As a supervisor, it is a challenge to supervise interns working with couples and families dealing with chronic illness. We want to help the patients while also taking care of the intern in training and being aware of our own personal feelings toward illness.
This challenge was evident during a case when an intern providing couples therapy asked for live supervision. One of the partners suffering with a demyelinating disease was very upset while the other partner seemed withdrawn and unresponsive. The intern worried that the partners had much to discuss but remained silent. During live supervision I validated the intern’s perception and asked what she suspected was occurring. It was what I feared; the non-ill partner does not seem comfortable giving care and may want out of the relationship. I struggled with my own reaction: - how could he be so insensitive to his partner’s suffering? Yet he appeared uncomfortable and I suspected he resented the care giving that had taken over his life. They had never planned on this. They had things to do, and adventures yet to experience. Illness can test relational bonds and I silently wondered could my own relationship undergo such a chronic test.
I felt sadness welling up in in me and decided to check whether the intern was possibly experiencing her own sadness. I discovered that the intern was feeling hopeless and helpless. Now I too felt caught. What if we urge the partners to speak honestly and someone dies in the process? What if they feel the therapy has done harm? What if the abandoned partner is unable to recover, and the partner who leaves is demonized? All those things a family therapist dreads and sees as failure. I suggested the intern invite the couple to talk about the things they were afraid to say to each other. As predicted the partner was not sure he could remain in the marriage. He had not signed up for this, and was thinking about divorce. She suspected he wanted out, and had been making preparations to find an assistant living home. There was no scene or outburst, just silence with the confirmation of what each had not been able to say to the other. With urging from the intern, the partners began to talk about their struggles and the domination of the illness in their life. As the session ended they both appeared relieved to have been able to speak about their worst fears. The relief was also experienced by the intern and supervisor.
Topics that are off limits need to be discussed to prevent the distancing that can occur in the relationship (Rolland, 1994). Giving space for tough conversations allows for all involved to draw on their resources and to live more authentically. As a supervisor, I encourage my interns to ask the tough questions when it appears a loved one is withholding, fearing the outcome. Carl Whitaker, a family therapist, said it is the “covert that we have to make overt” or it will create havoc.
As I recommend to the intern to probe and encourage honest dialogue with and between the patients there is the fear: - will it create a damaging experience for the intern and no benefit for the patients? Remember “do no harm” is an ethical and moral premise. As a supervisor the question is: - can I handle the fallout and take care of the intern while at the same time benefitting the clients? However, before the intern can do this level of work I have to be sensitive to the spoken and unspoken fears an intern may have working with patients who are chronically or terminally ill. I invite the intern to tell her own story about experiences with illness and frame the experience as a source of strength for the intern in working with the chronically ill.
I further invite the intern to speak about what may be unspeakable for her concerning illness. It is the speaking of fears that creates openness for one to experience compassion for the other and more importantly compassion for the self. As with the couple, it is a reminder that physical fragility does not necessarily portend emotional or personal fragility. As I explain to my interns I am also reminding myself that we are not defined by illness, condition, or even our feelings or thoughts. These are experiences to be shared in hopes of becoming more open, flexible, and free. When illness is an uninvited family member it is truly a collaborative effort between intern, patients and supervisor to discover the psychosocial map (Rolland, 1994) that provides support and reassurance for these tough conversations.
Rolland, J. (1994). Families, Illness, & Disability: An integrative treatment model. New York, N.Y.: Basic Books.
Connie S. Cornwell is Licensed Marriage and Family Therapist and Supervisor, Licensed Professional Counselor and Supervisor, Clinical Fellow and Approved Supervisor of American Association for Marriage and Family Therapy and Member of American Family Therapy Academy. Ms Cornwell has over 30 years of experience as a couple and family therapist, educator, trainer and supervisor. Ms Cornwell is the Senior Supervisor of the University of Texas Southwestern Medical Center Department of Psychiatry Family Studies Center in Dallas, Texas where she is training and supervising couple and family therapy interns, medical students and psychiatry residents.