A Good Intervention

I think as a therapist most of the interventions we try fall flat- even really good ones. It’s a tricky dance of meeting the client where they are in their lives, interpreting from that where they are in a present moment, and inferring from there where they need to be directed to explore. If we ever hit those three things with precision, we still have to have it phrased and timed in a way that the patient can hear and will go with us on. Needless to say again, this rarely turns out as we so eloquently design it to. Every once and awhile, we get lucky. Usually it is not when or where you would expect. Today I had a good intervention where all those factors were in alignment, and I feel that it actually was an important and useful intervention to the patient.

I was in a family session with my patient and her significant other. They were going back and forth about the fast approaching delivery of their child. My patient was passionately trying to communicate how well she had been doing in the program (which she really has) and how committed she is to changing; how hard she was working to beat her addiction, take care of her unborn baby, and fight her mental illness. Her partner was adamantly trying to communicate he wanted to be sure she was really committed and would be there for the baby and his concerns about the new financial responsibilities. I watched them do this song and dance for about five minutes or so. Then I said,

“You two have had this discussion before, haven’t you?” They said,

“Yes, many times.” I said,

“I find usually when we get into these discussions, we do it because there is something specific we are trying to get the other person to say to us, somewhere we want the other person to meet us. We will have the same discussion over and over again, getting nowhere, until we hear what we need to.” Then I asked each one of them by their name, “What is it you need to hear from [the other]?”

They paused for a moment, then said the most profound, simple and beautiful things to each other. The heated discussion became a true cathartic moment between the couple. I know they really did all the work, but my therapist heart felt proud having had a part in facilitating that moment as each person finally heard what they so badly needed to hear from the other. The sweet thing was the other person meant it all along, never knowing how healing a simple string of words were to the other.

“I know you can do this. I believe in you. I support you.”

“I will be there for my baby. I am not telling you, I am letting you know that this is the beginning of me showing you.”

Burn-out, Compassion Fatigue and Transference

I have been struggling with my new job this past week intensely and it has taken me some time to organize my thoughts. This past week my meltdowns have had everything to do with the coworkers, and nothing to do with the patients. That's a good diagnostic tool for indicating a major internal problem for the institution, I feel.

The problem is not that my coworkers are bad people. Quite the opposite, actually. They are wonderful people and I have fell into friendship or rather professional camaraderie with them with ease. I admire them as individuals, I admire their life and professional track records. It stops there. It used to make me frustrated but now I just feel extremely angry on this point.

One coworker, working as a contractual employee (fancy wording for more skilled temp workers) complains constantly about how horrible Johns Hopkins is to work for, how tough our particular unit within Johns Hopkins is, and how it is bum-luck to be a therapist all together. I have deduced from his complaints that really he is unhappy about not having benefits from his contracting management company (transference), exhausted from the number of patients on his case load (burn-out) and running out of sympathy for a population in substance abuse he has based his professional career upon (compassion fatigue).

A second coworker, working into her third year in this unit of Johns Hopkins cannot stop putting down the program she works for as "horrible" with terrible management and as a "ceiling-job" or job you just take for awhile before jump-starting to your actual career. Deducing her statements I found she is just carrying almost twice the caseload she should (burn-out), is rewarded minimally as all therapists are, but with no training to help her deal with this (transference) and with no training on this topic either, over empathizes with her patients to the point where she can be cold and unfeeling towards them and others now (compassion fatigue).

A third coworker, finishing her first year, worked 9 years previously for Baltimore City Department of Social Services. She believes this job to be easy to get and a huge backward step in her career; a holding place for her while she goes to school to get other certifications. I don't need to break down where her horrible attitude is from. All three problems (burn-out, compassion fatigue, and transference) probably happened in her first two months at DSS.

So enter brand new employee, freshly licensed, fresh out of grad school, ecstatic to begin her professional career with Johns Hopkins with other hard-working, highly qualified professionals surrounding her. Finally the hard work, money, hard work, studying, hard work, job interviews and hard work have paid off. In the first month, other than a complete lack of training or support of any kind, she hears from her coworkers she is at a dead-end job that requires no special knowledge, certification or trainings which is basically a holding place for many and a giant step backward for her, working for the horrible agency in the worse employer, Johns Hopkins. Leave it to the new, frazzled and heartbroken employee to be a professional, trained therapist to break down the feelings communicated and deduce the actual culprits. Not Johns Hopkins, not the unit, not the management, but our good old friends burn-out, compassion fatigue and transference. Not that it helps a whole heck of a lot to know this and still be stuck in this horrible working environment.

