Wednesday, April 1, 2009

Visceral

An interesting experience today. I am still thinking about it, obviously.

I was working on case management stuff in the office this afternoon and was slightly aware that an issue was happening in the next office over with a client that was endorsing some psychotic features as well as homicidal and suicidal ideation. I let my supervisor know that I was available if they needed help but never heard anything. About a half hour later, I was preparing to leave and I peeked down the hallway to see if everything was OK. My supervisor gave me the thumbs up sign and so I headed for the door. It occurred to me to check on my friend, the clinician dealing with the client, but I dismissed the thought thinking that I would just add to the drama rather than just letting it pass.

As I walked down the hallway, one of our psychiatrists said, "Alison, someone's calling you..." Sure enough, it was my friend. Now I'm kicking myself for not going to her first. I walk into her office to see what's up and she tells me that she just wanted someone to walk out with her. "Absolutely" I tell her. I wait for a moment as she gathers her things and notice that her face is crumpling. Getting red and emotional.

It hits me then that she just had an awful experience with that client. "What happened with that?" I ask. Her tears start fall and she is embarrassed. "Don't tell anyone that I'm crying", she says. "He just got to me." He got to her. My heart sinks for her. I know that feeling. Poor girl. They sometimes have this way of making you feel so vulnerable.

I tell her what I knew of the situation and tell her that it sounded scary enough. "It was that...but there was something about him. The way he was looking at me and he kept talking about voices that were following him. He was just so creepy. I think I got scared that I would be left alone with him." She pauses and then goes on. "You know how sometimes people tell you something and then suddenly you want them to stop, like you don't want to know anything else about them? Like it is too much? He just kept endorsing all these scary things and I just wanted it to stop. I don't want to be responsible for all that."

I shudder and believe her 100%. I didn't see him or even read his file, but when someone makes you react that fiercely, you have to listen. That visceral, gut reaction is so telling. And I think it goes off for different reasons. Sometimes it is a professional instinct. I think in today's instance, though, it was something different. Something more primal--like "you are a threat to me." To see her so shaken, I wonder if it was something about good vs evil. She clearly felt unsafe and threatened after only knowing him for an hour. What makes a teenager like that? I guess I find myself wondering if he was actually evil.

What is it about those people? What makes them so sick? How capable are they of committing the most horrific of crimes? How inevitable is it? How soon?

I am home now but keep thinking about my friend and sorry she had to cross paths with someone that sick in such an intimate way. In her tiny office in the corner of our little agency. In the afternoon when most everyone was already gone. When the snow was starting to fall and the sky turning grey and ominous.

"He's sick and needs help but I don't want him in our program." I'm remebering her saying. Her tears were falling again. "There's just something about him." She tries describing him again. I get the impression this young man knew his thoughts were demented yet almost got a high talking about them.

My friend and I are both small females. Young, blond, kind. Although we have our strengths and belong in this field just as much as the next person, days like today make me remember that we are perhaps more vulnerable than some of our cohorts.

She ultimately ended up cutting the evaluation with this client short "because of the weather" and I'll sit with her when she does the second half of it. My supervisor intervened by grabbing this boy's father and assessing for weapons in the home and making a plan to ensure that this boy would be monitored until he could get more help. This boy's father didn't take my friend's concerns seriously normalized the boy's thoughts. He's not going to do anything, we suspect.

It makes you wonder if this father has become so helpless when it comes to his son that he has to normalize things just to get through the day.

Working in this field does interesting things to your perspective, sometimes. I was telling my husband the other day how happy I get when I see teenagers do positive things because I have started to think that all teenagers are on the verge of spending their lives in jail and/or be addicted to drugs.

At the same time, those of us in the field understand the spectrum of what type of people we can help. Our version of normal. For our agency it's: Conduct Disorder? Check. Substance abuse? Check. Truancy? Check. Criminal behavior? Check. ADHD? Check. Runaway behavior? Check. Bipolar? Check (if medicated). Psychosis? No. Homicidal ideation. Not if active.

So now I say a small prayer for my friend. Heavenly Father, help her forget that scary person. Help that father find the right treatment for this boy. Keep us all safe from the sick people.

Tuesday, September 16, 2008

The Spiritual Dimension

Lately, when I've had extra work time, I've begun reading certain texts so that I can eventually become a better therapist. My supervisor lent me a book, The Use of Self in Therapy (Baldwin, 2000) that I've been slowly tackling. My post yesterday was inspired by a reading from Virginia Satir and today I'm going to quote Carl Rogers, another influential therapist.

