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Social work student internships are an indispensable ingredient in the formation of students’ professional identity. Field placements present a wide breadth of challenges that afford students fertile ground to refine their clinical skills of active listening, engagement, and relationship. The issues that are addressed by students specializing in psychosocial oncology and end-of-life care are unique. Students in these field placements are not only confronted by their clients’ dying and death, but forced simultaneously to reconcile themselves to their own mortality as well.

Why, you may ask, take on this unpleasant, frightening subject? Why stare into the sun? Why grapple with the most terrible, the darkest and most unchangeable aspect of life? […] Death […] is always with us, scratching at some inner door, whirring softly, barely audibly, just under the membrane of consciousness. (Yalom, 2008, p. 9)

Death is an inescapable mortal wound that everyone experiences. Engaging with those who are dying is not an isolated event, but instead, a collective experience. “Dying is a relational event, and the clinician cannot be neutral, absent, or objective” (Berzoff, 2008, p. 182). The realization of death can become a wellspring, therefore, for opportunity and growth. Its inevitability provides the impetus for us to engage with others in personal and intimate ways.

Although the universality of death has the potential to connect human beings to one another on a deeper level, it can lend itself to an existential crisis and heightened experience of death anxiety. Anxiety surrounding death references “the perceived amount of emotional distress provoked by the anticipated total nonexistence of the self” (Hui, Bond, & Ng, 2007, p. 200). Fear of death repeatedly is the “pink elephant in the room.” Its presence is palpable and yet it often remains unspoken. Death anxiety can range from a fear of ego-dissolution and annihilation to fear of the dead. It may reveal itself in anxiety over the process of dying and fear of the unknown. Field instructors can help students embrace these fears, reframe them, and understand how death anxiety can enhance the therapeutic relationship and their capacity to share in the suffering of the other.

Clinically, the experience of death anxiety may contribute to students’ difficulty in establishing alliances and facilitating rapport with their clients. The fear of death for instance, can manifest itself in students’ reticence in initiating dialogue with their clients and sharing in meaningful conversation pertinent to death and dying. Students may attempt to change the subject because of concern over upsetting their clients or engage in positive thinking or reframing of their clients’ experience. In its worse scenario, death anxiety may translate to an avoidance of the person who is at the end-of-life.

Professionals in end-of-life care have directed their attention to social work education and criticized the absence of adequate training at times within the arena of death, dying, and loss.  “Social work educators and clinicians have repeatedly pointed out the need for social work curricula to place more emphasis on social workers’ attitudes toward death, dying and bereavement” (McClatchey & King, 2015, p. 347). The inclusion of a curriculum that encourages self-reflection and centers on students’ attitudes and beliefs surrounding end-of-life care has a positive influence and direct correlation to their comfort level and openness to speaking with their clients about death and dying.

The importance of death education to impart content knowledge about the death process and gaining insight into the death attitudes of helping professionals has been emphasized by students, practitioners, educators, and ethicists. It is clear there is a near universal agreement on the need for the inclusion of death education in the training of helping professionals. (McClatchey & King, 2015, p. 346)

Therefore, it is critical that field placements situate emphasis on the experiential as well as the academic and clinical component. Supervisors can encourage introspection and help student interns begin the process of examining their insecurities and vulnerabilities pertaining to death, dying, and loss. This, however, would also require field instructors to exhibit a willingness to recognize and connect with their own death anxiety and the manner in which this impacts and directs their clinical work. Students not only model the clinical skills we impart to them, but also with their clients they mirror the supervisory experience.

The supervisory relationship has been heralded as the cornerstone in the development of effective clinicians and as the quintessential learning experience for the clinician, the foundation of students’ educational growth and development, and the therapeutic alliance in which supervisees develop their own style. (Sormanti, 1994, p. 75)

