There is a story here—but one, as yet, with no words.
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.
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.
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.
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.
A significant part of working with children involves working with family systems, and in community mental health, that often means contending with inter-generational trauma. I don’t think anything could have prepared me for the reality of that; I, under excellent supervision, expend a lot of mental energy trying to factor caregivers’ own personal issues into their choices with kids, adapting my message to what they can hear and take in at any given time. After all, if caregivers feel criticized, the likelihood of their support for therapy drops significantly, and change is unlikely to happen. Sometimes that means trading no change at all for painful slivers of increments. And sometimes, let me tell you, that trade becomes deeply sad and demoralizing. Like this month. Like this in-like-a-lion-and-the-lion-keeps-roaring March. I’m feeling spent by the effort of starting over every bloody session, and I just want to be mad and let it out. Indulge me?
If you are caring for a child who was born in withdrawal from drugs, abandoned, passed around, and abused in every possible way, and as a result lacks a sense of appropriateness and has a bottomless need for attention, please observe the following don’ts, in no particular order:
Don’t refuse to tuck her in because she hasn’t made her bed. Don’t deny her a birthday because you don’t like her behavior. Don’t send her to her room when she’s having a meltdown; don’t film her while she melts down further, desperate not to be rejected and alone. Don’t show the video to people and shame her. Don’t show the video to a therapist and expect sympathy for YOU, the person impassively holding your smartphone up while her struggle plays out. Don’t claim you’ve tried everything, because you haven’t if you haven’t rocked and cuddled her. Don’t expect her to act her age when that’s developmentally impossible. Don’t automatically take others’ word against hers, every time, not even teachers’; teachers see a lot, but not everything, and they aren’t always right. Don’t condemn her for craving electronics when you yourself bury your head in “Candy Crush” and other less important things when she’s trying to make eye contact with you. Don’t justify that by saying that she always wants attention. Don’t reject the games she likes to play with you. And speaking of games, don’t show mercy to other players but gloat (“Ha-ha!”) when you get her out, thinking you’re teaching her a lesson about fair play because, you say, that’s something she’s done. Don’t tell her it serves her right if she falls because she sat on a chair the wrong way. Don’t tell her she can’t have friends because she doesn’t know how to behave. Don’t tell her teachers, in front of her, that she’ll try to manipulate their sympathy. Don’t say, “We love you, but.” Don’t say you’re thinking you might not be able to keep her. Don’t say 100 no’s for every yes. Don’t miss every single chance to validate what she’s feeling, even when her therapist has explained quite clearly, with relatable examples, that validation isn’t agreement. Don’t take her to therapy, an hour a week, no matter for how many years, and expect the therapist to undo the damage of life in an unloving home. Don’t blame the therapist for failing, when the therapist is working hard to help the child feel like she matters. Don’t tell the child in your care that your life is shitty because you’re caring for her.
Sympathetic readers might appreciate the haunting song “Nearly Midnight, Honolulu,” by Neko Case. Thank you, Neko Case, for your vision and your songs. // 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. “The Numbers Game” (July 2017), now long delayed, will be continued in a future post, when I have more stamina for the topic. Thank you wholeheartedly for reading.
So I work with kids. I work with people who work with kids. In my free time, I read books about working with kids. I don’t, however, always drink the Kool-Aid. For example…
There are few phrases I find more inherently condescending than “Use your words.” This expression, all too common in English, is intended as a prompt to children to choose prosocial ways to communicate their wants and needs. At the best of times (which is by no means all the time) I think it’s meant to be empowering, a kind of “Go, you!” coaching. Even where the aim is worthy, though, the method makes me wince.
No caregiver enjoys tantrums. Kicking, flailing, screaming, wailing—that’s misery for all concerned, including children themselves. Just as newborns feel safer when swaddled, children are significantly happier when they’re regulated, i.e., in control of themselves.
In community mental health—where so many of the kiddos we see start their lives already burdened with trauma—tantrums can be even scarier, leading to assaults and destruction of property. One little boy I know, in the midst of a recent fit, climbed to the top of a fridge to grab the butcher knife kept there and threaten his family.
