Ann Maree
Hey, friends. Last week on the Safe to Hope podcast, I interviewed some friends of mine and colleagues, Julia and Patrick Fillnow. As you know or may have heard before, Julia is a licensed counselor, and Patrick, her husband is a medical physician, and then myself speaking into the conversation as a lay counselor, or otherwise known as biblical counselor, and oftentimes just an advocate. But we are, the three of us, some of the members of a team that we at Help[H]er highly recommend Christian institutions form when they are seeking to provide good care for victims and survivors. And so we all discuss together some of the strengths and weaknesses in our individual disciplines and the ways in which our participation in a caregiving team might complement one another. We ended up having such a rich conversation that I broke the episode into two parts, and so today we’re just going to air part two. And I’m just going to pick up right where we left off and go from there. 

Okay, so I mentioned before briefly, and it’s one of the main things that I wanted to talk to you both about, because it’s just, it’s revolutionary to the lay counseling model, and even, I think, in the pastoral ministry, and that is, ‘do no harm.’ It’s a commitment that both of you make in your different disciplines. And so I’d like to just hear from you, talk to us about that as a physician, and then also as a therapist. I want to get, I think I want to get at and Patrick, you take it whatever way you want to, but how do you how do you care for someone in a way that is going to harm? An amputation is going to hurt and but you’ve committed ‘do no harm.’ So help us understand that?

Patrick
Well, there, there is a difference between pain and harm, and the example of the amputation, there’s going to be a deeper reason for the severity of the of the care, and if there is infection that isn’t going to be able to be treated without amputation, then you’re actually going to cause more harm by not doing the amputation. And, yeah, I mean, I think that’s one of the key things to think through, when thinking through ‘do no harm,’ is that it’s extremely complex. We’re caring for deteriorating physical bodies. Things are not going to go well at some point. And then there’s this balancing of desires of the patient of long term outcomes, short term outcomes, discomfort, and it can be in some cases, really challenging. In other cases, it’s relatively straightforward, but understanding that, it’s different to know when to do the procedure, when not to do the procedure, and trying to take into account all of those different factors.

Ann Maree
How do you make those choices?

Patrick
Yeah, great. Great question. There’s this, there’s this idea in medicine about how to make the decision. And there are different types of decision making models, and the way I think about the different types of decision making models is that they’re on a spectrum, and so on one side of the spectrum, there’s paternalism, which essentially says that the physician decides. And the clear problem in certain circumstances with that is that the patient can lack autonomy. On the other end of the spectrum, is a decision making, model that you could call technical and in this model, the doctor doesn’t presume to know what’s best for the patient, but the physician essentially gives information, and then the patient decides. And then there’s numerous middle ground models. One is called a shared decision making model and in this model, the physician and the patient are working together to make an evidence informed decision that is meaningful to the patient. It takes into account the patient’s story, preferences, the particular circumstances, their desires for their life, but it also takes into account the data, the experience of the physician, and together, the patient and the physician come to a conclusion on what’s the best approach. And in primary care, that’s typically the decision making model we’re using, but different models of decision making are appropriate in different circumstances.

Ann Maree
Yeah, there’s a saying in missions, specifically from a book called When Helping Hurts that says, “avoid paternalism at all costs.” So my question to you is, is there, is there a situation a time that paternalism is the right approach to making a decision?

Patrick
There are situations where that is the most appropriate decision making model. So one example could be that in urgent and severe circumstances, maybe even if the patient isn’t thinking correctly, and those would be times where it’s inappropriate to just give the patient information and let them decide. So if a patient’s having a severe bleeding episode and is lightheaded and something needs to happen now, then the physician needs to decide, and if he doesn’t, then there would be harm that would happen to the patient. One specific example for me, on this side, where I was using a more technical approach to a problem where more of a paternalistic approach would have been appropriate, was in residency, we we do a lot of work in the intensive care unit, and in the intensive care unit, some patients don’t do well, and so you have to sit down with families and discuss options of care, and sometimes that requires a discussion about removing certain things, like ventilators from the care of the patient. And naive, I went into those discussions thinking, well, I will give information to the patient’s family, and then they’ll decide. And I quickly realized that it depended on, in some cases, not all cases, but in some cases, it depended on me and how I gave the information to the patient. And that didn’t sit well with me, so I talked to my attendings and teachers about it, and one, one of my attendings told me that, of course, it depends on how you say it, and it should, because you’re the physician and just giving data to the patient’s family puts them under undue stress. And that is not the right approach.

