About facing the shadows

Interests: Christian faith, therapy, incarnational living, simplicity, social work, middle east, languages, intentional community, cycling, and motherhood

Parenting Parallels to Therapy

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As a parent I have noticed there are a number of different camps in parenthood literature: ones that espouse behavioural modification shaping (i.e. cry it out in terms of sleep) and others who espouse attachment/ child-led philosophies that tend to emphasize the child’s innate ability to know what they need and face natural consequences. As a parents I have found wisdom in both of these camps.

Similarly in working as a therapist I have found competing theories in working with clients with what psychiatrists often call “behavioural issues”, or “personality disorders”.

These are clients who for whatever reason (often poor attachment growing up, but not always) employ coping mechanisms that keep them stuck in a negative emotional state over the long-haul and often involve intensive contact with the psychiatric system. Some approaches demand a very rigorous and structured approach, and others espouse a focus on the creation of re-creating an attachment relationship over many years in therapy.

In working with these clients, you are often presented with dilemmas familiar to being a parent to a child who has temper tantrums, misbehaves at school, or directs anger inwards at themselves. How do I respond to problematic behaviour and strong emotions in a way that shows love and respect ? How do I respond so that I do not inadvertently make the problem worse rather than better ?

However, unlike parents, I do not have the same amount of time, nor even trust with such clients; I might see my client one hour per week, rather than working with them 24 hours a day. In addition, the clinical situations I face require decisions that force me to balance the risks between encouraging positive change in the long-term, and short-term safety risks (i.e. suicide). I am usually the most recent therapist of a long list of helpers and caregivers that have tried to help them and have given up, left for other reasons, or passed them on to another care provider.

I am by no means an expert in helping these complex clients, but I do care about them and would aim to work therapeutically for their benefit and recovery.In my effort to try and be a contributing force for good in the my work I hope to actively process reflections from various books on this blog, beginning with “Doing Dialectical Therapy” by Kelly Koerner (2012).

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Never Insight Alone: DBT Therapy

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In Doing Dialectical Behavior Therapy, Koerner (2012) asserts states that “You’d never consider insight alone to be enough to change your golf swing or paint with oils.  Yet we often think that insight alone is somehow enough to change the complicated, highly habitual maladaptive behaviors of regulating emotion.”  

 What this means essentially is that understanding that what you’re doing is not working is not enough to change what your doing; you need to be taught and practice a lot. 

Similarly, telling someone what to do without actively assisting them to act out new skills can set someone up for failure.  However, even the act of learning a new skill needs to be handled with care to provide validation for their efforts and inherent value, especially when techniques to handle emotional pain aren’t performed perfectly the first swing. To do this you not only need to have the right information but deliver it in a wise way, like an excellent coach. 

Growing up, many of you played team sports; more often than not the coach would be a parent volunteer.  However as most of us know, there were good coaches, there were bad coaches and there were excellent coaches.

I had an excellent soccer coach throughout my childhood.  A tall lanky British born man with a distinct accent; he had nicknames for all of us.  He was no softy, but always explained his rationale “If I’m yelling at you on the field, it’s not because I don’t like you or am mad, it’s that I need to you to hear and respond quickly”.  This explanation helped poor sensitive spirits like myself.  He had a way of honing on your particular talents and garnering enough encouragement to keep trying at something that you’d failed at 100 times. For example, he knew I had a knack for heading the ball, and always stationed me near the net at corner kicks, despite playing left defence.  It was because of his coaching I eventually did score that way in a provincial championship game.   I can’t say that I didn’t shed quite a few tears on the soccer field trying to learn how to punt, but I kept persevering.  He had high expectations and outlined what it would take to improve, but never used high-handed verbal threats.  I thrived under his excellent coaching which was solution-based corrective feedback , with firm constant validation. 

This is what our clients need to move forward; excellent coaches, trained in their craft, knowledgeable about how they can move forward, providing corrective feedback in a validating way.  Looking back, I think the key to the success of my childhood coach was that he knew everybody as a person, our nicknames signified our value and belonging.  His connecting with each person, not just the stars made the biggest difference.

I’ve found similarly with some of my clients, I work as a coach, sIowly working out alternate strategies that work for them, without the use of deeper emotional processing therapy. For example I worked with a client who engaged in self-ham activity and suicidal urges, which was always precipitated by binge-drinking.  I went through this creative problem solving and testing out with him until he eventually felt confident in his chosen strategy and even if he relapsed into old ways was able to provide self-talk to himself realizing it was just a “slip” and continue on.  Yet throughout this process, I always encouraged him to see that he did have choices in how to deal with the problem, but they held different consequences.  This process has taken almost a year, long slow work with setbacks and small steps forward. Important work in the playing field of life.