In his article, he talked a lot about his career, which has largely been focused on a client-centered approach to therapy. He believes that when a therapist is able to really empathetically, positively, and honestly connect with a client on several different levels, empowerment can happen for the client. I was especially struck by this:

"I would put it that the best of therapy sometimes leads to a dimension that is spiritual, rather than saying that the spiritual is having an impact on therapy. But it depends on your definition of spiritual. There are certainly times in therapy and in the experiences I have had with groups where I feel that there is something going on that is larger than what is evident...sometimes in interpersonal relationships power and energy get released which transcend what we though was involved" (p.36-37).

I think I was struck because I've felt that spiritual dimension enter my sessions with clients and it has caught be off guard. I experienced it a little last night when I took a client to a Narcotics Anonymous youth meeting. Those instance catch you off guard because you wouldn't think that a room full of kids in their fluorescent Nikes, sideways hats, piercings, and war stories would be capable of dialoguing with those sorts of serious, even eternal concepts. The more I think about it, the more it makes sense. There is a larger part to life than we realize and when you loose your potential with drugs or violence, the desire to get your ducks back in a row takes on an existential and spiritual quest.

Before reading the quote, though, I guess I was thinking my thoughts about this issue were purely related to my own personal convictions about the purpose of life. It was interesting to see, though, that a hugely influential and nonreligious person agrees that this type of work has an undoubtedly spiritual element to it. In some ways, accepting that the spiritual dimension is there makes my job a little more daunting and in another way, it makes it an honor to help (or try to help) people in that way.

Monday, September 15, 2008

Inspired

I was just reading an article by Virginia Satir where she discusses the positive use of self in therapy. She says:

"...the therapist's task is to enable patients to utilize their own resources. If I believe that human beings are sacred, then when I look at their behavior, I will attempt to help them live up to their own sacredness. If I believe that human begins are things to be manipulated, then I will develop ways to manipulate them. If I believe that patients are victims, then I will try to rescue them. In other words, there is a close relationship between what I believe and how I act. The more in touch I am with my beliefs, and acknowledge them, the more I give myself freedom to choose how to use those beliefs" (Satir, 1987, p. 27).

I am inspired by this.

In school, I learned how important it is for a therapist/social worker to keep their opinions and experiences out of the helping relationship. The concept isn't complicated--if the helping person is always talking about what they went through or what they think is right or important, then the client/patient muddles their needs and goals with the therapist's. Boundaries get blurred, dependence is fostered and treatment goals become less sincere etc.

However, therapists can skillfully use their impressions, experiences, hopes to further the therapeutic relationship. It becomes a matter of selectively choosing what you want to share about yourself to further treatment. I love the idea that I can empower clients by helping them understand how sacred I believe they are...

Wednesday, August 20, 2008

Figuring Out What to Say

A lot of people ask me if my job as a social worker and therapist is hard. They assume I am depressed by the end of the day or am slowly developing a jaded outlook on humanity. They also try and convince me that people never change or want me to tell them stories that prove how degenerate my clients really are.

But in reality, that is not the hardest part. Sure, there are times I come home overwhelmed. When that happens, I vent to my husband, look for empathy in my teammates, or have a totally mindless night (complete with TV and ice cream). Of course I have stories that shock and I've met people I have little hope for. But those things haven't yet phased me.

What gets hard, though, is being a therapist, having aspirations of being a really good one, and wondering if I'll ever be good at my job. In other words, I worry I really suck. As you can guess from the title of this post, I often have a hard time figuring out what to say. For instance, I was talking on the phone this evening to a dad whose son just tested positive for THC. The son is on intensive supervised probation and has some serious consequences (ie Department of Youth Corrections, ie 1-2 years) that become very likely when mess-ups like these happen. Since my job is to help the youth stay in the home by improving family dynamics, I wanted to approach dad with the perspective of 'your son obviously has an addiction, he can't do this on his own, the situation is dire, he needs you...teenagers try to get away with as much as possible...you might be in a position to monitor him a little more closer and prevent another relapse'

But, of course, the conversation didn't go that way. Dad says, "Good, I hope he goes to jail. When he was in jail last time, I slept much easier. I've been so on edge lately, maybe this will help. Everyone should experience jail. He's almost a man. There's nothing I can do."

Well shoot! I got all tongue tied, as I do whenever I have to rebound after my approach is denied. I also get stuck in my client's problems, which, as my supervisor pointed out, is a terrible place for a therapist. I fumbled through the rest of the conversation, tried to not free dad from responsibility like he was wanting. But this dad had already sad it, ranted on about it, and I wasn't confident that I could change his mind. Maybe I am just too sympathetic. "Yeah", I think to myself, "with a kid that has put you through as much stress as you've been through, you actually might sleep better at night if he was in jail. Maybe jail is really what he needs'

A good therapist is on her feet. She can pull out powerful questions at the right time. In hindsight, those powerful questions might have been something like, "How do you think that makes your son feel to hear you say that you want him to go to jail?" or "You're right, your son is practically a man and yet it sounds like you agree that he isn't making very mature decisions. How can you show him how to be a man? He obviously isn't able to do it on his own quite yet" or...actually...I don't know. I still feel tongue tied. Because at the same time, maybe this dad is past helping his son. If so, I can't expect to change that and feel presumptuous making the assumption that this dad should want to be more involved in his son's life.

