and thoughtfully considered. If I am mistaken, it is always pointed out in a gentle and kind way with a goal of teaching and learning which is free from games of power and hierarchy, with few exceptions.

So why leave, you may ask? Why walk away from a situation in which satisfying professional relationships, clinical skill development, and challenging medical and psychosocial situations stimulate my mind, spirit and soul? It is because this level of engagement and deep involvement with extremely needy and often dysfunctional patients over a long period of time has whittled away at my core, slowly but surely damaging my ability to enjoy life outside of my work, causing such levels of stress that my personal quality of life has become diminished. Whether directly related to this job or simply a matter of synchronicity and coexistence , my own constellation of chronic illness, chronic pain, and long-term struggles with major depression are necessitating a change of lifestyle, a ratcheting down of the intensity I experience vis-a-vis my professional life. Perhaps I understand and empathize with my patients so well because of my own chronic illnesses, but because of those personal issues, that empathy, while helpful and useful therapeutically for my patients, is slowly but surely eroding my own ability for healing.

Drawing on my interest in Buddhism, I realize that these sensations and feelings, while sincere and quite real, are a manifestation of attachment. Various attachments arise in relation to possessions, people, relationships, circumstances, and even feelings and sensations. My reluctance to leave my workplace after seven years is, to a large extent, a reflection of a certain level of comfort I have developed, even though that comfort paradoxically coexists with burnout, overwork, and a growing sense of frustration with the intensity of the work and the programmatic dysfunctions of our organization. How to reconcile all of these factors and stay on the same path without incurring further personal damage?

I am at a turning point in my career. There are new avenues of nursing and my professional self which I long to explore, yet slogging away on the front lines of inner-city nursing practice---and the stressors therein---is most likely keeping me from pursuing those new avenues, my energy consistently sapped by the vicissitudes of the ol' 9 to 5.

So, I'll keep thinking, reflecting, meditating on it, and embrace these three more weeks of my leave of absence. Returning to work in mid-December, I fully expect at this point to return with my 30-day notice of resignation in hand. Sad, true, difficult, painful, challenging........necessary. And in the immortal words of Michelle Shocked, "the secret of a long life is knowing when it's time to go".

Back to the Drawing Board, Wherein the Heart and Mind Discuss the Future

Back to the subject of my (currently non-existent) work-life, although the job-share position was ostensibly approved by the powers that be, the nurse practitioner with whom I was planning to share said job has accepted another position. Thus, the job-share is now defunct, and a vast blank drawing board appears on my horizon. Yikes.

So, when faced with a blank drawing board, what does one do? At first, nothing. The blank space is kind of nice, isn't it? See how the light reflects? Notice how that blank space is one upon which any number of potential futures can be projected? Why don't we enjoy it for a while?

But then the Mind in all its glory jumps in, grabs some (thankfully erasable) markers, and goes to town.

"So," the Mind says. "We have Option 1: return to full-time job as planned, and decide to stick it out for another 6-12 months. See all of the gains and stress reduction from the leave of absence erased in a matter of weeks. Hmmm. Maybe not such a good choice." The Mind looks puzzled.

"Well, then," says the Mind. "Option 2 seems better: return to work for the required 30 days, close up shop, say our goodbyes, terminate with patients and colleagues, and skedaddle asap, no looking back. Not a bad scenario, if I do say so myself." Some skeptical interest is perceived.

"Or how about Option 3, perhaps?" asks the Mind hopefully. "Offer to work per diem for old employer after fulfilling 30-days of full-time work in order to fulfill leave-of-absence obligations. String together several other per diem positions---one of which is quite close to home, actually---and have a renewed sense of professional invigoration? Let "The Mrs." carry the health insurance benefits, and take this golden opportunity to cut loose from the 40-hour grind! Work when you want to---some weeks will be extra heavy, others can be quite light. What freedom! What a concept!" The mind smiles.

Then the Heart steps up to the plate, chiming in. "Oh, God! All of those patients with whom we have cultivated intimate working relationships for seven years! How would we say goodbye? How would we terminate? What would it do to them? To my colleagues? To the workplace? How can I handle so many goodbyes?" The Heart wrings its hands.

