MANUALIZED LABOR

 

When I contemplated a career in therapy, one of the elements that made my eyes light up was the prospect of continuing education. I looked forward to formal learning that never stopped, imagining something akin to master classes by the greats of the field. I didn’t imagine hauling ass through rush hour traffic to watch PowerPoint presentations illustrated with memes.

So far only about twenty percent of trainings have inspired me in my work—a pretty shabby average. The rest have just cost time and money when I can’t spare either for things that don’t feel essential. Like most licensed professionals, though, I’m required to meet a quota of CEUs.

Still evolving within the work, I nonetheless developed the core of my professional identity and preferences relatively early, with the support of an exceptional first-year internship supervisor, who emphasized the primacy of the therapeutic relationship and the value of simply, truly meeting clients where they’re at.

That’s not to say that my supervisor, a school social worker with an agency background, didn’t utilize specific strategies, tools, and techniques—in her case, an adventure-based approach along with play therapy. Rather, those things became a seamless part of her work and never took precedence over the present-moment needs of the kids she saw.

The therapeutic modalities that so often comprise the training opportunities available, by comparison, tend to seem rote and too directive in their approach. Or they feel so to me. “Visit one is for general assessment using the XYZ Mental Health Inventory; visit two is for problem-identification with cognitive mapping; visit three…” Etc.

There are many reasons for the manualization of therapeutic processes, including the mandate for brief therapy imposed by insurance companies, and the “soft science” complex that haunts a profession seeking status in a mechanistic, data-driven world.

People who know me would probably agree that I’m a stickler about many things, from the quality of the food I buy down to the commas in a piece of writing. But holding clients to a rigid framework ain’t my scene.

You could say I care more about “practice-based evidence” than I do about “evidence-based practice.” EBPs can certainly boast success stories, and I’m sure they work best when employed by their strongest adherents. Yet I know many clients who’ve “graduated” from CBT, DBT, and other acronymnal programs and express that they consider themselves none the better.

Then there are the trainings that feel like mere repackaging of modalities that have come before, the therapeutic equivalent of the “seven basic plots” in literature. In cynical moments, you might catch me saying, Maybe if I took mindfulness, broke it into ten components, and called it “Experiential Sensory Integrity Development (ESID),” I could start a 401K on the proceeds?

Many trainings seem to involve no actual “training” whatsoever, merely glossing their subject matter within advertisements for certification processes that cost upwards of ten times as much as the cost of admission for the 6 out of 40 CEUs you’re sitting there to earn, before your two licensed years are up and you (pay an additional fee to) start again.

To put it metaphorically, the latter type of training consists of allusions to a destination that lies perpetually just around the bend. The scenery feels so unchanging, in the classroom or conference room or partitioned hotel space—Warning: complimentary peppermints contain red dye and GMO corn syrup—it’s as though the vehicle is immobile. In those cases, the answer to “Are we there yet?” is, There is no “there” there.

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If only I could write book reports to earn my CEUs… I’m deeply grateful for my readers, and as always, I’d love to reach more. If you enjoyed this piece, please consider sharing it with anyone you feel might like it, too, by linking to it in whatever way works for you. I typically post once a month, so no barrage.

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THE POWER OF PRECEDENCE

I last wrote in a state of devastation that my thirteen-year-old client had reached a point where she’d felt she wanted to die, news that was coincident with a bout of uncertainty on my part about the career path I’ve been on. Before I share a positive development, it seems important to say a little more about that Tuesday evening.

It was my first time seeing Shona after her family’s February vacation abroad, and with the month of March came clinic “housekeeping” of various kinds. There was case management to check in on, and a quarterly review of Shona’s treatment plan. Did she still have the same goals for herself as when we began? Did she and her mom feel that progress had been made? What were our next steps?

From the start, our therapeutic pattern had been that Shona and I would spend the first half-hour or so alone, inviting her mom to join us for the time remaining. It was a pattern that paid heed to two needs: for Shona to have a chance to express herself without inhibition, and for the two of them to have space to strengthen their relationship, grappling with challenges in a safe and supportive environment.

Their work had paid off in a number of ways, from my perspective as observer, and we had had an outwardly positive, productive last visit, when we played with an experiential metaphor following an adventure therapy model. I felt good about where we had left things and was delighted, as always, to greet them in the waiting room. With the exigencies of paperwork in mind, I invited them back together.

The timing of that departure from precedent couldn’t have been worse. Because my attention was, from the first moment of session, divided—respectfully attentive to her mother, who speaks more assertively than Shona—and because there was “business” to see to, I gave insufficient consideration to Shona’s affect, registering that her spirits and energy seemed low but attributing that to the conflicts they described encountering upon their return home from the tropics.

They let me know that Shona had cut again a few days before, and we talked through that: what her trigger had been; whether she had tried other coping strategies and, if so, why they hadn’t worked; how she might move forward from there. We discussed the things that we usually discuss, but again, it wasn’t exactly the same. I neglected to ask the all-important question. Shona, thankfully, answered anyway.

Just as we were standing and confirming for the next week, Shona requested that her mom leave the room. Her mom seemed surprised, but unperturbed. “You want to talk to me alone?” I asked, redundantly. She did. After I escorted her mom out, I returned and focused on Shona. “You know how you always ask me my intent?” she said, without preamble. “This time I wanted to…” and she gestured to her wrists, her sign language for meaning to do real harm.

This moment contained more than words can relay. She would not have shared the difficult truth with me if she didn’t trust me, I know that—and I know that trust is built and sustained largely through reliability, which is a vital aspect of the therapeutic relationship. I am where my clients expect me to be, when they expect it; that simple, symbolic fact means a lot. I ask familiar questions that link each visit. I make myself as steady as I can, so clients can vary and change.

I think what I want to say here is that it doesn’t take long for rituals to root themselves. And unacknowledged changes in rituals can be upsetting, a private disappointment and source of confusion eroding trust in insidious ways. In daily life, this can be hard to address, but good therapy offers an opportunity to get one’s emotional needs met, if only within the bounds of that one relationship—and a good therapist pays attention for signs of those needs.

What do I mean about being steady so clients can change? From a biological perspective, no one is exactly the same from one minute to the next. We are all organic and constantly mortal, constantly a little deeper into our mortality, the conscious or subconscious fact of which can separate as well as unite us. But ritual matters. When I failed our precedent, it showed its strength. When I lacked awareness, Shona expressed herself—she sought the thing that was missing. She demonstrated that she had been actively present for our relationship, and she was courageous with me. In the midst of everything, I thanked her for that.