Death anxiety and unfamiliarity with regard to skills that are solicited in oncology social work and end-of-life care may account for students’ difficulty in recognizing the clinical dimension of these field placements. “Students sometimes expressed concern that an oncology setting is ‘not clinical enough’ and that they feel they cannot apply what they are learning in social work classes to their fieldwork” (Sormanti, 1994, p. 80). The clinical skills employed in oncology social work placements are unique and often different from interventions used for instance, in mental health venues. “Students describe clinical work as treatments with patients who can be labeled with a […] diagnosis and as work that can be done in an office setting in 50-minute hours under a mutually agreed-on client-worker contract” (Sormanti, 1994, p. 80). Students discover themselves struggling with the clinical skills of the capacity to sit with the silence and offer the gift of presence in end-of-life care. “Many students are uncomfortable with emotionality, in part related to their own histories, but also because they may not know ‘how to sit with it’ or what to ‘do with it’ professionally” (Urdang, 2010, p. 531). Students’ discomfort with these skills may preclude their ability to establish and foster therapeutic relationships with those who are dying. Beginning where the person is entails the recognition of the innateness of suffering in the human condition and readiness, therefore, to begin where death and dying are. “Being present means tolerating one’s own anxiety about death in order to be able to help clients and families to tolerate their own” (Berzoff, 2008, p.179).

The following excerpt illustrates the discomfort that students experience. S was a student intern working with a woman whose husband was diagnosed with stage IV metastatic pancreatic cancer. Her husband’s prognosis was poor and although death was present, it nonetheless remained the “pink elephant” as the student was reticent in opening the door. In addition to feeling confused and frightened by the prospect of her husband’s dying and death, S’s client also articulated struggling with anger over which she subsequently experienced guilt.

Student: I see. It’s good that you’re reaching out to us. We’re here to listen. So I understand that he’s receiving treatment for his pneumonia? How did that go?

Client: He’s doing well. He’s already back at home. Next month I’m going to meet with the oncologist. They said he still has a 4mm tumor left. They shrank it down from 6mm. They’re talking about putting him on additional chemotherapy to shrink the rest. He may even undergo a clinical trial. But my husband, he doesn’t want to. He said his body is not able to handle it right now. And I don’t blame him. I won’t force him to go back. But I’m sure he will change his mind once he talks to the doctor.

Student: Chemo must have been rough for him.

Client: Yeah it was. You know, he lost all of his hair. When it first started, he would just put his hand through his hair and a bunch of hair could come out. He decided to shave it all off. Now he wants to wear hats. I always joke with him and use humor to keep me positive.

Student: That’s admirable. Using humor is a very creative and effective way to cope. I’m glad you’re able to stay positive through all this.

Client: But, you know, I also get angry over all this as well. It just isn’t fair what is happening to him. And then I feel guilty for feeling this way. It’s hard sometimes.

Student: I understand that you and your husband moved recently?

Client: Yeah, I mean our families are here so there are always people checking in on us.

Student: I’m glad to hear that you have supportive people around you to help you cope with your husband’s diagnosis.

Client: I won’t give up. I always know that God is out there looking out for me and my mother in heaven is looking down on me.

In reflecting upon what transpired in the session, S was uncertain as to whether or not attention should center on anticipatory loss or, instead, the client’s anger and guilt. The student writes, “It seems like the client wanted a place to vent her worries that she cannot share with her husband. She mentioned feeling angry and that this might perhaps be a goal for her to work on. I did not dwell on it further as our time was up and I was not sure if the anger has anything to do with the cancer. However, this is a topic that can be clarified and possibly pursued if it surrounds her husband’s cancer. Maybe I should go over goal setting with her instead of letting her vent? Even though her initial request for counseling was simply to ‘have someone to talk to’ how do I shape this into a more structured and organized discussion?”

The establishment of the therapeutic relationship is an integral aspect of oncology social work and end-of-life care. Students discover themselves struggling at times with use of self and what they should disclose and reveal to clients within the session. Many students, for instance, who herald from mental health settings, are dissuaded from engaging in self-disclosure.

Several supervisors shared stories about students who were afraid to acknowledge that they used interventions such as physical contact and sharing of personal information, which the supervisors believed was appropriate to use, but students were discouraged from doing so in class. (Sormanti, 1994, p. 80)

Field instructors can respond to students’ concerns by helping them feel more comfortable with the clinical skills that are encompassed in their work with the dying. Helping students develop the art of presence and encouraging deep listening will enable them to interact with their clients in rich and profoundly empathic ways. In attempting to transcend narratives that have been solely reduced to clinical technique, Frank (1998) suggests that:

The deeply ill person is the immediately needy one, and this person’s story deserves primary attention. Clinicians may share parts of their own stories, but they do so in response to the ill person’s story. Reciprocity is sustained in the appreciation with which the clinician receives the patient’s stories. To give the gift of listening is to appreciate receiving the gift of a story. Not just understanding this reciprocity but embracing it seems to me to be the beginning of clinical work. (p. 200)

