Never Underestimate the Power of the Therapeutic Alliance
The phone rang. I was in my office, on my computer hyper focusing on an individual note I was trying to finish up and put in the patient's chart. I was startled by the sudden ring and grabbed the receiver. "Hello, Deirdre Forbes, intake." The voice on the other end was female and trying to explain she was the wife of a former client of mine. It took but a moment to make the connection and when I did, I knew why she had called.
Bill (not his real name) was my first client when I came to the hospital. While I'd been hired to work in a new inpatient, co-occurring disorder unit I'd been kept busy with other assignments while the unit was still in Miller and Rollnick's third stage of change --Preparation. So I was assigned to work in the AOD (alcohol and other drug) out patient program. While covering their intake desk one day, I received a call from our liver clinic. The social worker on the other end of the phone was inquiring about making an appointment for an intake. She stated the patient was in need of a liver transplant and while he had told them he had given up drinking and joined AA months before, they still needed some concrete proof of 6 months sobriety before being accepted for a transplant. I was the next counselor up to do an intake so I arranged for him to come in the next day and meet with me.
He arrived on time in a dark, ill fitting suit, white shirt and tie. I later discovered he had lost a considerable amount of weight in recent months and this explained the oversized suit. He presented as the type of client we all hope for, eager, friendly, open and grateful. Apparently he was in need of a transplant for two reasons. His liver had become cirrhotic from both alcohol and hepatitis C. The Hep C was determined to have come from a tattoo he received while in the navy many years before, as he was never an IV drug user. On top of that he had just learned that he also had liver cancer--not unusual for an already damaged liver however.
Sure enough he became the ideal client. He had good attendance, he was compliant and he carried a positive message to all who would listen.
In the "Big Book" of Alcoholics Anonymous there's the story of one of the founders of AA and his "spiritual awakening." While he was in the hospital for the umpteenth time being detoxed, he described seeing a white light and suddenly feeling very different. Bill never told me he had a spiritual awakening but he certainly did awaken spiritually. He saw life as something to celebrate, friends as precious gifts, a spouse as a guide and companion and AA as the foundation of it all.
As weeks turned into months, Bill was getting more and more anxious about actually making it to the top of the transplant list. One day he came in and told me that the physicians' assistant suggested he look in other parts of the country for a shorter list and move there--at least until getting the transplant.
The transplant list has a complicated formula for who moves up. And while it is national in format if you are in a catchment area with fewer people waiting you can move up the list faster than in NYC where the list is long. So Bill and Lilly, his wife, (not her real name) became proactive and began calling other hospitals and centers to find out about possibly getting on their list and the odds of how long the wait might be. They finally decided Florida was his best shot. So they found a rental apartment near the Medical Center, moved in and after a test here and interview there, he was placed on their list and told it could be a 6 week wait--far better than the 3 to 6 month wait in NYC. Two weeks later he got the call they had a liver for him. I got the call from him shortly thereafter. He was very excited and very hopeful.
There were complications during the transplant but nothing I knew Bill couldn't overcome. He was doing everything the transplant team had told him to do. He thanked God, AA and just about everybody else who ever came into his life for helping him through the ordeal.
A couple of months later after healing he came back north and stayed at his home in PA. There he belonged to a motorcycle club. He proudly got back on his bike and went on a day trip with "his gang." When that didn't quite dare life enough to make him feel completely alive, he decided to try skydiving. He called me on his cell while driving back from the jump. He said he couldn't believe how fabulous it was. He'd love to do it again, but Lilly made him promise not to do so.
He went back down south for routine tests and was met with the words no one wants to hear. "The cancer is back." The prognosis was bleak. The doctors would do what they could--chemo, pain meds, and 6 months to live. He couldn't stand going through the chemo again and decided he preferred a better quality of life without it was what he wanted. He and Lilly sold their house in Queens and purchased a condo in Florida. Bill found a new AA home group and became an active member doing service. He and Lilly decided they would enjoy whatever time they had left and planned a trip to Australia and a cruise. I learned all this because Bill would call me. Every few months when a holiday came up such as Christmas, Thanksgiving or even Valentines Day, he would call. He'd tell me he was "doing great!" He'd tell me how blessed and grateful he was for each new day. He'd tell me about his adventures and future plans, like purchasing an RV to travel across the country. Never did he fail to sound positive, up beat, happy and full of life. Sometimes he'd mention the pain but the alternative he found to be worse--taking pain meds, which clouded his thoughts and slowed him down. Sometimes he would get my voice mail. I actually enjoyed that even more because it gave me the opportunity to keep not only the message, but also his joyful uplifting voice. I would keep it until another message came along to replace it. I never knew which message was going to be his last. The prognosis of 6 months came and went without incident. He promised to remain in touch.
Every time a major holiday would go by and I did not hear from him I would become disheartened, wondering if he was gone. And then just when I was sure he must be, another call came through and there he was on the other end of the line sounding as grateful as ever and embarrassingly, thanking me for all I did for him. When I would sound surprised to hear from him he'd have the retort, "No, it's me. I'm not dead yet!"
The last recorded message I have from him is from last Thanksgiving. I can't quite remember when I last spoke with him "live."
And then the call from Lilly, "I knew Bill would want you to know that he finally passed away on Sept. 18th. He talked about you all the time. He had a difficult last three months because the tumors had spread all over his body. He became paralyzed and really couldn't do much for himself. We had hospice come in at that point and they were wonderful. He passed away at our home in Pennsylvania. I'm pretty sure he told me that it was you he had shared the dream with in which he was dead but he was still running around the house like a maniac mowing the lawn and fixing and repairing whatever needed taking care of." "Yes, I remember that dream," I told Lilly. "He told me you thought it meant his spirit was always going to be around that house because the work was never going to be done. Well a couple of nights after the funeral I had a friend staying here with me who said she woke in the middle of the night having thought she heard someone or something outside. I told her about the dream and what you said. I think it really is his spirit out there."
I cried for a long time after that phone call. My emotions were all over. I was sad that someone like Bill was no longer walking the earth. I was sad he and his wife were never able to have children. He would have been a great Dad. I was sad for me that I wouldn't get those occasional calls anymore to put me in my place and make me
realize how grateful I am for all I have.
I still find it remarkable that he stayed connected to me for three years after leaving our clinic. The big lesson for me is the power of that therapeutic alliance. I don't think it was anything I did in particular that allowed for that to happen but I'm grateful I was able to give that to him and somehow help him through his last days. But I am even more grateful for what he gave me.
So thanks Bill. You'll be in my heart and mind and even my voice mail, for the rest of the time I walk the earth. Thanks for showing me how to die with dignity and truly live one day at a time.
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