When children have facility with words, not only are they better able to make themselves understood by others, but they are also better equipped to make sense of events and form lasting memories. Thus the importance of reading to and with children, and talking over events both before they take place (in preparation) and after (to create narratives).
It has been demonstrated through studies that children from variously disadvantaged backgrounds typically hear far fewer words a day than their more secure counterparts—yet another way that inequality is perpetuated, making social strata more difficult for some to climb. Literacy programs seek to work against that pernicious trend.
“Use your words” is meant to work against the trend of tantrums, storms of tears, sullen silences. Does it? I haven’t seen the evidence. I know I have a contrary, independent streak and tend to want to kick over any traces that harness me to someone else’s direction or notion of labor; but from my perspective, the expression feels more like an impatient, insensitive dictum from on high than like a loving and truly attuned and listening encouragement.
Anything can be co-opted; but think of the ease with which grown people say “Use your words” to one another, with the explicit intent of being snide. If I were still a child, I wouldn’t have the words to say how I felt about hearing that from an adult, but I know it would make me feel as though the person speaking were asserting an unwelcome and invasive authority over me. How do you know what words are my words? What does it mean that you know, when I apparently don’t?
Another way to think about it is that in saying “Use your words,” the adult is often (and often unknowingly) simply outsourcing the hard work of relating, to the person least qualified to do it. “Use your words, as I wash my hands of this.” If words themselves are the point, why not just leave it at that? Would that not suffice as a reminder? “Use words” says much better, “Remember there’s a tool at your disposal.” Adding that possessive pronoun just raises questions about what the hell is meant, and who really owns what.
From a neuroscientific perspective, a child in a tantrum state or weeping fit needs first and foremost to calm down physiologically; the brain is not capable of cool reason and logic in a heated HPA cascade. And the way to calm a child is to love that child in ways the child can feel—to be patient; to touch if touch is welcome (or required for safety) and give near and supportive space if it is not; to offer sympathy for the strong emotions, via reflective statements. Not only does this demonstrate concern, but it models the exact behavior that’s desired: the positive use of words to communicate during a difficult time. When adults use their own words in prosocial ways, children are more likely to do the same.
Two excellent resources on working effectively with children are The Whole-Brain Child by Dan Siegel and Tina Payne Bryson, and How to Talk So Little Kids Will Listen by Joanna Faber and Julie King. I can’t recommend them enough!
Now: 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. “The Numbers Game” (July 2017), now long delayed, will be continued in a future post, when I have more stamina for the topic. Thank you wholeheartedly for reading!
We were walking together alongside the building when he veered away from me to climb the perimeter of an unused loading dock. He had done that before, on another walk, and appeared cheerfully confident of my discomfort as he placed one foot before the other on the concrete edge, tightrope-style. Dismissing my worries about his safety, he compared me to his granny, who was his guardian and whom he described as “your standard, everyday grandmother.”
Well, I didn’t correct him on that point; for a kid with his background, being able to take a caregiver for granted is a hard-won luxury. However, I can tell you, she was anything but ordinary. For one thing, she was actually his great-grandmother; her early life unfolded against a backdrop of WWII, yet she was still working full-time and ferrying kids to after-school activities when I started seeing them.
Before she obtained custody, she drove to Jason’s house each day—never knowing what she would find—to take him to school. Without her, he wouldn’t have gotten there, neglected among adults whose lives were given over to pills and needles. Now she was raising him. On a rainy afternoon, as she and I were chatting, I glanced down and noticed matching holes, big as silver dollars, worn into the top of each shoe; she laughed as she admitted she was too busy to try on new ones.
It’s thanks in no small part to her, I’m thinking, that Jason was able to hold his own in the world. His bravado on the loading dock notwithstanding, he had at least one quotidian fear that could send him into a panic. Perhaps that’s why it was tempting for him to show off a bit of fearlessness with me—it was probably empowering for him to scare me in that little way.