The Mind rests a reassuring hand on the Heart's virtual shoulder. "Look here, cousin. Don't get so worked up. People leave jobs all the time, even ones in which long-term therapeutic relationships have been nurtured." The mind smiles reassuringly as the Heart looks dubious.

"We all have to say goodbye and move on at some point," the Mind continues. "Patients know that clinicians come and go. It's part of the process. Perhaps your leave-taking will cause some of them to become more self-sufficient, more empowered. Just imagine the relief you would experience when you released yourself from the responsibility you feel for those eighty people and their well-being!"

The Mind and the Heart sit in silence for a while.

"Y'know," says the Heart. I need some time to consider these scenarios. It's just too much to process today."

"I understand," says the Mind. "Change is always hard. Take your time, enjoy the rest of your leave-of-absence, and know that this is all happening for good reasons. Remember that drawing board? We can leave it blank for a while."

"Thanks," says the Heart. "I can only take in so much change at one time. It was enough to accept a six-week leave-of-absence. Let's clean the basement, then we can make dinner and watch a movie."

"It's a deal," says the Mind. "We'll put the drawing board in the corner for now. Let's tackle that basement."

Of Heroes, Parity, and Economics

Last night's post only scratched the surface of the culturally accepted norm dictating that mental health is not on par with physical health when it comes to one's needs for rest and rejuvenation---especially where work is concerned.

Work is, for better or worse, part and parcel of our lives, a veritable necessity for putting food on the table and clothes on our backs. As we moved out of an agricultural society into an industrial---and eventually technological---society, it obviously became necessary for an astronomical number of individuals to become workers who performed duties under the auspices of companies and corporations which held our livelihoods in their hands. Granted, an agrarian society is no panacea---share-cropping and slavery are excellent examples of that scheme's miserable failings---yet the industrial age brought with it abuses and restrictions on individual freedom which, while not necessarily slavery in name, certainly have kept many segments of society in quite similar and dire economic straits.

So, when one has chosen to enter a field of work in which the vagaries of the economy and the edicts of one's employer shape one's destiny, there is a certain amount of freedom that is abdicated. That said, even the self-employed feel that they too must abdicate some freedoms in the face of restrictive tax codes and the high cost of health insurance and healthcare.

For myself, I have chosen to enter the "Medical Industrial Complex", to riff on a phrase originally popularized by Dwight D. Eisenhower in 1961. Within said Medical Industrial Complex, a hierarchy exists, similar to the hierarchies within other disciplines and professional societies. The members of such systems are rewarded for their work based upon algorithms which take into account such notions as experience, education, applicable skills, and other factors which make one a candidate for the assignment of various tasks and responsibilities.

As I stated in yesterday's post, certain segments of society are held in higher esteem than others, earning astronomically higher salaries and benefits than those of us who slog away in blue-collar, "pink-collar" and even many white-collar positions. Most of us would agree that celebrities---including many actors, some entertainers, as well as many professional athletes---receive remuneration for their efforts which far seems to outstrip the relative value and social import of their (cultural and economic) contributions to society. CEOs are another story, and the scale of their remuneration is also sorely out of balance (think Ken Lay, may his soul never rest).

I stated yesterday that the hypothetical baseball player who experiences occupational stress could be pretty certain that his salary---often in the millions, or at least hundreds of thousands---would not suffer in the face of a leave of absence for reasons related to stress.

In my post, I compared myself to that stressed-out baseball player. Let's imagine that I was a nurse who was experiencing incredible levels of stress and burnout by caring for the destitute, chronically ill, and elderly who live in that baseball player's hometown. Maybe several members of his extended family---saddled with substance abuse, mental illness, or other disabling medical conditions---were actually on my caseload. When I decide that I need to take a leave of absence due to stress related to my work, why is it that I---a person providing essential services related to the health, well-being and survival of members of that baseball player's family and community---must do so without pay and with risk of economic hardship, while the baseball player (who essentially swings a piece of wood at a leather ball and catches balls hit by others with the same piece of wood) rests on his laurels and fat bank account, taking a break from his on-the-job stress on Maui? What is wrong with this picture?

