MISSING PIECES

 

It was a cold, rainy November day in community mental health. I was stood up for the third week in a row by a parent who nonetheless makes no move to end services, meaning that I have to send a letter that indicates concern (without getting too personal) and points up my outreach efforts (without sounding overbearing). Despite a background in writing, such communications are grueling for me.

I spent 25 minutes on the phone with a juvenile probation officer, discussing a client’s obsession with his ex and his legal situation related thereto; then hung up and promptly wondered whether I’d betrayed his confidentiality in the little bit of talking I’d done, something that will likely nag at me long after my supervisor reviews it with me. I was beset and nuzzled by a hand-puppet seeking affection-by-proxy on behalf of a child I have frequently had to remind about personal space.

Holding respectful silence, I supported a young adult in the process of contemplating how much of her sexual trauma she needs and wants to share. I stepped with a mother and daughter into the furnace of long-fueled resentments. At one point, an adult psychiatric patient crunched through the snow to look in my window before continuing next door to pound on the glass of the doc, cursing and threatening him till police were called. Come to think of it, that’s what started the day.

Two client visits were easy and joyful and kept the lights bright in my brain after too many hours spent doing paperwork and hearing disappointing news. But the part of this Monday that I’ll remember most clearly is the call from Sue, a foster mother, to tell me about a question posed by my kindergarten client on the drive to school. Removed from her biological mother for gross medical neglect as well as alleged abuse, my client asked from the backseat, “Do you think you can love a person without liking them?” Six years old.

Every clinician I know has favorite clients and heartbreak clients, often one and the same. This girl stole my heart from the moment we met, and although I behave with the same playful professionalism I would with any client her age, I wish in a very real way that I could adopt her. That I can’t is one of a short-list of aches that descend from metaphor to dwell in my core.

I’d gone in early to finish an annual review, so the day felt extra-long. When I got home, my bootlaces wouldn’t loosen fast enough. Yanking, tugging, heaving, I got the right boot off, taking my sock with it. Stuck to the bottom of the sock, and hence to the bottom of my foot, the bottom of my day, the bottom of my ache, was a small puzzle piece. The crackled glaze on the curve of the Mona Lisa’s mysterious smile.

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Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me.

To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. 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! Thank you for your visit.

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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and happy Fall.

THE SYLPH AND THE SKY

 

When I accepted a job with a mental health agency, I had to give up the luxury, formerly afforded me, of a walking commute. I’m not someone who hates driving, but an hour a day, five days a week, is much more than I’m inclined to enjoy, especially considering environmental impacts.

Even so, I continue to feel grateful because, rather than strip malls and billboards, my route is lined with trees, a mountain view in one direction, big skies in the other. What a difference that has surely made, in the last three years, to my resilience.

I was sitting not long ago with a young teen girl. She was showing me art with a fantasy theme, scrolling through an album she had made on her phone. There were mermaids, griffins, fairies, elves, centaurs, etc, rendered in exquisite detail: manes and feathers and tails and wings.

Resting my arms on the kid-sized table in my office, I leaned in to admire each picture she shared and listen to her commentary. She was telling me in an offhand way that this was her art; she said she’d been busy all week with the drawing. “This is one of my favorites.” “This one was hard to get just right.” At one point, she swiped to a kneeling angel with double wings. “Hmm,” she said to me, with what I perceived as embarrassment, “I’m not sure why I made her naked—but you can’t see anything, so…”

She was showing me art she’d found online. I knew that, but I didn’t challenge her, just murmured admiration. And I didn’t question that choice, just noticed it, and noticed that it felt right, while wondering what various colleagues would do. When the slideshow came to an end, I said, “The world needs more magic, doesn’t it? Like the magic in you.” She fiddled with her phone. Without looking at me, she said, “Probably you say that to everyone.”

“Actually, I don’t,” I said—which is true. After a beat, I added, “Yes, I’m a counselor, and part of my job is seeing the best in people. But I don’t have to lie to do that.” She was quiet. Then she expressed interest in making art with me. As she drew, she sought to maintain her deception with remarks like, “I’m feeling too lazy to fix the nose.” “I guess I’ll leave the leg like that for now.”

My drawing, meanwhile, was abstract. I began with my non-dominant hand, a handy trick I was once taught, to quiet the critical voice, and delineated an oblong shape, with some internal contouring, vaguely resembling a seed, a flying saucer, or a cross-sectioned hard-boiled egg. Then I reached for the crayons and colored pencils.

“What are you making?” she asked.

“I don’t know,” I said, “I’m just having fun.”

Soon her paper turned over, and she, too, began making a more abstract design, scallop upon scallop. She told me, when she had finished, that it was a mermaid’s tail. And a thing of beauty it was.