Oncology social work and end-of-life care are emotionally laden field placements and students may feel overwhelmed and stressed by continually witnessing their clients suffering. The intensity and range of emotions that are articulated by clients can instill feelings of impotency in students. Field instructors have indicated an array of challenges oncology social work presents to students and have underscored several factors that can contribute to the complexity of supervising interns in these settings. The most notable influences on students are:

[…] constant confrontation with loss, dying, and death; exposure to physical mutilation and pain; negotiation between social worker and clients of intense affective responses over a long period; immediate and strong countertransference reactions; helplessness and frustration at ultimately being unable to save patients; and use of a less restricted, unconventional set of boundaries. (Sormanti, 1994, p. 78)

Students may discover they are unprepared for this work and field placements sometimes lack the support that is necessary to assuage the risk of vicarious trauma and compassion fatigue. Supervision, therefore, becomes more complicated and field instructors may assume greater responsibility with regards to addressing their students’ needs.

Encouraging self-reflection among students can prove beneficial in promoting professional growth and competency. The creation of a secure environment where students are able to engage in introspection is paramount to developing insight into their beliefs and values surrounding death, dying, and end-of-life care. “Students need educational support and direction to deepen their capacity to develop a professional self, including an ability to recognize, understand, and utilize their feelings and insights on behalf of their clients” (Urdang, 2010, p. 532). Working in oncology social work can become a potential battleground. A venue where students can process the clinical work and address countertransference may help to mitigate the risk for burnout.

CancerCare’s student internship program acknowledges the significance of individual supervision and student peer support groups as crucial in strengthening students’ resilience and enabling them to address the needs and concerns of their clients who are living with cancer or may be at the end-of-life. Social work professionals have emphasized the role of intersubjectivity in the therapeutic relationship, especially as it pertains to transference and countertransference. Urdang (2010) has issued a call for process oriented clinical work and states that:

Students need to understand the interactional nature of work with clients, how to process this internally, and, when appropriate, directly with clients; they first must learn how to process basic interview crunches before they can move on to more intense crunches […] from clients. (p. 532)

Utilizing process recordings, for instance, not only serves as a vital tool in promoting self-reflection but elucidates conscious as well as unconscious interpersonal dynamics between the student and client.

Recognizing the importance of death education in abating the impact of death anxiety, CancerCare has established “Let’s Talk about Death” round-table discussions.

Helping those coping with death, dying, and bereavement can provoke confusing and frightening existential questions and painful feelings of personal loss. Coming to terms with death involves both internal and interpersonal processes that are influenced by individual and societal death attitudes. These attitudes profoundly influence how one copes with death on an ‘up close and personal’ level as well as an abstract and complex concept. (McClatchey & King, 2015, p. 345)

In these discussions, students are afforded an opportunity to share and process feelings and fears they may harbor surrounding death and dying. In addition, CancerCare offers a variety of in-service programs that are designed to expand students’ comprehension of cancer, treatment, and loss. “Curricula that include discussions about the psychology of illness, including defenses and their usefulness in helping people adapt to the many anxieties raised by severe and life-threatening illnesses, would prepare students better for oncology placements” (Sormanti, 1994, p. 84). Bridging the academic component with the affective dimension of social work practice is integral to the development of clinical acuity in oncology social work and end-of-life care. “It is imperative that [students] are not only knowledgeable about the dying process but also feel a certain comfort level working with this population and have increased insight into their personal attitudes and feelings about death, dying, and bereavement” (McClatchey & King, 2015, p. 358).

Although death is an uninvited guest and is often depicted metaphorically as the Grim Reaper, it also has the potential of opening doors to greater interiority and increasing the depth of human relationships. R, a second-year student in CancerCare’s internship program, reflects:

The internship definitely guided me to raising self-awareness and comfort when having the conversation of death and dying with others. There seemed to have been emphasis on meeting the clients where they are in their journey – which I think is unique as CancerCare encourages this. I felt that the topic of death is very abstract and looking back at my experience, CancerCare seems to be open-minded and supportive in this area.

Students working in oncology social work field placements may find their clinical skills challenged by death anxiety. Supportive field instructors who are sensitive to the impact of death anxiety on students can help ameliorate their fear of dying. Students will then become empowered and can begin the process of embracing the challenge in order to enhance their connection to clients who may be at the end-of-life.


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