Teachers, nurses, police officers, EMTs, substance abuse counselors, social workers, senior center directors, outreach workers, AIDS workers, hospice counselors, homeless advocates, housekeepers, medical assistants, home health aides, daycare workers, laborers----we all experience on-the-job stress, yet it seems only the rich and famous can have respite without negative economic consequences. The families of people in the military live on food stamps in decrepit barracks for the enlisted, yet we say we "support the troops". Again, what is wrong with this picture?

Our measure of "heroes" is askew. Who truly are the heroes? Who should be celebrities? Where are the trading cards of famous nurses and home health aides? When will substance abuse outreach workers have their day? Something is wrong in a culture wherein those who care for the dying must themselves struggle to survive. This is an emergency of priorities, one for which parity and balance seem far beyond reach.

In essence, the true heroes go unsung, and the make-believe heroes take home the prize.

Injured Soul? You're On Your Own

Recently, an anonymous commenter on Digital Doorway responded to a post I wrote about nurses and stress. He or she wrote the following:

"One major reason why nurses are stressed is because hospitals are understaffed. Management has been able to get away with this understaffing because they don't have to pay for workload-related chronic stress injuries.

"This is discrimination against psychologically injured workers who succumb to excessive WORKLOAD by getting depression or other chronic stress diseases.

"The hard-working employee who sustains a mental injury due to overwork is left without compensation which means they usually then go through a downward spiral of bankruptcy, loss of home, loss of pension and all the further stress that goes along with poverty.

"No wonder we have a health care worker crisis!"

The commenter makes some salient points. Taking my circumstance into consideration, seven years of working with trauma survivors and giving my all to the care of vulnerable individuals has led me to make a decision to take six weeks of unpaid leave in order to collect myself and heal. Why, within this society, are individuals serving the poor, ill and traumatized left to their own devices when it comes to recovering from providing such a public service? Why must burned out teachers and nurses take unpaid leave and use up their personal savings at a time when their service has exacted a psycho-emotional toll on their health?

Now, to draw an apt comparison, if a professional baseball player experienced undue stress and psychological trauma from the vigors of the season's play, would he need to eschew his multi-million dollar salary in order to take a six-week leave to clear his head and regain balance? Would he be forced to use his savings to pay his bills and care for his family while he recuperates? Would some portion of his astronomical salary be withheld? That baseball player, handsomely compensated for his work (which, in my mind, bestows precious little benefit on humanity), will have little difficulty making ends meet while he rests and recuperates.

Furthermore, as an individual appreciated and respected far above the nurses, social workers, factory workers and teachers who are truly a part of the backbone of the society, the athlete in question will have no fear of income loss as a result of his temporary disability. In fact, a guest appearance on Oprah or a Newsweek expose on the psychological stresses of professional sports would most likely be in order. Our athlete suffers in ways which may actually enhance his career.

On the other hand, take a burned-out nurse like myself and consider my options. While I may have the Family Medical Leave Act to allow me up to 12 weeks unpaid time off, short-term disability insurance does not allow for disability for mental health or substance abuse. In fact, many long-term disability insurance policies also exclude a mental health benefit. Parity for those suffering from mental health-related injury are basically left out in the cold.

The conundrum is thus: if I injured my hand at work caring for a patient, workers' compensation would be a no-brainer. But if I injure my soul at work? I'm on my own.

Job-Share Ahoy!

Well, well, well. It looks like my workplace has conditionally approved a job-share for myself and a Nurse Practitioner colleague following the end of my medical leave of absence. Suddenly, the future looks a whole light brighter.

What does this new reality mean for the earnest nurse who is ever-so-steadily recovering and recuperating from acute burnout, vicarious traumatization, and compassion fatigue? The true meaning of this new reality is multifaceted. Initially, it means that I will no longer carry the emotional, psychological, and clinical weight of some 80 patients on my own shoulders. Instead of a caseload of 80 for which I am solely responsible, I will share a caseload of patients with a very competent Nurse Practitioner of whom I am exceedingly fond. I will be in the office three days per week, and she will be in the office the other two days. With our excellent rapport, open communication, and superb documentation, we will bear this load together, neither of us slogging through the dreaded five-day week. We will meet for lunch once a month to discuss cases, talk by phone, communicate by email, and otherwise work as a well-oiled clinical nurse-machine, free of the burnout born of the forty-hour week.

