“This patient isn’t getting any better. Am I really helping? Should I stop meeting with him/her?”
Many of you have asked me these questions, and I have asked them of myself as well. Let’s put the patients who are clearly getting worse, those who are medically unstable, and those who are suicidal into a separate category, and focus for a moment on those who simply seem to be stagnating on the recovery path.
Ambivalence about recovery is to be expected when working in this field. It is part and parcel of eating disorder treatment. I respectfully propose that the questions you ask are less about your patient and more about your own self-doubts and fear. If you are immediately offended by this suggestion, then please feel free to stop reading. You’re right, it’s not about you. People with eating disorders are beyond help and you should probably leave the field for something more financially rewarding.
If you’re still reading, you know that our personal insecurities about our professional worth can flare up even when things are going well; but they are most likely to attack when it appears that a patient is not making progress in their work with you. For those of us trained as dietitians, it is the exchange (or more specifically the giving) of information that we are told to emphasize. We are also taught to use outcomes to determine if we are effective – good results are evidence of a good dietitian. “My patient is improving, that means I did a good job.” But the patient in question isn’t making any (more) progress. Does this mean you stink? Probably not. Does it mean you should stop working with him/her? The answer to that is more complicated.
After sessions in which you mostly listened, didn’t provide much information, and didn’t observe any measurable improvement, you may feel helpless, hopeless, ineffective, and drained. Instead of recognizing your bad feelings for what they are – normal and natural consequences of a tough job – you may perceive that poor outcomes are your fault – you didn’t adequately prepare, you talked too much, you talked too little, you are not a specialist in this disease, etc. It is in an effort to mollify these feelings of ours that we respond with clever ideas like blaming ourselves for not being good enough or feeling guilty for accepting payment for the session since we “didn’t do anything.” Wrong wrong wrong.
If you were present, listened without judgment, and even sat in silence, you have done a lot. You have been a witness to your patient’s pain. You have believed them and believed in them. And you have given a gift that no one else in their life is providing – otherwise they wouldn’t need you. These all are doing SOMETHING – all valid uses of your time. Not to mention the possibility that if you weren’t in the picture, your patient might be doing worse – preventing relapse is certainly worthwhile.
When you ask me if you are helping your patient, I help you look for clues that indicate that your sessions are beneficial to him/her. The most obvious clue is that your patient is PRESENT. Even the ones who don’t say much, or don’t do much, are physically there. If they arrive on time, cancel appointments when needed in a timely manner and for a legitimate reason, and sit with you for the full time period, they are participating appropriately and likely gaining something from the experience. So even if your patient does not seem engaged in the work you are doing, and even if they cannot put into words what exactly is being accomplished, the fact that they simply show up may be a sign of progress toward recovery. The fact that you choose to accept their presence without requiring additional effort may be a healing interaction that some patients have never experienced. In essence you are communicating “I accept you as a human being, even if you are not ‘doing’ anything.” I’m not suggesting that sessions like this aren’t uncomfortable, but that is a separate concern, not an issue of effectiveness.
The second clue that your patient is benefiting from your work together is when he/she participates in the session – sharing thoughts, feelings, concerns; answering questions; doing assignments. Even if no measurable “progress” has been made, following through on commitments, sharing insights, sharing feelings, are all signs that movement is occurring. Building the foundation of a healing relationship is essential, just as it is when building a house, yet nothing may be visible on the surface. One dietitian described this situation as “renting my patient a room.” She felt she offered nothing more to her patient than a hotel. I asked her to imagine her patient sitting in her office alone, with no dietitian present at all. I suspect the patient would not have a conversation (even a conversation that is more like a monologue) with an empty office. Your presence provides, at the very least, a foil for your patient; someone with whom to argue or bounce ideas around. Once the conversation has started, you have an opportunity to direct it toward productive changes and nutrition-related topics. And on the off off off chance that all your patient really needs is a reason to get out of the house or some down time to gather his/her thoughts, then your office is just the place where that time out can happen. If you think your patient could get just as much out of a massage or a movie, suggest it, and I bet your patient immediately tells you why that wouldn’t be the same.
The third clue to your effectiveness is that you are worried in the first place. If you weren’t good at your job, you wouldn’t be worried about your patient doing well. You want to see your patient succeed, and you are willing to let go if you are not the right person to help, rather than blaming the patient for not getting better fast enough or pushing him/her “out of the nest” prematurely. Worrying about your effectiveness mans you care! And believe me, there are many reasons to be worried about your effectiveness. Are you actually harming people? Is the licensure board coming to take you to jail? Is this patient going ruin your reputation by telling others that you are unhelpful? Or sue you? These are the same questions we all have. And if you have already confirmed with your patient’s treatment team that the patient is not in danger at this level of care (or that the patient has been made aware of the danger and has rejected additional recommended treatment) and that you are working within the expectations of the team, then these questions are the poisonous fruits of anxiety, ie they can’t be answered, only managed.
Some patients actually tell you that your sessions are not helping. They could be right, but I’d rather entertain the possibility that they are wrong. Some patients get scared when things are going well and try to abandon you before their imagined abandonment by you. This may manifest as you trying to think of ways to discharge the patient before they tell you they are leaving you. Even if they don’t say express them out loud, you may pick up on your patients’ feelings of hopelessness, helplessness, and ineffectiveness. This is normal given the immense amount of work that recovery entails. And you are willingly doing this work with the patient. So you may also feel frustration or even despair. But your feelings of doubt do not prove that you are ineffective. Seeking support for those feelings of doubt, and allowing another human to see our vulnerabilities is one of the very skills we hope to instill in our patients.
It is wise to speak with a colleague to gain perspective on the situation and to get your personal baggage out of the way before you bring it up with your patient. After reassurance from your colleague, you may feel resolved and leave it at that. Or you may choose to bring up your concerns with your patient in a therapeutic way. “Sometimes I wonder if you are making changes that I am unable to see. I know something is going on in there. Would you be willing to share with me how our sessions help you change?” The self-doubt you feel as a caregiver is an extreme form of the same empathy that allows you to care. You don’t want to become a robot who doesn’t care if patients ever get better or not. Open your definition of “effective” and I am hopeful that you will see that you do, in fact, fit that definition.