And I think that's part of the issue--it is hard for me, in the moment, to 1.) trust my instincts 2.) feel confident enough to assert my professional opinion 3.) assess what the clients are actually bringing to the table 4.) know when it is ok to change directions or keep the conversation focused, no matter how badly the client is trying to steer it in a different direction. Yikes.

I need to learn distance, how to not get so wrapped up in what they are telling me. Keep my mind clear and keep a series of questions that will keep things moving forward. It is a balance between respecting their ideas while helping them grow. Ahhh...that is the hard part. Hopefully this will get easier. If it doesn't, the pressure to figure out what to say will wear me down. I don't want it to and they say that it takes practice and experience yet I can't help but wonder...'What if I'm just not cut out for this?' So, please, bear with me as I get past my insecurities and determine the extent of my abilities. The drive is there, no doubt! Hopefully it just takes a while and isn't something that will always be frustrating.

Monday, August 4, 2008

Sharing the Burden

Sometimes a huge barrier in my work with families is what we call 'the mental health piece.' This means that if moms, dads, or kids have a mental health problem like depression, bipolar or schizophrenia, progress is almost impossible because the individual with the mental health problem is essentially creating a roadblock for the rest of the family.

When that happens, we refer family members to a psychiatrist so they can get a mental health assessment. After the assessment, medication may be recommended or the psychiatrist may other treatment recommendations. If it is serious enough, it may be decided that our program will not be able to adequately address the client's needs. More than anything, the psychiatrist helps me share the burden of how to structure treatment with people that have serious mental health problems.

And why am I talking about this? A few weeks ago, a client admits he has been having suicidal and homicidal thoughts within the past month and also has a plan of how he would follow through with these thoughts if 'it ever got bad enough.' He also had a pretty high score on this legit depression inventory we give all clients at intake. Yikes, right? Right. Then within the next week, a whole bunch of other stressors occur; while he doesn't admit that he is thinking about suicide more, his affect is anything but cheery and I'm worried.

I put in a referral for him to see our psychiatrist (a free service) but the client doesn't want to go and is upset (probably an understatement) with me for putting in this referral. The client's dad also thinks I'm blowing things out of proportion and tries to normalize the kids thoughts.

That sort of conversation is actually really stressful. I am a private person so I totally understand not wanting to talk to a stranger about my most serious problems. YET--the burden of being the only who knows that this kid is having fairly active suicidal thoughts is not fun. In fact, it is rather scary. In addition to worrying about the overall safety and welfare of this kid and his family, I can't help but worry about the liability of having a kid die on my watch. Furthermore, if something (heaven forbid) were to happen, how would I handle the guilt, horror, shame, sorrow, etc while continuing to working in this field? That is the sort of thing you think about as you fall asleep at night. I hope it gets easier as I get better at having those conversations.

Needless to say, when my client showed up for his appointment, I did a jump for joy and breathed in some relief. Knowing that another mental health professional is in the picture to share the responsibility of keeping this kid safe is immensely comforting.

Luckily this kid is OK. The psychiatrist agreed that his depression was serious enough to warrant some professional monitoring on his end, but didn't think the kid needed hospitalization, medication, or something more intense than I could provide. In the month that has passed, his moods have improved as his situation has and I no longer worry about suicide. He has his follow -up appointment later this week and of course, he is mad at me for making him go again. At this point, I don't even care about his attitude. Having someone else confirm my instincts or point out something I didn't know is worth more than I ever realized.

Wednesday, July 30, 2008

Panic (Not Mine)

This afternoon I was working with a family where the mom always likes to remind me that her kid has Conduct Disorder (aka--a perjorative term for a kid who has been through a lot in his short life and is externalizing emotions). There is no doubt that he is potentially on the road towards a misery of antisocial behavior and its ramifications...I just don't like that term. Anyways, school's starting, he has terrible sleeping and social habits, and we were trying to figure out a plan to get prepared for school so truancy doesn't become an issue this year.

I start to suggest limiting his time at the computer by a simple equation of he has to do something productive for an hour a day or he loses an hour of computer time (he spends over 10 hours a day on it). The poor kid FLIPED OUT.