My sister gave me some good insight to all of this. She said, and I agree, that it doesn't matter who works around you. It doesn't matter what their attitudes are, what their licensing is (or isn't) or how they try to bring you down. What matters in the end is what you came there for: to help women that are in need. Regardless of the qualifications of others, I have to have confidence that my qualifications make me better trained to be able to meet that goal and avoid the three things that so quickly decapitate a less well prepared therapist. Pride be damned!

The ironic thing is, and in school they do not teach you this, the attitudes brought on by my coworkers are transferable to me if I do not pay attention to them and deal with them in the appropriate way. Much as I believe theirs has been, my vision can be skewed to make my own self miserable. Their anger and disdain and negativity can create transference in me of my job only one short month in. Their attitude has the potential to ruin it all; burn me out and get me on board their sinking ship, and in time, I believe that it will. There are only so many times you can be hit and remain standing.

So what to do?

Why, Baltimore?

Why, Baltimore, do you sell drugs for pain and suffering? Drugs for stealing, drugs for sex, drugs for more drugs and money?

Why Baltimore, do you sell drugs to your children and have children selling your drugs?

Why, Baltimore, do you sell drugs to your pregnant women, to your women whom you abuse and get pregnant? To the babies in their addicted mothers who are born addicted?

Why, Baltimore, do you fill your streets with pain and poverty, AIDS and tragedy? Murders, suicides, overdoses and somewhere in between?

Why, Baltimore, do you foster racial hate, sex and gender hate and hate for no reason at all?

Why, Baltimore, do you fill your cold empty streets, your dirty and condemned row homes, your vacant and crumbling buildings with crackheads, addicts and the homeless?

That you helped create?

For those who were born into drugs. Those born into poverty. Those born into the streets.

For those abused by their loved ones, those abused for love. For all those lives ruined by all types of abuse.

For those that know nothing else. For those doing only what they know. For those using all they have ever experienced to stop their pain.

Find yourself out of the pain of the city.

Reach towards those that love you. Reach towards those that will always be there for you. Reach for those who gave you a chance.

Reach towards someone who has been there before. Reach for someone who has succeeded. Reach for someone clean from using, healed from hurting and working for something better.

Reach for those that want to help you. Reach for professionals who give their careers and lives to help you. Reach for programs, reach for churches, reach for caring and safe strangers.

Reach for change and don't give up. You will find yourself in a different city.

Prego Therapy

I had every intention today of going to a cute cafe on the medical campus after work, or even a Borders or Panera closer to home, to sit down, read paperwork, sign up for benefits, and write a thoughtful blog. At the end of the day today I was so exhausted (as immersion into brand new experiences will tend to do to you) that I just went home. And ate sushi with some friends.

By the way, 895 really is the way to go to miss traffic.

After my first two days of training at Hopkins HR department, with my badge and my title and my benefits, I felt so accomplished, big-headed and proud. I am a Johns Hopkins therapist. I am only 25 years old. I was the youngest in my class of professionals in my training. I must have done some things right. I must be good at what I do. Some of that may have been deserved. Some of it was benign and naive happiness. All of it was naive.

Today was my first day on my unit. At the end of the day I felt inadequate, underexperienced, unprepared, adolescent (in my field/ability), and overwhelmed. My new unit is medical unit extended from the main hospital. Complete with doctors, psychiatrists, clinics, labs and an inpatient wing, one of the other wings is labeled "mental health" and is where the therapist offices are. Where my office is. All of the sections of the floors, as in many hospitals, are accessible only by keys and keycards, which we carry with our badges around our necks at all times.

I don't know what the point of this blog entry is about other than to give you a taste of my new work environment and my accompanying fears and uneasiness. The pride and excitement have taken a temporary backseat. I am worried now that I am in this position with so much trust, so much responsiblity, so much influence, if I am too young, too inexperienced and naive to do it well. There is such an overwhelming amount of things to learn and know. There is such an overwhelming amount of things to do and challenges to overcome. I am just realizing the size of the task and high demands of the career I worked so hard to get. I now have to prove to myself that this is where I belong and that I can measure up!

