“It is not that a person makes meaning, as much as that the activity of being a person is the activity of meaning-making. There is thus no feeling, no experience, no thought, no perception independent of a meaning-making context in which it becomes a feeling, an experience, a thought, a perception, because we are the meaning-making context.”
from The Evolving Self : Problem and Process in Human Development by by Robert Kegan
When I am listening to a client, I am listening to understand not just what happened to the client and how she feels about it but what she makes of it. What does it mean to her that this thing happened? How is it impacting her sense of self and the story of her life? On paper, lots of us have similar stories because we live out similar events (we go to high school, we get dumped by a guy, we grow up and move out, we think about getting married and so on and so on) but the meaning we make of those events can be very different. That’s why I never look at a client’s intake and think, “Oh I know what this is about!”
Often we come to counseling because the meaning we make from our stories doesn’t work for us. Bad things happen and maybe we think it’s because we are bad people and deserve to be unhappy. Or we punish ourselves because the autobiography we’re writing as we go is too rigid to contain a crisis we’re experiencing. Counseling gives us the opportunity to write a new, better, more worthy story. It can help us create a meaning that allows us to grow in understanding. Once we become cognizant of the fact that even if we aren’t be able to control what happens to us, we can control how we react, relate and integrate the event into the rest of our lives, we assume our rightful role as authors of our own lives. We can make a sense that serves us and stop being a victim of stories we never meant to tell.
When I first started my internship most of my clients were home-based, which means I go into their homes to work with them. We’ve since had to shut down our home-based program (funding issues — although we still do some home-based work through our school program) so now I only have two clients to visit each week.
I love home-based work. It’s an honor to be invited into a client’s life in that literal way and it also gives me a much more full picture of what’s going on and what’s most important to her. I also really like that it allows people who have many barriers to counseling get the help that they need and deserve. All the home-based clients I have are mothers and all have transportation and childcare problems that make it impossible for them to get to my office. So I come to them — perfect!
But home-based counseling can be complicated. The boundaries are different. Our ethical guidelines state that we can’t accept gifts from a client but can we accept a glass of water on a hot summer day? Is it ok if a client shows up to session in her pajamas? And what about all the things we learn about how to sit and where to sit and how to arrange our office chairs to promote sharing? Where does all of that go when you’re meeting in a client’s hotel room and sitting on the edge of her bed? I had questions about it and I wanted to talk to people more experienced than I am so I pitched an article to Counseling Today, which is the trade magazine for the American Counseling Association. The result, Home is where the client is, is in the September issue but you can read it online.
So after reading that this new-to-me blogger read it, I picked up The Lives They Left Behind: Suitcases From a State Hospital Attic from my library. (Note, if you click the title it takes you to the NYT review and I pretty much agree with the review.)
While the authors spend a lot of time arguing that mental illness doesn’t exist — at least in the patients they’re writing about — they didn’t convince me. Still you don’t have to deny mental illness to understand intuitively that the way we treat (and treated) those who struggle with mental health issues is (and most decidedly was) wrong wrong wrong. I finished the book last night and it was a nice segue from the lecture I attended last night about crisis care. The people on the panel all work for Netcare, which is basically Central Ohio’s emergency room for people having a mental health crisis. People who are suicidal, homicidal or actively psychotic end up there and Netcare acts as a sort of triage to help them get back on their feet. It’s true crisis care and from what I can tell the counselors there act more like social workers. As they talked about their jobs and the (lack of) resources for their clients it was a reminder of what we faced at shelter in the mid-90s. Clearly things haven’t improved since then. There just aren’t enough services for people with mental illness and while I agree that tearing down the old mental health “hospitals” was a good decision on humanitarian grounds, sending the people who need help out into the community without support systems in place was a recipe for disaster.
(It would have been nice if the hospitals had been revamped to go back to their Quaker roots.)
When we were at shelter we’d lament that there was no place to send our mentally ill clients that would just protect them and nurture them and let them be as crazy as they wanted to be. Obviously active suicidal or homicidal ideation needs intervention but many of the clients we kicked out of shelter were no danger to themselves or others. They weren’t mean or scary or dangerous; they just heard voices or struggled with paranoid delusions. They didn’t want medication but they also weren’t able to function (i.e., get a job, secure housing) without it. Some of them were lovely, kind people who just couldn’t follow a case plan. That made them wrong for our short-term, solutions-focused shelter but it would have been lovely if there was more housing for them. There was a very little but no where near enough and the wait list was impossible.
I was thinking of that especially when I got to this passage in the book:
Hearing voices in itself is not a symptom of an illness, but is apparent in 2-3% of the population. One in three becomes a psychiatric patient — but two in three can cope well,” according to Marius Romme, emeritus professor at the University of Maastricht in The Netherlands, and one of the key researchers in this area. “The difference between patients hearing voices, and non-patients hearing voices, is their relationship with the voices. Those who never became patients accepted their voices and used them as advisor. … When you identify hearing voices with illness and try to kill the voices with neuroleptic medication, you just miss the personal problems that lay at the roots of hearing voices — and you will not help the person solving those problems. You just make a chronic patient.”
p. 53 of The Lives They Left Behind: Suitcases From a State Hospital Attic
The text goes on to say that most people who hear voices do so after a traumatic event — a triggering event — and that drugs are only effective in about 1/3 of the patients who receive them. It makes me wonder about helping people manage the voices differently and I’m going to look further into Dr. Romme to see if there is more about this. The text argues that if therapists address the underlying emotional event that triggered the voices that medication will not be needed at all and this may be true for some (if not all) so I’m going to look Dr. Romme up for that, too.
I’ve been mildly surprised by how many counseling theories deny that organic mental illness exists. I’m not talking like a philosophical discussion about how culture defines illness; I’m talking about how some theorists think mental illness is always an emotional disorder. I don’t buy that. I think cultural discussions are interesting (and necessary) but I think it’s pretty dang clear that some people have brains that make them unhappily mentally ill and that for those people the drugs that work effectively are a god send. There is a murky area though when we’re talking about patients’ rights and individual experience. When I think about some of our shelter clients and whether or not it was reasonable to expect them to conform in order to get food and shelter.
Also if you want to see the exhibit that the book is based on, here it is: The Willard Suitcase Exhibition