Ann Maree
Oh my gosh, I’m listening to with my lay counseling hat on, and thinking how well this could map on to caregiving from a pastor or a lay counselor in the church. I think what we’re seeing more often is the lean towards a paternalistic approach to care, whereas it’s appropriate at times, I have pastors who call me, two of them this week, who are desperately helping women, and I’m encouraging them to help the women by letting her make her decisions, and they just want to protect her, and I keep telling them she needs to set the pace for that. You can’t run in and do that. But there are times when a pastor has to act quickly. And so I see that map on so well, technically, yes, you know, providing all of the information that they need to know to make their decisions. I see that too, the middle ground, the shared decision making with trauma patients, so important. And I see Julia’s just nodding her head. So I’m gonna, I’m gonna let her speak to this one too, but I’m excited to see this in writing, because it’s such a great teaching for the church.

Julia
Yeah, and I think what we’re saying is that care is very nuanced. There’s no one size fits all approach that is going to work for a particular client or church member or patient, that you have to consider both the role of the person involved in the context in order to give the right care. Yeah, and this is something we see in the counseling space too, where if I’m sort of formulating a treatment plan with my client, that’s shared decision making, and they’re coming under my care, my protection, and so their needs come first, and what they deem as the most distressing part of their lives and something that they want to work on, I allow them, or I want them to, in some ways, lead where they want to go, but that’s completely different. If a client is telling me that they’re suicidal, so at that point in time, I’m still giving them a choice, but they have two choices. 

Ann Maree
You limit them. 

Julia
Yes. What feels best for you? Can we call somebody to take you to the hospital, or do I need to call the ambulance? And that’s ultimately for their good, for their protection, for their care. I don’t eliminate choice to harm them, but ultimately to protect them.

Ann Maree
Patrick, would you… Would you say this is an easy any of them are easy processes in the decision making process?

Patrick
I think the extremes can be easier on the physician, because in my example, I think one of the reasons I use the technical approach is because I was uncomfortable. I didn’t want to impact this huge decision for the patient. I was anxious, and so it was… the approach that I was using was about me, not primarily about the patient, even though I was saying like the patient’s family decides. And yeah, the shared decision making model, it can be very complex and sometimes frustrating, and sometimes it can require more effort and time and conversations with the patient, but data does show that if patients are on board with the plan, then the plan may actually happen. 

Ann Maree
It might work. 

Patrick
And when there is buy in, then the treatment goes better. So the work in most of primary care decisions, the work to do the shared decision making model is definitely worth it, but it’s certainly not as easy as saying, “Hey, do this…do that because I said so.”

Ann Maree
Yeah, and you alluded to that power you have as the physician. What kind of characteristics are kind of required for the person who makes those decisions. I mean, we go back to the responsibility you have as a physician and the responsibilities that you have before a board. So talk about the requirements of character, I guess.

Patrick
Yeah, I mean, we’ve mentioned a few times, but humility is one factor, one you know, character trait that I think is a requirement and a good primary care doctor. If we’re talking specifically about shared decision making, then there needs to be curiosity about what are the desires? There needs to be an ability of the physician to wait for answers to uncover what’s behind symptoms and sometimes the patients don’t even know exactly the underlying desire so that can take time and multiple visits to get at.

Ann Maree
I’m already planning a class that you’re going to teach…

Julia
We see so much! 

Ann Maree
Oh gosh, yes. Never realized, yeah, I’m applying it as you’re speaking. 

Julia
I think something that Patrick also touched on was just the awareness of yourself. So in those cases where he becomes anxious at the responsibility in front of him, it’s easy for him to defer to somebody else, whereas, you know, others of us, when we become anxious, maybe we tend to want to control more. And so knowing, kind of how you respond in stressful situations or in situations they’re ambiguous is really important.

