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Hearing Voices — The Quiet Courage of Hospice Social Workers

By J. Scott Janssen, MSW, LCSW

“Anybody tries touching my grandpa, I’ll kill him.”

Ronnie slammed the door, clicking the lock that separated him and the body of his just deceased grandfather from the rest of us. The house full of family members was suddenly quiet.

Ronnie’s sister gave me a look as if to say, “You’re the social worker. Do some social work.”

His mother appeared ready to explode. “I swear I’ll bury that boy right beside his granddad.”

I took a deep breath, scanning the silent crowd. “Is there anyone he might listen to?” I asked. His mother shook her head, “When he gets like this, he doesn’t listen to anyone.”

All eyes were on me. It appeared I’d been elected.

Over the years, I’ve interviewed many social workers interested in joining my facility’s hospice team. After every interview, I imagine how each candidate might respond to a situation such as the one involving Ronnie. The interview questions rarely vary: Why do you want to work with people who are terminally ill and their families? How do you see yourself functioning as part of an interdisciplinary team? What kinds of challenges do you imagine hospice patients may be facing? How about personal and professional boundaries?

One of my favorite questions centers on what qualities and abilities are essential in a good hospice social worker. The answers over the years have been fairly uniform: empathy, good listening skills, observational and communication skills, nonjudgmental acceptance, self-awareness, the ability to remain calm in a crisis, strong advocacy, and knowledge about models of psychotherapy.

It surprises me that no one has ever said courage. I’m not talking about the stare-down-the-bad-guys kind of courage of which Hollywood is so fond. I’m talking about the quiet, understated courage that is an essential, yet often unacknowledged, quality of all hospice social workers—the courage to move toward another’s suffering even if it means knocking on a door behind which an athletic-looking young man has locked himself after threatening violence.

Voices on the Way to Courage
Ronnie’s sister still is giving me the look. “What kind of social worker are you anyway?”she seemed to be saying.

I’m nervous as the voices try to hook me. You know the voices I’m talking about. We all carry them: voices of doubt and self-consciousness. No matter how robust our confidence or how much experience we gather, there always will be situations that trigger them. Years ago, they would have quickly built into a loud clattering chorus: “You’re out of your league,”; “Here’s where everyone will see what a terrible social worker you are”; “You’re not smart enough for this”; “You don’t know enough”; “Run!”

Learning to dance with these voices and move them into the background so that we can stand firmly and compassionately amidst stressful situations is the foundation of this kind of courage.

Being a hospice social worker provides ample opportunities to build this foundation. It’s easy to feel ill equipped when working with people who are suffering or when people are asking big questions that have no easy answers. Why must I die? How will I go on without my beloved partner? Feeling ineffective is understandable when so much is beyond our control. It’s in situations like this that the voices often arrive and when courage is cultivated.

Though I’ve been a hospice social worker for a while, I don’t have any foolproof blueprint for standing firm when the voices arrive. But, having been scared out of my wits on more than one occasion, I can tell you what has helped me keep them in perspective and grow this kind of courage.

First, I accept these voices as a normal part of being human. I’ve noticed that sometimes when social workers hear the voices, they take it as confirmation that there really is something lacking in themselves or their skills. If the voices are telling me this, it must be true. I’ve fallen into this trap myself, but I have learned that just because the voices are talking doesn’t mean they are telling the truth.

Pay Attention
I’ve also learned to practice being aware of the voices without reacting to them, just naming them and letting them go: “There’s the thought about not being smart enough”; “There’s the voice demanding that I be perfect.” Just because the river of thoughts and emotions is churning doesn’t mean it has to carry you away. You can sit on the bank and simply watch it go by.

Being aware of how the mind sometimes works can come in handy. When I studied cognitive-behavioral therapy, for example, learning about cognitive distortions such as emotional reasoning or jumping to conclusions was an eye-opener. I found that many of my voices grew out of such distortions and that recognizing them—“There I go overgeneralizing again”—was very helpful.

I pay close attention to the language of my internal dialogue. Whenever I find myself using words such as should, never, always, or can’t, my antennae go up: “I should be better at this by now”; “I always get stuck here.” Using such words rings a mental alarm reminding me to breathe, pay attention, and not get hijacked by the voices.

