What We Don’t Get Taught

Have been lucky enough to do some clinical supervision with Judy McGehee.  As I’ve mentioned before, she and some interns have been providing free services to their community for some time now.  Some concerns I’ve had with other venues of supervision have come up the last couple of times we’ve met.

Clinical supervision, like therapy, is different things to different people.  Many times it’s the opportunity to “present cases”, problem-solve clinical, legal, ethical issues and etc.  It’s also a place for us to have the opportunity to discuss or work out struggles we have as therapists- something that certainly should go on for our entire careers.

One of the things I like to do in supervision is talk about the issues that are not necessarily explicitly processed when we go to school.  There’s lots of these sorts of concerns…  how to deal with our own feelings as therapists.  Issues of responsibility- where ours are vs. where the clients’ responsibilities are, how much is “enough”, concerns when we’re sometimes working harder than the client is (or not).  Handling boundaries about parents endeavoring to influence issues discussed (or simply perspectives about them), concerns that arise in couples therapy or family therapy like one person in the “group” disclosing something that affects the others outside of the “group” proper.  How to handle when a client isn’t being honest about a problem or circumstance or behavior.  Determining how to handle “terminations”- planned discharges, “therapeutic discharges”, discharges against medical advice… sometimes when a child is “pulled” from treatment by a parent against the better judgment and suggestion of the therapist.  Speaking of, there is little discussion about how to handle referrals to other types of resources or therapists.  Specific methods to avoid (or deal with) “burnout”.  Very “nuts and bolts” concerns like documentation, treatment planning, dealing with insurance companies and such.  Fee setting.  What to do if a therapist runs into a client outside of the office or other milieu.  How to handle when a client is “stonewalling”. Handling clients that are self-medicating.  My personal favorite is specific goals and underlying philosophy of our methods as therapists.  There are many, many more.

It is of course really important to do case conference, have both group and individual forums for processing what is happening with specific clients or groups and the like.  I find it of great import too however, to discuss the above issues.  It is one thing to discuss a specific case, but I think it another to discuss what it is about that case that will come up (or has) repeatedly, in a principled manner.  Would argue too that discussing issues like responsibility, boundaries, terminations, referrals etc often lead to greater resolution with clients “in the room”, as well as provide a way of generalizing our knowledge and methods, thus making it a more organized and effective way of treating folk.

Am not suggesting that these things never occur.  It has definitely been my experience however, that most of the above ideas are not discussed in depth, if at all.  Certainly concerns of symptom ID and management, differential diagnosis, theoretical orientation and etc are of great import, but it is uncomfortable and counterintuitive to run into a circumstance that occurs frequently or that is a fundamental part of operating in our discipline (treatment planning, for example) that is largely omitted from our education.

More than anything else, I think I’m advocating for more of a focus on our underlying philosophy for employing the methods that we do as therapists.  I’m not simply trying to help someone (or their parents) improve failing grades, or get someone in a relationship to be more sensitive or attentive, or even to diminish “depression”.  What I hope to achieve in most (most) circumstances, is to:

1.  Insure safety and stability necessary to do “The Work”.  (absence of suicidality, abstinence from drugs, ETOH, or a behavior, have medical concerns be ruled out by a physician, insure that necessary resources to do the work are in place, etc)

2.  Identify “issues”- the events (relationships, circumstances, etc) or other causes that prompt us to feel mad, sad, afraid, ashamed, and/or hurt and/or “behave” in ways we struggle with.

3.  Process those issues in a way that diminishes, transforms, and/or (almost) eliminates them and subsequently behaviors, choicemaking, or perspectives that might contribute to these issues in an ongoing way.

4.  Provide a “body of material” (patient education, referral sources, resources etc) that enables the client to be able to do these things without the therapist.

5.  Insure that the client has sufficient resources (support groups, family, friends, etc) that support the work and use of that material in an ongoing way.

These are an oversimplification, but I think they go beyond simply “resolving a problem”, eliminating a behavior and etc.  Much of the inner workings of these ideas don’t get processed as much as I’d hope while we’re being educated about our discipline, but again, of course this philosophy likely exists in many of our “theoretical orientations”.  In my sense of things, the presence of such a philosophy doesn’t go far enough- we as individual therapists need to have a grasp of our own sense of these things to make them as effective as possible.