Ann Maree
So knowing yourself you’re talking about too? 

Julia
Yeah. 

Ann Maree
And I know you as a counselor, you were probably also in counseling at some point during your training. 

Julia
Yes, yes. 

Ann Maree
Patrick, is that a requirement for a physician in his training? Is he in some sort of maybe mentoring, not necessarily counseling relationship?

Patrick
Yeah, I think the… I would characterize medical training as, after the first two years of Medical School, where you’re primarily in book, a study, then the next five years is primarily mentoring. And you know, medicine is both an art and a science, and you don’t pick up the art from reading a textbook. You see how other physicians relate to patients. You see, oh, that would have been a better question to ask, and that is where a lot of the learning happens, at the bedside with other doctors.

Ann Maree
When I looked at do no harm, there were a lot of different each institution seemed to have a different emphasis take on it, whether it was required, all these different as if it’s not law, so to speak. But you we know that’s the physician’s commitment. Can you explain at all, ‘do no harm.’

Patrick
I mean, I think we, yeah, that’s really complicated. And I think as you practice medicine, you see that there’s many layers to it, and the desire is always to help, but unfortunately, harm can occur through inappropriate science or art and not understanding the diagnosis, not applying the right treatment, would be examples of harming that would occur from inappropriate science and then from an art perspective not uncovering the actual need, not by making the patient feel safe so that they they can say what is needed to be said. Or what’s the most important thing that needs to happen at the visit. And there’s levels to this, but then there’s the, you know, reality of even if everything goes perfectly well, there’s sciences is not math, and there’s not always a perfect answer and sometimes there can be bad outcomes, even when everything is done correctly. But in that circumstance, I don’t think that that’s the main thrust of ‘do no harm,’ because, rather, I think the thrust of ‘do no harm’ is to not overestimate your ability to heal and not underestimate your ability to harm.

Ann Maree
That’s a good way to put it.

And Julia, do you have, as a social worker and a counselor, therapist, have a similar I think we’ve established that, but maybe just talk about it.

Julia
Yeah, I do. It’s part of our Code of Ethics that we sign and commit to as clinicians. And you know, different clinicians, based on their licensure, have different code of ethics. And if it doesn’t explicitly say, ‘do no harm’ there, the flavor is still there, right? So it’s there’s an aspirational quality to our ethics. That says, as far as it depends on me, I will be a part of the process of this person’s healing and not their harm. And you know, there’s a lot of different kind of subcategories that could go along with that that explains how we ‘do no harm.’ Again, some of them are very explicit, such as, never have a sexual relationship with a client. Unfortunately, that has to be in there. And then there’s other considerations, such as understanding power and authority in the counseling room, as Patrick was speaking to understanding your scope of practice and competency. If you are not trained in a specific area, you do not treat. And informed consent, which means that you are giving your client information so that they can make the best decision for them. If they don’t have all of the information, they can’t make the best decision for them. So those are some sort of categories that we think about to limit the harm. Doesn’t mean that there won’t be discomfort. In fact, in therapy, there is a great amount of discomfort, and that’s normal to get to the other side of healing. Oftentimes things get worse before they get better in the counseling room, but I’m also constantly assessing what the client is able to tolerate, their level of discomfort, whether we need to pull back or change a different method of treatment so that they don’t become too overwhelmed. And you know, unfortunately, if you don’t do those things, and if you’re not aware, then, especially for clients who have experienced trauma, it can be a very re traumatizing experience, and so I want to limit that as much as possible.

Ann Maree
Think in terms of what I read in Dr Gingrich’s book about lay counselors, supporting the professional counselor on a care team. What then would my participation look like in helping you as you’re caring for the client. Demystify that for me, it’s like a supporting role of sorts. 

