On the Front Lines of Crisis Work

What Keeps a Clinician Going in High-Stakes Therapy?

Gary Weinstein

My pager is a tiny sound-knife, slicing into my sleep. I sit upright, disoriented. What? What! It's Sunday, 2:30 a.m., and I'm the clinical social worker on call for our upstate New York public hospital. "They need you," says Liz, the overnight Emergency Department clerk. "There's a trauma and a lot of family. They need social work."

I dress in the dark and jump into my car. The streets are empty, abandoned by a sleeping world. Traffic lights blaze for no one; the street lamps are strung like jewels. As I pull into the ED parking lot, I see a mass of police cars, Emergency Medical Transport vans, and flashing lights. An African American family mills around the entrance, while perhaps a dozen others—friends, other relatives—pace frantically nearby. I'm waved through the door by security and walk quickly to the trauma room, where I see 20-some medical staff intently pumping, infusing, and cutting. Bloodied clothes and sneakers litter the floor.

As I step back out, the charge nurse, Bette, greets me. "What do we have?" I ask.

"We need you with the people out front," says Bette. "No one's been able to talk with family yet. We need the patient's parents, a wife, or a significant other inside. Nobody else—no young children, no friends. Can you sort that out and accompany them in?"

There'd been a picnic. A hot summer day and a neighborhood dispute had turned to shooting. A young man named Cyrus Johnson had been shot point-blank in the chest. Now half the neighborhood is here, pacing, cursing, nearly frantic.

I feel wide awake, pumped up. I prize this feeling—a razor-sharp sense of purpose, laced with something like fear—in the moment I confront a new situation, a new family. I came to this regional public hospital four years ago, assigned first to the inpatient psychiatry unit and then to the Emergency Department, where I now work. One of 30 social workers among 6,000 hospital employees, I'm called on in the midst of emotional crisis, when family or patient turmoil becomes too intense for medical staff to handle. It's psychotherapy in the moment, with people I don't know and may never see again—people facing some of the most terrible moments of their lives.

I'm not new to crisis work. Before coming to the hospital, I spent nine years counseling county prison inmates, men who regularly dissolved into rage or tears, threatened suicide, or vowed to kill someone. Earlier, I directed a Salvation Army shelter for teen runaways who required 24-hour care. And now, at 3 a.m. on a Sunday morning, I'm standing beneath blazing fluorescent lights in a hospital hallway and readying myself to meet a distraught family. I feel in my bones that this is vital work; I want to do the best I can for the people I'm about to meet.

At the same time, I want to flee. I want to burrow back into bed and escape all this tumult and pain, this unrelenting test of my ability to be of any use. I've been doing crisis work, in one form or another, for nearly 30 years. I've confronted a number of forks in my professional road, opportunities to take a less demanding route. But I've chosen to continue on this path, accompanying others who've been suddenly, often brutally, cast out of life's safety zones. The reasons I stay aren't simple, and they continue to shift and surprise me.

"This Isn't Happening!"

As I step outside the ED entrance and greet the murmuring crowd of relatives and friends, all eyes fasten on me. Seconds slow and divide. I know that the next words I speak will turn their world.

"I'm social work," I say, using the hospital vernacular. "Cyrus is still with us. I just saw the doctors working on him. They're giving it everything they have."

I hear a collective exhalation of breath. He's alive.

"Does Cyrus have parents here? A partner? The doctors would like them to come inside." I pause. "I'm sorry. This must be awful for all of you."

A girlfriend and an ex-wife emerge from the night crowd, hand in hand. They point beneath a street light across the lot to Cyrus's mother, Claudia. She's pacing, alone, her voice piercing the night. "It didn't have to happen! You save my boy! I told the cops to watch them people! How many times I call them?"

Then Cyrus's parents appear, and I usher them, the girlfriend, and the ex-wife inside and into the ED's designated family room. After settling them in, I step out briefly to check on the patient.

I poke my head through the curtain of the trauma room to see white coats completely circling Cyrus. I can see only his uncovered feet. One resident I know turns, catches my eye, and gives me the subtle frown and headshake I recognize immediately: things are dire.

Returning to the family room, I hear anger, raised voices.

"There's gotta be some payback!" cries Rhonda, Cyrus's ex-wife.

"Don't you talk that way, Rhonda! You honor Cyrus and hold your tongue," warns his father, Fred.

"And let the shooters walk away?" counters Keisha, the girlfriend. "We can't do that!"

"Folks," I say. I wait for them to calm down. "I just looked in. They're still working hard in there." I realize I'm dispensing happy talk, something vaguely positive but fundamentally evasive. I'm offering hope even though I have little, or perhaps none. Is this wrong? What on earth should I say?

They're nearly silent now. Fred sits hunched over, his head in his hands. Claudia stomps her feet and mutters. The two younger women sit shoulder to shoulder, arm in arm, rocking. Just then, two physicians appear at the threshold. Dr. Roonig, a trauma specialist, motions to me. "We're ready to tell them," she whispers. I lead them into the family room and make swift introductions.

"He's gone. I'm sorry," she says. Her voice is neutral, factual. Everyone gasps. Keisha collapses to the floor, while Rhonda clings to her on the way down. Fred is bent over, his shoulders heaving. "Not my boy!" Claudia howls, her voice hoarse with rage and pain. "Oh, mighty Lord, no!"