Would say further that none of this is supported unless part of our own supervision is about dealing with our own experience both as a therapist, and a person outside of therapy.  My ability to problem-solve many of the issues “not discussed” above is diminished by not having the opportunity to explore these things as part of our own clinical supervision.  The largest of these things for me are the underlying treatment philosophy, and the effectiveness and grace that I deal with my own life- including my life as a therapist.

Honoring What Is.

Laughing to myself a little now because, though I intended to write about honoring our feelings and “sense” (perception?) of things, was quickly reminded of how hard it is to know how we feel in the first place.

That aside, the idea of “honoring” our feelings has come up a lot lately.  Am assuming we’re in a place to know how we feel to begin with.  Don’t run with this idea and think honoring our feelings is in conflict with my earlier suggestions that our feelings aren’t necessarily facts.  Paraphrasing one of my “heroes” (though he’d certainly admonish me for having any heroes in the first place, particularly him…), Sheldon Kopp has noted along with so many others (Tolstoy, Jung…) how curious it is that we spend so much time and energy actively not honoring our experience of things.  In favor of doing so we dismiss our feelings, compare our insides to others’ outsides, diminish the importance of our feelings (sometimes by comparing ours to what others have been through), distract ourselves (food, buying, drugs, sex, alcohol, TV…) and etc.

The consequences of not honoring our feelings are huge.  It can cause depression, acting angry (as opposed to being angry), addictions, irritability, not acting as the person we’d like to be, allowing people to violate our boundaries, is a huge factor in a lack of self esteem and more.  It can cause us to not trust our own eyes and ears when we maybe ought to.  It can keep us in relationships that are not healthy for us.

Honoring them is arguably as difficult as not honoring them.  It’s likely one of the primary reasons we don’t honor them.  For many of us, it’s not even an idea we’ve really considered.  Much could (and will, eventually) be written just about how to have our feelings in the first place.  Once we do have them though- honoring them and doing so gracefully is a very difficult challenge.

From my sense of things, “feelings” are called that for a reason.  It’s so tragic that we behave in a way that indicates we often think we ought to do everything possible with them besides simply having them.  They’re called feelings because we’re supposed to feel them.  They give us messages about our environment and allow us to heal.  Feeling them and not “folding, spindling, or mutilating” them is the first step.  Once we have them, giving them a name is useful- I always begin with encouraging mad, sad, glad, afraid, ashamed, and/or hurt.

Am also a huge fan of treating them gently once we have them and have named them, whether they “make sense” or not.  Not being gentle with them exacerbates them, or simply prompts us to change or otherwise avoid/ignore them.

Once having them, naming, and being gentle with them, we’ve begun to honor them.  If we know we have them, know what they are, and are experiencing them without trying to do something unkind with them (make other people see/think differently, harming ourselves, avoiding them with some of the behaviors above and more), we can process them based on what they are.  Crying when we’re sad or hurt, are pretty clear ways to honor our feelings.  Telling other people what is happening for us when we feel ashamed (some say “guilty”, or less than, broken, etc…) honors our experience.  Telling other people how we feel honors them.  Asking people to be with us when we’re scared or feel broken is a great way to honor our experience of things.  Being mad instead of acting mad (a subject for a whole other missive) is a way to honor it.

We don’t honor our feelings in relationships either.  We’re loyal to people that are disloyal to us.  We treat ourselves more poorly than other people often do, but when we do get treated poorly by others, we oft treat them more gently than we do ourselves, or ignore it wholesale.  Though we may get our feelings hurt about something, we keep it secret.  Sometimes we are sad or hurt or ashamed or angered by something, but keep it from the other person as not to hurt their feelings, but are often taking from them the chance to do or see something different.

Sort of wishing I hadn’t begun writing about this particular thing.  Honoring our feelings is dependent on so many things- not doing things to get in the way of feeling them, having simple names for them, having them gracefully, treating them gently, not thinking or communicating about them as facts, processing them.  So much might be written about any of those ideas.  It’s come up so often recently, and is such an important idea though, am compelled to put at least something out there about it.

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