He jumped up, stands in his mom's face, yells expletives at her and his body positioned like he might hurt her. I got up, yelled at him to back off, and moved to separate them (which was probably stupid). Before I reached them he had already left the room and went outside, breaking the screen door on his way out.

That part wasn't a big deal. Sure it got my heart pounding and I was thinking, OK so if he hits her, what do I do? But I've had to intervene in situations like that before. Teenagers get really pissed sometimes. I get that.

The saddest part was 15 minutes later...I finished calming things with his mom and wanted to check on the kid (14) and get him to do a UA for me (yes, I have to collect pee for a living).

The poor kid was curled up in the fetus position on the back swing. I asked him what he was thinking and he just loses it. Starts heaving heavy sobs...I let him cry for a moment but started to worry this was something else when he starts gasping for air and saying he feels funny all over.

From that point on, I just treated his behavior like a panic attack. I've never had them, just heard and read about them, so who knows what was effective. I sat next to him on the swing, patted his sweaty back (does that break the personal space boundary for the therapist of a 14 year old boy?) engaged him in some breathing and counting exercises and told him what was going on in his body and why he was probably feeling what he was feeling. He cycled in and out of his sobs and choking for breath several times, but he eventually calmed. Whew.

When it was over, he let out his Beavis and Butthead laugh and kept muttering comments like "This is probably the most akward thing ever for you, isn't it?" "Wow, you've probably never seen anything like that before, huh?" or "I guess I'm just a pissed off little kid" "I don't know where that came from...I'm really sorry" etc. Embarrassment. The stoic 14 year old trying to make a comeback. I assured him that I've seen much worse and was glad it happened in front of me because I now I know what emotions are really running through him. We created a plan for if something like that happens again and I was gone.

I guess I'm writing about this because it was a little shocking. I'm still so green at this job that I haven't seen it all yet. He's a tall lanky kid, wears a lot of black, and has a way of glaring and rolling his eyes that you would not believe. Sometimes I've wanted to pull a Homer Simpson move by ringing his neck and saying "Why you little..."

But then the contrast of tonight. The fetal position and tears. Hearing him talk about the only reason he's living where he's living is because his dad beat the sh** out of him and he didn't want to deal with that anymore. Can you blame him?

So...now I am trying to figure out what our next step is. How do we address his anger, his anxiety, his need for control while not letting him get away with everything?? Teaching his mom to be the comforter instead of me? Thank goodness for supervisors and team members. My work is cut out for me.

Friday, July 11, 2008

Court

Juvenile court is shockingly informal. People come in and out of the courtroom at will and huddles of people are everywhere...in the corners, the doorway, the pews. I'm usually part of those huddles, consulting the adolescent on what is happening, what the judge will be looking for, how the attorney will bargain...the guardian ad litem (the court appointed legal advocate for the youth), the caseworker, and the defense attorney usually do all the speaking. I sit back since the court is their arena for progress and the home is mine. At the very least, I try to say something strengths-based to the family; listening to the "professional team" as they point their fingers at all the changes that haven't been made gets old.

Anyways, the courtroom is loud and chaotic, nervous energy emanates from kids and parents. I understand that energy, I feel it for my clients sometimes. Will they been taken away to detention? Will the judge order work weekends, community service, question the youth's safety in the home? Sometimes you see the defiant teen, more concerned with their style than their charges. Sometimes there's the tired parent, almost hoping the court system will make their lives easier by enforcing a harsh consequence on their child. On some levels I understand where they are coming from and on another, I am a complete stranger.

As people come and go and talk in huddles, a trial or court review is always happening, too. When I first started going, I wanted to listen to all the stories and study the expressions of the kids and parents as they faced the magistrate...now I've accepted the fact that it is too noisy to understand much and it isn't really my business. I don't know if I'd want everyone hearing about what I did and/or why I can't just shape up.

I always get a pang of pity when the kids from detention show up...they wear green jump suits and their wrists and ankles are in shackles. No make up, hair products, fancy shoes, jewelry...none of the embellishments that the rest of the adolescents in the courtroom thrive on. They are led in by a police officer and told to sit on the benches to the side of the magistrate, removed from everyone else. The police officer remains by their side, just in case. Whether they look terrified, resigned, angry...they all look so young. Babies, really. Their immaturity gets me every time; I find myself always wondering how much responsibility they should be forced to take for their crimes. There's something depressing, chilling, and horrifying about seeing a child locked up.

I know I'm the bleeding heart, giving everyone the benefit of the doubt. That's why I do what I do, I get to be one that points out what they do well, listen to their goals, look for exceptions. It is flawed, I know. People hide things, history repeats itself, and you can't force change, even though the courts mandate it. My couple hours in juvenile court every now and again make me proud to be the court appointed optimist.