 

Wrestling with God

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There is a story in the Bible where God wrestles with Jacob (Genesis:22-32). He is alone, anxious and facing death by his brother. He has sent all of his family over to the other side of the river and there he meets a man/angel at night with whom he wrestles with. Before the match is ended Jacob demands a blessing and states that he will not let him go until he gets one. He receives a new name, not Jacob but Israel “because you have struggled with God, and with humans and have overcome.”

Recently I was unexpectedly admitted into the hospital for a surgery because of a serious infection that had developed quite rapidly. It was there that I was alone, at times praying desperate prayers of healing from an unbearable fever, prayers that a doctor would come and announce that my surgery was no longer delayed, and then prayers to be released home.

The struggles people come to in therapy are equally formidable, like a gash or a wound that ceases to heal instead of languishing in their pain or ignoring increasing symptoms someone decides to enter the battle of inner pain. They may face the taunts that were said to them earlier in life, the pain of loss or abuse, and struggle through them as they sit with a therapist. This struggle itself may bring up strong emotions, including anger, resentment that have not before been voiced.

I always wondered at the story of Jacob. How could someone have the audacity to struggle with God? How could he win? How did he know to ask for a blessing? Similarly, how do we know when is the right time to face the hurt that lingers? How do some overcome quickly and others take years to feel healing emotionally?

I recently took a course in Emotionally-Focused Therapy for Individuals. One primary thing I learned was that behind every emotion is a need- sometimes we need to ask a part of ourselves- or God for this to heal, just like the blessing that Jacob asked from God. From fear we may seek safety and reassurance. From sadness we may want comfort or love. On each of our journey I pray that we have the will to engage in the struggle through hard emotions and hard times and the courage seek the blessing that we need to heal.

The Sun Came Out!

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This week-end marked a new pattern from the usual, eat work, sleep routine. I was off for 4 days for the Easter long week-end. The weather was beautiful. Sunny, clear blue skies, warm weather.

The most perfect weather for Easter sunrise services, gallivanting by bike around the city with my toddler in tow, and planting a new crop in the backyard garden.

One amazing thing about beautiful weather is not only the ability to lift one’s spirits, but also to bring people together.

Since being introduced to Christian communal living 10 years ago in the Downtown Eastside living out the call of radical hospitality has been one of the main ways my family expresses our faith. This call is taken literally from Jesus’ teaching when he was confronted with the role of power and prestige in his day.

Jesus challenged the privileged of his day “When you give a dinner or banquet, do not invite your friends or your brothers or your relatives or rich neighbors, lest they also invite you in return and you be repaid. But when you give a fast, invite the poor, the crippled, the lame, the blind, and you will be blessed, because they cannot repay you. For you will be repaid at the resurrection of the just”. (Luke 14:12-13).

All winter it seems that I have been living for myself; socializing with the people at work I get along with, visiting family, dutifully going to church. But this week-end was different. This weekend I felt alive again because I was able to live out Jesus’ call of inviting people into our home for dinner who cannot pay us back.

This happened on various occasions every day where friends from our church here in the inner city came and dropped in. I was able to be present most of the time and share friendship and a few honest conversations, including some laughs.

This week-end also included gathering with a few other local churches in our neighborhood for Easter Services who have similar values. I reveled in the collective prayers on Easter morning and the strength of each voice and their diverse emphasize on different parts of God’s work (salvation, creation, beauty, atonement, etc). It was incredibly uplifting to be surrounded by such a tangible cloud of witnesses.

It was enough to jolt me out of my eat, work, sleep haze and remind me that, yes, Jesus still dwells in me and sometimes, I get a glimpse of what it is to live in the Kingdom of God.

Working Creatively in Mental Health Case Management

As mentioned in a previous post, I have been working in the area of case management for the past 6 months, with some therapy with a handful of clients- for example with a caseload of 50-60 client I may do more regular therapy with 5-10 of them.

There is a movement to adopt “recovery” oriented language and outlook but to date I have seen only glimpses of it in case management, but when things get tough (hospitalizations, etc) this language of looking at someone’s strengths, good reasons for their actions and own abilities gets thrown out the window in lieu of mechanisms of control.

In times of crisis and challenge it seems more common to start the see the client as problematic in our conversations together as professionals. For example very often people are described in the following ways: “she is very dependent”. “she is non-compliant” “requires redirection frequently”. This paternalistic lingo evolves in part by being a “manager”, rather than a therapist or a supporter.

It has become rarer now since becoming a case manager that I share with my colleagues with amazement of accomplishments that my clients have made or the amazing insight that they arrived at in session that day. Even if they are doing well it may also be attributed to the role of medication, which may be true in part, but also denies the client the victory of their own self-accomplishment.

As a case manager I spend so much time on medication refills and psychiatrist appointments that it seems like a big switch of gears to put on a therapeutic lens in each conversation. Many other professionals try to assure me that this is too much to expectof myself. However, I yearn to give the same attention and curious wonder to my clients I only see half an hour per month (or more frequently when medication changes are being made or person is unwell) as those I see every two weeks for therapy.