I acknowledge that I am lucky to be able to either 1) afford to pay a pro-rated increased rate for my health insurance as a part-time employee or, 2) take part in my wife's health plan under the auspices of her place of employment. With health insurance being one of the major factors for many workers staying in jobs which they dislike or cause them undue stress, I realize that I am privileged in having choices vis-a-vis my healthcare and insurance.

As far as generating income, I also realize how lucky I am that, as a registered nurse, the ability to earn money on a per diem basis is one which makes the nurse a hot commodity in the current job market. With two per diem positions already in my employment portfolio---one with a visiting nurse agency and the other at a urban community health center) this part-time nurse can choose to earn extra money one week and slouch around the house the next. What better burn-out prevention could there be?

Taking a leave of absence was a leap of faith which was initiated by my wife (with only a mild threat of divorce) and embraced whole-heartedly by me when I realized that there was no other way for me to regain my emotional balance. With chronic illnesses slowly overtaking my previous state of relative good health, we both acknowledged that something had to give (and I had already "given at the office", so to speak).

Now, as the layers of stress begin to unravel after two weeks' leave, I now face the next four weeks of leave with a desire for further healing and recuperation. With part-time employment and brighter prospects at work, perhaps my life is truly turning around.

Nurses and Stress: A Rant

Thanks to a comment on yesterday's post, I was recommended to read this article on stress and healthcare workers. Brief and to the point, the article elucidates that Canadian "nurses, doctors and lab technicians have the highest levels of stress related to their jobs" of all interviewees, with 45 percent reporting that there work was "quite" or "extremely" stressful.

The International Labor Organization has identified nursing as an industry with relatively high levels of stress and burnout. In identifying the sources of stress in nursing, they elucidate thus:

"The role of nursing is associated with multiple and conflicting demands imposed by nurse supervisors and managers, and by medical and administrative staff. Such a situation appears to lead to work overload and possibly to role conflict. One form of such conflict often mentioned in surveys of nurses relates to the conflict inherent in the instrumental and goal-oriented demands of "getting the patient better" and those related to providing emotional support and relieving patient stress. Role conflict of this kind may be most obvious when dealing with patients who are critically ill and dying. Indeed, one of the areas of nursing that has attracted particular attention has been critical or intensive care nursing. Health care is also a sector which suffers a high rate of violent behaviour (see our pages on violence at work).

"Many studies on stress in nursing have attempted to measure, or have speculated on, the effects of such stress on nurses’ health and well-being. There appears to be general agreement that the experience of work-related stress generally detracts from the quality of nurses’ working lives, increases minor psychiatric morbidity, and may contribute to some forms of physical illness, with particular reference to musculoskeletal problems, stress and depression."

Hmmmm, says the nurse on medical leave of absence.

In South Africa, stress has been identified as the major cause of a nursing shortage in the setting of HIV/AIDS care. The BBC reported earlier this year that stress was harming nurses' sex lives, causing nurses to smoke more, and that stress-related absences from work costs the British National Health Service more than 300 million pounds per year.

Many nurses complain about frozen wages, lack of clinical supervision, increasing nurse-patient ratios, and rapidly shrinking benefit packages. While loss of benefits and frozen wages are ubiquitous across the general workforce (unless you're a CEO, member of Congress, movie star, or professional athlete, of course), nurses face other stressors which are singular to their profession. Workers in other professions also naturally face challenges typical to their careers and workplaces, and each of us can truly only speak from our own work experience.

We simply have to face the facts. Americans (and workers in other countries, as well) work too hard, earn too little, have paltry time for vacation and leisure, and are expected to marry their jobs to a degree never before expected in the history of labor. Unions have slowly been dismantled and vilified over the last century (especially here in the US), and healthcare benefits have crumbled, leaving many of us paying higher premiums and copayments for office visits, procedures, and medications. With housing costs and fuel costs through the roof, our paychecks have less buying power than they used to, and those of us in the middle class and working class are left to pick up the crumbs left behind by the 1 percent controlling the wealth.