Multiculturalism and Counseling

The article I promised:

An important concern in the contemporary field of psychology is multicultural diversity. This is defined as cultural/racial/ethnical general belief systems; a given set of beliefs attributed to a given society (Sue and Sue, 1999)1. Currently the field of psychology is seen as very Westernized or based on Western cultural values. This presents a problem to practicing counselors as they attempt to apply Western cultural values to a variety of belief systems. The issue is also an important topic in current research. This article reflects upon the recognized characteristics of culture as seen in contemporary psychology and defined by research. It includes my suggestion for a small but important alteration to the concept of culture to better apply the principles discussed in these articles to culturally diverse approaches to treatment in mental health.
Sue and Sue (1999) use clinical examples to divide cultural barriers into three main categories: culturally-bound values, class bound values, and language barriers. Each category represents a group of differences between Westernized cultural beliefs and those of other cultural groups. Cardemill and Battle (2003)2 highlight six main steps to effective multicultural counseling. The six steps include suspending preconceptions about race, ethnicity, and beliefs, acknowledging power dynamics, and continued education about cultural diversity. They suggest that knowledge about cultural issues is not necessarily adequate, and counselors need to understand tactful and appropriate ways to address culture in therapy. Cardemill and Battle emphasize the need for counselors to overcome limitations of their own culture in order to successfully help diverse clientele.
In an article entitled, “White Privilege: Unpacking the Invisible Knapsack” by Peggy McIntosh (1989)3, the predominance of Western culture in daily society is examined in a very different way. Instead of looking at the therapeutic process and how it has been shaped by Western cultural values, McIntosh reveals an alarming list of privileges intrinsic to the cultural majority. She compares the implicit system of white privilege to the operation of the current gender system: males, just like whites, reinforce their unearned power through ignorance of its source. In other words, McIntosh feels it is necessary to fully recognize benefits based on skin color and race in society, before one can change the differential power dynamic.
Psychology can be ineffective for large populations simply due to ignorance of varying viewpoints. It is my opinion that though simple to address through education and application of knowledge of multicultural issues in a therapeutic setting, the basic definition of culture is subsumed in this approach. Given this definition of the problem, I believe a pattern of beliefs and behaviors emerges (see Figure 1). The process is relatively simple. A person has their individual knowledge and beliefs based on their life experiences. This in turn affects the way this person views other people. The way that this person views other people is attributed to racial/ethnical attributes, and generalized to form stereotypes. These stereotypes become widespread and distorted. Due to these stereotypes, the next individual’s viewpoint is altered to include specific expectations based on race and ethnicity. These beliefs reflect ignorance and incorrect information, and need to be changed through an understanding of cultural diversity. Learning about cultural diversity may remove old beliefs, but instates new beliefs which are still tied to race and ethnicity. Therefore, I believe the tendency for this individual to incorrectly assume information about a person based on race and ethnicity is reinforced.
In this way, I conclude that cultural understanding perpetuates the survival of stereotypes based on race and ethnicity (Figure 1). Ethnicity refers to a cultural group to which one is bound by location and/or birth. It is determined by popular practices within a certain region, and the spread of those cultural practices within groups around the world through immigration and emigration. Cultural beliefs based on ethnicity are often related to history and tradition. Race, on the other hand, refers to physical attributes common to a group of people. It is determined by genetics, especially as dominant or recessive traits are expressed repeatedly within certain groups. Cultural beliefs have nothing to do with race, but are often attributed to race by society. It is clear then that when discussing cultural beliefs intrinsically neither ethnicity nor race predetermines systems of belief. Therefore, it is my opinion that it is not logical to include ethnicity and/or race as a basis on which to pin cultural belief systems.
More simply put, though many beliefs have a history and are rooted in traditions, this does not necessarily affect those who chose to adopt a given belief system. Furthermore, the physical appearance of a person has no bearing on what belief system they choose to adopt, other than those projected onto them by society. I feel that it makes sense to separate cultural belief systems from any type of ethnical or racial interpretation.
If cultural assumptions come about due to ignorance, yet they cannot be interpreted racially or ethnically, how are cultural misconceptions and understandings resolved? Just as suggested by Sue and Sue (1999) and Cardemill and Battle (2003): education and exploration. Only a slight modification is needed in each of these processes to avoid the recapitulation of false assumptions (see Figure 2).
Essentially, the beginning of the process of enculturation cannot be changed. What I think can be changed is the approach taken to identify individual cultural beliefs and how they relate to the belief systems of others. My revision is simple: instead of learning about cultural beliefs in relation to specific populations of people based on ethnicity and race, learn about cultural beliefs as extant, general groupings of belief systems. In this way ignorance of cultural variety can be decreased without reinforcing any type of assumptions (Figure 2).
Remember, it is not just that inappropriate stereotypes need to be unlearned, but also that it is necessary to eliminate cultural assumptions completely. Here is an example of a stereotype as it relates to incorrect cultural assumptions:
Ryan grew up in Chicago’s inner city. He lived with his mother, and has never met his father. His mother has struggled to hold down several different jobs simultaneously to provide for both her drug habit and her son’s needs. As a means of coping, Ryan joined a gang and dropped out of school. He dresses in gang-related clothing and paraphernalia. Despite this, he greatly respects his mother, and occasionally attends church with her. What race and/or ethinicity would you assume Ryan is? What are his cultural beliefs?
Ryan is in fact a Caucasian American citizen born in New York City to an upper-middle class family. It is fairly obvious that the example above is an exaggerated stereotype of many minority classes, when in fact this is not necessarily the case. However, after knowing that Ryan is white, does it seem less odd that he goes to church on Sundays? This is because it is assumed he is Christian since he is Caucasian.
The reason this is assumed is for reasons very similar to those pointed out by McIntosh (1989). It is not recognized that certain features and belief systems commonly associated with race/ethnicity can be an incorrect or even detrimental assumption. Cardemill and Battle point out the importance of using cultural assumptions as guidelines only, and that not everyone from a given ethnic or racial group fits within these boundaries. However, I argue that ethnicity and race are completely independent from belief systems, and should therefore be separated in definition.
The second part of resolving cultural misconceptions in counseling is in application. As explained by Cardemill and Battle (2003), knowing correct cultural information is only half the battle. There is another important piece: incorporating that information into the counseling session, to benefit the treatment of the client. Cardemill and Battle (2003) and Sue and Sue (1999) agree that this incorporation step is generally exploration.
I believe exploration involves listening to the client and guiding them in an understanding of their own belief systems. Just as we may not necessarily be aware of our own enculturation, so the client may benefit from becoming aware of theirs. As the client explores and understands their own cultural beliefs, we, as culturally educated therapists can reference the body of information we have acquired about common cultural practices to guide the exploration process. In this way we can be objective, tactful, and more aware of the nuances of belief affecting the behaviors and experiencing of the client. To a certain extent, regardless of cultural values, all experience is unique to each individual’s perception of that event (Figures 1 and 2) and the therapeutic process can only be helped by a better understanding of these perceptions.