Talking back can help, too. Years ago, I’d get into arguments with the voices, exposing the flaws in their assessment and demanding they cease and desist. These days, I smile as though cranky old friends who no longer have power over me have come to visit.

Sometimes when the voices are whipping through my mind, I use somatic strategies. My favorite is to take a deep breath, focusing on and extending the inhaling and exhaling. Sometimes I’ll put my hand on my heart while I breathe. If I’m feeling fear or anxiety, I might smile ever so slightly, sending a physical cue to my nervous system that everything’s OK and I need to slow down. I’ve learned where my muscles tighten when the voices are trying to pull me into their trance-stance. Now I go right to my shoulders, jaw, and neck and relax the tension.

Some hospice social workers I know use visualization. One told me that when she hears the voices (which tell her she is incompetent and inexperienced), she imagines listening to a radio station playing loud and obnoxious music, and then she turns down the volume. Another (whose voices tell him he is an unlikeable blabbermouth) imagines a swarm of mosquitoes buzzing around his head just as he reaches for a can of bug spray.

Though the voices can be harsh and irrational, it’s important not to make them into the enemy. They often come from places where we are wounded or from unconscious defenses. When we learn not to get hooked by what the voices tell us, they may have valuable messages for us. The voices that lash out at others have helped me identify situations and behaviors where I’ve needed to develop greater compassion and understanding. And when voices of self-criticism kick in, I now see them as timely reminders to pay attention to what I’m seeing and feeling in the moment. What is going on right now? What am I picking up?

Often those little voices sense something I’m not conscious of yet: fear, transactional landmines, subtle double messages, undisclosed lines of conflict, or hidden agendas. Maybe the voices know before my conscious mind that a particular patient reminds me of someone else with whom personal stories are connected. By making friends with the voices, you not only take away their power to upset you, you also enlist them in the deepening of insight and awareness.

Open the Door
Ronnie’s uncle is getting restless. “If that boy doesn’t come out of that room, I’m going to kick down that door and drag him out.”

I smile and suggest we hold his offer as plan B. As I stand to walk over to the bedroom door, I’m aware of something else that being a hospice social worker has taught me. Behind the swirling energies of anxiety and doubt, there’s a deep internal reservoir of strength and wisdom within me and everyone I meet. When the voices arrive these days, they remind me to do three things: focus my internal and external attention to see what may have aroused them, decipher what the real message is, and go into this deep place of calm and strength to find the voice beneath the voices.

There are many ways to make this move. Some hospice social workers I know use mantras, affirmations, or prayers. Others use metaphors, somatic cues, or mental images. I become aware of my breath, relax the tension in my shoulders, and remind myself to go slow and be love. Though other voices may be chirping away, this deeper, truer voice is the only one I listen to in such moments.

There is no one to impress, no pressure to fix the unfixable, take away suffering, or say the perfect thing. This voice knows there is no perfect thing. This voice knows it’s all about attunement, caring, and the courage to listen deeply. This voice trusts that people are resilient and creative, not apt to break however hard the challenges they face, however fiercely their own voices of doubt are shouting, or however dysfunctional their behavior in the moment appears.

If there is an essence to my clinical practice, it is this: When I’m with hospice patients and families, I speak to the deep inner voice within each patient, the one beneath all the other voices, whether or not patients are connected in the moment with this voice.

As I move toward the door, I know that inside Ronnie’s head his voices are stirring, too. Strong emotions are pulsating. His nervous system is firing away. His heart is breaking. I think, “He’s hurting. He’s doing the best he can in this moment. Open your heart, and let him know you care. Let him know it’s safe.”

Hospice social workers also know about the courage to knock on doors. Every day, we knock on the doors of people who are dying and the families caring for them. Every day in conversation, we knock metaphorically on doors that may lead into the center of powerful and complex thoughts, feelings, and relational dynamics.

As I knock on Ronnie’s door, I trust that beneath the storm of his emotional pain, the drama of his defenses, and the voices chattering in his head, there is a place of wisdom that can guide him out of the hole into which he’s dug himself. It’s not my job to do the work of finding this place for him. But it is my job to leave the voices of doubt, fear, and judgment aside and have the courage to knock.

— J. Scott Janssen, MSW, LCSW, has been a hospice social worker for 20 years and currently works for Duke Hospice in Durham, NC. He is author of the book The Dawn Is Never Far Away: Stories of Loss, Resilience, and the Human Journey.