I thought about her on my drive home, and our time together. Her observations of the pictures she showed me were often poetic, which is a gift of hers. A sylph perching on a mountain ledge and gazing at the sky was “trying to understand the clouds.”

Lately I’ve been leaving the radio off for the day’s-end commute. I open the windows enough for fresh air, not so much that I’m buffeted. The air rushing past fills my ears in a pleasant way, and I feel any tension in my face relax.

This girl, my client, made a meaningful choice. Really, more fabrication than deception. I believe she wants to possess the skill that she admires, to have a direct connection to a world of possibilities much grander and more colorful than she perceives in her actual life. Given what I know of that life, why would I seek to take such a dream from her? Like an imaginary friend, it will fade when she has no further need of it.

Sometimes the clouds take strange shapes. That evening, it was as if an enormous, thick, soft anvil rose up from the horizon. I drove toward it, trying to understand it.

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How is it the end of August already? I’m deeply grateful for my readers, and in 2018, 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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and warm regards.

 

WORK-LIFE RESONANCE

 

I recently sat in on my first Aikido class. Afterward, I was pleased to tell acquaintances that I now know how to throw a grown man to the ground. That was just silly bravado for my own amusement, however, and not at all reflective of the discipline. What you learn in Aikido, as the sensei put it, is how to help someone fall.

That concept speaks to my sense of the work I do.

Vulnerability tops nobody’s list of favorite mammalian sensations; certainly it doesn’t top my own. For me, the experience of vulnerability can evoke fight, flight, and freeze simultaneously, an anti-trifecta. So I empathize with those who are ambivalent about therapy, instinctively resistant to the deeper conversations.

My faith in the depths is firm; my compass points inward. But the “fall” into therapy has to be taken with great care and companionship, and one of the best ways to achieve that—in addition to active listening and the sensitive use of silence—is through reflective statements. Not a flurry of questions, chop-chop-chop like karate. Minimal use of questions, maximal use of restatement, summary, and gentle extrapolation, always open to correction.

This approach is beautifully described and detailed in Miller and Rollnick’s Motivational Interviewing, one of the most inspiring texts of my education. MI is the Aikido of therapy! It’s rewarding to work in such an intentional way, to assist the fall—and the standing back up.

I was sitting with a traumatized tween girl on the floor in my office. Her chaotic life experiences were poignantly evoked by the careful way she organized my dollhouse, visit after visit, arranging everything just so. One particular afternoon, she was highly escalated from the car ride to the appointment; she had shared information about her trauma with her mother, and her mother had gotten angry.

My dollhouse is an eco-friendly Scandinavian wooden “chalet” that can be separated into two parts. For the first time, the girl separated them and set one part off at a distance: “This needs to be its own house.” Sometimes that’s what’s needed, I said.

She described to me the conversation in the car as she worked on one house. I continued to reflect and validate what I heard her say. After a while, I asked her permission to share a thought I had. She granted it, and I proposed that her mother may have been too upset to give her the response she needed, but that we could try again to talk all three together when things were calmer.

She reached for the “other” house, saying, “I guess this actually belongs here,” and put them back together again, making a new space of the whole. And she started, for the first time, to tell me the story of her trauma, using the dolls and furniture as props to her narration. When her mother joined us, they were calm together. The work continued, and the work began.

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Monday I had my four-year anniversary with this site! I’m deeply grateful for my readers, and in 2018, 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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and best wishes.

 

IT’S THE LITTLE THINGS

 

 

Thank you for being my client.

 

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The month has gotten away from me, so I’ll just slip this photo in under the wire and keep writing for next month. I’m deeply grateful for my readers, and in 2018, 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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and best wishes.

 

ALL THAT GLITTERS IS NOT GOLD

Like a human cousin of the Corvid family, I was once upon a time a child who loved anything that sparkled. Mica, tinsel, brooches on ladies’ coats. I played an angel in my second grade holiday pageant, and the gilded poster-board wings hung in my closet until after I had graduated college, when my mom tactfully asked if I wanted to keep them.

I’ve got three hunks of pyrite at home that say I haven’t entirely outgrown scintillation; but I newly hate glitter. It contributes to the microplastics polluting the planet’s water and species. Many in the profession of Youth & Family Therapy espouse the making of glitter bottles as coping tools, and until recently, I was more repelled by the larger, more obvious plastic involved. Now it’s the razzle-dazzle that concerns me most. It’s the bellies of seabirds and fish that matter to me. Our health isn’t separate from theirs.

I know what it’s like to grow up in tight financial circumstances and feel a fervent longing for anything that seems to bespeak prosperity and success. I still feel some reflexive awe when recalling a cardboard crown with convincing paper gems that I could glue on where I chose. I remember the power of certain aspirational goods: name-brand sneakers, clothing, toys, and even snacks.