Are nurses stressed? Of course we are. We earn moderate incomes within a high-stress industry where workloads have exponentially increased and benefits faltered. Retirement seems less than certain, the economy continues its volatile course, and the healthcare industry asks more and more of us without offering any further compensation. Still, I never regret my career choice, and have even encouraged others to walk this path. Nurses are always needed, work is generally easy to find, and when the economy hits bottom, we will still be irreplaceable, since illness never takes a holiday.

So, what's an earnest nurse to do, you ask? Dedicated to my chosen career, I take a few weeks to reassess my options, care for my body and mind, soul and spirit, and plan to reenter the fray with---perhaps---a hopeful and newly-minted outlook and approach. I have been ravaged by the effects of stress and vicarious traumatization, and I now attempt to reconstitute myself during this brief hiatus. I consider myself both lucky and blessed, and pray for my nursing brethren who are unable to afford the luxury of such self-care. May we all be free from suffering.

Open Heart---An Appreciation

I have a predilection for reading books about medicine and nursing, and nothing pleases me more than discovering yet another satisfying or thought-provoking read, of which there have been many, and of which I fully expect hundreds more such experiences.

Apropos of such literary leanings, today's praise report involves Open Heart: A Patient's Story of Life-Saving Medicine and Life-Giving Friendship by Jay Neugeboren. The author is best known for his book Imagining Robert, the story of his brother's struggles with mental illness and the burdens born by the families of individuals thus afflicted.

Open Heart tells the story of Mr. Neugeboren's experience as a man of more than sixty years of age, who, in excellent and athletic physical condition, experiences symptoms which go misdiagnosed for months, eventually leading to emergent quintuple-bypass surgery which saves his life. In the process of telling his story, the author not only communicates wonder over the technological developments which contributed to his survival. Mr. Neugeboren delves deep into the psyche of lifelong friendship, its importance to quality of life, and the challenges faced by the patient who confronts an often splintered and impersonal healthcare bureaucracy. His insights into the world of medicine, doctor-patient relationships, as well as his relative position as a upper-middle-class author whose well-heeled and educated childhood friends---all of whom are doctors, by the way---contribute to his well-being through their advocacy, professional connections, and knowledge.

There are many ironies addressed in Open Heart, not the least of which is the notion that, even given his relative privilege and access to high quality healthcare, several of Mr. Neugeboren's medical providers completely missed his tell-tale signs and symptoms of ischemic heart disease, putting him at great risk of debilitating illness and eventual death by myocardial infarction or stroke. That said, the author also is very determined to clearly acknowledge the additional (and enormous) privilege of having well-educated doctors within his closest circle of friends, all of whom went out of their way to support him, advocate for him, and procure for him the finest surgeons, hospitals, and medical treatment possible within the American healthcare system.

Despite (or perhaps in response to) his own class privilege and elevated societal status as a successful author, Mr. Neugeboren spends a great deal of time discussing what is wrong with American healthcare, eventually coming to the conclusion that access to appropriate, high-quality, affordable, and timely healthcare is the crux of the challenge facing the United States today vis-a-vis the health of its citizens. While he does not offer specific policy solutions to resolve the current healthcare crisis, the author does indeed use citations of appropriate literature to drive home the conclusion that the American healthcare system is broken, the poor are often left out in the cold, and that too many Americans go without healthcare in a country which spends more per capita on healthcare than any other industrialized nation. Taking his findings further, Mr. Neugeboren extrapolates his conclusions further into a global picture, wherein AIDS and other controllable diseases continue to ravage less developed countries, mostly due to a lack of political and economic will on the part of the United States and its economic peers. To wit,

"Valuing freedom of choice over constraints, and individual freedom over government regulation in the specific ways Americans do, we seem a long way from knowing how and when, if ever, we will be able, if in inevitably imperfect ways, to set reasonable and effective national healthcare policies."