Julia
No, I love that, because I’m limited as a clinician. I spend 50 minutes to an hour with them in the counseling room, and then they leave and go live their lives, and 90% of the work is taking what we’re discussing and the tools that they’re learning in the counseling room and applying them so your role is so significant. You have eyes on their day to day life. You know their family members. You know their church community. You see them on a Sunday, you greet them. You have much more intimate, in some ways, contact with them than I do. One of the things that just comes to mind is I love when my clients are able to, as they feel comfortable, process with friends and like counselors what they’re learning in the counseling room and what they’re processing. And if you’re even able to okay your counselor is noticing these things. I want to learn more and more about that, like, what does that look like, and how does that work? Work out in your life? And I think it’s really key for a person to have that kind of partnership and community.

Ann Maree
I do often find and I’m not counseling right now. I’m just doing mostly advocacy work. But that doesn’t mean that I’m not, quote, unquote, counseling or always counseling one another in some way or another, but I do find that I love to do this when somebody I’m working with in advocacy tells me what their therapist said. I’m like, great. Do that go with that? I like to be able to defer to the therapist because, you know, mainly, I think several of the things that we’ve been talking about, one of them being diagnoses, the education, the sheer amount of hours of supervision, and then I like the idea of being the admin to the therapist. And then also the encourager. And I think that’s really a big part of the position for advocacy is to encourage. And that would be encouraging…What did your therapist say to do? How did they tell you that this would be helpful? How can I encourage you in this? And yeah, I love the idea of the hand in hand, yeah.

Julia
And because we’re so limited, we have 50 minutes, maybe once a week, maybe every other week. We are limited, and how much spiritual care and direction we can give them, and that’s a piece that you offer them.

Ann Maree
Yeah. I mean, that’s like an add on so I can hear and that’s what I’m trying to do as well. Thank you for bringing that up. I’m trying to hear what you’re saying as observational…you see the outside behavior….and I’m trying to know encourage them, and I’m not, I’m not doing confrontation. That’s not the style of care I give. I’m doing the opposite. I’m trying to encourage them with some sort of knowledge about God that’s going to bolster them in that, in that behavior that they’re trying and you’re helping them improve. I don’t want to say fix, but you know what I mean, just work on, I guess. And so that’s, that’s where my training comes in, in that I can tell stories from Scripture. I can tell stories from others or myself even, and then how I was able to navigate who God says He is, according to what I’ve experienced, and then put those two two things together. So that’s, that’s another way I see a partnership. 

So, we’ve talked a little tiny bit about that power that we have. Each of us has a power in the counseling, in the caregiving role. I would say this could be a strength and a weakness for the lay counselor, and that is the biblical we’ve talked about this a little bit too, but the biblical aspect of what we’re saying. However, I would also say that as a female, as a lay counselor, I don’t have the kind of power that a pastor has. Or let me say it differently. I don’t represent power the way a pastor represents power. But when I put the word Bible on anything, I say, I come in with like, Oh, you’re authoritative. So I really have to be careful with my language when I use scripture, obviously being careful what Scripture to use and not misuse it, but also framing it in such a way, so like I said at one point during our conversation, that it’s a desirable piece of information about who God is. I think the one thing that I did benefit greatly from in seminary, there was many things, but one of the counseling things that I benefited from was one of our professors used to say all the time, you’ve gotta make God bigger, more beautiful than their current situation. And so that’s how I’m trying to use Scripture. It can be awfully tempting to be more directive and more paternalistic and say, well, Scripture says. Yes, and there’s no two ways about it. I think one of the ways that comes out the most is when we’re talking with a traumatized victim of abuse is forgiveness. Yes, forgiveness is required as a believer, but let’s talk about that. Let’s have a big, long, patient conversation about what that means and what it doesn’t mean, how to do it, how not to do it, whatever that that might be. Instead of just… you need to forgive him, you know, and being very simplistic about it anyway. That’s all I’m thinking about, the lay counseling, biblical counseling model as it relates to power. I would love to have you confront me. If there’s something else you see, feel free to do that. I’ll see if I can answer it. But what do you what do you guys think about that in your role, power and authority, or the temptation to it?