Footnotes
1Sue, D.W. & Sue, D. (1999). Barriers to effective multicultural counseling and therapy.
In Sue, D.W. & Sue, D (Eds.), Counseling the culturally different: Theory and
practice (pp. 53-73).

2 Cardemil, E. V. & Battle, C. L. (2003). Guess who’s coming to therapy? Getting
comfortable with conversations about race and ethnicity in psychotherapy.
Professional Psychology: Research and Practice, 24, 278-286.

3McIntosh, Peggy (1989). White privileges: Unpacking the invisible knapsack. Peace and
Freedom, 10-12.

Recant

So my last post was a bit bitter and I realized I probably worried some people that I hadn't been successful in my job search. Luckily the rant has a happy turnaround. Let me take a moment to set the record straight. Finding a full time job is a full time job, but if you put in that much effort, it will pay off. Hopefully my professional experiences at my new place of employment with Johns Hopkins will inspire some new insightful things to say and a revival of my dying blog.

I know I also told some of you I signed a contract to be published in a monthly psychology publication. I submitted my first piece last month, but it may be that the funding for the publication fizzled before the publication got started. We'll see. Either way, I'll try and remember to post the article I submitted in the near future on multiculturalism in counseling.

Until then...

It's a jungle out there.

It has been almost a year since my last post, and for my excuse I say, "It's a jungle out there."

My last post was about a month after finishing grad school. Since then I have invested my energy in advancing in my job and licensing as a therapist. This achieved, I should be a happy 20-something enjoying my young career.

Except that I'm not. For all those living under a rock, let me enlighten you: there are no jobs available. There are no jobs to be found. All the promises in grad school of "becoming a therapist" upon getting your diploma became transparent to me after the first month of job searching with no luck. There are few if any jobs for what you want and those that exist have a horde of applicants so large, you'd have to be Einstein to get them. Good luck all.

Except bad luck all! I deserve the job! Here I am licensed, ready the be therapeutic, without any options. So for all of you who think a grad degree or a license is all the hard work, it isn't. It's just the beginning. Remember the excitement of finally getting into college? Finally getting into grad school? Finally getting your internship? Finally graduating? Finally licensing? Still you have nothing. The most important step: finally having a job.

That pays you what you deserve? Let's just cut our losses at employed.