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.

2 Comments (+add yours?)

  1. Petar Sardelich MFT/PT/MAC
    Jun 02, 2010 @ 17:43:10

    That's a great question too Stan. Am interested too in how we can encourage us to consider these kinds of things more directly in the educational process.Mulling this too, I started to think of how much we get taught that is not wholly relevant (and if that matters). For instance: at this point, besides the first organized body of "defense mechanisms", there is little (overstating) from Freud that is helpful in my goals to get people out of treatment and keep them out of treatment. I can't think though of anything that gets more attention in school than his theories. I appreciate that he is arguably the person that got us thinking most about psychology/psychiatry- but I'm unsure if this is more important than say, a specific body of material of how to do "grief work", helping an addict of some type with denial, or specific skillsets for symptom management of mental illnesses, for instance.

    Reply

  2. stan
    Jun 02, 2010 @ 05:35:55

    couldn't agree more with your 'positioning' above..When I teach a set of clinical skills (e.g. MI), I like to accompany the lesson with a reflective discussion. Last quarter I played a few minutes of Miller and Rolnick, asked students to pay attention to the small details, and then pelted them (gently) with questions about how they deal with rejection….

    Reply

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