The doctor-patient relationship also plays a significant role in Open Heart, and Neugeboren describes how managed care, too much reliance on technology, and the economic pressures which drive the American healthcare system have only served to undermine the trust between patient and doctor. He continues,

"We might begin, if only begin, it occurs to me, by thinking in terms of what my friends and I have been talking about---providing those contexts in which greater access to care, continuity of care, long-term care, preventive measures, and public health measures are encouraged and endowed. If, too, we restore the doctor-patient relationship to a central position in medical care, and if we avail ourselves of the marvelous technologies that exist while at the same time remaining skeptical of those technologies that are more expensive than they are curative (and that cause us to neglect more urgent health-care needs), then, I say, we have a pretty good shot at making it happen."

Neugeboren outlines how American tobacco companies prey on the young and the poor---both here and abroad---to make their profits while undermining the health of the world. He elucidates how access to quality care is often blocked by a class-based system which favors the wealthy and shuttles the poor to understaffed, overburdened, and poorly funded public healthcare facilities. The author also expounds how, in our post-modern awe of expensive technological advances, we have lost sight of what is most important in healthcare---the face-t0-face meeting of doctor and patient. And if that doctor is constrained from spending more than ten minutes with each patient due to increasing malpractice insurance, sky-rocketing overhead, and endless student loan repayments, this is a recipe for misdiagnoses, under-diagnosis, shoddy care, and missed opportunities for preventive measures which can ward off the advent of chronic (and ultimately expensive) disease.

On a global scale, one of the author's closest friends, Jerry Friedland, a medical doctor committed to fighting AIDS in Africa, describes his frustration at the (as of 2002) inadequate response to AIDS in Africa by the industrialized world. Taking a potentially controversial stance, Mr. Friedland and Mr. Neugeboren describe how Americans are quick to respond to sudden catastrophes---like 9/11, where 3,000 people died, however tragically---with fervor and purpose, yet, in the face of a long-term catastrophe like AIDS, we lose our momentum, even in the face of more than 3 million deaths per year in sub-Saharan Africa alone. Of course, they hasten to add, 9/11 was a watershed moment for the world and deserved the attention which it garnered, yet the relative loss and destruction inherent in that singular event cannot compare numerically with the ravages of worldwide disease, antibiotic-resistant organisms, global poverty, famine, ongoing war, and genocide. According to Dr. Richard Horton, the editor of The Lancet, "the major issue in medicine is not one of maintaining the pace of discovery, but of making sure there is equitable access, throughout the world, to the discoveries we have already made."

Citing studies by the World Health Organization, Neugeboren implores the reader to comprehend that, between 1990 and 2020, "unipolar depression (also called clinical depression) is second behind ischemic heart disease, in rank order of the global burden of disease (a measure of health status that quantifies not merely the number of deaths but also the impact of premature death and disability on a population)." He also cites a study stating that, "of the ten leading causes of disability worldwide, five are psychiatric conditions (depression, alcoholism, bipolar disorder, schizophrenia, and obsessive-compulsive disorder)." Food for thought.

Immunization, preventive healthcare, sanitation and hygiene, screening technologies, life-saving medicines---these are all well-understood tools in our arsenal against disease, yet economic constraints, xenophobia, and lack of political will often prevent such simple technologies from reaching those most in need. Lobbyists for the tobacco, alcohol, and firearm industries fill the halls of our Capitol every day, squeezing out the small voices who call for parity, justice, and equal access to quality healthcare for all. It is a sad state of affairs, and authors like Jay Neugeboren are able to bring such disparities to bear with wit, wisdom, and personal reflection.

Open Heart not only explores the challenges of personal, national, and global healthcare in the 21st century. It is also an ode to friendship, to connection, to self-reflection, and to gratitude for life. From the micro to the macro, from the familiar to the foreign, we are urged to consider the whole, be it our best friend down the street or an AIDS orphan in Niger. There is no qualitative difference between your visit to your local doctor and that orphan's need for a 20-cent immunization against measles. But there is a quantitative difference, and that orphan, sadly, is much more likely to be denied what she needs to survive.

We have a choice, and Mr. Neugeboren has given us a gift to once again see that choice clearly. I, for one, accept that gift gratefully, and will continue to bear in mind the lack of such a qualitative difference between me and that orphan, and will use my voice to remind others of her equal right to life, liberty, health and the pursuit of happiness.

Leave of Absence and Its (Dis)Contents

Being on a leave of absence presents a series of challenges, most of which I would deem "problems of luxury", yet their problematic quality is still worthy of my attention. And it is these challenges which occupy my mind most vividly from day to day.

