One reason we have so many disagreements with each other is that there is Big Truth and little truth and we get mixed up over which is which.
There is the Truth (I walked towards you) and the truth (I lunged at you aggressively, I simpered as I tiptoed to you, I drunkenly veered your way). We both may agree on the Truth (I did indeed move from one end of the room to the other end of the room where you were standing) but we may violently disagree on the truth. You might say I deliberately tracked mud onto your just shampooed carpet. I might say that I was in a hurry because the phone was ringing. We might both be right. We might both be wrong.
Clearly, truth telling can create a lot of conflict.
So much of our struggling in our relationships has to do with telling our truths and denying your truths. We get hung up on specifics and never get to what’s really wrong. We are so busy defending our truth (You did call. You did not call. You never call. Well, you’re never home.) and so we argue argue argue but we never make any resolution.
A long time ago there was a woman at the shelter where I worked who was a liar. She had a very complex, very disturbing story about abuse and it was clearly not true (nor was she delusional). One of the case managers got a little obsessed with trying to get this woman to admit that the story wasn’t true but the rest of us felt (and told the case manager this at the weekly staff meeting) that what was True was that this woman felt victimized and harmed and wanted/needed attention around that. Now mind you, we were an emergency shelter so it was not our job (or our expertise) to counsel but we felt that what was more important than forcing this woman to shed her truth was to figure out how to help her within that truth so that she could get to the next place — secure housing, real therapy, etc. This haggling over details wasn’t getting anyone anywhere.
So the truth is not always True and the Truth doesn’t always matter.
Sometimes counseling is mucking around in truth and listening hard and honestly? To me it can feel a lot like writing an essay. If you’ve done any writing then likely you know how you write into what you know that you didn’t know you knew. (My favorite quote about this is: “How will I know what I think until I see what I say?” That’s E. M. Forster.) That’s how counseling can be, too. Just as we write to understand ourselves and the editor helps the writer (myself or others) in the process, so in counseling there is that storytelling structure.
So you can show up at a counseling office without any idea of what you’re thinking because part of finding out what you think is seeing what comes out of your mouth.
The counselor is a lot like an editor helping you make sense of your story. You don’t have to understand your story when you come to the counselor because she’s not listening for The Truth, she’s listening for your truth and seeing the big structure so she can ask the questions that will help you understand your experience.
Ok so I told you that counseling does indeed work but I haven’t told you why it works. When I got my first clients and had been working with them long enough to see change happening, I went to my supervisor and said, “I don’t know why this works. Maybe it’s magic.” Because I went into it thinking that I was going to have to give advice or direction and instead I found that my clients were more likely to make real progress when I didn’t do those things.
This is a rookie therapist mistake, trying to make something happen in every session. See, it’s easy to catch the client’s anxiety. If a parent is coming in feeling pretty desperate about things needing to change and you’re the therapist focusing on her, it’s easy to catch her desperation. Especially if at the end of a tearful intake she looks at you and says, “Please help me.” But what the therapist needs to do is to tune in empathetically (feeling and acknowledging the client’s desperation) without letting that desperation become hers. That’s why you’ll hear therapy-type folks talking about countertransference — that’s when we let your stuff become our stuff or trigger our stuff and an ethical therapist is always on the look out for it. When a client looks at the counselor and says, “Please help me” the counselor needs to remember that her job is to help the client save herself because doing the saving for our clients is a short-term solution that can often do more harm than good.
Anyway. Back to my “maybe it’s magic” feeling. Of course counseling isn’t magic but it sure does feel like it when it’s working. When I have a great session with my clients I feel like we’re in the flow together. I can absolutely feel that magic happening.
There are three elements that bring the flow: The Client, The Therapist and The Therapy. This time around I’m going to talk about The Client.
Obviously the client has a pretty enormous impact on how her therapy goes because it all starts with her. All of it. She has to be open to it; she has to believe in it (or be willing to try to believe); and she has to work. Counseling isn’t easy. It takes a lot of self-reflection and willingness to change and we all know that change is hard.
Counseling can start working way before the client shows up at the office. It starts when she first thinks about getting help. To do that, she has to be able to say, “Enough is enough. Things need to be better.” That’s a big thing to say. Then she has to find a therapist, then make the call, then make the appointment and then make every (or almost every) appointment after that. She has to open herself up to trusting the therapist and the therapeutic process. Probably only about 95% of the therapy happens in the office because the client has to take what she’s learned out of the office and apply it to the rest of her life. And she has to do the changing. I may get to be there with her for part of it but then my clients take that magic we create together out into the world and the big life-changing epiphanies, those happen on her own time.
Sometimes a client comes to me because she’s ready to think about change but she’s not ready to do it. That’s ok. If a client comes to counseling and realizes that she wants to maintain the status quo, that’s her right. I still think of that as a positive because I know that life is a journey, not a destination and sometimes our journeys are more meandering than straightforward. What I hope is that the act of getting therapy — of making the decision, of finding the counselor, of making one or more appointments — empowers her to do it again in the future when she’s more ready for it.
When I worked at the shelter we had some clients who came to us more than once (the lifetime maximum per our policies was three visits) because they weren’t ready to work a case plan the first or second time. But I got the privilege of hearing the return clients say, “I know you felt like I wasn’t listening but I was. I took that thing you all taught me and I applied it and now here I am, ready to do what I need to do.”
Likewise I feel privileged to be part of my clients’ journeys even when I’m there somewhere at the start or in the middle of big change and not there at the end. Lemme tell you, it’s an honor. And my goal then is to make sure that their experience in counseling is a productive one so that if/when they’re ready to find a counselor somewhere down the line, they won’t have as many barriers.
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