Part of this is beginning to think creatively, more visually and outside the box. I would like to dream to find new ways to engage their strengths and goals. This involves taking the time in each conversation to wonder out loud with someone about the future, about the ideas, about what is going well in their lives.

I have tried to have the lenten practice praying for my clients as I see them. I would also like to take time, even 15 minutes a day to think openly and creatively about one of my clients and think and plan a way forward. A therapist I used to work with used to set aside a day a month to plan and think about the work she was doing with her clients. In my work a blank calendar would definitely not go unnoticed, so a little bit integrated in would be the best strategy.

I’m curious to here about strategies of working creatively with long-term and chronic clients that you have used as a fellow therapist or ideas you may have from those outside the field. For those in mental health and case management how have you managed to refocus on recovery and strengths. Please share!!!

Happiness is…

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I recently attended a workshop by a well-known local psychologist on the topic of CBT and mindfulness. He mentioned that from talking to clients he has found that most people are searching to for “happiness”. For example we toll away at jobs that we do not enjoy for the end result of retiring comfortably and being “happy”. Of course, these culturally prescribed routes rarely produce happiness and sometimes people find they are the opposite of happy even while pursuing happiness. Depression is widespread in our culture(and among those who follow Jesus) and is characterized by hopelessness and lack of will to live and isolation/withdrawl from relationships.

For those who follow Christ I wondered if we too are aiming for happiness? The teachings of Jesus surprisingly do not seem to advocate for the goal of happiness and when happiness is spoken off it appears in an upside-down manner. For example in the beatitudes (Matthew 5:1-12) Jesus speaks of being blessed or in some translations “happy” when we are poor, mourn, meek, merciful and persecuted. It seems that happiness, instead of a goal, is a by-product of a lifestyle of both weakness and righteousness. In all of this we are called to “rejoice and be glad, because great is your reward in heaven…” (Matthew 5:12). Somehow we are supposed rejoice- celebrate – an action- not a mood stated- with the challenges in this present life with the insight and hope that God will reward us in heaven.

I have been meditating and memorizing Philippians 4:4-13 for the last month. Philippians was written by Paul from prison to the community in Philippi. He too is advocating a joyful/happy action “Rejoice in the Lord always I will say it again Rejoice”. It is in this passage that he explains that he has learned to be content in any and every situation (Philippians 4:11). This goes counter to our cultural “quest” for happiness through the usual route.

However, unlike mindfulness which aims to find inner peace through the moment Paul emphasizes that we are content in the Lord, who strengthens us. We rely on God’s strength to renew us and give us the “peace of God, which transcends all understanding”.

Being and feeling happy is cherished for a reason- it renews our spirit, we can keep on going in this hard challenging world. Can followers of Christ really hope to be happy? What can we say to clients who hope to be happy? Is it even an achievable goal?

The Hazards and Joys of work in Mental Health

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One of the riskiest and most challenging aspects of working in mental health is that of suicide.  For those who are depressed, bipolar, and psychotic that risk is very high.  We do everything in our power to prevent such tragedies.

In the last two weeks at work I have witnessed two contrasting stories on the topic.  Firstly, a client committed suicide that was on the caseload of one of the case manager.  This client’s life was very hard, she suffered from extreme highs and lows and she had numerous previous attempts where she had escaped death. The case manager noted that on the weekend that it happened there was a hang-up message from that client.  So close to asking for help.  This was very hard for the case manager and for all those who had worked with the client over the many years.

The second story is one of miraculous grace.  A client of a different case manager told me that one of her clients told her that over the week-end her client had prepared to commit suicide and was ready to do it and at that very moment her phone rang and the client picked it up.  It was his daughter who he had not heard from in 10 years calling to say that she wanted to come and visit him shortly.  This stopped the man in his tracks and he sought out help.

I have never experienced the loss a client by suicide, but I understand that most people who work in mental health do so at some point in their career.  I know that likely I would struggle emotionally and feel guilt and wonder what I could have done.  I know it would be an incredibly painful experience.  Trusting in God, as a loving father, I know he loves that deeply wounded and through the second story see that he does miraculously use us weak human beings for his means of grace in this world.

I was interviewing and listening to a new client the other day as she told me her story of death of all of those close to her, parents who were not available or in jail, and chronic physical problems. I  also read the chart to see also that she had experienced abuse in foster case.  It is so easy to understand how people become so hopeless when they experience life as unhappy and without joy as this woman described.  I just wanted this client to experience the love of Jesus.  The story of the phone call reminds me that God moves in mysterious ways gently and unexpectedly through each person’s life.

My lenten discipline for this season is to endeavour to pray for each client before seeing them and ask that God would give me openness, patience, love and grace.