First and foremost, during this time of rejuvenation and mental/emotional recovery, I am faced with the question of whether or not to return to my full-time job. Being on a medical leave of absence, I am required by law to return to work for at least 30 calendar days following my leave, yet the future beyond those thirty days is wholly uncertain, professionally speaking. My job---and all of its vicissitudes and benefits---is doubtless waiting for me to return in just under a month, and my desire to embrace that 40-hour challenge once again is waning daily.

So, the questions remain. What would it mean to leave my workplace, my work family, the comfort of the familiar? How would it impact my career, my personal life, my clinical development, my future as a nurse? How much should I worry about my patients and how my leave-taking will effect them? How much of my patients' experience is my responsibility? Haven't I given them enough for seven long years?

If I do indeed decide to leave my position, it begs the question of how I will move forward, earn a living, and piece together a sane, healthy work life, unencumbered by the burnout with which I have lived for far too long. Luckily, Mary is poised to have benefits early in 2008, ostensibly freeing me from the oh-so-American shackles of sticking with a job solely for the health insurance.

This opening which I have created for myself is truly an opening---a portal of opportunity---through which I can walk, run, saunter, stumble, or fall. The mode of entry through said portal still remains to be seen, but the desired outcome is, in the final analysis, sanity.

Daylight Dawns

Daylight dawns on Sunday morning after spending the night in ICU tending to my mother-in-law. The paradoxes of a hospital stay abound. Throughout the day yesterday, she was encouraged to stay awake all day in order to reprogram her brain to get sleepy at night. So, we did our best to stimulate her during the day and keep her from sleeping too much.

And then arrives the night shift. Settled intermittently in a marginally comfortable lounge chair next to her bed, I observe throughout the night how ICU is anything but restful. Noisy carts are pushed up and down the halls at all hours----shouldn't they have silent rubber wheels? The patients' sleep is interrupted almost hourly: phlebotomy, respiratory therapy, blood pressure, medications, portable chest x-rays. Nurses and therapists come and go, some chatting loudly as they enter the room. A long night is made more exhausting by the irony of turning the clocks back one hour at 2am. A long night made longer.

As for me, I can make myself comfortable enough, but the constant interruptions, beeping monitors, nurses bustling in and out, noisy carts in the hallway---it's enough to drive one 'round the bend.

In one of our chats in the wee hours, my sweet mother-in-law and I joke about how much patience it takes to be a patient, and how little rest one gets in the hospital. I remark about how she was forced to stay awake during the day, only to be tortured throughout the night at the moment she had fallen asleep. She's not amused.

If I wasn't so tired, it would be funny. For now, the irony will have to do. One comes to the hospital for healing, but the nature of the hospital environment denies one the rest one so desires and needs. Oh, the irony of it all!

Postcard from Texas

We are presently here in Temple, Texas, checking in on Mary's mother who is in ICU following carotid artery bypass surgery. Tonight, I will do the midnight to 6am shift (most of which will be spent sleeping in the recliner behind the curtain by the window) so that she can have her needs met if she wakes in the middle of the night. (There's nothing more miserable than having a nasogastric tube down your throat and nobody around to feed you ice chips when you're parched.)

Overall, though, this "caregiving visit" is a relative breeze: time by the hotel pool, writing emails and blog posts on the hotel computer, chatting with my father-in-law and the nurses as we sit in the room passing the hours, or wandering this strange Texan town. Plus, it's 80 degrees and sunny all day.

Beginning a leave of absence from nursing and being in such a hospital/medical environment could very well set off my stress buttons, but my role here is so minimal---so "nurse lite", if you will---that it is a pleasure to be of service. My skills are helpful in identifying when, for instance, Mary's mom's oxygen saturation is getting low and she needs the cannula back on, or perhaps to listen to the doctor and translate some of the medicalese for her dad. Energy output and stress? Almost zero. Value? High.

Anyway, nurses serve a purpose in families, and my "nurseness" certainly does come in handy at times like these. As long as my boundaries are clear and self-care remains of primary concern, no harm done and all is well.

