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Medical Family Therapy Intern Part II: How do I Help?

Posted By Lisa Zak-Huner, Wednesday, June 15, 2011
November 2010:

It’s a typically non-typical day at the family medicine primary care clinic. ALL my morning patients show up. That must be a record! More often than not, my patients no-show. That’s just one of the changes I’m getting used to working here. As I’m working to fulfill my university’s graduation requirements for clinical hours, I sometimes feel stressed when patients do not show. Other times, I am quite relieved to have some time to write case notes, consult with other providers, process, and maybe catch a bite to eat. It feels like a roller coaster.

After this morning, my head is as full as my caseload. At maximum, I have about 5 minutes between sessions to digest what just occurred with one patient and prepare for the next. This particular day, I’ve switched therapy rooms twice- conducting therapy in two of the faculty physicians’ offices. The clinic serves a very high needs population- low income, immigrant, severe psychosocial stressors, complex health concerns (diabetes, chronic pain, GI problems, renal failure, obesity etc), non-English speaking, severe mental health issues (PTSD, severe depression, severe anxiety problems) etc. So, I sometimes pray for the days in grad school where a couple’s ‘only’ problem was infidelity.

In the past four hours, I have worked with someone who has severe depression, anxiety, and alcoholism. The depression is so severe that we mostly sit in silence. The patient struggles to make eye contact and stutters out a few short sentences while staring out the window. The safest topics to discuss include children, the weather, sports, and plans for the weekend. I feel like it’s a combination of an interview and an awkward conversation with a stranger. I wonder how this has been helpful for the past 5 weeks. My head tells me this must be or the patient would probably not keep coming. Regardless, I feel uneasy. Even with all my knowledge of projection, transference, and counter transference, I can’t help but feel depressed and anxious as we leave the office.

Another patient is struggling with chronic pain from an old injury. She retells the same story about medical mismanagement of her pain. I can almost recite the ten year history with her. Most of session is spent validating feelings of mistrust, deceit, hurt, and skepticism. I think back to Arthur Kleinman’s book Illness Narratives. Conceptualizing her story from this perspective helps guide our sessions, my suggestions to her physician, and my sense of competence. The anxiety and depression from session one has waned. Instead, I want to feel comfortable with the repetition and make sense of it. I come back to the same question. Am I helping? How? It certainly doesn’t feel like I’m pulling much from the different models of family therapy I learned that are supposed to guide my interventions. No time to process that- the next patient is here.

I spend the next two hours in another crash course on Hmong culture. One patient’s depression and suicidality have decreased, but perhaps only me and her primary physician notice. The depression remains severe. I go with my gut on this one. Teach me about your culture, I ask. If I don’t understand what guides your interpretation of past and present experiences, therapy won’t be the most effective. The patient’s normally flat affect disappears a little and I see a small amount of brightness. Even though we’re working through an interpreter, (which normally seems to slow down the process) the session flies by. I’m soaking up everything I’m learning, and the patient is very interactive. I’ve gone from feeling uncertain and somewhat uncomfortable about the first two sessions to feeling like I’m on track.

The next patient is new and not really sure what I do and how I can help. It ironically parallels my own general feelings this fall. We talk (again through an interpreter) about what the primary physician recommended for treatment and how she’s described my role. The patient is not very clear, and my explanation does not seem to clarify anything. However, since the physician has said I can help, she is more than willing to keep returning for future sessions. Right now, I’m not sure where to head with her case either.

The rest of the day flies by. I try to make sense of what happened during the morning. Over lunch I balance supervision, food, case notes, and more spontaneous consultations with other clinic staff. During the afternoon, I switch gears. I’ve gone from provider to teacher. I walk into the precepting room to see which resident I have not shadowed and evaluated. I ask one if I can tag along for the afternoon to help him get his patient-centered evaluations out of the way. We don’t know each other well since our time at the clinic hasn’t overlapped much. I don’t know what to expect or how he might view a mental health intern serving as a mental health preceptor for the afternoon. I’m acutely aware of the power dynamics- I am younger, female, an intern, and a mental health professional. I’m also still learning what I can offer in the world of medicine and how to do it. Everything I’ve learned in theory is being tested. In all, we see about ten patients ranging from well-child checks to chronic pain, tension headaches, and diabetes management. By the end of the day I am exhausted. I’ve gone up and down, riding a roller coaster of stress, emotions, and feelings of incompetence versus competence.


Today:
This blog feels long, overwhelming, pressured, and too detailed. Perhaps it’s the perfect way to communicate my experience. I can’t edit these days. They occur in full force- fast, detailed, and sometimes overwhelming. I’ve learned how to ride the roller coaster a bit better. I’m far from being comfortable, but I know how to hold on and not get sick. And every now and again when it takes an unexpected turn, I get excited. I don’t panic. I hold on tighter, lean into the curve, and look around. Just as the roller coaster drops, I relax a little. Through this, I see how I can help and am reminded of why I enjoy this work.


Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

Tags:  family therapy  medical 

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