Keisha's mouth is agape. "He's gone? No, you didn't say that!" she pleads. "I'm carrying his baby!"

I remind myself that this family doesn't need any words from me, at least not right now. I breathe deeply and sit quietly with Cyrus's family as they cry, shake, and try once again to seek refuge in disbelief. "This isn't happening! He was doin' so good!" I stay with my breath, listening, meeting their eyes. Finally, Keisha looks up at me. "Now what do we do?"

But my pager is vibrating. The ED needs me to help place a psychiatry patient. Quickly, I gauge how much more time I can spend here without letting the psychiatry patient wait too long. I ask what might be of help right now. A clergyperson? Glasses of water? A phone? "I'll bring you to Cyrus soon," I tell them. "I'll help you through this in the coming hours." Then I excuse myself, promising to return quickly. It's nearly 4 a.m. I walk down the hall to meet my next patient.

Talking in Code

Dorothy is sequestered in a locked, barren ED room, on watch. She's a slight woman in her mid-fifties, her salt-and-pepper hair disheveled and her jeans street-dirty. They've taken her shoes; in her stocking feet, she paces rhythmically.

As I introduce myself, she spews a cascade of non-sequiturs, accusations, and suspicions, interlaced with demands for water, another blanket, to go home, to call her lawyer. She's been here before. She knows the drill. "You know why I'm here, don't you? Tell them—you're the robot!" she scowls at me.

Psychiatry staff will confirm that Dorothy needs inpatient care, but what I can't bear to tell her is that our psychiatric unit is full. We may have to transfer her to another hospital, perhaps more than 50 miles from here. Worse, she may be transported by police, subjecting her to more stress.

I spare her the details. She's confused and afraid enough. As it happens, a bed will open upstairs on our psychiatry unit later in the day. Meanwhile, I try to reassure her, using her own language, trying to match her code.

I excuse myself and walk quickly back down the hall to the family room, where Cyrus's people still sit, weeping. I spend the rest of the night with them.

Listening to Chopin

A neighbor of mine—a psychotherapist well acquainted with the hospital—joked that I must be a masochist to jump from a prison yard to a psych unit. Her comment still burns. I can't help but wonder what continues to draw me to these extremes of psychotherapy.

I do have a sense of what led me to the work. Growing up in middle-class New Jersey, I felt loved and cared for, but carefully protected from major upsets. My gentle parents edited out the raw footage of life; I have no memory of seeing a dying person, or real rage, or raw grief. I was kept safe but spared the experience of being fully alive.

Consciously or unconsciously, crisis social work has delivered me to the walled-off side of life—to the heart of human suffering. When I step into the hospital in the middle of the night, it's as though curtains are drawn back: the actual curtain to the treatment room and the figurative curtain hiding the wounded world from me. I'm a first responder. I feel myself waking up, growing up.

It's tough work. The river of grief, rage, and fear of those I work with runs so deep and wide that I sometimes can't imagine how I can help them navigate it. The stakes are high; what if I blow it with this desperately fragile individual? Unlike office-based therapy, I may not see this person next week, or ever, to follow up.

Several months into the work, something crumbled inside me. I was swept by waves of anxiety, accompanied by depression and terrible insomnia. It was as though my patients' anguish and neediness had poured into me; irrationally, I began to fear that mental illness was contagious. I felt fragile and wracked. I wished I'd never taken the job.

My wife, Trina, listened to my despair through long, troubled nights. A close friend, Robin, told me of his bouts with psychotic depression during an especially difficult job transition. Several coworkers revealed vulnerabilities, and even breakdowns, that they'd endured and survived. I was astonished and comforted by the willingness of so many people to be with me in my pain, and to share their own. As winter yielded to spring, the days lengthened; I got my hands in the dirt and gardened. I began to feel better. The air and sun helped, but I knew I couldn't have survived that dark season without the presence and caring of others.

Afterward, I thought seriously about leaving the job. If there'd ever been a time to switch gears and seek easier, calmer work, this was it. But once I'd regained my balance, I found myself feeling new compassion for the patients sitting across from me. How thin is the membrane between adept functioning and crippling dysfunction! The psych unit is widely seen as an alien place, the butt of degrading jokes about odd and unknowable "others." Yet, some years back, one of my closest friends had been hospitalized here. Several acquaintances were admitted during my two-plus years on the unit. Hospital staff and their relatives, university professors and students, community leaders—all took up residence on this hall while I was on staff. How tenuous the line we draw between our patients and us! Today I sit here in a tie and badge. Tomorrow I may wear a gown and a bracelet.

***

This blog is excerpted from "Life, Death, Madness" by Gary Weinstein. The full version is available in the July/August 2008 issue, Ain't Dead Yet!: Against All Odds, Community Mental Health Fights to Hold On to Its Vision.

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Topic: Challenging Clients & Treatment Populations | Trauma

Tags: child trauma | clinical social work | clinical social worker | death | Depression & Grief | grief | grief and loss | grief counselor | inner city | licensed clinical social worker | post traumatic stress | PTSD | ptsd treatment | social work | treating ptsd | violence

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