Patrick
Yeah, I think the potentially one temptation is to not think much about it, and to go about your job or in my context there, there’s a number of different factors. So the patient comes typically with a need which makes the patient more vulnerable. And then a lot of times, there’s… they didn’t go to medical school and residency this, so there can be a knowledge gap which also makes the patient vulnerable, and just not recognizing those facts can lead to a visit that potentially isn’t as beneficial. Then if as a physician, you’re, you know, that’s more top of mind. It just changes the approach of the visit. And not to say that, you know, power, by definition, is bad. I mean, if I would imagine, if you’re a patient, you would want somebody that did a lot of training and knows more than you do. I mean, that’s a good thing, but not recognizing that gap and can be challenging.

Ann Maree
Yeah, thank you for even bringing up that part of, they come to you with this position of vulnerability that they come to me the same, you know? And I’m sure Julia is going to say the same thing,

Julia
Yeah. I mean, they’re experiencing great suffering. They often feel weak, they feel shameful. And where there’s that great need and vulnerability, there’s there is a powered inferential and as Patrick said, we have to be aware of it, and if we don’t think that it exists, we’re actually more likely to function out of an unhealthy power dynamic. I need to know when to use power, the power that I have for good, for the benefit of my client, and when I need to put it down. I’m also often trying to flip the power dynamic in the counseling room with my teenagers, especially with victims of abuse and victims of trauma, that I’m trying to empower them and show them that you know they know, they know more about their story in their lives than I do. So I need to be a learner. I need them to teach me, and in that way, I’m flipping that dynamic.

Ann Maree
Yeah, that’s excellent. Yeah.

Patrick
That’s true for all our circumstances, that the specific of the need is going to be understood, typically, more by the patient or the person bringing the need.

Ann Maree
Yeah, Chris Moles talks about power under, all the time. Maybe not Chris. Maybe it’s Jeremy Pierre, one of the guys in the domestic abuse world.

Julia
And some clients like want me to be this powerful figure and tell them what to do and tell them what to do. 

Ann Maree
That’s our default. 

Julia
Yeah, I remember I had one client who was significantly emotionally and psychologically abused by her parents, and all she knew in relationships was power over, power under. And so she came into the office feeling like that was the only safe way to experience a relationship. So she demanded a lot of me to tell her what to do, to be the power in the room. And. And there was one point in our session where I told her, I’m not going to be your abuser. I refuse to do that. You’re worth more than that. She didn’t like it, but that was the process of us flipping the power dynamic so that she can heal.

Ann Maree
Oh, great stuff, guys, I appreciate so much your wisdom and just getting inside your head a little bit, because it is very applicable to helping, I think churches, leaders, lay counselors, pastors just get some insight into people care that they may not have had elsewhere. It’s not a dig in any way. It’s just here. Maybe this will help you. So again, thank you, friends.

Julia
Such a pleasure.

Patrick
Thanks for having us. Yeah.

Ann Maree
That’s all for today, and we do thank Julia and Patrick for making this happen, for thinking carefully and thoughtfully through some questions and the discussion. Like I said, there’s a whole lot more we could have touched on. 

Season Five is coming up. The Safe to Hope story begins again on September 9, and we are grateful and excited to share the story of a couple who, having experienced domestic abuse in their home, are now reconciled, and this is so rare statistically. So it is with pleasure that we are offering this insight to our audience. Renee and Charles will each tell us their story, and then Tabitha Westbrook, Chris Moles, Greg Wilson and our audience favorite, Darby Strickland, will all speak into their situation. So we look forward to being back on the air September 9 for that season.

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Safe to Hope is a production of HelpHer. Our Executive Producer is Ann Maree Goudzwaard. Safe to Hope is written and mixed by Ann Maree and edited by Ann Maree and Helen Weigt. Music is Waterfall and is licensed by Pixabay. We hope you enjoyed this episode in the Safe To Hope podcast series. 

Safe To Hope is one of the resources offered through the ministry of HelpHer, a 501C3 that provides training and resources for those ministering in one-another care and advocacy for women in crisis in Christian institutions. Your donations make it possible for HelpHer to serve as they navigate these crises. All donations are tax deductible. If you’d be interested in partnering financially with the ministry, go to help her dot help and click the give link in the menu. If you’d like more information or would like to speak to someone about ministry goals or advocacy needs, go to HelpHer.help. That’s help her dot help.

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