One of the harder parts of my job, though, is swallowing my environmental dismay to meet kids where they’re at, including acknowledging their sadness and/or excitement over things all too likely made by other kids halfway around the world. My concern is—has to be—the emotional hunger that makes conspicuous consumption so much more appealing. But sometimes I feel, as I listen, an ache for the larger world, of which my lead-free, plastic-free, glitter-free office is just one, infinitesimal part.

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I’m deeply grateful for my readers, and in 2018, 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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and best wishes.

 

 

 

THE NUMBERS GAME, PART TWO (OR, MY SO-CALLED THERAPEUTIC LIFE)

One of the many challenging aspects of working in community mental health is that you are, de facto, expected to practice as a generalist. In Youth & Family work, this means taking any client between preschool and 21, with pretty much any kind of issue. It doesn’t matter if you have little to no training or skill with a particular developmental age or diagnostic picture. You learn as you go, or not. At least within the session itself, your clients sink or swim with you; elsewhere, other factors can and often do play the determining role in outcomes.

Of course, any profession will involve on-the-job learning. Still, upon reflection, does working without expertise or even affinity, in some highly sensitive cases, seem therapeutic? We have supervision, but not in vivo; we have training opportunities, but not often or intensively enough. As regards this lack of choice, I’m reminded of an obnoxious rhyme I heard while volunteering in a kindergarten, summoned on such occasions as the passing out of birthday lollipops: “You get what you get, and you don’t get upset.” Yes, in fact, you do get upset! And clients may get upset—rightly so, if they’re not adequately helped where such help might be possible but wasn’t in the roll of the dice. A prohibition against feelings and preferences helps exactly no one.

But back to generalist practice. Let’s say I have a caseload of 25 (again, as mentioned before, that’s on the most absurdly, luxuriously modest end of the community mental health spectrum). Let’s say the work week begins, and maybe I get lucky with an easy sort of Monday, six clients back-to-back but all doing relatively well. I may leave work feeling buoyant and thinking, optimistically, “It’s time I got around to reading more about blended families!” But then I remember that I started a book, some time back, on post-traumatic play, which is still relevant and likely ought to take priority. I decide that I should focus on that.

Tuesday, though, is rougher and brings fresh urgency to the need to research conflict resolution and nonviolent communication, to provide a distillation of resources to a weary and worried single parent who is hungry to learn how to talk to her teenage son before he slips away from her care and into a life of delinquency; she wants more than the basic guidelines I’ve already offered. I plan to assemble some things in the morning… Wednesday finds me, however, scrambling to photocopy materials on fight-flight-freeze and executive function, in order to best and most clearly explain brain processes to some guardians at their wit’s end and contemplating giving up a child, already abandoned multiple times, to the custody of the state. Her fate isn’t in my hands, but my success with the guardians feels as important as if it were.

Then Thursday? Thursday brings a mandated client who would probably rather chew glass or walk across hot coals than engage in therapy. I’m often successful building rapport in such cases, and even look forward to them, but this one’s giving me a run for my money, and my thoughts turn, yearning, to the book on motivational interviewing that I love but never have time to reread from beginning to end. Friday, my lightest day, nonetheless may remind me that if I had more expressive activities up my sleeve, I might better assist a boy in foster care who appears to lack the words for what he may feel.

I have hesitated over the subtitle, “My So-Called Therapeutic Life,” because to some extent it feels self-indulgent. First of all, yes, these are first-world problems. Second, I’ve had some truly amazing therapeutic experiences, and have been in awe of many of my clients and the challenges they overcome. I’m grateful for the chance I’ve had to start where I started and do the work that I’ve done. But I decided to include the subtitle because, as my colleagues and anyone who has ever worked in an agency all seem to agree, the pressures are such that there is little sense of grounded, focused, therapeutic practice. To summon the energy to try and create that experience for clients from hour to hour, can be exhausting and sometimes unrealistic.

I love reading. I love learning. I love doing good work. But, as it happens, I couldn’t live much better than hand-to-mouth on what I’m paid, in the part of the country where I currently live, and the stress of that is too much for me. So, when I leave my agency, it’s not to go home and read, but to race to another job, where I spend evenings and weekends. I average 65 hours a week, and it’s sometimes been up to 80. Additionally, in this milieu, we are buried in avalanches of paperwork, so I’m often working from home to try, in vain, to catch up. When I have free time, which is rare, I almost don’t know what to do with myself, despite a healthy number of outside interests. But I’ll tell you this: lately I spend most spare minutes dreaming of the day when I can leave my job(s) and start living another, more fulfilling kind of therapeutic life: one in which I can rest, nourish my spirit, and educate myself to better serve clients who are not stuck with me by lottery, but who elect to see me week by week. A life, for me and for clients, of choosing and making.

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I’m deeply grateful for my readers, and in 2018, 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.

Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. Text and image copyrights held by me. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you, and best wishes for (finally!) Spring.