So, dear Reader, remember the end of Daylight Savings Time tonight, set those clocks back, gain that hour of precious beauty sleep, and enjoy your Sunday, wherever you fare.

From deep in the heart of Texas,

A Nurse at Rest

Taking Leave: Exit Stage Left

Today saw the beginning of my leave of absence. "Taking leave"---an interesting concept to digest. Add to the notion of leave-taking the additional concept of "absence". But will the heart grow fonder? Only time will tell.

Divesting myself of my work responsibilities (and my attachment to caring for my patients), I extricate myself from the melee and enter a period of intentional self-care. What will become of me as I venture into these less travelled waters? Will I veer off course? Will I become lost in a maze of doubt and guilt? Or will I rise to the occasion, embracing this sense of freedom, allowing the emergence of a new feeling of expansion and openness to self-renewal? I think my old friend time will also tell me this story as well.

Just yesterday, in a moment of absolute serendipity and Jungian synchronicity, I attended---along with my wife and several colleagues---"Behavioral Health Grand Rounds" at a local medical center, wherein a world-famous doctoral psychologist lectured on the concept of "Vicarious Traumatization".

Also known as "V.T.", Vicarious Traumatization is the concept that a professional caregiver/therapist comes into contact with a traumatized individual as well as that individual's trauma material, consequently becoming retraumatized him- or herself in the course of that therapeutic relationship. It is well-known that a vast majority of clinicians who choose to work with trauma survivors have experienced significant traumas in their own lives, thus creating a dynamic in which an empathic and sensitive professional is repeatedly exposed to clients' trauma, and in the professional's commitment to providing therapeutic care, harm is actually done to the caregiver in the course of that relationship. Also known as "secondary trauma", V.T. is indeed a direct cousin to PTSD (Post-Traumatic Stress Disorder).

For better or worse, I am no stranger to PTSD myself, having been diagnosed in 2001 following the murder of my best friend by police in an unfortunate (and wholly avoidable) tragic set of circumstances which I have previously mentioned here on Digital Doorway. With this personal history, it is extremely clear to me that a number of my patients---whose lives are chaotic and rife with the effects of trauma---have begun to trigger my own trauma history as I go about the business of my work as a nurse.

Working in an ambulatory setting and caring for patients over years of close relationship and involvement in my patients' lives, the boundaries between myself and my clients are, by definition, more fluid than those practiced by many other health professionals. While these less rigid boundaries do indeed lead to more intimate therapeutic alliances with patients and their families, the cumulative effect on my psyche has certainly begun to be noticeable vis-a-vis the deleterious effects of such closeness in regards to my mental, spiritual and physical health.

There are those of us who consciously choose to work with members of society who have long suffered from the effects of abuse, neglect, poverty, and societal disenfranchisement. When one decides to immerse one's self in such an environment of lack and struggle against long odds, one must expect to pay a price for such involvement, especially if one is what I will deem "an empath". Being an empath is, in my book, a laudable occupation of spirit, yet the toll one pays for such a gift is often paid for dearly with stress-related illness.

So, exit The Nurse Protagonist to Stage Left, the curtain drawing temporarily on the well-furnished set of vicarious trauma, burnout, and compassion fatigue. As said Nurse Protagonist goes about reclaiming his sense of self and new-found (but temporary?) occupational freedom, we will be keen to discover along with him what new pathways of self-care and renewal will be embarked upon.

Is it difficult for our Nurse Protagonist to relinquish his sense of commitment and responsibility? Mais oui, monsieur (sings the Greek Chorus at Stage Right).

Can he embrace the challenge of enhanced selfishness, taking full advantage of this golden opportunity for renewal? Perhaps (says the orchestra conductor from the pit below).

Will he emerge from this time of self-reflection a changed man, a healthier man? We certainly pray for his deliverance from the throes of personal trauma (shout those who love and care about him from the bleachers).

Lastly, will he return to his place of work in five weeks, only to begin the traumatization process anew? (His patients and colleagues, friends---and psychotherapist---all wait with baited breath in the lobby.)

Stay tuned as the weeks unfold, as our traumatized Nurse Protagonist makes his way along this long ignored path of self-care and renewal. Admission is free. And the outcome? Certain to entertain.