by Robert J. Lanz, LCSW
Although empathy isn’t a necessary requirement for making a competent evaluation on a patient, it is my personal belief that many evaluations I was called upon to perform also provided an opportunity for an intervention. By that I mean, my job required that I make evaluations on the salient issues and then make recommendations for the patient to follow upon discharge. At that point, technically, I could walk away and say I’d done the job. I didn’t have to like the patients and it didn’t matter whether or not they liked me. But if I made an evaluation and a recommendation, then my hope was the patient would buy into the plan. That’s where empathy came in. If the patient didn’t think I understood how he felt, then he might have thought that I didn’t care how he felt, and if he thought I didn’t care how he felt, it was unlikely he would have gone along with my recommendations, even if they were right for him.
It is always important to remember the basics.
People resist change even when it is in their best interests.
If a person believes an idea is his own, that’s called insight, as in “I figured out what to do all by myself” and if he does the patient is much more likely to feel that the idea has validity. The whole deal behind therapy is helping people develop the quality of insightfulness or as the Buddhists say, mindfulness. Working in the ER, we were at a disadvantage with regard to this, because as a rule, brief interventions don’t lead to insight. On the other hand, a crisis often breaks down defenses and once defenseless, the patient may be more open to becoming insightful. Or, he can put up more defenses and stay locked into bad judgment. Our view was that every crisis presents a danger and every crisis provides an opportunity.
A good social worker tries to maximize opportunities while downplaying the dangers. Sometimes this works and sometimes it doesn’t. But if it doesn’t work and the patient doesn’t develop the necessary insight, I was never one to let him leave sightless, so I always tried to give him some outsight.
I’ll go through that again.
Insight-the patient’s own take on what needs to change.
Outsight- my take on what the patient needs to change. Not as persuasive as insight, but better than no sight.
All sight is improved with empathy.
Some nights the ER was so busy the extra allotment of time needed to develop insight wasn’t available. If I were to take the time to work on it with one patient or family then another family or patient is given less time for their needs. Those were the nights I felt burned out, wanting to fix things and not having the time to do so. In making an evaluation, I may have met my professional mandate, but I have fallen short of my personal mandate to promote hope and understanding. Those circumstances tend to burn anybody out.
But that just begs a bigger question. When is it all right to give up? After considering the literature on burnout, I have a couple of thoughts, that taking care of yourself comes first, and that you can’t help anyone until you’ve helped yourself.
I often had those thoughts late at night when I was tired and cranky and had just about enough of the natural abuses of the ER, feeling that my empathy was wasted on the “regulars”. Under those circumstances it never seemed to gain the traction necessary to initiate change in them. After midnight or thereabouts, I didn’t feel like walking a mile in their moccasins because every time those moccasins arrived at a fork in the road they headed in the wrong direction, many times stepping off an emotional cliff. They walked over to the corner where the crack dealer did business. They walked right by the mental health clinic where there was a bag of medications waiting from them to pick up. They walked right back to the motel they just left in an ambulance after getting assaulted by a boyfriend. Many times, I just couldn’t take that walk to nowhere. But I would have if I’d thought for a moment it would have helped get THEM somewhere.
Then there was another philosophy, the one expressed by my most self-destructive, drug-addled, eating-disordered patient, who said to me, “Never give up Bob. Never give up.”
When my severely depressed patients would tell me they wanted to give up because they couldn’t see the light at the end of the tunnel, I’d tell them to take a few more steps, maybe there’s a curve in the tunnel and maybe then you will see the light. I guess that’s the answer. Let me try those moccasins on.