Someone had given him a pen that wrote in invisible ink. He brought it to show me once, and was writing secret hieroglyphs on the waiting room walls when I walked out to greet him. They would only be visible in purple light, he said. I think about that, and I think about his history, which he wasn’t inclined or equipped to discuss. Hopefully that exploration would happen one day. So much of our lives are written in invisible ink; it takes the right kind of light, shone in the right places, to reveal what is hidden in plain sight. At its best, counseling can shine a soft violet beam—which is, in fact, a careful reflection of a client’s own light.
Late November is meant, in my part of the world, to be a season of gratitude. This year I feel grateful on Jason’s behalf for the care I saw him receive—for the memory of his great-grandmother’s hand ruffling his red hair as she said, when I asked how his week had been, “He’s a good boy.” And I’m grateful for the invisible heart he drew on my hand. Despite innumerable washings since, it’s still there.
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. If you enjoyed this piece, I hope you’ll consider sharing it. 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. “The Numbers Game” (July 2017), now long delayed, will be continued in a future post, when I have more stamina for the topic. Thank you for reading!
“Therapy is not meant to last forever,” I tell my kid clients during our first visit. After inviting them to express their feelings about being brought to counseling, I ask them to think about how they’ll know when the work of therapy is done. What will have changed for them?
In asking this, I hope to empower them and shape our work according to their priorities, not necessarily, or only, those of their caregivers. After all, change requires buy-in. Simultaneously, it is my way of planting a seed for one of therapy’s most important flowerings: the good goodbye.
Everyone can expect to experience loss over the fullness of a lifetime; but childhood, for the clients we see in community mental health, can already be replete with losses both clear and ambiguous. Parents especially seem to disappear, in the county where I currently work—into jail, substance use, other towns and states, other relationships and families, mental illness, accidents, suicide, and even death by homicide.
Such loss is complicated in untold ways, with impacts on identity and self-esteem, attachment, concentration, decision-making, moods, stress, coping style, and the immune system. A positive therapeutic relationship, while not “fixing” all that’s gone before, can be a corrective experience, providing safety, reliability, tolerance and adaptability, support and regard, healthy boundaries, respect, and (crucially) warmth. I would contend that when therapy “works,” that corrective quality is the main reason why.
Bringing closure to all the relating that’s come before, the good goodbye is one that is anticipated, planned for, and—though there’s room for sad feelings as well—celebrated together as an accomplishment. I like to provide client-specific “transitional objects,” small items that can carry forward the memory and meaning of our time together. I’ve given skeleton keys, worry stones, figurines, feathers, memory books, and (so far) one mixed CD, all accompanied by notes or letters of congratulations. One spunky little girl I see has already requested brownies, though the end is not yet in sight; for a teen with a love of savory sweets, I made rosemary shortbread.
Needless perhaps to say, all this preparation is as much for me as for the client. I, too, experience some attachment in my work with clients, to varying degrees, and the good goodbye helps me to find closure for work that has impacted me as well. (In The Body Keeps the Score, Bessel van der Kolk espouses the belief that clients can’t grow and change if they can’t see their impact on their worker; I’m hopeful that my clients can see theirs on me.)
The good goodbye is also a corrective experience for me for other losses, both personal and professional—those goodbyes that never resolve. When denied it—when, as happened late this spring, a favorite client simply drops off the map, our work together feels as open-ended and prone to fraying as an unfinished hem. Though coached by colleagues to trust and let go, it is hard not to comb over my memories of our last visit, for possible clues. Did an errant remark cause pain or offense that the client or caregiver wasn’t comfortable addressing?
It’s impossible to know. Some clients aren’t good about calling under any circumstances, let alone the momentous ones that announce the end. My lost client had made radical progress—was he just doing well enough that he felt he was done? Although I give all credit to him and his mom, did disappearing feel necessary to him, in order to own his gains? Or could it be that a lack of experience with healthy endings might have caused him and/or his mother to dread the emotions of closure? When people protect their emotions, it is often (and often unwittingly, though not always) at others’ expense.
In any case, I send my best wishes to him.
Out of respect for client privacy, names here are always changed or omitted. Text and image copyrights held by me. If you enjoyed this piece, I hope you’ll consider sharing it. 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. “The Numbers Game” (July 2017) will be continued in a future post, when I have more stamina for the topic. Thank you for reading!