OCCUPATIONAL HAZARDS

 

I noticed right away the whiff of chemicals on his coat, but I didn’t want to embarrass or offend him, so I didn’t ask him to hang it up in the waiting room. I thought of him as shy and inward, in ways that might have had to do with poverty and tumult, and I didn’t want to drive him further down into any of that. I did mention lightly that I noticed something, and he told me it was diesel that had spilled on him. I opened the window, giving the excuse that I was warm, while keeping my sweater on. Did he catch that discrepancy of logic? If so, it wasn’t apparent. I liked him but didn’t know if I was reaching him in any helpful way. We sat in long silences together while he sorted out the tactile puzzles next to him. I asked him to name his feeling when he solved one, and encouraged him to notice sources of pride in his life. I told him he deserved to feel pride, and his eyebrows went up—his strongest reaction ever in session, I think. Not because of him, but for the sake of my breath that day, I was relieved when he left. He’d been sitting on a pillow that I knew would never air out; I would have to remove it. The day proceeded. I saw two more clients, then transferred my plants from the windowsill, where the morning sun through the glass is always too intense, to the little table where I sit with kids, and left for my evening job. The next morning when I unlocked my office, the diesel was still eye-burningly thick in the air, and my fluorescent pothos, formerly a glowing green, thick and exuberant with leaves, was at least half-dead—the wilted leaves brown and sickly slick. Pothos rate high among potted plants both for ease of growth and for their ability to clean indoor air; I felt as though this one had taken the hit for the other two plants in my office, and for me. I picked the dead parts off and discarded them, realizing only later that I should’ve photographed the whole plant first, to capture the devastation that had been wreaked, that evidence of ecosystem in action. Then I did what I had to do: I opened my window and sat at my desk to start notes. Absentmindedly I reached for my mug, forgetting that the water had sat overnight, and realized I was tasting diesel fumes that had settled there. I spit into the garbage, rinsed my mouth, washed the cup multiple times in the staff kitchen, rinsed my mouth again, drank filtered water. Every day for over a week, I came in to more dead leaves. At first dark like overripe bananas, then dwindling to jaundiced leaves with darker spots, like burn marks. The foliage sparser and sparser as I pruned and hoped for recovery. An acquaintance who heard about all this, after the fact, said, “Never sacrifice yourself that way again. Ask for the coat to come off.” Well, the boy didn’t wear the coat next time I saw him, which, given patterns of attendance in such an agency, wasn’t a mere seven days later. It got warmer. But meanwhile—just imagine—he’d been walking around like that, breathing that in.

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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.

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.

 

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.

USE WORDS.

 

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.

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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!

 

 

 

 

 

INVISIBLE INK

 

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.

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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. 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!

(UN)PLANNED OBSOLESCENCE

 

“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.

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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!